Healthcare-associated infections

4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections: A challenge for change

Infection Control and Hospital Epidemiology

Global control of health-care associated infections

Countries from across the world gathered in Astana, Kazakhstan, in October 2018, to reaffirm and expand their commitment to prioritise, promote, and protect the health and wellbeing of their populations. This was the opportunity for a new generation of health policy makers and leaders to honour the ideals of the 1978 Alma-Ata Declaration1WHOGlobal Conference on Primary Health Care, 25–26 October 2018.https://www.who.int/primary-health/conference-phcDate: 2018Date accessed: March 20, 2019Google Scholar and to reinterpret these in the current era. Over the past 40 years, many countries have designed health systems that improve access to quality essential services, social stability, and health security, as well as having economic benefits.2WHOTogether on the road to universal health coverage. A call to action.https://apps.who.int/iris/bitstream/handle/10665/258962/WHO-HIS-HGF-17.1-eng.pdf;jsessionid=F247E4CB8C9AEA227138F1844D636EF1?sequence=1Date: 2017Date accessed: March 18, 2019Google Scholar The health-related aspects of the UN Sustainable Development Goals have a strong focus on universal health coverage (UHC), with quality of health services increasingly emphasised as essential for success.3WHODelivering quality health services: a global imperative for universal health coverage.https://www.who.int/servicedeliverysafety/quality-report/en/Date: 2018Date accessed: March 18, 2019Google Scholar When Florence Nightingale, considered the mother of infection prevention and control (IPC), echoed the Hippocratic ideal to "first, do no harm" in the 1860s, she recognised that the first steps to providing organised beneficial health care were inherently risky in nature. Although Florence Nightingale was a late adopter of the germ theory of disease, she was among the first to recognise that a caregiver could be at the origin of patient harm, particularly infection. She was an early pioneer of the practical application of quality improvement at the bedside. Health-care-associated infection remains an ever-present companion, irrespective of where and when it is delivered. Health-care-associated infections are a consequence of poor-quality care and a deadly cause of harm affecting hundreds of millions of patients worldwide every year.4WHOReport on the burden of endemic health-care associated infection worldwide: a systematic review of the literature.https://apps.who.int/iris/bitstream/handle/10665/80135/9789241501507_eng.pdf;jsessionid=B24D98407633F9FEE01C9329D89EDA7B?sequence=1Date: 2011Date accessed: March 18, 2019Google Scholar They generate twice the total burden of disability-adjusted life-years than all other 32 communicable diseases reported in Europe.5Cassini A Plachouras D Eckmanns T et al.Burden of six healthcare-associated infections on European population health. Estimating incidence-based disability-adjusted life years through a population prevalence-based modelling study.PLoS Med. 2016; 13: e1002150Crossref PubMed Scopus (295) Google Scholar Antibiotic-resistant microorganisms are responsible for most infections and 75% of disability-adjusted life-years attributable to antimicrobial resistance (AMR) in Europe are due to health-care-associated infections.6European Centre for Disease Control and Prevention and OECDAntimicrobial resistance. Tackling the burden in the European Union. Briefing note for EU/EAA countries.https://www.oecd.org/health/health-systems/AMR-Tackling-the-Burden-in-the-EU-OECD-ECDC-Briefing-Note-2019.pdfDate: 2019Date accessed: March 18, 2019Google Scholar This places a clear duty on policymakers, health leaders, facility managers, and practitioners who design, build, and operate health systems to ensure that they prevent the spread of infections. Without this essential foundation for quality health services, UHC risks being an empty promise.7Ghebreyesus T How could health care be anything other than high quality?.Lancet Glob Health. 2018; 6: e1140-e1141Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar IPC is an evidence-based approach to halt the spread of infection and AMR.8Storr J Twyman A Zingg W et al.Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations.Antimicrob Resist Infect Control. 2017; 6: 6Crossref PubMed Scopus (194) Google Scholar It embodies all three core domains of quality care (ie, care that is safe, effective, and people-centred), and strongly supports the attainment of other key global health priorities that will eventually contribute to high-quality UHC (figure). Strong IPC capacity and programmes ensure adequate preparedness and response to protect people from outbreaks. Their reinforcement is an essential pillar for recovery and health system strengthening after the shock of an epidemic. IPC is also complementary to and enhances water, sanitation, and hygiene (WASH) interventions. WASH monitors infrastructure indicators, whereas IPC provides evidence of an effect on health workers' behaviour and patient outcomes through improved infrastructures. Synergies and interconnections are particularly effective when IPC supports strategies aimed at reducing AMR. Notably, the increasing availability of IPC equipment and infrastructure (eg, alcohol-based handrubs) at the point of care and isolation beds are associated with a proportionate reduction of the most common AMR patterns that are associated with health care.8Storr J Twyman A Zingg W et al.Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations.Antimicrob Resist Infect Control. 2017; 6: 6Crossref PubMed Scopus (194) Google Scholar Combining IPC interventions with antimicrobial stewardship programmes is the most effective approach.8Storr J Twyman A Zingg W et al.Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations.Antimicrob Resist Infect Control. 2017; 6: 6Crossref PubMed Scopus (194) Google Scholar, 9Baur D Gladstone BP Burkert F et al.Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis.Lancet Infect Dis. 2017; 17: 990-1001Summary Full Text Full Text PDF PubMed Scopus (389) Google Scholar Among these, hand hygiene is the most crucial, whether implemented as a stand-alone intervention or integrated into multifaceted interventions.9Baur D Gladstone BP Burkert F et al.Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis.Lancet Infect Dis. 2017; 17: 990-1001Summary Full Text Full Text PDF PubMed Scopus (389) Google Scholar, 10Luangasanatip N Hongsuwan M Limmathurotsakul D et al.Comparative efficacy of interventions to promote hand hygiene in hospitals: systematic review and network meta-analysis.BMJ Glob Health. 2015; 351: h3278Google Scholar IPC interventions often provide a starting point for developing a culture of quality improvement in health facilities. Despite this compelling evidence, only 58% of countries report having a national IPC programme or plan and related guidelines. Even more alarmingly, only 15% have a system to assess their compliance and effectiveness.11WHOFood and Agriculture Organization of the United Nations (FAO)World Organisation for Animal Health (OIE)https://apps.who.int/iris/bitstream/handle/10665/273128/9789241514422-eng.pdf?ua=1Date accessed: March 19, 2019Google Scholar These gaps are more striking in low-income countries where surveillance indicators for infections associated with health care are present in only 5% of countries and the monitoring of IPC in only 30% (WHO, unpublished data). In a global call to action in 2017, leaders of the Global IPC Network identified global and country-specific IPC priorities to be achieved by 2022.12Allegranzi B Kilpatrick C Storr J Kelley E Park BJ Donaldson L Global Infection Prevention and Control Network. Global infection prevention and control priorities 2018–22: a call for action.Lancet Glob Health. 2017; 5: e1178-e1180Summary Full Text Full Text PDF PubMed Scopus (58) Google Scholar These priorities require serious reflection and forceful actions. World Health Assembly resolutions can provide a strong basis for policy and regulation development and enforcement. Powerful resolutions on AMR and sepsis prevention already exist and new ones on patient safety and WASH are in the pipeline for full endorsement by the World Health Assembly in 2019. IPC is a key element. None of these resolutions can be implemented without strengthening the size and competencies of health work forces, which are also essential to achieve UHC, because inadequate staffing substantially increases the risk of infection and spread of AMR.7Ghebreyesus T How could health care be anything other than high quality?.Lancet Glob Health. 2018; 6: e1140-e1141Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar As an immediate tangible action, WHO calls upon everyone this year to be inspired by the global movement to achieve quality UHC and has crafted its global hand hygiene campaign message to achieve this wider goal: "clean care for all—it's in your hands!" The call to action has also been expanded and adapted to facilitate ownership and adoption by specific audiences, including highlighting clean care as a human right for all patients. Additionally, WHO strongly encourages ministries of health and health-care facilities to bridge the gap in the scarcity of IPC data by participating in a global survey on the level of progress of IPC and hand hygiene programmes. Clean and safe care should be universally available to every person worldwide. It can be achieved through improved IPC practices and monitoring everywhere, driving the foundation for quality care in the UHC era. This work is supported by WHO, Geneva, Switzerland, and the Infection Control Programme and WHO Collaborating Centre on Patient Safety (SPCI/WCC), University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland. Hand hygiene research activities at the SPCI/WCC are supported by the Swiss National Science Foundation (grant 32003B_163262). DP works with WHO on the Private Organizations for Patient Safety—Hand Hygiene initiative. The aim of this WHO initiative is to harness industry strengths to align and improve implementation of WHO recommendations for hand hygiene in health care in different parts of the world, including in the least developed countries. In this instance, companies/industry with a focus on hand hygiene and infection control-related advancement have the specific aim of improving access to affordable hand hygiene products, as well as through education and research. All other authors declare no competing interests. The opinions expressed in this Article are those of the authors and do not reflect the official position of WHO. WHO takes no responsibility for the information provided or the views expressed in this Article. We thank Rosemary Sudan for the professional editing assistance and Maraltro for the figure design. We also thank Safiah Mai for providing background documentation about universal health coverage.

