Ignaz Philipp Semmelweis (1818–1865) – a public health visionary and champion of hand hygiene

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.

To the Editors: Standard infection control precautions and centralized prevention/education has improved health care outcomes for patients and health care workers (HCWs).1–3 In resource-limited health care settings, implementation of these practices is challenging and transmission of highly resistant organisms within health care facilities is described.4–7 High rates of needle stick injuries8 and unsafe injection practices9 occur in clinics and hospitals where blood borne infections such as hepatitis and HIV are common; postexposure prophylaxis is infrequently accessed.10 Alcohol gels are perceived as expensive and may be unavailable, and many settings lack appropriate hand-washing facilities.11 Personal protective equipment is often absent, and medical equipment may be old and in disrepair. Strict standards for environmental controls are difficult to maintain, and health care facilities themselves are often archaic. International recommendations are available for infection control, but programs are not consistently regulated and have few monitoring and enforcement programs.12–14 The National Institute of Allergy and Infectious Diseases (NIAIDs) supports 6 networks conducting HIV-related clinical research. Many clinical research sites (CRSs) are located outside of the United States in resource-limited settings. CRS that have access to the patients and resources necessary to perform high-quality research are limited and usually engage in diverse research. A single site might have studies focusing on the prevention of mother-to-child transmission of HIV, intensive pK studies involving new drugs for multiresistant organisms, and protocols testing second-line antiretroviral therapy. Standard clinical care is provided in often-crowded facilities, where research subjects are present for many hours. Anecdotal observations have suggested that there are significant variations in infection control practices among the sites. METHODS A survey of the infection control resources and practices at the CRS outside of the United States was undertaken, led by the Office of HIV/AIDS Network Coordination. Sites were asked about a formal infection control program, staff safety, respiratory hygiene and tuberculosis control, hand hygiene capabilities, injection practices, and blood safety. RESULTS Overall, 74 sites were offered the survey, and 32 returned completed surveys. Twenty-three of 32 AIDS Clinical Trials Group sites completed the survey. Selected results are summarized in Figure 1.FIGURE 1: Selected infection control practices at international NIAID-funded HIV clinical research sites.Infection Control Organization Eighty-six percent of sites had an infection control policy, of these 55% were specific to the CRS. Seventy-five percent of sites had an infection control officer, directly employed by the sites, half the time. The sites without an infection control policy frequently did not have policies addressing the domains surveyed. Respiratory Sixty percent of sites reported a triage system to identify participants with potential respiratory infections. Commonly, the study participant was placed in a well-ventilated area and provided a mask. Less than half of respondents (45.2%) conduct protocol procedures with participants with known or suspected tuberculosis (TB) in a separate clinical area. Natural and mechanical ventilation were common methods of ensuring respiratory hygiene. N95 masks were available in the general clinic, in 39% of sites (12/31). Ultraviolet lights were present in 8/29 general clinical areas and 4/13 dedicated sputum collection areas indoors. A dedicated space for sputum collection was present in 55% of the CRSs. Space for sputum collection was most commonly an area outside (approximately 55%) or a dedicated sputum collection area inside (approximately 45%). In the space for sputum collection, natural and mechanical ventilation were used as infection control measures. Twenty-five percent of sites reported surgical masks worn by patients. Staffs were provided N95 masks 50% of the time in the dedicated sputum collection area; 2/11 sites reported that N95 respirators were available. Educational material on cough hygiene was available at 40% of the respondent sites. Forty-five percent of sites had TB surveillance programs for staff and routinely screened staff for TB infection 71% of the time. Hand Hygiene All sites reported sinks with running water; most had manual soap dispensers (25/32) and paper hand towels (27/32). Hand sanitizers were available at half of the sites. Water basins filled remotely were used in some areas in 15/32 sites, bar soap in 13/32 sites, and cloth hand towels in 11/32 sites. Blood Safety All sites reported a policy for management of needle stick injuries, and all sites had appropriate postexposure prophylaxis for HIV. The source patient is tested for hepatitis B at 58% of sites and hepatitis C at 39% of sites. Postexposure protocols for hepatitis B were present in 42% of sites. Most sites reported a needle recapping policy (71%), and 58% used safe needle systems. Sharps containers were generally