Qualitative outcomes of Clean Cut: implementation lessons from reducing surgical infections in Ethiopia

Aviva S Mattingly, Nichole Starr, Senait Bitew, Jared A Forrester, Tihitena Negussie, Sylvia Bereknyei Merrell, Thomas G Weiser, Aviva S Mattingly, Nichole Starr, Senait Bitew, Jared A Forrester, Tihitena Negussie, Sylvia Bereknyei Merrell, Thomas G Weiser

Abstract

Background: Clean Cut is a six month, multi-modal, adaptive intervention aimed at reducing surgical infections through improving six critical perioperative processes: 1) handwashing/skin preparation, 2) surgical gown/drape integrity, 3) antibiotic administration, 4) instrument sterility, 5) gauze counts, and 6) WHO Surgical Safety Checklist use. The aim of this study was to elucidate themes across Clean Cut implementation sites in Ethiopia to improve implementation at future hospitals.

Methods: We conducted semi-structured interviews of 20 clinicians involved in Clean Cut at four hospitals. Participation was limited to Clean Cut team members and included surgeons, anesthetists, operating room (OR) nurses, ward nurses, OR managers, quality improvement personnel, and hospital administrators. Audio recordings were transcribed and coded using qualitative software. A codebook was inductively and iteratively derived between two researchers, tested for inter-rater reliability, and applied to all transcripts. We conducted thematic analysis to derive our final qualitative results.

Results: The interviews revealed barriers and facilitators to the implementation of Clean Cut, as well as strategies for future implementation sites. Key barriers included material resource limitations, feelings of job burden, existing gaps in infection prevention education, and communication errors during data collection. Common facilitators included strong hospital leadership support, commitment to improved patient outcomes, and organized Clean Cut training sessions. Future strategies include resource assessments, creating a sense of responsibility among staff, targeted training sessions, and incorporating new standards into daily routine.

Conclusions: The findings of this study highlight the importance of engaging hospital leadership, providers and staff in quality improvement programs, and understanding their work contexts. The identified barriers and facilitators will inform future initiatives in the field of perioperative infection prevention.

Keywords: Ethiopia; Quality improvement; Resource limited; Surgical infection.

Conflict of interest statement

TGW is the clinical advisor for Lifebox.

References

    1. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–499. doi: 10.1056/NEJMsa0810119.
    1. Collaborative G, Thomas HS, Weiser TG, Drake TM, Knight SR, Fairfield C, Ademuyiwa AO, Aguilera ML, Alexander P, Al-Saqqa SW. Pooled analysis of WHO surgical safety checklist use and mortality after emergency laparotomy. Br J Surg. 2019;106(2):e103–e112. doi: 10.1002/bjs.11051.
    1. Furuya EY, Dick AW, Herzig CT, Pogorzelska-Maziarz M, Larson EL, Stone PW. Central line–associated bloodstream infection reduction and bundle compliance in intensive care units: a national study. Infect Control Hosp Epidemiol. 2016;37(7):805–810. doi: 10.1017/ice.2016.67.
    1. Bledsoe BE, Sweeney RJ, Berkeley RP, Cole KT, Forred WJ, Johnson LD. EMS provider compliance with infection control recommendations is suboptimal. Prehosp Emerg Care. 2014;18(2):290–294. doi: 10.3109/10903127.2013.851311.
    1. Clean Cut [].
    1. Vohra RS, Cowley JB, Bhasin N, Barakat HM, Gough MJ. : attitudes towards the surgical safety checklist and factors associated with its use: a global survey of frontline medical professionals. Ann Med Surg (Lond) 2015;4(2):119–123. doi: 10.1016/j.amsu.2015.04.001.
    1. Russ SJ, Sevdalis N, Moorthy K, Mayer EK, Rout S, Caris J, Mansell J, Davies R, Vincent C, Darzi A. A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project". Ann Surg. 2015;261(1):81–91. doi: 10.1097/SLA.0000000000000793.
    1. Aveling EL, McCulloch P, Dixon-Woods M. A qualitative study comparing experiences of the surgical safety checklist in hospitals in high-income and low-income countries. BMJ Open. 2013;3(8):e003039. doi: 10.1136/bmjopen-2013-003039.
    1. The World Factbook, United States [].
    1. Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field methods. 2006;18:1. doi: 10.1177/1525822X05279903.
    1. Patton M: Qualitative Research & Evaluation Methods: integrating theory and practice. In., 4th edn. Thousand Oaks, CA: Sage Publications; 2015.
    1. Thomas D. A general inductive approach for analyzing qualitative evaluation data. Am J Eval. 2006;27(2):237–246. doi: 10.1177/1098214005283748.
    1. Miles M, Huberman A, Saldana J. Qualitative data analysis, a methods sourcebook, 3rd edn. Thousand Oaks, CA: Sage Publications; 2014.
    1. Saldana J. The coding manual for qualitative researchers, 3rd edn. Thousand Oaks, CA: Sage Publications; 2016.
    1. Curry LA, Nembhard IM, Bradley EH. Qualitative and mixed methods provide unique contributions to outcomes research. Circulation. 2009;119(10):1442–1452. doi: 10.1161/CIRCULATIONAHA.107.742775.
    1. MacQueen K, McLellan-Lemal ME: Team-based codebook development: structure, process, and agreement. Handbook for team-based qualitative research; 2008.
    1. Creswell JW: 30 essential skills for the qualitative researcher: Sage Publications; 2015.
    1. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. doi: 10.1191/1478088706qp063oa.
    1. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. doi: 10.1186/1748-5908-4-50.
    1. Forrester JA, Koritsanszky LA, Amenu D, Haynes AB, Berry WR, Alemu S, Jiru F, Weiser TG. Developing process maps as a tool for a surgical infection prevention quality improvement initiative in resource-constrained settings. J Am Coll Surg. 2018;226(6):1103–1116.e1103. doi: 10.1016/j.jamcollsurg.2018.03.020.
    1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008;337:a1714. doi: 10.1136/bmj.a1714.
    1. Aveling E-L, Dixon-Woods M, McCulloch P, Kayonga Y, Nega A: Optimising surgical safety checklist implementation: key lessons for practitioners and partners. In: University of Leicester; 2015.
    1. Aveling EL, Zegeye DT, Silverman M. Obstacles to implementation of an intervention to improve surgical services in an Ethiopian hospital: a qualitative study of an international health partnership project. BMC Health Serv Res. 2016;16(1):393. doi: 10.1186/s12913-016-1639-4.

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