Responsibility for managing healthcare-associated infections: where does the buck stop?

Looking back to move forward

Supplement: STRIVE1 October 2019The Centers for Disease Control and Prevention STRIVE Initiative: Construction of a National Program to Reduce Health Care–Associated Infections at the Local LevelFREEKyle J. Popovich, MD, MS, David P. Calfee, MD, Payal K. Patel, MD, MPH, Shelby Lassiter, BSN, RN, CPHQ, Andrew J. Rolle, MPH, Louella Hung, MPH, Sanjay Saint, MD, MPH, and Vineet Chopra, MD, MScKyle J. Popovich, MD, MSRush University Medical Center, Chicago, Illinois (K.J.P.), David P. Calfee, MDWeill Cornell Medicine, New York, New York (D.P.C.), Payal K. Patel, MD, MPHUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., S.S., V.C.), Shelby Lassiter, BSN, RN, CPHQHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.L., A.J.R., L.H.), Andrew J. Rolle, MPHHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.L., A.J.R., L.H.), Louella Hung, MPHHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.L., A.J.R., L.H.), Sanjay Saint, MD, MPHUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., S.S., V.C.), and Vineet Chopra, MD, MScUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., S.S., V.C.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-3529 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Health care–associated infection (HAI) remains an important problem in the United States (1, 2). Central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) are among the most common device-associated infections, whereas Clostridioides difficile and methicillin-resistant Staphylococcus aureus (MRSA) are among the most prevalent pathogens causing HAI. In 2011, there were an estimated 721 800 HAIs in U.S. acute care hospitals, with C difficile, S aureus, Enterococcus species, and gram-negative bacilli being the most common pathogens (3). To address the burden of these infections, evidence-based infection prevention strategies, including "bundles" or combinations of interventions, have been developed and successfully implemented in many hospitals to prevent HAIs (4–8). For example, bundles have been created to decrease CLABSI (4), CAUTI (5, 9), and MRSA bloodstream infection (6, 7). In U.S. intensive care units, there has been a substantial reduction in CLABSIs, thought to be in large part due to implementation of bundles (4, 10).Many U.S. hospitals, unfortunately, continue to experience high rates of HAI (11) because of low compliance with infection prevention practices, poor organizational culture, financial limitations, limited engagement from front-line personnel, and limited leadership support (12). Of note, assistance from external sources, such as local, state, and national groups (including public health departments, quality improvement organizations, hospital associations, and academic medical centers), can help reduce HAI (13, 14). However, the ways and extent to which these entities engage with hospitals to improve HAI rates vary, resulting in heterogeneity of outcomes (12). Comprehensive solutions to this complex dynamic within and across hospitals, states, and the country have not been developed. In particular, strategies to help hospitals that continue to have high rates of HAI are needed.To reduce infections in hospitals with high rates of HAI, the Centers for Disease Control and Prevention (CDC) funded a prospective, interventional, nonrandomized, quality improvement program that spanned multiple hospitals and states. Development, implementation, and execution of the program was performed by the Health Research & Educational Trust (HRET), a not-for-profit research and education affiliate of the American Hospital Association, along with several partners, such as state hospital associations (SHAs), professional societies, and scientific experts from academic medical centers. Collectively, the program was titled CDC STRIVE (States Targeting Reduction in Infections via Engagement). This article provides a summary of how STRIVE constructed the building blocks for a national effort intended to reduce HAIs in participating hospitals.Program Goals and StructureThe STRIVE initiative focused on bringing national health care professional societies, subject-matter experts, and state-level health care organizations together with short-stay and long-term acute care hospitals to improve infection prevention and control practices. The overall objective of the program was to identify, partner with, and collaborate with hospitals struggling to reduce HAI by pairing national subject-matter experts with state, regional, and local organizations to effect sustainable change (Figure 1).Figure 1. Overall flow of the CDC STRIVE program.CDC = Centers for Disease Control and Prevention; STRIVE = States Targeting Reduction in Infections via Engagement. Download figure Download PowerPoint To deliver on this ambitious goal, the STRIVE initiative had 3 specific aims: 1) strengthen infection control practices through dissemination and implementation of CDC's Targeted Assessment for Prevention (TAP) strategy; 2) strengthen relationships among SHAs, state health departments, and other state HAI partners, such as the Centers for Medicare & Medicaid Services Quality Innovation Network–Quality Improvement Organizations, to create a structure to facilitate durable implementation of best infection control practices; and 3) provide technical assistance to facilities to improve implementation of infection control practices in existing and newly constructed health care facilities. Reductions in C difficile infection (CDI), CLABSI, CAUTI, and hospital-onset MRSA bloodstream infection in participating hospitals were chosen as measures to determine initiative success.Program planning for STRIVE began in September 2015. Subject-matter experts from multiple organizations were identified by CDC and HRET and brought together to form a national program team to provide oversight for the program and build educational content. Members of the national program team included representatives from CDC, HRET, Association for Professionals in Infection Control and Epidemiology, American Society for Health Care Engineering, Society of Hospital Medicine, and University of Michigan Health System.Stakeholder Considerations in Designing STRIVE InterventionsThe CDC outlined several objectives to increase alignment and coordination of HAI prevention efforts across stakeholders: First, identify strategies to improve infection control implementation activities on a state- and facility-level; second, identify indicators of capacity (infrastructure, staffing, partnerships, and training), ongoing regional collaboratives, and other contextual factors (such as state-level mandates) that may affect implementation of infection prevention efforts; and third, identify roles of state partners (state health departments, SHAs, Quality Innovation Network–Quality Improvement Organizations) in the coordination, integration, and alignment of infection prevention and control activities.Eligibility and Selection of Participating HospitalsThe CDC STRIVE initiative focused specifically on hospitals with a disproportionately high burden of HAI. To target these facilities, the CDC used National Healthcare Safety Network (NHSN) data from the first 2 quarters of 2015 to identify states with hospitals that had a high burden of CDI and a high burden of at least 1 of the following HAIs: CLABSI, CAUTI, or hospital-onset MRSA bloodstream infection. "High burden" was defined by examining the cumulative attributable difference (15) (using the U.S. Department of Health and Human Services' 2020 HAI goals as the standardized infection ratio target). Hospitals with a cumulative attributable difference above the first tertile (that is, the top one third) were designated as having a high burden of HAIs. Data for all 4 infection types were combined to identify hospitals with CDIs plus at least 1 other HAI with cumulative attributable differences above the first tertile.Three methods were used to identify eligible states. First, CDC identified states with the largest number of hospitals that met inclusion criteria. These states thus became the main focus of STRIVE efforts. Second, to include sites that may also benefit from STRIVE, HRET applied the CDC approach with publicly available Hospital Compare state-specific data to identify additional hospitals with a high burden of HAIs not included in the cumulative attributable difference first tertile. Finally, a few interested states not included in the above were allowed to volunteer to participate in STRIVE. Using these methods, 34 states and the District of Columbia were identified for possible inclusion in STRIVE.Rather than approach hospitals directly (and in keeping with the STRIVE goal to strengthen state and local partnerships to combat HAI), HRET shared the list of potentially eligible hospitals with SHAs and asked them to recruit sites. In this way, the CDC and HRET engaged SHAs to reach out to hospitals to inform them about the program, solicit their interest, and recruit them to participate. As word of the intervention and program spread, a few states that were not identified by the CDC also requested to participate in the STRIVE program, because they viewed this program as important to help improve hospital infection control practices.To better consolidate efforts and understand the impact of interventions, recruitment within STRIVE occurred within waves, leading to 4 cohorts of hospitals (Table): cohort 1 (June 2016 to April 2017), cohort 2 (November 2016 to October 2017), cohort 3 (April 2017 to March 2018), and cohort 4 (June 2017 to May 2018). Cohort 1 was identified as a pilot cohort in which interventions to reduce HAI were developed and pilot-tested in conjunction with key stakeholders. In total, 443 short-stay and long-term acute care hospitals from 28 states and the District of Columbia participated in 4 overlapping, 10- to 12-month cohorts (Appendix Figure). In 2015 (before the intervention), the median cumulative attributable difference values for cohorts 2, 3, and 4 were as follows: CAUTI, 0.67 (interquartile range [IQR], –0.62 to 4.22); CLABSI, 1.46 (IQR, –0.02 to 5.44); CDI, 5.04 (IQR, 0.16 to 17.48); and MRSA, 0.45 (IQR, –0.15 to 2.67).Table. Characteristics of Hospitals Participating in the STRIVE ProgramAppendix Figure. States that enrolled