Interventions for preventing or controlling health care-associated infection among health care workers or patients within primary care facilities: A scoping review

BACKGROUND

This review aimed to synthesize the evidence on infection prevention and control interventions for the prevention of health care-associated infection among health care workers or patients within primary care facilities.

METHODS

PubMed, CINAHL, EMBASE, and CENTRAL databases were searched for quantitative studies published between 2011 and 2022. Study selection, data extraction, and quality assessment using Cochrane and Joanna Briggs tools, were conducted by independent review with additional sensitivity checking performed on study selection.

RESULTS

Four studies were included. A randomized trial and a cross-sectional survey, respectively, found no statistical difference in laboratory-confirmed influenza in health care workers wearing N95 versus medical masks (P = .18) and a significant inverse association between the implementation of tuberculosis control measures and tuberculosis incidence (P = .02). For the prevention of surgical site infections following minor surgery, randomized trials found nonsterile gloves (8.7%; 95% confidence interval, 4.9%-12.6%) to be noninferior to sterile gloves (9.3%; 95% confidence interval, 7.4%-11.1%) and no significant difference between prophylactic antibiotics compared to placebo (P = .064). All studies had a high risk of bias.

CONCLUSIONS

Evidence for infection prevention and control interventions for the prevention of health care-associated infection in primary care is very limited and insufficient to make practice recommendations. Nevertheless, the findings highlight the need for future research.

Infection prevention and control (IPC) implementation in low-resource settings: a qualitative analysis

BACKGROUND

The coronavirus disease-2019 (COVID-19) pandemic has again demonstrated the critical role of effective infection prevention and control (IPC) implementation to combat infectious disease threats. Standards such as the World Health Organization (WHO) IPC minimum requirements offer a basis, but robust evidence on effective IPC implementation strategies in low-resource settings remains limited. We aimed to qualitatively assess IPC implementation themes in these settings.

METHODS

Semi-structured interviews were conducted with IPC experts from low-resource settings, guided by a standardised questionnaire. Applying a qualitative inductive thematic analysis, IPC implementation examples from interview transcripts were coded, collated into sub-themes, grouped again into broad themes, and finally reviewed to ensure validity. Sub-themes appearing ≥ 3 times in data were highlighted as frequent IPC implementation themes and all findings were summarised descriptively.

RESULTS

Interviews were conducted with IPC experts from 29 countries in six WHO regions. Frequent IPC implementation themes including the related critical actions to achieve the WHO IPC core components included: (1) To develop IPC programmes: continuous advocacy with leadership, initial external technical assistance, stepwise approach to build resources, use of catalysts, linkages with other programmes, role of national IPC associations and normative legal actions; (2) To develop guidelines: early planning for their operationalization, initial external technical assistance and local guideline adaption; (3) To establish training: attention to methods, fostering local leadership, and sustainable health system linkages such as developing an IPC career path; (4) To establish health care-associated (HAI) surveillance: feasible but high-impact pilots, multidisciplinary collaboration, mentorship, careful consideration of definitions and data quality, and "data for action"; (5) To implement multimodal strategies: clear communication to explain multimodal strategies, attention to certain elements, and feasible but high-impact pilots; (6) To develop monitoring, audit and feedback: feasible but high-impact pilots, attention to methods such as positive (not punitive) incentives and "data for action"; (7) To improve staffing and bed occupancy: participation of national actors to set standards and attention to methods such as use of data; and (8) To promote built environment: involvement of IPC professionals in facility construction, attention to multimodal strategy elements, and long-term advocacy.

CONCLUSIONS

These IPC implementation themes offer important qualitative evidence for IPC professionals to consider.

Time for a renewed focus on the role of cleaners in achieving safe health care in low- and middle-income countries

Water, sanitation and hygiene, collectively known as WASH, is an enabler of infection prevention and control (IPC), both of which contribute to safe, quality health care and the prevention of spread of antimicrobial resistance (AMR). This discussion paper considers the importance placed on the role of hygiene, including cleaning and those who clean, in health care facilities, within the context of existing data, guidelines and initiatives. Informed by this, the paper presents five areas for consideration that have the potential to strengthen and further demonstrate the value of this important cadre of staff and their role in clean, safe healthcare, particularly in low- and middle-income countries. The considerations centre around actions to overcome the current data gaps, including the paucity of national data on environmental cleaning and the training of cleaners; strengthening the implementation of norms and standards; combining global and national advocacy efforts; revisiting investment; and addressing research gaps on the issue. The need to act, in line with WHO and UNICEF recommendations to address this overlooked and undercompensated workforce and to elevate their status as important contributors to IPC, WASH and AMR is a pressing one.

Enhancing engagement beyond the conference walls: analysis of Twitter use at #ICPIC2019 infection prevention and control conference

BACKGROUND

Social media may provide a tool, when coupled with a patient-included™ conference, to enhance the engagement among the general public. We describe authors and potential readers of Twitter content surrounding a patient-included™ scientific congress, the International Consortium for Prevention and Infection Control (ICPIC) 2019.

