Barriers-enablers-ownership approach: a mixed methods analysis of a social intervention to improve surgical antibiotic prescribing in hospitals.

OBJECTIVES: To assess an intervention for surgical antibiotic prophylaxis (SAP) improvement within surgical teams focused on addressing barriers and fostering enablers and ownership of guideline compliance. DESIGN: The Queensland Surgical Antibiotic Prophylaxis (QSAP) study was a multicentre, mixed methods study designed to address barriers and enablers to SAP compliance and facilitate engagement in self-directed audit/feedback and assess the efficacy of the intervention in improving compliance with SAP guidelines. The implementation was assessed using a 24-month interrupted time series design coupled with a qualitative evaluation. SETTING: The study was undertaken at three hospitals (one regional, two metropolitan) in Australia. PARTICIPANTS: SAP-prescribing decisions for 1757 patients undergoing general surgical procedures from three health services were included. Six bimonthly time points, pre-implementation and post implementation of the intervention, were measured. Qualitative interviews were performed with 29 clinical team members. SAP improvements varied across site and time periods. INTERVENTION: QSAP embedded ownership of quality improvement in SAP within surgical teams and used known social influences to address barriers to and enablers of optimal SAP prescribing. RESULTS: The site that reported senior surgeon engagement showed steady and consistent improvement in prescribing over 24 months (prestudy and poststudy). Multiple factors, including resource issues, influenced engagement and sites/time points where these were present had no improvement in guideline compliance. CONCLUSIONS: The barriers-enablers-ownership model shows promise in its ability to facilitate prescribing improvements and could be expanded into other areas of antimicrobial stewardship. Senior ownership was a predictor of success (or failure) of the intervention across sites and time periods. The key role of senior leaders in change leadership indicates the critical need to engage other specialties in the stewardship agenda. The influence of contextual factors in limiting engagement clearly identifies issues of resource distributions/inequalities within health systems as limiting antimicrobial optimisation potential.

A 12-Month Review of Revisional Single Anastomosis Gastric Bypass for Complicated Laparoscopic Adjustable Gastric Banding for Body Mass Index over 35.

BACKGROUND: In many countries, laparoscopic adjustable gastric banding (LAGB) was previously the most commonly performed bariatric procedure due to its operative safety and early efficacy. This procedure is now superseded because of doubtful long-term results and late complications. Many people eventually required revisional bariatric surgery such as conversion to single anastomosis gastric bypass (SAGB). This study aims to assess the safety and durability of single-stage conversion from LAGB to SAGB in patients who are intolerant to LAGB and who also fail to lose weight, or re-gain weight. METHODS: Seventy-four patients with BMI > 35 kg m-2 were selected from a prospective bariatric database between July 2012 and December 2015 for revisional laparoscopic SAGB surgery and were followed up at 6 weeks, 3, 6 and 12 months after their operation. RESULTS: The mean BMI at 6 weeks, then 3, 6 and 12 months were 41.6 ± 7.66, 38.8 ± 7.54, 35.4 ± 7.10 and 33.2 ± 7.34 kg m-2, respectively. The mean percentage EWL at 6 weeks then 3, 6 and 12 months were 21.0 ± 9.12, 37.8 ± 12.5, 55.1 ± 15.8 and 67.0 ± 19.6%, respectively. Postoperative follow-up at these times were 97, 85, 69 and 46%, respectively. Early (< 30 day) morbidity was 20.3% with major complications of CD grade 3a or more of 13.5%. CONCLUSIONS: This study demonstrates that single-stage revisional SAGB after a failed LAGB achieved good short-term weight loss and low 30-day morbidity.