with the STRIVE program.In total, 443 hospitals from 28 states and the District of Columbia participated. Recruitment occurred as follows: cohort 1 (June 2016 to April 2017), cohort 2 (November 2016 to October 2017), cohort 3 (April 2017 to March 2018), and cohort 4 (June 2017 to May 2018). Hashing indicates states that participated in more than 1 cohort. STRIVE = States Targeting Reduction in Infections via Engagement. Download figure Download PowerPoint Informing Change—Designing InterventionsPractice Change AssessmentDuring STRIVE, participating hospitals were asked to complete a survey instrument to identify and address gaps in HAI prevention at the beginning of cohort enrollment (baseline) and at the end of the study wave (comparison) (Figure 2). This gap assessment could be done using either the CDC's Infection Control Assessment and Response (ICAR) survey (16) or the STRIVE Practice Change Assessment (PCA). The ICAR had been previously developed for state health departments to assess infection prevention practices in hospitals. The PCA, based on the ICAR, was modified to focus on 8 domains germane to the STRIVE program. Four of the domains focused on specific HAIs—CDI, CLABSI, CAUTI, and hospital-onset MRSA bloodstream infection—whereas the remaining 4 domains focused on hand hygiene, personal protective equipment, environmental cleaning, and antimicrobial stewardship.Figure 2. Education and engagement interventions implemented for participating hospitals.CDC = Centers for Disease Control and Prevention. Download figure Download PowerPoint Baseline surveys were administered by each participating hospital with support and (at times) a site visit by the state partners. If a hospital had completed an ICAR in the year before STRIVE, they were able to reuse that survey for their baseline assessment. A summary report from these assessments was provided to each site, highlighting opportunities for improvement and a list of STRIVE content and resources to assist in addressing these gaps.Education: Foundational and HAI-Specific Web-Based ModulesSubject-matter experts created educational materials for 12 different topics. Development of educational materials by experts occurred via in-person meetings and work group conference calls. Two primary topic domains were identified around which program education would be focused: foundational and HAI-specific elements.The foundational domain emphasized core infection control practices that are known to have variable compliance but are critical for success of any HAI prevention initiative (for example, hand hygiene, personal protective equipment use, and environmental cleaning). Many are considered "horizontal" infection control strategies in that they affect not one but many pathogens and HAIs. Eight elements for the foundational domain were identified: 1) competency-based training, auditing, and feedback; 2) hand hygiene; 3) personal protective equipment; 4) environmental cleaning; 5) antimicrobial stewardship; 6) making an effective infection prevention business case; 7) patient and family engagement; and 8) socioadaptive strategies for preventing infection.The HAI-specific domains were concentrated on best practices for preventing CDI, CLABSI, CAUTI, and hospital-onset MRSA bloodstream infection. In total, subject-matter experts created 51 short (10 to 20 minutes), Web-based, on-demand educational modules covering key topics in the 2 domains (Appendix Table).Appendix Table. Overview of the 51 Web-Based Learning Modules Developed for the STRIVE ProgramA 2-tiered intervention approach was developed for the HAIs targeted in STRIVE. Tier 1 interventions were defined as basic, evidence-based interventions that every hospital should have in place (for example, ensuring that central lines are placed aseptically). Foundational elements remained a critical aspect across tier 1 for the HAI-specific modules as these elements generally have demonstrated success, are economically efficient, and have multiplicative effects across HAIs. Foundational elements are also crucial to have in place before more complex technical and social interventions are introduced. Tier 2 interventions were generally considered more complex, "advanced" steps for hospitals to take once tier 1 interventions were reliably in place but not leading to a decline in a particular HAI. In general, tier 2 interventions were considered to require increased human and economic capital compared with tier 1.Engaging Sites: Learning Action ForumsIn conjunction with the Web-based modules, monthly learning action forums were hosted by HRET for all cohorts. These monthly, 1-hour webinars were discussion-based and interactive and were built on supporting the didactic content from the curriculum's on-demand courses. They provided hospitals with an opportunity to share their infection prevention strategies, challenges, and successes, thereby strengthening engagement and learning across member sites. The learning action forums also allowed national subject-matter experts to interact with hospitals and answer questions related to webinar content or materials. The lead for most learning action forums was often an infection preventionist or someone with a role in quality at the local hospital. The lead would distribute the webinar information to staff, which typically included nurse managers, environmental services, frontline clinicians, and other clinical and nonclinical staff, depending on the topic of the learning action forum.Education: TAP StrategyThe TAP strategy (15) developed by the CDC can be used not only to identify facilities and units with a high burden of HAIs, but also to highlight gaps in infection prevention. In this way, finite infection prevention resources can be directed to areas of greatest opportunity. The TAP strategy incorporates the TAP reports generated in the CDC's NHSN, along with standardized assessment tools and implementation strategies for CLABSI, CAUTI, and CDI.Feedback from the cohort 1 pilot revealed that additional, more intense education and training on how best to use TAP reports was needed. Although most hospital infection preventionists had heard of the TAP strategy, most lacked in-depth knowledge, and few organizations were actively using TAP resources. Therefore, many state-level in-person meetings incorporated TAP training, provided by their state health departments, to drive increased understanding of this strategy. In addition, from June 2017 to January 2018, the CDC collaborated with HRET to develop and deliver four 90-minute webinars on how to run and interpret TAP reports and use TAP strategies and resources to maximize HAI prevention. To further support state partner knowledge of this valuable resource, the CDC provided a webinar in December 2017 for state partners, providing additional education around how to use TAP reports and strategies at the state level to promote HAI prevention work.Strengthening Partnerships Through Coaching and CollaborationState health departments and SHAs collaborated to support hospitals in administering the PCA or ICAR, interpreting results, and finding resources to address identified gaps. In addition, state health departments were instrumental in educating hospitals on running and using TAP reports, utilizing STRIVE venues, such as in-person meetings and site visits in each state, along with the SHA. In addition, the SHA program lead (and often their health department partners) supported hospitals via monthly one-on-one calls, webinars, or office hours open to all STRIVE hospitals. These touch points were used for shared learning and coaching from the state mentors and experts around barriers and action planning to reach goals. Upon request, subject-matter experts from the national program team would also join such calls to add expertise. The state partners often acted in the role of encourager and cheerleader for teams to support momentum as well.State In-Person MeetingsOn the basis of feedback from cohort 1 pilot sites, state-level in-person meetings were implemented for all participating states in cohorts 2 to 4. Although the online and virtual materials were felt to be helpful, sites in cohort 1 felt that bringing hospitals and state partners together in person was necessary to support building relationships. Such meetings also provided protected time and space for hospital participants' learning and networking with peers as well as state and national experts.ImplementationIn contrast to single-unit interventions often found in infection control projects, the focus of this program was large-system transformation (17) to influence multiple hospitals, organizations, and health care providers. The national program team developed a full STRIVE implementation plan focused on leveraging content for both foundational and HAI-specific practices. The curriculum was divided into 3 phases: onboarding to the STRIVE program, foundational infection prevention strategies, and education targeted to the program's 4 HAIs.In May 2016, onboarding started for cohort 1, which included a general program overview, team formation, and education regarding ICAR/PCA assessments and TAP strategy. The rollout for Web-based modules then occurred for cohort 1 as follows: July to October 2016 (foundational elements modules), November 2016 to January 2017 (HAI-specific tier 1 modules), and February 2017 to March 2017 (HAI-specific tier 2 modules). These modules were available to all subsequent cohorts throughout their 12-month collaborative after their onboarding. Web modules for STRIVE can be found at www.cdc.gov/infectioncontrol/training/strive.html.ConclusionThe STRIVE initiative, coordinated by the HRET and funded by the CDC, brought together state-level organizations with short-stay and long-term acute care hospitals across the country to improve infection prevention and control practices for hospitals with a disproportionately high burden of HAIs. Federal funds for this initiative were in part in response to the lessons learned with Ebola and how stakeholders were interested in strengthening state partnerships and infection control measures in preparation for any future emerging infectious disease. Through the STRIVE initiative, the architecture of preventing HAI shifted from hospital-based to instead utilizing national efforts to effect local improvement efforts in hospitals across the United States.

