Elsevier

Australian Critical Care

Volume 26, Issue 4, November 2013, Pages 173-179
Australian Critical Care

Clinical components and associated behavioural aspects of a complex healthcare intervention: Multi-methods study of selective decontamination of the digestive tract in critical care

https://doi.org/10.1016/j.aucc.2013.04.002Get rights and content

Abstract

Background

This study sought to identify and describe the clinical and behavioural components (e.g. the what, how, when, where and by whom) of ‘selective decontamination of the digestive tract’ (SDD) as routinely implemented in the care of critically ill patients.

Methods

Multi-methods study, consisting of semi-structured observations of SDD delivery, interviews with clinicians and documentary analysis, conducted in two ICUs in the UK that routinely deliver SDD. Data were analysed within-site to describe clinical and behavioural SDD components and synthesised across-sites to describe SDD in context.

Results

SDD delivery involved multiple behaviours extending beyond administration of its clinical components. Not all behaviours were specified in relevant clinical documentation. Overall, SDD implementation and delivery included: adoption (i.e. whether to implement SDD), operationalisation (i.e. implementing SDD into practice), provision (i.e. delivery of SDD) and surveillance (i.e. monitoring the ecological effects). Implementation involved organisational, team and individual-level behaviours. Delivery was perceived as easy by individual staff, but displayed features of complexity (including multiple interrelated behaviours, staff and contexts).

Conclusions

This study is the first to formally outline the full spectrum of clinical and behavioural aspects of SDD. It identified points in the delivery process where complex behaviours occur and outlined how SDD can be interpreted and applied variably in practice. This comprehensive specification allows greater understanding of how this intervention could be implemented in units not currently using it, or replicated in research studies. It also identified strategies required to adopt SDD and to standardise its implementation.

Introduction

Healthcare interventions are typically complex1 and involve two broad interacting categories of components: (1) clinical components, i.e. the clinical materials or equipment of the intervention and related features and (2) associated behavioural aspects i.e. the actual behaviours required to deliver the intervention in practice. Healthcare interventions are often specified clinically without explicitly addressing associated behavioural aspects required for successful delivery.2, 3 Thus, interventions may be implemented differently across sites, potentially leading to variable effectiveness and resultant consequences for patient outcomes. The need to fully describe healthcare interventions has been widely recognised, together with the need to report interventions in such a way as they could be directly replicated by others.4

Selective decontamination of the digestive tract (SDD) is an intervention that has been shown to reduce hospital acquired infection rates and mortality in critically ill patients.5, 6, 7 SDD involves the application of antibiotics and antifungals to the mouth, throat and stomach combined with a short course of intravenous antibiotics.8 Despite considerable evidence supporting the benefit of SDD,5, 6, 7 adoption internationally is low.9, 10 Amongst proposed reasons for this lack of adoption are controversies surrounding prophylactic use of antibiotics and associated risk of antibiotic resistance11, 12 and purported difficulty of SDD implementation and delivery.13

Considerable variation exists in the clinical components of SDD evaluated in trials and used in clinical practice. A recent systematic Cochrane review noted that trials used different SDD protocols and investigators use different definitions for SDD.6 In addition, behaviours related to the delivery of SDD have not been systematically described in the literature. As such, a standardised and fully specified protocol outlining both clinical components and associated behavioural aspects of SDD implementation and delivery in practice does not exist but could be very beneficial in both widespread clinical adoption and future effectiveness or implementation trials.

This study sought to describe the clinical components and associated behaviours related to SDD implementation and delivery in clinical practice.

Section snippets

Study design

An in-depth multi-methods study design14 was used in two UK intensive care units (ICUs) where SDD was routinely administered – with the ‘site’ (unit of analysis) consisting of an ICU. Data were collected from three sources: direct observation of SDD delivery at the bedside; face-to-face semi-structured interviews with clinicians responsible for implementing and/or delivering SDD; and systematic assessment of written documentation (e.g. SDD protocols, training documents) (Fig. 1).

Sampling and recruitment

All UK ICUs

Results

Site 1 implemented SDD 3.5 years prior to this study in response to increased hospital acquired infection rates and was the most recent adopter of SDD in the UK. Collected data comprised 4 observations; 8 interviews (intensivists [n = 3], nurses [n = 3], microbiologists [n = 1], pharmacists [n = 1]) and 3 SDD documents (protocol, prescription chart, training slides). Site 2 implemented SDD as part of an effectiveness trial 26 years prior to this study. Collected data comprised 3 observations; 8

Discussion

In line with frameworks for intervention development1 and description,4 this study is the first to formally seek to describe the full clinical components and associated behavioural aspects of SDD and to describe how they impact on SDD implementation and delivery in practice. There are several advantages of describing an intervention behaviourally alongside clinical descriptions. First, it demonstrates procedural complexity and the situations in which complexity may be experienced. This

Conclusion

This study is the first to develop a formal description of the full clinical and behavioural components of SDD and to describe how they impact on SDD implementation and delivery in practice. We identified a wide range of behaviours involved in delivering SDD, several of which were not included in local SDD protocols. Significant protocol adaptations resulting from these behaviours were observed across sites – supporting the need for routine behavioural specification in SDD delivery protocols.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

JJF and BHC designed the study. ARB and ACG assisted with recruitment of participants. SUD collected data. SUD and ED analysed the data. All authors provided critical comments on drafts of the analyses and contributed critically for important intellectual content to the manuscript. All authors read and approved the final manuscript and all those entitled to authorship are listed as authors.

Acknowledgments

We would like to thank all the clinical staff who provided their time and expertise by participating in this study. This project was funded by the UK National Institute for Health Research (NIHR), Health Technology Assessment (HTA) programme. Visit the HTA programme website for more details www.hta.ac.uk/2299. ACG is a NIHR Clinician Scientists award holder, and is grateful for funding from the NIHR comprehensive Biomedical Research Centre funding stream. The Aberdeen Health Services Research

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