Background
Materials and methods
Search strategy
Study selection
Data extraction and quality assessment
Implementation intervention classification
EPOC implementation subcategory | Definitiona | Examples |
---|---|---|
Organisational culture | Strategies to change organisational culture | Multidisciplinary teams, steering committees, regular briefings, leadership/leaders’ involvement |
Audit and feedback | A summary of health workers’ performance over a specified period of time, given to them in a written, electronic or verbal format. The summary may include recommendations for clinical action | Feedback sessions, personal performance feedback, posting SSI or compliance rates |
Clinical incident reporting | System for reporting critical incidents | Critical Incident Reporting Systems |
Monitoring the performance of the delivery of healthcare | Monitoring of health services by individuals or healthcare organisations, for example by comparing with an external standard | Monitoring compliance with SSI preventive measures, monitoring SSI incidence |
Communities of practice | Groups of people with a common interest who deepen their knowledge and expertise in this area by interacting on an ongoing basis | Regional hospital collaboration to regularly exchange knowledge and improve quality |
Continuous quality improvement | An iterative process to review and improve care that includes involvement of healthcare teams, analysis of a process or system, a structured process improvement method or problem solving approach, and use of data analysis to assess changes | Regular meetings to review compliance with preventive measures and when necessary to eliminate barriers to improve quality of care |
Educational games | The use of games as an educational strategy to improve standards of care | Video games, smartphone-based games, quizzes |
Educational materials | Distribution to individuals, or groups, of educational materials to support clinical care, i.e., any intervention in which knowledge is distributed. For example this may be facilitated by the internet, learning critical appraisal skills; skills for electronic retrieval of information, diagnostic formulation; question formulation | Posters, newsletters, bulletins |
Educational meetings | Courses, workshops, conferences or other educational meetings | Educational sessions, educational lectures, grand round lectures, workshops |
Educational outreach visits, or academic detailing | Personal visits by a trained person to health workers in their own settings, to provide information with the aim of changing practice | Site visits by a trained healthcare professional to educate groups or individuals |
Clinical Practice Guidelines | Clinical guidelines are systematically developed statements to assist healthcare providers and patients to decide on appropriate health care for specific clinical circumstances’(US IOM) | Developing a new clinical practice guideline, choosing evidence-based guidelines |
Inter-professional education | Continuing education for health professionals that involves more than one profession in joint, interactive learning | Interdisciplinary education |
Local consensus processes | Formal or informal local consensus processes, for example agreeing a clinical protocol to manage a patient group, adapting a guideline for a local health system or promoting the implementation of guidelines | Clinical practice guideline development with agreeing from all levels |
Local opinion leaders | The identification and use of identifiable local opinion leaders to promote good clinical practice | Involvement of project officers, study champions |
Managerial supervision | Routine supervision visits by health staff | Supervision by managerial staff |