Given the evolving epidemiology of healthcare-associated infections (HAIs) in children and the intense national focus by clinicians and regulators on infection prevention efforts, the goal of this commentary is to describe the activities and achievements of the Pediatric Leadership Council (PLC) of the Society for Healthcare Epidemiology of America (SHEA) and to highlight potential opportunities within the field of pediatric hospital epidemiology and infection prevention. Although preventing infections has been recognized as a critical component of healthcare for over 150 years [1, 2], the field of hospital epidemiology and infection control as a focused area of practice is relatively young. The Hospital Infections Unit was established at the Centers for Disease Control and Prevention (CDC) in 1966 [3] in the context of the emergence of hospitalacquired Staphylococcus aureus infections. The landmark SENIC (Study on the Efficacy of Nosocomial Infection Control) Project in the 1970s established that implementing effective infection prevention and control programs in hospitals could reduce HAI rates by up to 32% [4]. Over the last 15 years, much attention has been focused on HAI as a continuing major threat to the safety of patients in a variety of healthcare settings [5]. Hospitals and healthcare systems have worked hard to institute evidence-based practices to prevent infections. This work has occurred in children’s hospitals in parallel to the efforts occurring in hospitals that treat adult patients. Differences between adult and pediatric populations require that typical approaches for infection prevention be tailored to meet the needs of children. Issues such as age-related differences in development, immunity, device utilization, and availability of specific technologies, along with the ultimate goal of family-centered care, all contribute to and impact the risk of HAI for children [6]. At a national level, pediatric hospital epidemiologists have advocated for consideration of these special approaches as infection prevention policies are developed (eg, through the inclusion of a pediatric infectious diseases [ID] physician on the Healthcare Infection Control Practices Advisory Committee [HICPAC] since its establishment in 1991) and have conducted original research to generate knowledge and test the efficacy of preventive interventions in pediatric populations. In recognition of the need for better data on pediatric HAI, in 1997 the CDC and the National Association of Children’s Hospitals and Related Institutions established the Pediatric Prevention Network, a multinational collaborative of 77 children’s hospitals whose goals included assessing the prevalence of HAI and antimicrobial resistance and ultimately improving pediatric outcomes [7]. SHEA is a professional society founded in 1980, and its mission is to prevent and control healthcare-associated infections and advance the field of healthcare epidemiology through research, education, and translation of knowledge into effective policy and practice. In 1995, a pediatric special interest group (PSIG) within SHEA was created as an informal gathering of professionals who were interested in the unique challenges of infection prevention for children. Over the next 15 years, PSIG members worked to provide pediatric expertise in healthcare epidemiology and represent the Invited Commentary

