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Implementing infection prevention practices across European hospitals: an in-depth qualitative assessment
  1. Lauren Clack1,2,
  2. Walter Zingg2,
  3. Sanjay Saint3,4,
  4. Alejandra Casillas5,
  5. Sylvie Touveneau2,
  6. Fabricio da Liberdade Jantarada2,
  7. Ursina Willi1,
  8. Tjallie van der Kooi6,
  9. Laura J Damschroder3,
  10. Jane H Forman3,
  11. Molly Harrod3,
  12. Sarah Krein3,4,
  13. Didier Pittet2,
  14. Hugo Sax1,2
  15. PROHIBIT Consortium
    1. 1 Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
    2. 2 Infection Control Programme, University of Geneva Hospitals, Geneva, Switzerland
    3. 3 Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
    4. 4 Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
    5. 5 Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, USA
    6. 6 Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
    1. Correspondence to Professor Hugo Sax, Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, Raemistrasse 100/HAL14, 8091, Zurich, Switzerland; hugo.sax{at}


    Objective The Prevention of Hospital Infections by Intervention and Training (PROHIBIT) project included a cluster-randomised, stepped wedge, controlled study to evaluate multiple strategies to prevent catheter-related bloodstream infection. We report an in-depth investigation of the main barriers, facilitators and contextual factors relevant to successfully implementing these strategies in European acute care hospitals.

    Methods Qualitative comparative case study in 6 of the 14 European PROHIBIT hospitals. Data were collected through interviews with key stakeholders and ethnographic observations conducted during 2-day site visits, before and 1 year into the PROHIBIT intervention. Qualitative measures of implementation success included intervention fidelity, adaptation to local context and satisfaction with the intervention programme.

    Results Three meta-themes emerged related to implementation success: ‘implementation agendas’, ‘resources’ and ‘boundary-spanning’. Hospitals established unique implementation agendas that, while not always aligned with the project goals, shaped subsequent actions. Successful implementation required having sufficient human and material resources and dedicated change agents who helped make the intervention an institutional priority. The salary provided for a dedicated study nurse was a key facilitator. Personal commitment of influential individuals and boundary spanners helped overcome resource restrictions and intrainstitutional segregation.

    Conclusion This qualitative study revealed patterns across cases that were associated with successful implementation. Consideration of the intervention–context relation was indispensable to understanding the observed outcomes.

    • infection control
    • implementation science
    • qualitative research
    • hospital medicine

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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    • LC and WZ contributed equally.

    • Contributors LC, WZ, AC, ST, FdLJ and HS were involved in study design, data collection and analysis. SS, LJD, JHF, MH and SK were involved in study design and provided expert guidance in qualitative research methods. UW contributed to qualitative analysis. TvdK served as a liaison between the InDepth study group and the quantitative work package. DP obtained project funding and was involved in study design. LC and HS drafted the initial manuscript, which was revised by all coauthors. LC, WZ, DP and HS are guarantors.

    • Funding The study was funded by FP7 Health (241928) and The Swiss National Science Foundation (grant no. 32003B_149474)

    • Competing interests None declared.

    • Patient consent Not required.

    • Ethics approval The study protocol was approved by the Institutional Review Board at participating hospitals.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Collaborators PROHIBIT Consortium: R Ahmad, B Allegranzi, B Cookson, M Dettenkofer, P Gastmeier, H Grundmann, S Hansen, P B Heczko, A Holmes, Y Kyratsis, A Magiorakos, M Martin, D Pittet, H Richet, H Sax, E Szilágyi, B van Benthem, T van der Kooi, A W Wu, and W Zingg.

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