Clinical components and associated behavioural aspects of a complex healthcare intervention: Multi-methods study of selective decontamination of the digestive tract in critical care
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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Cited by (7)
Implementing selective digestive tract decontamination in the intensive care unit: A qualitative analysis of nurse-identified considerations
2014, Heart and Lung: Journal of Acute and Critical CareCitation Excerpt :The, multi-method study was undertaken in Canada, the United Kingdom (UK) and Australia/New Zealand (ANZ) from 2010 to 2012 to develop an understanding of issues related to current lack of adoption of SDD and considerations for its implementation into clinical practice. The full study protocol has been published elsewhere.17,18 Stage 2 of this research program was a Delphi study to identify the range of stakeholders' beliefs, views and perceived barriers relating to the use of SDD.
Infection prevention in the ICU: More than just picking one or another preventive measure
2013, Australian Critical CareAntibiotic susceptibility trend before and after long-term use of selective digestive decontamination: a 16 year ecological study
2019, Journal of Antimicrobial ChemotherapyA guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems
2017, Implementation ScienceSelective decontamination of the digestive tract and oropharynx: After 30 years of debate is the definitive answer in sight?
2016, Current Opinion in Critical Care