Infection control and prevention (the routine use of infection prevention and control policies, procedures, and interventions in healthcare institutions) is fundamental to improving patient care outcome while ensuring the health and safety of healthcare workers, patients, and visitors. Healthcare facilities with an effective infection prevention and control (IPC) program have demonstrated a decrease in healthcare-associated infections, a common complication of interaction with healthcare, through adherence to IPC guidelines resulting in safer clinical care environments and impacting patient morbidity and mortality. A safer clinical care environment and adherence to certain basic principles are fundamental for IPC programs, all leading to an impact on patient morbidity and mortality. However, recent experience in developed countries suggests possible lowering of hospital-acquired infection rates is achieved only when infection control is accepted as core to the healthcare institutions. The prevalence of hospital-acquired infection (HCAI) is well known in developed countries (Rosenthal et al. 2011). These infections incur additional costs, extend hospitalization, increase treatment costs, increase antimicrobial resistance, increase disabilities, and increase patient morbidity and mortality. It is generally accepted due to a lack of robust surveillance systems that HCAIs are higher in low- and middle-income countries and especially in LMIC intensive care units. Healthcare-associated infection rates are generally higher in low- and middle-income countries compared with high-income countries resulting in a relatively larger incidence of patient mortality, disability, and additional healthcare cost. An earlier observation, the SENIC Study (1985) published by Haley RW et al. showed that 6% of nosocomial infection can be prevented by minimal infection prevention and control efforts and 32% could be prevented by a very well-organized infection prevention and control program. More recent published guidelines have demonstrated that it is possible to control the spread of multidrug-resistant Gram-negative and Gram-positive bacteria priority organisms in low- and middle-income countries using IPC interventions despite resource limitations (WHO 2017). This narrative will attempt to define the important concept of “PROGRESS”—a roadmap to define the essential aspect of starting an infection prevention and control program “from scratch” with emphasis on resource-limited settings. The acronym PROGRESS from scratch in a resource-limited setting in low- and middle-income countries attempts to define mechanisms and multimodal strategies for starting IPC programs to reduce the overall patient morbidity and mortality associated with HCAIs in these settings.

