Clinic barriers and facilitators to the implementation of a decolonization strategy for Staphylococcus aureus in hip and knee arthroplasty: A qualitative study

Background: Decolonization is an important infection prevention and control strategy in the surgical context. Preoperative decolonization of hip and knee replacement patients reduces the incidence of surgical site infections (SSIs), but the implementation of decolonization protocols has been uneven. Understanding the clinical level barriers and facilitators that affect implementation may increase the effectiveness of preoperative decolonization strategies. Methods: Leveraging ongoing quality improvement (QI) activity to reduce SSIs amongst hip and knee replacement patients in Alberta, Canada, qualitative methods were deployed. Semi-structured interviews (n=2) were conducted with surgeons, and focus groups (n=9) were conducted with seven nurses and two administrative staff to understand barriers and facilitators to the implementation of a provincial decolonization strategy. Interview questions were developed in conjunction with the Theoretical Domains Framework (TDF) and the research team. An inductive analysis derived from a Grounded Theory (GT) approach was conducted with the assistance of NVivo software. Results: Knowledge and understanding of the decolonization strategy were central to implementation. When present, they acted as facilitators, but when absent or inconsistent, they were significant barriers to implementation. Specifically, clinics needed more knowledge and direction on how to deliver the decolonization strategy to patients receiving homecare; who had repeat surgeries; who required surgery during COVID-19 outbreaks. Conclusions: Knowledge and understanding was a core category which summarized seven subcategories found within our GT analysis. A successful decolonization strategy will benefit from adopting further planning and development for specific patients and respiratory outbreaks such as COVID-19. Further aspects that may act as facilitators include having a champion in each clinic, regular reporting, and audit and feedback strategies. Findings from our study can provide information on the barriers and facilitators of a decolonization strategy and can be used in making the decolonization strategy successful.