Original Article Implementation strategies to reduce surgical site infections: A systematic review Promise Ariyo MD MPH 1 , Bassem Zayed MD 2 , Victoria Riese MLIS, AIHP 3 , Blair Anton MLIS, MS 3 , Asad Latif MD MPH 1 , Claire Kilpatrick MSc 4 , Benedetta Allegranzi MD 4 and Sean Berenholtz MD, MHS 1 1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States, 2 Antimicrobial Resistance and Infection Control Team, WHO Regional Office for Eastern Mediterranean, Cairo, Egypt, 3 Welch Medical Library, Johns Hopkins University, School of Medicine, Baltimore, Maryland, United States and 4 Infection Prevention and Control Global Unit, Department of Service Delivery and Safety, World Health Organization, Geneva, Switzerland Abstract Background: Surgical site infections (SSIs) portend high patient morbidity and mortality. Although evidence-based clinical interventions can reduce SSIs, they are not reliably delivered in practice, and data are limited on the best approach to improve adherence. Objective: To summarize implementation strategies aimed at improving adherence to evidence-based interventions that reduce SSIs. Design: Systematic review Methods: We searched PubMed, Embase, CINAHL, the Cochrane Library, the WHO Regional databases, AFROLIB, and Africa-Wide for studies published between January 1990 and December 2015. The Effective Practice and Organization Care (EPOC) criteria were used to identify an acceptable-quality study design. We used structured forms to extract data on implementation strategies and grouped them into an implementation model called the “Four Es” framework (ie, engage, educate, execute, and evaluate). Results: In total, 125 studies met our inclusion criteria, but only 8 studies met the EPOC criteria, which limited our ability to identify best practices. Most studies used multifaceted strategies to improve adherence with evidence-based interventions. Engagement strategies included multidisciplinary work and strong leadership involvement. Education strategies included various approaches to introduce evidence-based practices to clinicians and patients. Execution strategies standardized the interventions into simple tasks to facilitate uptake. Evaluation strat- egies assessed adherence with evidence-based interventions and patient outcomes, providing feedback of performance to providers. Conclusions: Multifaceted implementation strategies represent the most common approach to facilitating the adoption of evidence-based practices. We believe that this summary of implementation strategies complements existing clinical guidelines and may accelerate efforts to reduce SSIs. (Received 12 September 2018; accepted 6 December 2018) Surgical site infection (SSI) is a global problem associated with increased mortality, hospital length of stay, hospital readmissions, and costs. 1–5 In the United States, SSIs added >1 million patient days and $1.6 billion in costs in 2005. 6 In Europe, between 2013 and 2014, SSIs varied by surgical procedure from 0.6% to 9.5% per 100 proce- dures. 7 In low- and middle-income countries (LMICs), SSIs are the most frequent healthcare-associated infection (HAI). 4 Compelling evidence shows that several effective interventions prevent SSIs, and both the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC) recently issued guidelines outlining the most appropriate prevention measures. 8–12 However, evidence-based recommendations are often not delivered at the bedside. 13–15 One possible explanation is limited guidance on translating evidence-based recommendations into routine practice. Several approaches have been described to improve adherence with evidence-based interventions. 16,17 One practical implementa- tion model used to translate evidence into practice is known as the “Four Es”: engage, educate, execute, and evaluate. 18 Use of this model has been associated with significant and sustained reductions in HAIs, including state and national collaborative pro- grams. 19–23 This model also has been used in initiatives to prevent thromboembolic events and to increase early mobility practices among hospitalized patients. 24,25 This model focuses on adminis- trative and clinical stakeholders and has technical and adaptive (cultural) work to foster the translation of evidence into bedside practice. Finally, the Four Es model was recently incorporated into expert guidance documents to support efforts to translate rec- ommendations for HAI prevention into practice and accelerate improvement efforts. 26 We conducted a systematic review of the literature to iden- tify studies describing implementation strategies to improve adherence with evidence-based SSI-prevention interventions. Our objective was to summarize implementation strategies using Author for correspondence: Promise Ariyo, Email: pariyo1@jhmi.edu Cite this article: Ariyo P, et al. (2019). Implementation strategies to reduce surgical site infections: A systematic review. Infection Control & Hospital Epidemiology, https://doi.org/ 10.1017/ice.2018.355 © 2019 by The Society for Healthcare Epidemiology of America. All rights reserved. Infection Control & Hospital Epidemiology (2019), 1–14 doi:10.1017/ice.2018.355