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This content is taken from the BSAC's online course, Utilising Social Science and Behaviour Change in Antimicrobial Stewardship Programmes: Improving Healthcare. Join the course to learn more.

Skip to 0 minutes and 4 seconds The first step in a behavioural approach to designing and reporting interventions is to define the problem in behavioural terms. What needs to be done differently by who, where, to whom, and when. In this video, we will apply the AACTT framework to two studies of interventions that targeted surgical antibiotic prophylaxis. The action in both studies was stopping prophylactic antibiotics. Both interventions included explicit assignment of responsibility for stopping antibiotics to the surgeon. However, in dull, pharmacists issued a default order to stop the antibiotics after 24 hours so the surgeon had to override this in order to continue antibiotics. Pharmacists were expected to contact surgeons if antibiotics were continued.

Skip to 0 minutes and 55 seconds In contrast, in Sun, the surgeon was expected to stop the antibiotics, but no other actors were identified. The context for both studies were surgical wards. In Dull, these were multiple wards across two hospitals, whereas in Sun, there was a single cardiac surgery ward. Both studies targeted adult patients undergoing elective coronary artery bypass grafts, but Dull also included patients undergoing other cardiac surgery, as well as orthopaedic, colorectal, gynaecological, and vascular surgery. Both studies specified the time when prophylactic antibiotics should be stopped with standards from national quality improvement projects. Dull specified that antibiotics should be discontinued within 24 hours after surgery and time and within 48 hours for cardiac procedures.

Skip to 1 minute and 49 seconds Sun specified that antibiotics should be discontinued within 24 hours after coronary artery bypass graft surgery. Both interventions improved performance but did not reach the target of 95% reliability in the first six months after the intervention started. In Dull, the surgical infection prevention team noted that there remained room for improvement and went to the pharmacy and therapeutics committee to request that it approve an automatic stock water on prophylactic antibiotics after 24 hours (or 48 hours for cardiothoracic procedures). Following this approval, if a surgeon issued an order for prophylactic antibiotics for more than 24 or 48 hours, pharmacists stop the medication without consultation with the surgeon, which was associated with sustained improvement to 95% reliability.

Skip to 2 minutes and 43 seconds In contrast, there was no change to the intervention in Sun, despite the fact that the process was only 60% to 70% reliable. These studies show that establishing a reliable process with stopping prophylactic antibiotics may require identification of more than one actor, as well as a review of the actions that they perform if the intervention goal is not achieved. In comparison with stopping therapeutic antibiotics, changing behaviour to stop prophylactic antibiotics is likely to be much less challenging for two reasons. First, the patients are undergoing elective surgery, and most hospitals will have a list of these patients and the surgeon who will perform the operation, which facilitates the identification of both the target, patients, and the actors for the interventions.

Skip to 3 minutes and 33 seconds Second, there is compelling evidence that stopping prophylactic antibiotics after 24 hours does not increase risk of surgical site infections, and that failing to stop antibiotics is likely to increase risk of clostridium difficile infection. This evidence can be used to increase motivation by influencing beliefs about consequences. In contrast, few hospital systems have data about antibiotic prescribing to hospital inpatients, so there is no easy way to identify target patients. For example, those who’ve received antibiotics for at least three days. In addition, the consequences of stopping therapeutic antibiotics will be much more debatable than for stopping prophylactic antibiotics.

Applying AACTT

In this video, we will apply the AACTT framework from Step 1.6 to two studies of interventions that targeted surgical antibiotic prophylaxis. Both studies targeted adult patients undergoing elective coronary artery bypass grafts.

As seen in the study, both interventions improve performance; however, they did not reach the target of 95% reliability in the first six months after the intervention started. This coincides with the additional factors mentioned in Step 1.8, proving that establishing a reliable process and constant reviewing is crucial to improving performance.

In the downloads section you will find a blank copy of the Supplementary Material for Presseau – use the information from slides 2-4 of the video presentation to complete the single Actor version with details from Sun and the multiple Actor version for Dull. The slides are available to download in PDF form.

Once complete, the model answers for both the single and multiple Actor versions can be found in the downloads section. In the comments let us know if your answers were the same or if there were any differences.

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This video is from the free online course:

Utilising Social Science and Behaviour Change in Antimicrobial Stewardship Programmes: Improving Healthcare

BSAC