Title: Improving surgical antimicrobial prescribing practice
Funder: Health Education England

Abstract: Background A high proportion of secondary-care antimicrobial prescribing occurs in surgery and inappropriate use has been widely reported, leading to patient harm. To bring about sustained changes in antimicrobial prescribing behaviour (APB) interventions must address the contextual factors influencing practice. AimsTo improve antimicrobial prescribing for surgical patients by working with surgical teams to design and implement system-level change, informed by a deep understanding of the influences on their antimicrobial prescribing practice. Objectives To undertake a qualitative evidence synthesis to explain how and why contextual factors interact to influence APB among surgical teams; To conduct an ethnographic study at two hospitals, using direct observation and semi-structured interviews, to test theories and ideas generated in Phase I to advance insights into surgical APB; and To use a co-creation quality improvement methodology to design and implement system-level change to improve surgical APB.Research question How and why do contextual factors interact to influence surgical APB and what can be done to improve antimicrobial prescribing practice? Methods The study has three phases; each informs the next: I: Qualitative evidence synthesis (meta-ethnography). A systematic search will be undertaken to identify qualitative articles addressing APB within surgery, in hospitals, in developed healthcare systems. Evidence will be synthesised to facilitate identification of overarching constructs and theory-building, broadening understanding of surgical APB. II: Ethnography. Purposively-selected surgical events will be observed, at two hospitals, to investigate how antimicrobial prescribing processes are working. Fieldnotes will be typed up daily to ensure rich accurate data are recorded. Additionally, purposively-selected surgical team members will be invited to participate in face-to-face semi-structured interviews until thematic saturation is achieved. Close attention will be given to leadership, identified as important in previous research. All interviews will be recorded and transcribed verbatim. The fieldnotes and interview transcripts will be analysed using the framework approach. III: Quality improvement. Purposively-selected surgical team members, at one hospital, will be invited to participate in an innovative quality improvement intervention ('Change Laboratory'). This methodology, underpinned by Cultural-Historical-Activity-Theory, embraces the complexity and challenges within work processes; leads to system-level change; and has previously been implemented successfully in a surgical context. In collaboration with participants, current practice will be analysed to identify the most important barriers to implementing best practice antimicrobial guidelines. New ways of working/procedures will be documented in detail and reconsidered by participants prior to implementation. Outcome measures will be monitored to assess the impact. Phases II and III will not commence until Health Research Authority approval is granted. Timelines for delivery Four years (75%). Anticipated impact and dissemination Findings will be actively communicated to multiple groups including surgical and stewardship healthcare workers, managers, academics, patients and members of the public, using appropriate media. Insights into surgical APB will enable stewardship teams to tailor interventions to improve practice. A rich description of the quality improvement process ('journey') and outcomes will be actively shared with other hospitals to encourage them to use the tools developed; to learn from our experiences; and to tailor the solutions to meet their needs/context.

Lay abstract: Aims of the research This study aims to improve antibiotic prescribing for patients who have operations (surgery) by working with surgical healthcare workers to introduce new ways of working that are informed by a deep understanding of the influences on their antibiotic prescribing practice. Background to the research Antibiotics are used to treat or prevent bacterial infections; however, incorrect use can lead to increased adverse side-effects, including surgical wound infections. Government targets have been set, to halve inappropriate antibiotic prescribing by 2021, because unnecessary use can change bacteria so that antibiotics no longer work. When this happens, some infections become untreatable and certain operations become unsafe as antibiotics are needed to prevent infection.Research shows that surgical teams (including surgeons, anaesthetists, junior doctors, pharmacists and nurses) do not always use antibiotics in the best way. We must improve surgical antibiotic prescribing but to be effective we must understand what influences practice. Design and methods used The study has three parts, with each part informing the next: Previous studies on antibiotic prescribing in surgery will be identified and analysed to discover what is already known on the topic and to allow comparison between studies. Bringing the studies together will help us to see the 'whole picture' and to develop new ideas about the important influences on antibiotic prescribing practice. Surgical team members from two National Health Service (NHS) hospitals will be observed in the workplace and interviewed, to explore influences on their antibiotic prescribing decisions. Notes written during the observations and audio recordings from the interviews will be closely studied and analysed. This will lead to a deep understanding of what influences the surgical teams when they make antibiotic prescribing decisions. Surgical team members from one NHS hospital will work together, with a trained facilitator, to look at current antibiotic prescribing practice (identified in part two). The group will design and introduce new ways of working, to improve antibiotic prescribing for surgical patients. Surgical wound infection rates and antibiotic prescribing will be monitored before and after the change, to assess the effect of the new way of working.Patient and public involvementPatient and public involvement is woven throughout the fabric of this research. Initially, before the study had been clearly defined, the topic was discussed with a panel of patient representatives allowing them to share their opinions and concerns and help shape the study design. Then, during the development of the study, patient representatives have been asked for feedback, which has been incorporated. The Plain English Summary was co-written with a patient representative and has been improved based on feedback from five more patient representatives. As important stakeholders, a range of surgical team members have also been consulted throughout the process. During the study, patient representatives will be asked for feedback on key parts of the study. Additionally, a patient representative, surgeon and anaesthetist have agreed to be part of the study management group. This will ensure a range of viewpoints are considered throughout the study (for example when developing study materials, analysing findings and deciding on ways to share the findings). Dissemination Findings will be shared with healthcare professionals, academics, patients, carers and members of the public via publications, conferences, a short video, short summaries and other materials appropriate to the target audience. Insights from the study will help healthcare workers to improve antibiotic prescribing practice in surgery, to reduce surgical wound infections and other unintended harm. A rich description of the third part of the study, and its effects, will enable other hospitals to learn from our experience and introduce similar changes, tailored to their own needs.

Research activity codes: 6.1 PHARMACEUTICALS;6.4 SURGERY
Health categories: GENERIC HEALTH RELEVANCE