Patient-mediated interventions | Any intervention aimed at changing the performance of healthcare professionals through interactions with patients, or information provided by or to patients | Patient feedback, patients as committee members |
Public release of performance data | Informing the public about healthcare providers by the release of performance data in written or electronic form. | Publicly accessible websites that provide performance reports |
Reminders | Manual or computerised interventions that prompt health workers to perform an action during a consultation with a patient, for example computer decision support systems | Checklists, automatic electronic reminders, protocols |
Routine patient-reported outcome measures | Routine administration and reporting of patient-reported outcome measures to providers and/or patients | Assessing patients’ experience of symptoms through questionnaires before and after interventions |
Tailored interventions | Interventions to change practice that are selected based on an assessment of barriers to change, for example through interviews or surveys | Developing implementation interventions based on previously identified barriers |
Effectiveness analysis
Results
Review statistics
Characteristics of the included studies
First author, year, country | Study design | Type of surgery | Sample size | SSI Outcome | SSI rate | Compliance rate |
---|---|---|---|---|---|---|
Bull, 2011, Australia [34] | Cohort (before/after) | Colorectal surgery | Baseline: NR Cohort: 142 | Baseline: NR Cohort: 10 | Baseline: 15% Cohort: 7% | Baseline: 5,3% (global) Cohort: 21,1% (global) |
Cameron, 2015, UKc [35] | Cohort (before/after) | Gastrointestinal surgery | Baseline: 58 Cohort: 73 | Baseline: NR Cohort: NR | Baseline: NR Cohort: NR | Baseline: 31% (global) Cohort: 73% (global) |
Cima, 2013, US [36] | Cohort (before/after) | Colorectal surgery | Baseline: 531 Cohort: 198 | Baseline: 52 Cohort: 8 | Baseline: 9.8% Cohort: 4% | Baseline: only for individual measures Cohort: only for individual measures |
Connolly, 2016, US [37] | Cohort (before/after) | Colorectal surgery | Baseline: 379 Cohort: 328 | Baseline: 122 Cohort: 27 | Baseline: 32.2% Cohort: 8.2% | Baseline: NR Cohort: NR |
Crolla, 2012, Netherlands [38] | Cohort (before/after) | Colorectal surgery | Baseline: 349 Cohort: 377 | Baseline: 85 Cohort: 61 | Baseline: 21.6% Cohort: 16.2% | Baseline: 10% (global) Cohort: 80% (global) |
DeHaas, 2016, US [39] | Cohort (before/after) | Colorectal surgery | Baseline: 277 Cohort: 254 | Baseline: 49a Cohort: 13a | Baseline: 17.58% Cohort: 5.11% | Baseline: NR Cohort: NR |
Elia-Guedea, 2017, Spain [40] | Cohort (before/after) | Colorectal surgery | Baseline: 70 Cohort: 79 | Baseline: 22 Cohort: 11 | Baseline: 31.4% Cohort: 13.9% | Baseline: NR Cohort: NR |
Forbes, 2008, Canadac [41] | Cohort (before/after) | Colorectal or hepatobiliary surgery | Baseline: 105 Cohort: 103 | Baseline: 15a (superficial) Cohort: 9a (superficial) | Baseline: 14.3% (superficial) Cohort: 8.7% (superficial) | Baseline: only for individual measures Cohort: only for individual measures |
Frenette, 2016, Canada [42] | Cohort (before/after) | Hepatobiliary Surgery, Solid Organ Transplantation (liver, kidney, pancreas) | Baseline: 453 Cohort: 971 | Baseline: 79 Cohort: 80 | Baseline: 17.4% Cohort: 8.2% | Baseline: 45.1% (global) Cohort: 60.3% (global) |
Garcell, 2017, Qatarc [43] | Cohort | Appendix surgery | Baseline: 59 Cohort: 300 | Baseline: NR Cohort: NR | Baseline: NR Cohort: NR | Baseline: only for individual measures Cohort: only for individual measures |
Geubbels, 2004, Netherlands [44] | Cohort (before/after) | Appendix surgery | Baseline: NR Cohort: NR | Baseline: NR Cohort: NR | Baseline: 14.9% Cohort: 3.6% | Baseline: NR Cohort: 81% (individual measure) |