available. DISCUSSION Healthcare-associated infections are an important cause of morbidity for patients, and health care providers in resource limited settings. A recent meta-analysis suggested that rates of indicator healthcare-associated infections might be more than double those of resource rich settings.15 Our survey suggested important areas for improvement in the delivery of health care associated with NIAID-sponsored clinical trials. There is good evidence that organizational support for infection control reduces the transmission of infectious agents and reduces mortality and morbidity in the acute care setting.16,17 Critical elements include staff trained in the principles of infection prevention, surveillance, and enforcement of preventative measures. Prevention of occupational illnesses requires preemployment assessments and immunization for vaccine-preventable illnesses. A quarter of the sites did not have appropriate personnel tasked with infection prevention. Those sites that did not have specific policies related to infection control also did not have policies to address most of the infection control domains. TB transmission in the health care environment is well described. The association with HIV infection is important, and instances of transmission clusters of highly resistant TB have been documented.18,19 A review examining the incidence and prevalence of latent TB infection among HCW in low- and middle-income countries suggested that HCW were at significant risk for TB disease compared with the general population.20 Even in areas where transmission of TB has been described, infection control procedures may be lacking. In eThekwini Municipality, Durban, RSA, only a quarter of primary health clinics triaged patients with cough. This is consistent with our experience. Patients with known or suspected TB are seen in the same facility as patients without TB, and segregation of individuals who might be infectious is not commonly undertaken. Cough hygiene has been promoted in resource-rich settings as a way of reducing spread of respiratory pathogens, fewer than half the sites had information available about cough hygiene. Hand hygiene is a critical measure to reduce health-care-acquired infections. Improvement of hand hygiene practices has been associated with reduced infection rates in hospitalized patients.21 In 2009, the WHO described best practices for hand hygiene and methodologies for local manufacture of inexpensive hand sanitizing gel.22,23 The multimodal strategy was tested in a reference hospital in Mali and found to be feasible, affordable, and effective.24 The WHO has ongoing efforts to promote hand hygiene using alcohol-based hand rubs throughout the world; however, a recent survey in Uganda of attitudes toward infection control gel for hand hygiene was perceived to be expensive and unavailable.11 In our survey, hand hygiene practices varied widely; alcohol-based gel was not generally available. The use of hand basins with standing water accompanied by bar soap and multiuse towels was striking. HCW are at risk for infection with blood borne pathogens, and needle stick injuries are common. One survey in Malawi suggested that half of nurses had a needle stick injury within the previous year.25 This rate is similar to rates in resource-rich settings before the widespread adoption of engineered needle-safe solutions.26 The consequences of outdated needle practices combined with high prevalence rates of HIV, hepatitis B, and hepatitis C may be catastrophic.27 Although postexposure prophylaxis is available for injuries that might be capable of transmitting HIV, it is unknown to what extent the work force is at risk for hepatitis B, as the information is not collected before employment. Participation in research should not place patients at more risk when compared with the local standard of care. The concentration of patients with communicable diseases drawn to the research site to participate in clinical protocols and the need for prolonged face-to-face interactions could lead to an increased risk for preventable infections in the research setting compared with the clinical environment. Arguably, research settings should set and demonstrate higher standards for clinical care, even when these levels cannot be implemented immediately throughout the health care system. Ethicists have commented that researchers should not replicate unacceptably low local standards but should seek to establish competent levels of care that can ultimately be feasibly implemented in the health system, for the benefit of all patients.28,29 Our survey demonstrated important areas for improvement in infection prevention. There are good precedents in the resource-limited setting for developing standards for hand hygiene and the prevention of blood borne illnesses. The most pressing need is for a protocol for the prevention of TB transmission. This has been developed and is being implemented at our sites. TB infection control, however, is best undertaken in an environment of other infection prevention efforts. NIAID and other research sponsors have a unique opportunity to model better health care infection control practices; it is hoped that this will lead to improved health care outcomes.

