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OBJECTIVES: To assess an intervention for surgical antibiotic prophylaxis (SAP) improvement within surgical teams focused on addressing barriers and fostering enablers and ownership of guideline compliance. DESIGN: The Queensland Surgical Antibiotic Prophylaxis (QSAP) study was a multicentre, mixed methods study designed to address barriers and enablers to SAP compliance and facilitate engagement in self-directed audit/feedback and assess the efficacy of the intervention in improving compliance with SAP guidelines. The implementation was assessed using a 24-month interrupted time series design coupled with a qualitative evaluation. SETTING: The study was undertaken at three hospitals (one regional, two metropolitan) in Australia. PARTICIPANTS: SAP-prescribing decisions for 1757 patients undergoing general surgical procedures from three health services were included. Six bimonthly time points, pre-implementation and post implementation of the intervention, were measured. Qualitative interviews were performed with 29 clinical team members. SAP improvements varied across site and time periods. INTERVENTION: QSAP embedded ownership of quality improvement in SAP within surgical teams and used known social influences to address barriers to and enablers of optimal SAP prescribing. RESULTS: The site that reported senior surgeon engagement showed steady and consistent improvement in prescribing over 24 months (prestudy and poststudy). Multiple factors, including resource issues, influenced engagement and sites/time points where these were present had no improvement in guideline compliance. CONCLUSIONS: The barriers-enablers-ownership model shows promise in its ability to facilitate prescribing improvements and could be expanded into other areas of antimicrobial stewardship. Senior ownership was a predictor of success (or failure) of the intervention across sites and time periods. The key role of senior leaders in change leadership indicates the critical need to engage other specialties in the stewardship agenda. The influence of contextual factors in limiting engagement clearly identifies issues of resource distributions/inequalities within health systems as limiting antimicrobial optimisation potential.

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INTRODUCTION: Gallbladder torsion is a rare condition of increasing prevalence in recent years. It is often difficult to diagnose pre-operatively and delayed intervention can lead to significant complications. PRESENTATION OF CASE: We present a case of an 81 year old lady who presented with symptoms of cholecystitis for 24 h with no evidence of cholelithiasis on imaging. She deteriorated within 24 h of admission despite intravenous antibiotics; Emergency laparoscopy was performed which showed the gallbladder malrotated 180 ° with features of necrosis. Laparoscopic cholecystectomy was performed without complications. DISCUSSION: The cause of gallbladder torsion are thought to be due to underlying anatomical variations or loss of elasticity associated with aging. Diagnosis is difficult clinically and radiologically, however, features such as "whirl sign" and "cystic duct knot sign" have been described. Due to ischemia associated with torsion, clinical vigilance and early intervention is recommended to prevent potential fatal sequelae particularly in the elderly population. CONCLUSION: Gallbladder torsion is a rare finding that can be difficult to diagnose clinically, we are hoping to promote awareness to prevent complications associated with delayed therapy.

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Rare case of an elderly male presenting to the emergency department with an acute abdomen few days post accidental ingestion of his dentures. A detailed history along with a CT abdomen showed perforation in the sigmoid colon adjacent to the site of the swallowed denture.