Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

VA Health Systems Research

Go to the VA ORD website
Go to the QUERI website

IIR 20-101 – HSR Study

IIR 20-101
Assessing the Sustainability of Compliance with Surgical Site Infection Prophylaxis After Discontinuation of Mandatory Active Reporting
Hillary J Mull, PhD MPP
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
Boston, MA
Westyn Branch-Elliman MD MS BA
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
Boston, MA
Funding Period: October 2021 - September 2026


Background: SSIs are common and preventable adverse surgical outcomes that account for substantial morbidity and mortality. Pre-operative antimicrobial administration reduces SSI; post-operative antimicrobials do not reduce SSI but do increase other post-operative adverse events. In 2005, the VA implemented the Surgical Care Improvement Project (SCIP) to increase compliance with peri-operative quality metrics, including appropriate antimicrobial use. SCIP included a set of publicly reported evidenced-based antimicrobial guideline compliance metrics targeting high-risk surgeries. The metrics required resource-intense manual review as part of the VA’s External Peer Review Program (EPRP). In 2015, SCIP achieved sustained compliance with antimicrobial use metrics exceeding 95% and the program was retired due to the high costs of manual review with minimal expected additional benefit. This IIR proposal is guided by the Dynamic Sustainability Framework and examines whether the antimicrobial practice changes achieved by SCIP were sustained and how they spread to surgeries and practice areas beyond the original scope of the program. This multiple PI submission by Dr. Hillary Mull, PhD and Dr. Westyn Branch-Elliman, MD, MMSc builds and expands upon their prior VA-funded collaborative work applying electronic algorithms to measure antimicrobial use and identify adverse outcomes. Significance/Impact: Improving antimicrobial prescribing and surgical quality are major VA goals. In FY 2018, within the VA, there were 190,000 surgeries among SCIP-targeted specialties (cardiac, orthopedic, general/colorectal, gynecology and vascular). Of these, 64% were outpatient, where the PIs found high rates guideline discordant post-operative antimicrobial use, which contribute to substantial patient harms. Thus, the potential impact of the research on direct clinical care is high. In addition, there are limited studies examining what happens to practice change after discontinuation of active programs designed to support compliance with evidence-based guidelines. The proposed study will close this gap in implementation science research. Innovation: In line with the VA’s Learning Health System directive, this project will use the VA’s electronic health record data to develop algorithms to identify pre-and post-operative antimicrobial use based on the PI’s prior work. These electronic data mining algorithms capture structured and text note data and represent a significant technological advancement over costly manual review. This study also answers important questions about the sustainability of practice change after discontinuation of an active policy with input from frontline staff. Specific Aims: 1) Measure sustainability of antimicrobial prophylaxis guideline compliance after SCIP retirement and assess whether practice changes spread to SCIP-excluded procedures; 2) Assess facilitators and barriers to implementation sustainability through staff interviews, and map results to implementation strategies; 3) Develop an implementation playbook with assessment tools, training curricula and other elements to support scale-up and spread of evidence-based antimicrobial practices in a future HSR&D Hybrid III trial. Methodology: Aim I will adapt existing informatics algorithms to extract pre-and post-operative antimicrobial use from clinical note texts and antimicrobial orders for each of the SCIP surgeries. Previously manually reviewed 2005-2015 EPRP data will be used as the gold-standard for adapting and refining the data mining tools. SCIP sustainability will be measured by applying the validated antimicrobial compliance algorithms to 2005-2020 data and performing interrupted time series analyses. SCIP spread within specialties will be assessed with regression models. Aim II will use qualitative interviews with frontline staff to identify reasons for sustainability of evidence- based practice using constructs in the Dynamic Sustainability Framework and will triangulate qualitative and quantitative data to ascertain the long-term impacts of SCIP. Aim III will develop an implementation playbook with input from our Operational Steering Committee comprised of national and local VA surgical stakeholders. Next Steps/Implementation: Test implementation playbook in a Hybrid Type III study to improve practice.

External Links for this Project

NIH Reporter

Grant Number: I01HX003231-01A1

Dimensions for VA

Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects.

Learn more about Dimensions for VA.

VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address.
    Search Dimensions for this project


Journal Articles

  1. Branch-Elliman W, Elwy AR, Lamkin RL, Shin M, Engle RL, Colborn K, Rove J, Pendergast J, Hederstedt K, Hawn M, Mull HJ. Assessing the sustainability of compliance with surgical site infection prophylaxis after discontinuation of mandatory active reporting: study protocol. Implementation science communications. 2022 Apr 25; 3(1):47. [view]
  2. Shenoy ES, Branch-Elliman W. Automating surveillance for healthcare-associated infections: Rationale and current realities (Part I/III). Antimicrobial stewardship & healthcare epidemiology : ASHE. 2023 Feb 10; 3(1):e25. [view]
  3. Branch-Elliman W, Elwy AR, Chambers DA. Embracing dynamic public health policy impacts in infectious diseases responses: leveraging implementation science to improve practice. Frontiers in public health. 2023 Aug 17; 11:1207679. [view]
  4. La J, Fillmore NR, Do NV, Brophy M, Monach PA, Branch-Elliman W. Factors associated with the speed and scope of diffusion of COVID-19 therapeutics in a nationwide healthcare setting: a mixed-methods investigation. Health research policy and systems. 2022 Dec 14; 20(1):134. [view]
  5. Branch-Elliman W, Sundermann AJ, Wiens J, Shenoy ES. Leveraging electronic data to expand infection detection beyond traditional settings and definitions (Part II/III). Antimicrobial stewardship & healthcare epidemiology : ASHE. 2023 Feb 10; 3(1):e27. [view]
  6. Branch-Elliman W, Sundermann AJ, Wiens J, Shenoy ES. The future of automated infection detection: Innovation to transform practice (Part III/III). Antimicrobial stewardship & healthcare epidemiology : ASHE. 2023 Feb 10; 3(1):e26. [view]

DRA: Acute and Combat-Related Injury, Other Conditions, Health Systems
DRE: Prevention, Treatment - Implementation, TRL - Applied/Translational
Keywords: Care Management Tools, Guideline Development and Implementation, Healthcare Algorithms, Knowledge Integration, Sustainability
MeSH Terms: None at this time.

Questions about the HSR website? Email the Web Team

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.