Looking back to move forward

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

Transmission of Hepatitis C Virus Associated with Surgical Procedures—New Jersey 2010 and Wisconsin 2011: February 27, 2015 / 64(07);165-170

The study aimed to identify factors affecting hospital infection prevention and control practices among medical personnel at Kampala International University Teaching Hospital in Ishaka, Uganda. The research was conducted using a quantitative descriptive research design. The result revealed that 76% of respondents felt they had sufficient knowledge about infection control and prevention practices. However, 34% of respondents found precautionary measures interfered with their work, and 70% recap needles after use. Only 32% reported a 0.3% chance of acquiring HIV after a needle stick injury. The study also showed 44% of respondents had received training on hand washing within 6 months. Most respondents 78% were able to wash hands before and after procedures. Only 44% of respondents had received training on waste segregation within a 6-month period. Policies and guidelines also influenced infection prevention and control practices. 52% of respondents considered the hospital infection prevention and control committee active, and 78% of them believed that waste segregation and post-exposure prophylaxis policies were available in their departments. The study found that hand washing is being carried out as recommended due to adequate on-the-job training. However, 54% of staff perceive hand washing as a challenge, and 78% were able to wash hands before and after every procedure as recommended. Only 30% of workers have access to a regular supply of soap and detergents for washing hands. Waste segregation is being practiced as recommended, but challenges persist for medical personnel. The management team should integrate infection prevention and control into the regular supervision of healthcare providers. The study suggests that promoting hand washing in a hospital requires adequate training, facilities, supplies, staffing, and a positive attitude. It recommends frequent hand washing training, accessible running water infrastructure, disposable towels, and soap and detergents. Staff should be trained on attitude change and proper waste segregation. Keywords: Hospital, Infection, Waste, Hand washing, supplies, training.

Transmission of infection by gastrointestional endoscopy: May 2001

BackgroundHealthcare-associated tuberculosis (TB) has become a major occupational hazard for healthcare workers (HCWs). HCWs are inevitably exposed to TB, due to frequent interaction with patients with undiagnosed and potentially contagious TB. Whenever there is a possibility of exposure, implementation of infection prevention and control (IPC) practices is critical.ObjectiveFollowing a high incidence of TB among HCWs at Maluti Adventist Hospital in Lesotho, a study was carried out to assess the knowledge, attitudes and practices of HCWs regarding healthcare-associated TB infection and infection controls.MethodsThis was a cross-sectional study performed in June 2011; it involved HCWs at Maluti Adventist Hospital who were involved with patients and/or sputum. Stratified sampling of 140 HCWs was performed, of whom, 129 (92.0%) took part. A self-administered, semi-structured questionnaire was used.ResultsMost respondents (89.2%) had appropriate knowledge of transmission, diagnosis and prevention of TB; however, only 22.0% of the respondents knew the appropriate method of sputum collection. All of the respondents (100.0%) were motivated and willing to implement IPC measures. A significant proportion of participants (36.4%) reported poor infection control practices, with the majority of inappropriate practices being the administrative infection controls (> 80.0%). Only 38.8% of the participants reported to be using the appropriate N-95 respirator.ConclusionPoor infection control practices regarding occupational TB exposure were demonstrated, the worst being the first-line administrative infection controls. Critical knowledge gaps were identified; however, there was encouraging willingness by HCWs to adapt to recommended infection control measures. Healthcare workers are inevitably exposed to TB, due to frequent interaction with patients with undiagnosed and potentially contagious TB. Implementation of infection prevention and control practices is critical whenever there is a possibility of exposure.