In this special issue, we have described results from the IMPAQ-RAND team’s formal longitudinal evaluation of HHS’s National Action Plan to Prevent Healthcare-associated Infections1 and have discussed efforts to address healthcare–associated infections (HAIs) at the state, regional, and local levels. In this final article, we take a step back to consider briefly the overall impact of the Action Plan and to describe some possible future directions for addressing HAIs. While HAIs are not new, the environment of the modern healthcare system provides some new challenges and opportunities for eliminating HAIs. In the context of extraordinary medical advances during recent decades, healthcare has become increasingly complex, and many common medical procedures and treatments can also be the source of HAIs. For example, widespread use of antibiotics to combat infection can also lead to increased antimicrobial resistance, whereas beneficial but invasive medical procedures, including surgery or the use of catheters, can compromise the body’s natural defenses. Further, as more and more patients survive life-threatening diseases, the treatments used to address many diseases weaken some patients’ immune responses, making them more vulnerable to HAIs. Today’s healthcare system makes use of a complex network of venues that provide differing levels and types of care; however, as patients move frequently across healthcare and home venues, they have the potential to carry with them strains of organisms that can transmit HAIs to others. There is widespread recognition of the personal and financial costs associated with HAIs, including the potential for loss of life or impaired functioning, billions of dollars spent annually to treat HAIs, and decreasing public trust in the healthcare system. Awareness of these issues led to the development of HHS’s National Action Plan to Prevent Healthcare-associated Infections, which we have discussed in this special issue of Medical Care. HHS’s Action Plan was the result of both a growing enthusiasm for using evidence-based strategies and guidelines to prevent and mitigate HAIs as well as frustration at the lack of a prioritized and coordinated approach for addressing HAIs, an adequate infrastructure for aligning interventions, and a robust system for measuring progress. The focus on evidence-based strategies and guidelines grew out of a major paradigm shift that occurred during the first decade of the 21st century, as data emerged showing that substantial numbers of hospital-based HAIs were preventable with use of evidence-based strategies.2 These include activities such as reducing the initial and ongoing use of antibiotics and limiting the use of devices known to compromise the body’s natural defenses (eg, catheters) to only those situations in which use is known to improve medical outcomes. Other evidence-based interventions include standardizing the use of hand-washing, and “bundling” evidence-based medical care practices to ensure that each individual procedure occurs as it should and when it should. Multiple public and private organizations have prompted healthcare organizations to implement evidence-based interventions to improve patient outcomes. The enthusiasm for developing and implementing evidence-based procedures also contributed to the expectation that effective prevention practices could be rapidly identified and implemented in healthcare facilities across the nation. This hope turned to frustration, as stakeholders-ranging from local healthcare practitioners to national policy leaders-recognized that too many guidelines were being recommended and that a prioritized and coordinated approach for addressing HAIs was lacking. This frustration was articulated in a 2008 report released by the Government Accountability Office (GAO), which criticized the federal effort to address HAIs, focusing on the multitude of clinical practices for preventing HAIs and related adverse events, the fragmentation of data across government agencies, and the lack of interoperability across databases.3 The GAO emphasized the need for improved coordination of HAI prevention efforts and recommended that the Secretary of HHS identify “priorities among the recommended practices in CDC’s guidelines and establish greater consistency and compatibility of the data collected across HHS on HAIs.”3 The GAO report was followed by congressional hearings on HAIs. Prompted by Congress, HHS developed its Action Plan to enhance collaboration and coordination and to strengthen the impact of national efforts to address HAIs. WAS THE ACTION PLAN RESPONSIVE TO THE NEED FOR PRIORITIZATION OF HAI PREVENTION PRACTICES AND COORDINATION OF DATA SOURCES? A key overarching issue for the IMPAQ-RAND evaluation of HHS’s Action Plan was whether or not the Action Plan was responsive to the 2 major concerns that motivated its development: first, the need for prioritization of HAI prevention practices and, second, the need to coordinate disparate federal data sources for tracking HAIs. Overall, our evaluation found that the Action Plan addressed both these issues. Prioritization of HAI Prevention Practices First, the Action Plan made many efforts to prioritize HAI prevention practices. Evidence for the prioritization began with the Action Plan’s selection of 6 conditions and the development of targets and metrics for these conditions. The initial version of the Action Plan, released in 2009, prioritized HAI prevention practices associated with hospitalizations as compared with other venues. Over time, the Action Plan expanded its focus to include ambulatory surgical centers, dialysis centers, and long-term care venues. The Action Plan also initially focused on efforts to reduce HAIs among hospital patients, as was appropriate, as patients have been the main victims of HAIs. Subsequently, the focus shifted to include influenza vaccination for healthcare personnel as a strategy for interrupting the pattern of unvaccinated healthcare workers contributing to infection risk for vulnerable patients. The Action Plan prioritized HAI prevention practices through its research strategies and has established and applied well-developed criteria for identifying those research methodologies and projects most likely to generate new knowledge to support evidence-based strategies and procedures for HAI prevention. Furthermore, the use of incentives to encourage healthcare practitioners and practices to systematically collect data to support Action Plan metrics and targets offers further evidence of prioritization of HAI prevention practices. Coordination of HAI Data Systems The Action Plan also improved coordination of HAI data systems across HHS agencies. This was a major goal in the Action Plan in 2009, with the establishment of national metrics with corresponding 5-year prevention targets. The Action Plan commitment to system-level metrics and targets illustrates an intent to make an observable difference, not just with processes but with outcomes. The public commitment to achieving the targets by 2013 focused a broad and diverse set of efforts on a uniform set of goals. The Action Plan selected data sources and baseline years for each metric. Stakeholders iteratively and rigorously pursued strategies for improving definitions of infections and for refining data collection tools to enable assessment of progress toward achieving target goals. To focus all of the national, regional, state, and local efforts on a transparent assessment of HAI rates over time requires substantial coordination and messaging. The Action Plan has led to reductions in HAI rates with progress made toward most targets for which associated data are available. HOW WELL DID THE ACTION PLAN ADDRESS THE CHALLENGE OF FINDING CONSISTENT AND SUSTAINABLE RESOURCES TO SUPPORT IMPLEMENTATION? Although the Action Plan can be considered successful in addressing the challenges of prioritization and coordination, the absence of predictable fiscal resources dedicated to curbing HAIs has been notable. During the early 21st century, the lack of predictable and sustainable resources has become a reality for large government programs, particularly those spanning multiple stakeholders. Action Plan leadership, through its Steering Committee, was able to draw from and build upon the long-standing and extensive support of its lead agencies, generating extraordinary clinical, intellectual, political, and leadership resources that convened to address one of the most devastating epidemics ever known to our nation. A strength of the Action Plan has been its effective and astute leveraging, on an ad hoc basis, of already existing resources. However, a predictable and steady flow of resources has not been readily available. In the absence of a sustained influx of resources, the pace of advancement may have been muted and enthusiasm for growth by key stakeholders somewhat slow. Although agency collaboration has been substantial, relationships among stakeholders and potential collaborators may have been strained as agencies and organizations competed for limited resources. If there is one counterfactual consideration relevant to the contexts in which the Action Plan and its goals were developed, it is how the Action Plan advances might have been different if explicit resource needs were estimated, tested, and shared with stakeholders and the public. This would have been consistent with the principle of transparency that the Action Plan supports and would have provided some boundaries for federal stakeholders to assess realistic goals within a specified time period. In addition, concerns of critics of the Action Plan, particularly external stakeholders and clinical practice settings that initially questioned the gap between ambitious Action Plan goals for expansion and the lack of financial support for their own local efforts, might have been mitigated if a shared understanding of available resources and costs had been more widely recognized. Despite this limitation, the Action Plan’s ability to leverage available infrastructure and resources has supported substantial and ongoing progress during a challenging economic period. FUTURE DIRECTIONS Moving forward, HHS leadership will need to decide how best to sustain the momentum achieved through the Action Plan to continue to reduce and, eventually, to eliminate HAIs. Particular attention will need to be focused on securing the resources—both financial and nonfinancial—that are necessary to sustain progress. A key decision point for healthcare policymakers is to determine the extent to which the campaign to eradicate HAIs should be aligned with—or in some cases embedded within—other healthcare efforts. The potential for alignment offers opportunities to leverage existing resources and capabilities within the healthcare system on an ongoing basis. We highlight 4 potential opportunities below. Managing HAIs Within the Broader Patient Safety Movement A key strength of the Action Plan was the creation of a dedicated federal home for coordination. This coordinating body identified gaps in HAI prevention infrastructure and helped ensure the ongoing engagement of key stakeholders in the Action Plan. Maintaining such a leadership body in the future would help keep the focus on HAIs. However, a key issue is to determine the relative allocation of federal funding specifically to support the HAI effort as compared with a broader investment in the patient safety movement—which includes HAIs as well as other preventable conditions. There may be advantages to making the HAI effort an important component of patient safety overall rather than a movement of its own. Substantial infrastructure investments for preventing HAIs will also be applicable to other major healthcare challenges that span venues and require multiple diverse inputs. With this regard, the Action Plan provides a model for the broader patient safety agenda which like HAIs spans beyond hospitals to other healthcare settings in which improvement infrastructure is typically less developed. Using Information Technology (IT) to Monitor and Address HAIs HAI data and monitoring pose an ongoing challenge because of the significant expense and effort required to support HAI surveillance and reporting. The ongoing growth of health IT, including the use of electronic health records, provides a potential opportunity to improve HAI care both for individual patients and for population health as a whole. Health IT can be used to automate many of the steps involved in collecting data on HAIs: IT can be used to bring together all the information on a particular patient, and then data can be combined across patients to provide a better understanding of how a particular HAI affects population health. To enhance HAI data and monitoring, additional investment is needed to automate HAI surveillance and reporting. This will require collaboration and cooperation with health IT vendors and commitment to basing surveillance on entire episodes of care, which can span months for conditions such as surgical site infections (which optimally take into account a follow-up period), or for conditions such as Clostridium difficile (which can recur multiple times within the same patient). These advances should be paired with a more aggressive approach to data validation, that is, ensuring that data have been collected in a fair and unbiased way that uses best practices. Because data collection occurs at the state and local levels, it will be essential to engage major state-level and local-level and other private stakeholders with interests and expertise in HAI data validation in the identification of best practices and the development of feasible data validation strategies. The expansion of health IT, although complex, offers the promise of increasing collaboration and leveraging resources across both the public and private sectors and spanning the national to local levels. Connecting the Basic Science and Epidemiology of HAIs With Prevention Practice and Implementation Science Moving forward, knowledge development surrounding HAIs will be well supported with a balanced investment in a 4-pronged approach that includes: (1) basic science, (2) epidemiology, (3) development of prevention practices, and (4) implementation science—as well as linking findings across these disciplines. The Action Plan succeeded in endorsing a research agenda that highlights HAI-related gaps for each of these areas and shows how advances in each area are needed to move forward the other areas. Following the model of translational research, the discovery of the basic mechanisms of HAIs will inform a better understanding of the epidemiology of HAIs, and, subsequently, the development of prevention practices and new findings from implementation science, which feeds back into the overall scientific evidence base for HAIs. The Action Plan has already developed criteria for prioritizing HAI research that is likely to have a high impact in eliminating HAIs. Now, it is important for healthcare leaders to evaluate the research that has been carried out to determine where high-value research has occurred and to decide whether the prioritization criteria still hold. This type of feedback can enhance an understanding of which research is most helpful. It will also be critical to emphasize implementation science, that is, the development of learning laboratories in which research occurs in real-world clinical settings.4,5 One of the challenges that the Action Plan sought to address was the need for a multipronged approach to address HAIs—which come in many forms and are transmitted through multiple sources across diverse locations—but one that does not overburden the individuals, mostly at the local, regional, and state levels, who are responsible for implementation. This balance has not yet been fully achieved, and continuing efforts will be required to determine which approaches are providing the highest value. Taking Advantage of State-of-the-Art Implementation and Dissemination Tools The adoption of HAI prevention practices can be augmented by taking advantage of state-of-the-art implementation and dissemination tools. Aligning with the larger patient safety and implementation science movements will increase the likelihood that HAI research results will be effectively translated into improved human health. Implementation science has been developing new methods for assessing the effectiveness of healthcare interventions and approaches. These include meta-analysis, cost-effectiveness studies, and patient-centered outcomes research. AHRQ’s evidence-based practice centers have been developing reports on which HAI interventions improve outcomes in which settings.6 CONCLUSIONS Although the potential directions described above suggest ways in which the HAI movement can be aligned with other efforts to achieve economies of scale, it is important to emphasize that a specific focus on HAIs will continue to be necessary—whether or not HAI-related efforts are folded into the larger patient safety movement. In the future, continuing efforts will be required to track progress in addressing the most pervasive HAIs and to identify new infections and means of transmission and to find ways to address those HAIs. Although the Action Plan has improved the prioritization and coordination of efforts related to HAIs, attention to these processes must be ongoing. Regular evaluation of HAI-related efforts, including self-monitoring of key implementation goals, can support this need. A self-monitoring approach will allow Action Plan leaders to build upon the insights achieved through the external evaluation. Supplementing the development and utilization of longitudinal HAI rate trend reports with additional metrics about the implementation of HAI supportive infrastructures, engagement of stakeholders, outcomes of research funding, and adoption of evidence measures can serve as ongoing tools that the Action Plan can internalize as part of its own infrastructure. Careful monitoring of these metrics will inform how the context and goals of the Action Plan are translated into key decisions, processes, and outcomes. This type of self-monitoring is likely to improve the Action Plan’s effectiveness even further.