Grant, 2018 (Epub 2017), US c [45] | Cohort (before/after) | Colorectal surgery | Baseline: 401 Cohort: 763 | Baseline: NR Cohort: NR | Baseline: NR Cohort: NR | Baseline: NR Cohort: NR |
Hechenbleikner, 2015, US [46] | Cohort (before/after) | Colorectal surgery | Baseline: Cohort: 387 | Baseline: Cohort: 71 | Baseline: 22.4% Cohort: 18.9% | Baseline: only for individual measures Cohort: only for individual measures |
Hedrick, 2007, US [47] | Cohort (before/after) | Colorectal surgery | Baseline: 175 Cohort: 132 | Baseline: 45 Cohort: 21 | Baseline: 25.6% Cohort: 15.9% | Baseline: only for individual measures Cohort: only for individual measures |
Hedrick, 2007, US [48] | Cohort (before/after) | Intra-Abdominal Surgery | Baseline: 379 Cohort: 390 | Baseline: 35a Cohort: 22a | Baseline: 9.2% Cohort: 5.6% | Baseline: only for individual measures Cohort: only for individual measures |
Hewitt, 2017, US [49] | Cohort (before/after) | Colorectal surgery | Baseline: 489 Cohort: 212 | Baseline: 68 Cohort: 10 | Baseline: 13.9% Cohort: 4.7% | Baseline: NR Cohort: 80% (global) |
Kao, 2010, US [50] | Cohort (controlled staggered before/after) | Colorectal surgery, abdominal hysterectomies, and abdominal vascular operations | Baseline: 91a Cohort: 62a | Baseline: 4a Cohort: 2a | Baseline: 4.4%a (colorectal) Cohort: 3.2%a (colorectal) | Baseline: NR (graphical only) Cohort: 63.7% (global) |
Keenan, 2014, US [51] | Cohort (before/after) | Colorectal surgery | Baseline: 212 Cohort: 212 | Baseline: 55a Cohort: 18a | Baseline: 25.9%a Cohort: 8.5%a | Baseline: NR Cohort: only for individual measures (narrative) |
Keenan, 2015, US [52] | Cohort (before/after) | Colorectal surgery | Baseline: 337 Cohort: 285 | Baseline: 116a Cohort: 26a | Baseline: 34.4%a Cohort: 9.1%a | Baseline: NR Cohort: only for individual measures |
Kilan, 2017, Saudi Arabia [53] | Cohort (before/after) | Gastrointestinal surgery | Baseline: 55 Cohort: 214 | Baseline: 5 Cohort: 11 | Baseline: 9.1% Cohort: 5.1% | Baseline: 47.3% (global) Cohort: 82.2% (global) |
Knox, 2016, Australiac [54] | Cohort (before/after) | Abdominal general surgery | Baseline: 100 Cohort: 100 | Baseline: NR Cohort: NR | Baseline: NR Cohort: NR | Baseline: 18% (global) Cohort: 15% (global) |
Larochelle, 2011, USc [55] | Cohort (before/after) | Colorectal surgery | Baseline: NR Cohort: 706 | Baseline: NR Cohort: 87 | Baseline: NR Cohort: 12.3% | Baseline: NR Cohort: only for individual measures |
Lavu, 2012, US [56] | Cohort (before/after) | Pancreatic surgery | Baseline: 233 Cohort: 233 | Baseline: 35 Cohort: 18 | Baseline: 15.0% Cohort: 7.7% | Baseline: NR Cohort: narrative only (global) |
Liau, 2010, Singapore [57] | Cohort (before/after) | Gastrointestinal and hernia surgery | Baseline: 1065a Cohort: 2408 | Baseline: 33a Cohort: 12 | Baseline: 3.1% Cohort: 0.5% | Baseline: NR Cohort: only for individual measures |
Losh, 2017, USc [58] | Cohort (before/after) | General, orthopedic, colorectal, oncological, OB/GYN, neurosurgery and urology surgical subspecialties | Baseline: NR Cohort: NR | Baseline: NR Cohort: NR | Baseline: 6.9%b Cohort: 1.6%b | Baseline: NR Cohort: NR |
Lutfiyya, 2012, US [59] | Cohort (before/after) | Colorectal surgery | Baseline: 430 Cohort: 195 | Baseline: 91 Cohort: 13 | Baseline: 21.16% Cohort: 6.67% | Baseline: NR Cohort: NR |
Mammo, 2016, USc [60] | Cohort (before/after) | Colorectal surgery | Baseline: 273 Cohort: 212 | Baseline: 5a (deep) Cohort: 0 (deep) | Baseline: 1.8% (deep) Cohort: 0% (deep) | Baseline: only for individual measures Cohort: only for individual measures |