Background: Infection control practices played a major role in prevention of SARS-CoV-2 in healthcare settings. Aim of the study was to know the compliance to infection control and prevention practices by healthcare workers in COVID-19 pandemic and the measures taken for prevention of SARS-CoV-2 spread in the hospital.Methods: An observational study was conducted at tertiary care hospital for a period of one month. All healthcare workers involved in patient care of COVID-19 and non COVID-19 was observed for their infection control practices. Areas were divided in two category, intensive care unit and indoor wards for audit. Environmental samples of various surfaces from intensive care unit and wards were taken and analyzed for the presence of SARS-CoV-2 RNA by reverse transcriptase polymerase chain reaction.Results: Overall compliance to infection prevention practices were improved during pandemic. Hand hygiene compliance in intensive care unit and indoor wards of COVID-19 unit were 78.66% and 74.36% whilst in non COVID-19 units was 72.47% and 62.31% respectively. Compliance to revised biomedical waste (BMW) policy at COVID-19 unit were 85.20% and 71.49% in intensive care unit and ward respectively. However, at non COVID-19 unit, it was 65.22% and 57.60%. Nursing station and doffing area of ICU at non-COVID-19 unit showed presence of SARS-CoV-2 virus. While all samples collected from COVID-19 unit were negative.Conclusions: Infection prevention and control practices play a key role to curtail transmission of infection. Awareness among healthcare workers, hospital environment, and usage of personal protective equipment should be optimized even at non COVID-19 facility.

To determine the relation of the availability of personal protective equipment (PPE) and engineering controls to infection control (IC) practices in a prison healthcare setting, and to explore the effect on IC practices of a perceived organizational commitment to safety. Cross-sectional survey. The study population was drawn from the 28 regional Correctional Health Care Workers Facilities in Maryland. All full-time Maryland correctional healthcare workers (HCWs) were surveyed, and 225 (64%) of the 350 responded. A confidential, self-administered questionnaire was mailed to all correctional HCWs employed in the 28 Maryland Correctional Health Care Facilities. The questionnaire was analyzed psychometrically and validated through extensive pilot testing. It included items on three major constructs: IC practices, safety climate (defined as the perception of organizational commitment to safety), and availability of IC equipment and supplies. A strong correlation was found between the availability of PPE and IC practices. Similarly, a strong correlation was found between IC practices and the presence of engineering controls. In addition, an equally strong association was seen between the adoption of IC practices and employee perception of management commitment to safety. Those employees who perceived a high level of management support for safety were more than twice as likely to adhere to recommended IC practices. IC practices were significantly more likely to be followed if PPE was always readily available. Similarly, IC practices were more likely to be followed if engineering controls were provided. These findings suggest that ready availability of PPE and the presence of engineering controls are crucial to help ensure their use in this high-risk environment. This is especially important because correctional HCWs are potentially at risk of exposure to bloodborne pathogens such as human immunodeficiency virus and hepatitis B and C viruses. Commitment to safety was found to be highly associated with the adoption of safe work practices. There is an inherent conflict of "custody versus care" in this setting; hence, it is especially important that we understand and appreciate the relation between safety climate and IC practices. Interventions designed to improve safety climate, as well as availability of necessary IC supplies and equipment, will most likely prove effective in improving employee compliance with IC practices in this healthcare setting.

Aerosol generating procedures, dysphagia assessment and COVID-19: A rapid review.

Background Traditional health practitioners remain a primary point of contact for healthcare in rural communities, especially during health emergencies, due to their accessibility, cultural alignment, and affordability. However, critical deficiencies in infection prevention and control practices, among these practitioners, significantly contribute to healthcare-associated infections, increasing morbidity and mortality. This paper aims to highlight hygiene and infection control protocols observed by medical students during their community medicine postings among traditional health practitioners in rural Nigeria. Fieldwork context Final-year medical students observed practices and informally interacted with traditional health practitioners (Traditional bone setters and Traditional birth attendants) during their field placements in Odukpani LGA, Cross River State. Key observations Medical students observed several infection control gaps among traditional health practitioners, including inadequate hand hygiene, unsterile instrumentation, poor waste disposal, and unsanitary conditions. Treatment procedures often lacked proper aseptic techniques, with limited access to antiseptic or disinfectants, and disposable equipment were frequently reused. Additionally, patient records were poorly maintained, and referral systems unclear. Conclusion Strategic collaboration initiated during medical training through community-based postings could be a viable pathway to improve hygiene and infection control practices among traditional health practitioners for better health outcomes.