Background. Today, the topic of combating Healthcare-Associated Infections (HAIs) is becoming increasingly relevant. The World Health Organization has developed the concept of Infection Prevention and Control (IPC), which is a key component of quality control and patient safety in hospitals. Aim. To analyze modern methods of infection prevention and the role of healthcare workers in the effective implementation of infection control measures, according to the data of modern literature sources. Materials and Methods. We analyzed the literature on prevention of hospital-acquired infections, as well as the importance of infection control in improving patient safety, the role of medical staff in the provision of medical care. The search for scientific information was carried out using the scientific databases Scopus, PubMed, Web of Science, Google Scholar. Results & Conclusions. Hospital-acquired infections are a serious public health problem associated with increased patient morbidity and mortality, as well as an economic burden on healthcare systems. Approximately 10% of hospitalized patients in high-income countries are affected by HAIs. Infection control is defined as a set of effective organizational, preventive and anti-epidemic measures aimed at preventing the occurrence and spread of healthcare-associated infections. Healthcare workers play an important role in the effective implementation of infection control measures. The use of Personal Protective Equipment (PPE), hand hygiene, environmental cleaning, screening and isolation, sterilization and disinfection, surveillance and reporting, vaccination and the introduction of innovative technologies in hospital infection control are important elements of the prevention and control of HAIs. Hospital infection control is essential to protect patients, healthcare workers and the wider community from HAIs. These measures are important to protect patients, healthcare workers and all society. Keywords: hand hygiene, healthcare-associated infections, infection prevention.