Misteli, 2012, Switzerland [61] | Cohort (before/after) | Vascular, visceral, and trauma surgery (Subgroup: Cholecystectomy and Colon Surgery) | Baseline: 483 Cohort: 257 | Baseline: 44 Cohort: 25 | Baseline: 9.1% Cohort: 9.7%a | Baseline: 41% (individual measure) Cohort: 56% (individual measure) |
Nordin, 2018 (Epub 2017), US [62] | Cohort (before/after) | Pediatric gastrointestinal surgery | Baseline: NR Cohort: 1595 | Baseline: NR Cohort: 75a | Baseline: 7.1% Cohort: 4.7% | Baseline: 43% (global) Cohort: 80% (global) |
Pastor, 2010, US [63] | Cohort (early and late implementation period) | Colorectal Surgery | Baseline: 238 Cohort: 235 | Baseline: 45 Cohort: 49 | Baseline: 18.9% Cohort: 19.4% | Baseline: 30% (global) Cohort: 50% (global) |
Pérez-Blanco, 2015, Spain [64] | Cohort (before/after) | Colorectal surgery | Baseline: 218 Cohort: 124 | Baseline: 60 Cohort: 21 | Baseline: 27.5% Cohort: 16.9% | Baseline: 62.6% (global) Cohort: 81,1% (global) |
Reames, 2015, US c [65] | Cohort (before/after) | Abdominal general surgery | Baseline:14,005 Cohort: 14,801 | Baseline: 449a (superficial) Cohort: 474a (superficial) | Baseline: 3.2% (superficial) Cohort: 3.2% (superficial) | Baseline: NR Cohort: NR |
Tanner, 2016, UK [66] | Cohort (before/after) | Colorectal surgery | Baseline: 127 Cohort: 166 | Baseline: 31 Cohort: 46 | Baseline: 24% Cohort: 28% | Baseline: only for individual measures Cohort: 19% (global) |
Tillman, 2013, US [67] | Cohort (before/after) | Cardiac surgery, colorectal surgery, general surgery (non-colorectal non-vascular), gynecologic surgery, orthopedic surgery, thoracic surgery, and vascular surgery | Baseline: 79 Cohort: 104 | Baseline: 19 Cohort: 12 | Baseline: 24.1% (colorectal) Cohort: 11.5% (colorectal) | Baseline: only for individual measures Cohort: only for individual measures |
Vogel, 2010, Germany [68] | Cohort (before/after) | Colorectal surgery | Baseline: 332 Cohort: 341 | Baseline: 26 Cohort: 12 | Baseline: 7.8% Cohort: 3.5% | Baseline: NR Cohort: narrative only (global) |
Vu, 2018 (Epub 2017), US [69] | Cohort (before/after) | Colorectal surgery | Baseline: NR Cohort: NR | Baseline: NR Cohort: NR | Baseline: 6.7% Cohort: 3.9% | Baseline: only for individual measures Cohort: only for individual measures |
Waters, 2017, US [70] | Cohort (before/after) | Colorectal surgery | Baseline: 2408 Cohort: 2873 | Baseline: 193a Cohort: 172a | Baseline: 8% Cohort: 6% | Baseline: only for individual measures Cohort: only for individual measures |
Wick, 2012, US [71] | Cohort (before/after) | Colorectal surgery | Baseline: 278 Cohort: 324 | Baseline: 76 Cohort: 59 | Baseline: 27.3% Cohort: 18.2% | Baseline: only for individual measures Cohort: only for individual measures |
Wick, 2015, US [72] | Cohort (before/after) | Colorectal surgery | Baseline: 310 Cohort: 330 | Baseline: 59a Cohort: 24a | Baseline: 18.8% Cohort: 7.3% | Baseline: NR Cohort: NR |
Willis, 2016, US [73] | Cohort (before/after) | Appendix surgery (Pediatric Complicated Appendicitis) | Baseline: 191 Cohort: 122 | Baseline: 50a Cohort: 14a | Baseline: 26.2%a Cohort: 11.4%a | Baseline: NR Cohort: 87.5% (global) |
Distribution of implementation interventions
First author, year | Audit and feedback | Organi-sational culture | Monito-ring the perfor-mance of the delivery of healthcare | Re-minders | Educa-tional meetings | Local con-sensus processes | Continous quality improve-ment | Local opinion leaders | Edu-cational materials | Clinical practice guidelines | Educa-tional outreach visits, or academic detailing | Commu-nities of practice | Tailored inter-ventions | Mana-gerial super-vision | Interpro-fessional education | Clinical incident reporting | Educa-tional games | Patient-mediated inter-ventions | Public release of performance data | Routine patient-reported outcome measures | Number of imple-mentation strategies used in studies |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Bull, 2011 [34] | X | X | X | X | X | X | X | X | 8 | ||||||||||||