Objectives:Effective adherence to infection prevention and control practices is needed to reduce the rate of healthcare-acquired infections among healthcare workers. Policies to control healthcare-acquired infections among healthcare workers can be designed and implemented using information on adherence to infection prevention and control practices adherence and its determinants. This study, therefore, sought to assess the adherence to infection prevention and control practices among healthcare workers during the 2019 Coronavirus disease pandemic.Methods:A multicentre cross-sectional study was conducted among 323 randomly selected healthcare workers in four health facilities in the Suame Municipality, Ghana. Data on participants’ socio-demographics, knowledge of infection prevention and control practices and adherence to infection prevention and control practices were collected using a pre-tested structured questionnaire. Multivariate logistic regression analysis was used to examine the effect of demographic characteristics and knowledge of infection prevention and control on adherence to infection prevention and control practices among study participants.Results:Over three-quarters (75.9%) of the study participants had adequate knowledge of infection prevention and control practices with a significant knowledge gap in the colour coding of bin liners for waste segregation (35.6%). The proportion of study participants who reported good adherence to infection prevention and control practices was 86.7%. Healthcare workers who were 33 years and above (Adjusted odds ratio (AOR): 0.27; 95% Confidence interval (CI): 0.08–0.92) and absence of an infection prevention and control committee at the facility AOR: 0.25; 95% CI: 0.08–0.73) had reduced odds of good adherence to infection prevention and control practices. Nursing staff (AOR: 9.49, 95% CI: 2.51–35.87) and having adequate knowledge of infection prevention and control practices (AOR: 2.66; 95% CI: 1.19–5.97) were associated with increased odds of good adherence to infection prevention and control practices.Conclusion:Adherence to infection prevention and control practices was high among this sample of Ghanaian healthcare workers. Interventions and strategies to improve adherence should include the setting up of infection prevention and control committees, education and strict observance of colour coding of bin liners for waste segregation and intensification of training of healthcare workers in infection prevention and control practices.

Occupational health and safety is a crucial element in every organization, especially in a health care setting. Health care workers (HCWs) play a role as vectors and reservoirs for the spread of infection from patient to patient and staff as well. Infection control and prevention practices are essential elements of quality health care and patient safety in health facilities. Objectives: This study was aimed at assessing the levels of knowledge, attitude, and practice scores of the HCWs towards infection control at three public sector hospitals in Peshawar KPK. The study will help policymakers in the design and development of appropriate infection prevention programs and strategic plans by identifying the gap in infection control practices. Method: An institution-based cross-sectional study was conducted to assess the knowledge, attitudes, and practices of nurses regarding infection prevention and control by using a validated and structured questionnaire in three tertiary care hospitals in KPK. The sample size was calculated by using the Raosoft calculator, and the sample size was 318 nurses from these three hospitals, including those nurses who were willing to participate in the study and nurses who had more than one year of experience. Data was analyzed using SPSS version 22. Result: The participants were 55% male and 45% female; 55% were married, 42% were unmarried, 2% were divorced, 51% were diploma holders, 49% were degree holders, and most of the participants were charge nurses, which is 89%, and 11% were working in different administrative positions. Most of the participants who completed the survey were working in intensive care units, which is 66%, and others working in general wards and OPDs. 61% of nurses got information about safety precautions from training, 61% and 29% from books, and 10% from other resources. Participants who got training were 52%, and 48% of participants did not get any training on infection control precautions. Nurses who had knowledge about safety precautions were 84%; only 16% had not enough knowledge about infection control precautions. In attitude and practice about infection control, 58% were in compliance with practice, and 88% showed a positive attitude regarding infection control practices. Conclusion: In the conclusion, we can say that there is enough knowledge among nurses regarding infection control practice, but implementation of this knowledge in practice should be ensured by doing strict supervision of infection control practices in every health care facility.

Infection prevention and control, lessons from the COVID-19 pandemic and what happens next?