SHEA/APIC guideline: infection prevention and control in the long-term care facility, July 2008.

BackgroundThe core components (CCs) of infection prevention and control (IPC) from World Health Organization (WHO) are crucial for the safety and quality of health care. Our objective was to examine the level of implementation of WHO infection prevention and control core components (IPC CC) in a developing country. We also aimed to evaluate health care-associated infections (HAIs) and antimicrobial resistance (AMR) in intensive care units (ICUs) in association with implemented IPC CCs.MethodsMembers of the Turkish Infectious Diseases and Clinical Microbiology Specialization Association (EKMUD) were invited to the study via e-mail. Volunteer members of any healt care facilities (HCFs) participated in the study. The investigating doctor of each HCF filled out a questionnaire to collect data on IPC implementations, including the Infection Prevention and Control Assessment Framework (IPCAF) and HAIs/AMR in ICUs in 2021.ResultsA total of 68 HCFs from seven regions in Türkiye and the Turkish Republic of Northern Cyprus participated while 85% of these were tertiary care hospitals. Fifty (73.5%) HCFs had advanced IPC level, whereas 16 (23.5%) of the 68 hospitals had intermediate IPC levels. The hospitals’ median (IQR) IPCAF score was 668.8 (125.0) points. Workload, staffing and occupancy (CC7; median 70 points) and multimodal strategies (CC5; median 75 points) had the lowest scores. The limited number of nurses were the most important problems. Hospitals with a bed capacity of > 1000 beds had higher rates of HAIs. Certified IPC specialists, frequent feedback, and enough nurses reduced HAIs. The most common HAIs were central line-associated blood stream infections. Most HAIs were caused by gram negative bacteria, which have a high AMR.ConclusionsMost HCFs had an advanced level of IPC implementation, for which staffing was an important driver. To further improve care quality and ensure everyone has access to safe care, it is a key element to have enough staff, the availability of certified IPC specialists, and frequent feedback. Although there is a significant decrease in HAI rates compared to previous years, HAI rates are still high and AMR is an important problem. Increasing nurses and reducing workload can prevent HAIs and AMR. Nationwide “Antibiotic Stewardship Programme” should be initiated.

In healthcare facility design, especially in hospitals, infection control is paramount due to the vulnerability of patients to nosocomial or healthcare-associated infections (HAIs). Despite advancements in medical practices and infection control measures, HAIs remain a significant challenge to patient safety and public health, particularly within hospital settings. Integrating adaptive architecture principles into hospital design and infrastructure presents a promising approach to addressing this issue. This paper examines the intersection of adaptive architecture and infection prevention in hospitals, with a focus on designing and constructing healthcare facilities to effectively curb the spread of infections. By incorporating adaptive architecture, hospitals can create environments that are responsive to the dynamic needs of patients, staff, and infection control protocols. Design elements such as flexible room layouts, easily adaptable ventilation systems, and antimicrobial surfaces can help minimize the risk of HAIs by reducing pathogen transmission and promoting cleanliness. Additionally, strategic placement of hand hygiene stations, isolation rooms, and patient flow pathways can optimize infection control practices and enhance patient safety. Strategically locating hand hygiene stations, isolation rooms, and patient flow pathways optimizes infection control practices and improves patient safety. By combining innovative design strategies and advanced technology, hospitals can better combat HAIs, fostering safer environments for patients and healthcare staff. This paper investigates how the collaboration of adaptive architecture and infection prevention can yield more robust and efficient healthcare facilities in the fight against HAIs. Keywords - HAIs, Adaptive Architecture, Infection, adaptable ventilation, flexible layouts, antimicrobial surfaces.

Documentation, composition and organisation of infection control programs and plans in Australian healthcare systems: A pilot study