Since their inception, hospital infection prevention (IP) and Antimicrobial Stewardship Programs (ASP) have worked to deploy interventions to mitigate risk of infection and antimicrobial resistance arising from our usual systems of care.1 They generated advances in quality improvement and patient safety, even before these were recognised fields. In an early evidence report commissioned by the US Agency for Healthcare Research and Quality in 2002, 4 of 11 safety practices with strongest supporting evidence were directly related to IP.2 An updated report in 2013 included six IP/ASP interventions in the top 10 safety strategies ready for widespread adoption.3

Despite the high-quality evidence supporting these IP/ASP interventions, our approach to adding these to our current practice sometimes feels like adding scaffolding to a rickety building. It supports the underlying structure but remove the scaffolding without fixing the building, and it may just come tumbling down. Consider efforts to improve hand hygiene, which have traditionally involved leadership/accountability, measurement/feedback and communication/marketing, while ensuring that hand sanitizer is available represents one of the only system changes in the WHO hand hygiene bundle.4 Nobody can deny that these interventions can lead to improved hand hygiene and some have even elegantly demonstrated significant reductions in healthcare-associated infections.5 But the question remains whether the scaffolding approach fosters sustainability of hand hygiene compliance without considering system changes that address recognised behavioural factors.6 Similarly we know that audit-and-feedback of targeted antimicrobial therapy leads to reductions in days of antimicrobial therapy, with some studies even demonstrating associated decreases in Clostridium difficile infection, an intended benefit of reducing antibiotic use.7 8 Yet when audit-and-feedback is discontinued, antimicrobial use rises again, suggesting that behaviour change does not easily result from this type of intervention, which requires continuous deployment to sustain these outcomes.9

Hand hygiene and ASPs are obviously worth continuing to invest in even though they require continuous effort to sustain. But our approach, which has largely involved extraneous interventions, does not lead to durable practice change because the underlying system drivers remain. Consider a common example encountered by ASPs: a patient being treated for asymptomatic bacteriuria. Based on good randomised trial evidence showing no benefit from antimicrobial treatment outside of pregnancy or invasive urological procedures,10 antimicrobial stewardship teams frequently recommend discontinuation of antibiotics in this situation and provide in-the-moment education, only for the same scenario to repeat itself over and over on the same clinical service, and on countless other services around the world. The reason that feedback to clinicians fails to change this recalcitrant prescribing practice is that it is simply a workaround to the problem of treatment of asymptomatic bacteriuria, which is rooted much deeper than a simple knowledge deficit that education will be able to remedy. In fact, our usual systems of care is hard-wired to generate these antibiotic prescriptions as a ‘downstream’ consequence of the excess urine cultures ordered.11 Multiple studies suggest that positive results from these overordered urine specimens significantly bias our clinical judgement in favour of a diagnosis of urinary tract infection (UTI), even when patients technically lack any specific acute urinary symptoms.11 12 These results frequently influence clinicians to interpret subtle changes in patients as symptoms of infection even when these tests were submitted with a low pretest probability of UTI. As a result, some ASPs have even shifted to an ‘upstream’ focus on urine culture ordering practices through implementation of diagnostic algorithms. But scaffolding further interventions to the urine culture ordering problem is again fraught with challenges of changing our engrained ‘culture of culturing’ urine throughout healthcare delivery.13–15

The limitations of extraneous IP/ASP interventions are not surprising when we consider that our existing systems of care are largely the product of conventional and historical practice, and were never purposefully designed to promote patient safety. When it comes to urine cultures for example, the default has always been to leave ordering to the discretion of front-line clinicians who send urine specimens for culture whenever UTI may even loosely enter their minds. It is a simple non-invasive test that takes little effort to collect, and microbiology laboratories play a largely passive role in processing all these specimens. The output from this system is that patients frequently have multiple urine cultures throughout a single hospital stay as part of routine investigations for a variety of different non-specific reasons. And the positive results that ensue greatly influence the well-intentioned clinicians who care for these patients.11 16 This problem, like many others faced by IP/ASP, is simply too large and pervasive to tackle by relying on reminders and educational interventions alone.

To advance the fields of IP and ASP, we need to move from scaffolding our existing systems of care with more interventions that rank low on the hierarchy of effectiveness, to rethinking the building architecture itself and how it can be redesigned to promote better resource utilisation and patient outcomes. This rebuilding approach is much harder to undertake than adding supporting structures to our usual practice, but the final result is dramatically different. Some successful examples are available in the literature, with two recent published studies highlighted here.

At a community-based academic hospital in Toronto, the ASP worked with key stakeholders to completely revamp the process of urine culture ordering in the emergency department (ED) to prevent antibiotic prescriptions for asymptomatic UTIs.17 Rather than focusing on the conventional assumption that urine culture practices reflect a lack of knowledge regarding appropriate indications for ordering, the improvement team recognised that these specimens are frequently collected pre-emptively in the ED to facilitate patient management. Specifically, nurses would anticipate the possible need for a urine culture and collect it from the patient to prevent having to go back to collect a specimen later after the order was received by the physician. The change idea was quite simple: allow nurses to collect these urine specimens to facilitate patient flow in the ED but no longer process them in the microbiology laboratory unless a separate ‘Process’ order is entered by the physician following their clinical assessment. This new model of care resulted in an immediate decrease in detection and treatment of positive urine cultures, with only a 1.5% false omission rate.17 As an additional safety measure, the unprocessed urine specimens were kept up to 48 hours in a preservative-based collection tube to give the physician ample opportunity to ‘Process’ these specimens if a UTI was suspected later.

Other examples of effective system changes are also emerging in IP programs. Cincinnati Children’s Hospital Medical Center, like many institutions, implemented a standard perioperative bundle in 2009 in an attempt to reduce their incidence of neurosurgical infections. They saw no impact on these infection rates and realised that the adherence to this bundle, which included evidence-based interventions like preoperative chlorhexidine bathing, remained very inconsistent. They convened a multidisciplinary team to find ways to better standardise these evidence-based practices and identified simple changes like assigning specific tasks to different stakeholders and integrating them into routine perioperative workflow. Adherence to the bundle increased markedly from 56.3% to over 80%, which was sustained over 2 years and associated with a clear shift in the incidence of surgical site infections.18 This example once again highlights that improved uptake of best practices occurs through system change rather than simply adding reminders to complete these tasks.

The gap between best practices in IP/ASP and what happens in reality represents the opportunity for quality improvement. When our approach to addressing this gap relies only on effortful practice to ensure these best recommendations are followed, frustration ensues when the same persistent behaviours lead to preventable patient harms. Ever-increasing reminders, checklists and even performance report cards enjoining clinicians to do the right thing will probably never achieve sustained improvements for patients and will do nothing to the feelings of burnout and change fatigue affecting many clinicians.19 In these situations, it can be tempting to blame the culture of our organisation instead of our approach. Recently, Jay Lorsh and Emily McTague from Harvard Business School offered a refreshing perspective.20 They argued that culture is not the culprit. Culture is not even something that you ‘fix’, but rather something that evolves when you have put in place new processes or structures.

Our focus must be on these structural changes, fostered by more collaboration between content experts in IP/ASP and those with training in improvement science. New systems that promote a ‘work smarter, not harder’ approach, as highlighted by the two above examples, are more likely to lead to sustainable IP/ASP improvements, and to achieve the quadruple aim: enhanced patient experience, improved outcomes, decreased cost of care, and increased fulfilment of healthcare providers.19 21