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Implementation of infection control best practice in intensive care units throughout Europe: a mixed-method evaluation study

Hugo Sax12*, Lauren Clack12, Sylvie Touveneau1, Fabricio da Liberdade Jantarada1, Didier Pittet1, Walter Zingg1 and PROHIBIT study group

Author Affiliations

1 Infection Control Programme, University of Geneva Hospitals and Medical Faculty, World Health Organization Collaborating Centre on Patient Safety, Geneva, Switzerland

2 Division of Infectious Diseases and Hospital Epidemiology, University and University Hospital of Zurich, Zürich, Switzerland

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Implementation Science 2013, 8:24  doi:10.1186/1748-5908-8-24

Published: 19 February 2013



The implementation of evidence-based infection control practices is essential, yet challenging for healthcare institutions worldwide. Although acknowledged that implementation success varies with contextual factors, little is known regarding the most critical specific conditions within the complex cultural milieu of varying economic, political, and healthcare systems. Given the increasing reliance on unified global schemes to improve patient safety and healthcare effectiveness, research on this topic is needed and timely. The ‘InDepth’ work package of the European FP7 Prevention of Hospital Infections by Intervention and Training (PROHIBIT) consortium aims to assess barriers and facilitators to the successful implementation of catheter-related bloodstream infection (CRBSI) prevention in intensive care units (ICU) across several European countries.


We use a qualitative case study approach in the ICUs of six purposefully selected acute care hospitals among the 15 participants in the PROHIBIT CRBSI intervention study. For sensitizing schemes we apply the theory of diffusion of innovation, published implementation frameworks, sensemaking, and new institutionalism. We conduct interviews with hospital health providers/agents at different organizational levels and ethnographic observations, and conduct rich artifact collection, and photography during two rounds of on-site visits, once before and once one year into the intervention. Data analysis is based on grounded theory. Given the challenge of different languages and cultures, we enlist the help of local interpreters, allot two days for site visits, and perform triangulation across multiple data sources.

Qualitative measures of implementation success will consider the longitudinal interaction between the initiative and the institutional context. Quantitative outcomes on catheter-related bloodstream infections and performance indicators from another work package of the consortium will produce a final mixed-methods report.


A mixed-methods study of this scale with longitudinal follow-up is unique in the field of infection control. It highlights the ‘Why’ and ‘How’ of best practice implementation, revealing key factors that determine success of a uniform intervention in the context of several varying cultural, economic, political, and medical systems across Europe. These new insights will guide future implementation of more tailored and hence more successful infection control programs.

Trial registration

Trial number: PROHIBIT-241928 (FP7 reference number)

Implementation; Infection control; Catheter-related bloodstream infections; Hand hygiene; Intensive care units; Best practice; Organizational culture; Organizational case studies; Organizational innovation; Organizational decision making; Patient safety