Cameron, 2015 [35] | X | X | 2 | ||||||||||||||||||
Cima, 2013 [36] | X | X | X | X | X | X | X | 7 | |||||||||||||
Connolly, 2016 [37] | X | X | X | X | 4 | ||||||||||||||||
Crolla, 2012 [38] | X | X | X | X | 4 | ||||||||||||||||
DeHaas, 2016 [39] | X | X | 2 | ||||||||||||||||||
Elia-Guedea, 2017 [40] | X | X | X | X | 4 | ||||||||||||||||
Forbes, 2008 [41] | X | X | X | X | X | 5 | |||||||||||||||
Frenette, 2016 [42] | X | X | X | X | X | 5 | |||||||||||||||
Garcell, 2017 [43] | X | X | X | X | 4 | ||||||||||||||||
Geubbels, 2004 [44] | X | X | 2 | ||||||||||||||||||
Grant, 2018 (Epub 2017) [45] | X | 1 | |||||||||||||||||||
Hechenbleikner, 2015 [46] | X | X | X | 3 | |||||||||||||||||
Hedrick, 2007 [47] | X | X | X | X | X | X | 6 | ||||||||||||||
Hedrick, 2007 [48] | X | X | X | X | X | X | X | 7 | |||||||||||||
Hewitt, 2017 [49] | X | X | X | 3 | |||||||||||||||||
Kao, 2010 [50] | X | X | X | X | X | 5 | |||||||||||||||
Keenan, 2014 [51] | X | X | X | 3 | |||||||||||||||||
Keenan, 2015 [52] | X | X | X | X | X | 5 | |||||||||||||||
Kilan, 2017 [53] | X | X | X | X | X | X | X | X | 8 | ||||||||||||
Knox, 2016 [54] | X | X | 2 | ||||||||||||||||||
Larochelle, 2011 [55] | X | X | X | 3 | |||||||||||||||||
Lavu, 2012 [56] | X | 1 | |||||||||||||||||||
Liau, 2010 [57] | X | X | X | X | X | X | X | X | 8 | ||||||||||||
Losh, 2017 [58] | X | X | X | X | X | X | X | X | 8 | ||||||||||||
Lutfiyya, 2012 [59] | X | X | X | X | X | X | 6 | ||||||||||||||
Mammo, 2016 [60] | X | X | 2 | ||||||||||||||||||
Misteli, 2012 [61] | X | X | 2 | ||||||||||||||||||
Nordin, 2018 (Epub 2017) [62] | X | X | 2 | ||||||||||||||||||
Pastor, 2010 [63] | X | X | X | X | X | X | X | 7 | |||||||||||||
Pérez-Blanco, 2015 [64] | X | 1 | |||||||||||||||||||
Reames, 2015 [65] | X | X | X | X | X | X | X | X | X | X | 10 | ||||||||||
Tanner, 2016 [66] | X | X | X | 3 | |||||||||||||||||
Tillman, 2013 [67] | X | X | X | X | X | 5 | |||||||||||||||
Vogel, 2010 [68] | X | X | X | X | X | 5 | |||||||||||||||
Vu, 2018 (Epub 2017) [69] | X | X | X | X | X | X | X | X | 8 | ||||||||||||
Waters, 2017 [70] | X | X | 2 | ||||||||||||||||||
Wick, 2012 [71] | X | X | X | X | X | X | X | X | 8 | ||||||||||||
Wick, 2015 [72] | X | X | X | X | X | X | X | X | 8 | ||||||||||||
Willis, 2016 [73] | X | X | X | X | 4 | ||||||||||||||||
Number of studies the implementation strategy was used in | 32 | 28 | 26 | 21 | 18 | 14 | 11 | 10 | 6 | 4 | 4 | 3 | 3 | 2 | 1 | 0 | 0 | 0 | 0 | 0 | |
% of studies the implementation strategy was used in | 80% | 70% | 65% | 52.5% | 45% | 35% | 27.5% | 25% | 15% | 10% | 10% | 7.5% | 7.5% | 5% | 2.5% | 0% | 0% | 0% | 0% | 0% |
Effectiveness of implementation interventions
Studies with 3–5 vs. 1–2 implementation interventions | Studies with 6–8 vs. 1–2 implementation interventions | Studies with 3–5 vs. 6–8 implementation interventions | |||||||
---|---|---|---|---|---|---|---|---|---|
Difference | 95%-confidence interval | p-value | Difference | 95%- confidence interval | p-value | Difference | 95%- confidence interval | p-value | |
baseline | 7.8% | [−0.2│15.8] | p = 0.055 | 0.8% | [−7.4│9.0] | p = 0.843 | 7.0% | [0.1│14.0] | p = 0.049 |
cohort | 3.5% | [−2.5│9.5] | p = 0.241 | 0.8% | [−5.4│7.0] | p = 0.785 | 2.7% | [−2.6│7.9] | p = 0.305 |
Studies with top five implementation interventions vs. studies without | |||
---|---|---|---|
Difference | 95%-confidence interval | p-value | |
baseline | −3.6% | [−11.0│3.8] | p = 0.324 |
cohort | −2.1% | [−7.4│3.1] | p = 0.418 |