METHODS

Retrospective observational analysis of Twitter users posting with the #ICPIC2019 hashtag during the conference. Tweet authors, overall followers, and active followers were categorized according to their Twitter biographies using unsupervised learning. Diversity of professional backgrounds of Tweet authors and their followers was explored. Network analysis explored connectedness between the reach of authors.

RESULTS

In total, 1264 participants attended ICPIC 2019, of which 28 were patients. From September 7 to 16, 2019, we were able to categorize 235'620 (41%) followers linked to 474 (76%) authors. Among authors and followers, respectively 34% and 14% were healthcare workers, 11% and 15% were from industry representatives, 8% and 7% were academic researchers. On average, 23% (range 9-39%) followers belonged to the same categories as authors. Among all followers categorized, only 582/235 620 (0.25%) interacted with original messages, including healthcare workers (37%), global and public health (12%), academic research (11%) and those from industry (11%). Though the similarity between Tweet authors and followers was supported by network analysis, we also observed that non-healthcare workers (including patients) appeared to have more diverse followers.

CONCLUSIONS

We observed the participation of numerous Tweet authors and followers from diverse professional backgrounds potentially supporting the benefit of including patients in conferences to reach a more general, non-specialized public.

Implementation of surgical site infection surveillance in low- and middle-income countries: A position statement for the International Society for Infectious Diseases

Surgical site infection (SSI) rates in low- and middle-income countries (LMICs) range from 8 to 30% of procedures, making them the most frequent healthcare-acquired infection (HAI) with substantial morbidity, mortality, and economic impacts. Presented here is an approach to surgical site infection prevention based on surveillance and focused on five critical areas identified by international experts. These five areas include

1. Collecting valid, high-quality data;

2. Linking HAIs to economic incapacity, underscoring the need to prioritize infection prevention activities;

3. Implementing SSI surveillance within infection prevention and control (IPC) programs to enact structural changes, develop procedural skills, and alter healthcare worker behaviors;

4. Prioritizing IPC training for healthcare workers in LMICs to conduct broad-based surveillance and to develop and implement locally applicable IPC programs; and

5. Developing a highly accurate and objective international system for defining SSIs, which can be translated globally in a straightforward manner.

Finally, we present a clear, unambiguous framework for successful SSI guideline implementation that supports developing sustainable IPC programs in LMICs. This entails

1. Identifying index operations for targeted surveillance;

2. Identifying IPC “champions” and empowering healthcare workers;

3. Using multimodal improvement measures;

4. Positioning hand hygiene programs as the basis for IPC initiatives;

5. Use of telecommunication devices for surveillance and healthcare outcome follow-ups.

Additionally, special considerations for pediatric SSIs, antimicrobial resistance development, and antibiotic stewardship programs are addressed.

Testing of the WHO Infection Prevention and Control Assessment Framework at acute healthcare facility level

BACKGROUND

Monitoring and evaluation are an essential part of infection prevention and control (IPC) implementation. The authors developed an IPC assessment framework (IPCAF) to support implementation of the World Health Organization (WHO) guidelines on core components of IPC programmes in acute healthcare facilities.

AIM

To evaluate the usability and reliability of the IPCAF tool for global use.

METHODS

The IPCAF is a questionnaire with a scoring system to measure the level of IPC implementation according to the eight WHO core components. The tool was pre-tested qualitatively, revised and translated selectively. A convenience sample of hospitals was invited to participate in the final testing. At least two IPC professionals from each hospital independently completed the IPCAF and a usability questionnaire online. The tool's internal consistency and interobserver reliability or intraclass correlation coefficient (ICC) were assessed, and usability questions were summarized descriptively.

FINDINGS

In total, 46 countries, 181 hospitals and 324 individuals participated; 52 (16%) and 55 (17%) individual respondents came from low- and lower-middle income countries, respectively. Fifty-two percent of respondents took less than 1 h to complete the IPCAF. Overall, there was adequate internal consistency and a high ICC (0.92, 95% confidence interval 0.89-0.94). Ten individual questions had poor reliability (ICC <0.4); these were considered for revision according to usability feedback and expert opinion.

CONCLUSIONS

The WHO IPCAF was tested using a robust global study and revised as necessary. It is now an effective tool for IPC improvement in healthcare facilities.

Technology for the prevention of antimicrobial resistance and healthcare-associated infections; 2017 Geneva IPC-Think Tank (Part 2)

Background

The high burden of healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) is partially due to excessive antimicrobial use both in human and animal medicine worldwide. How can technology help to overcome challenges in infection prevention and control (IPC) and to prevent HAI and emerging AMR?

Methods

In June 2017, 42 international experts convened in Geneva, Switzerland to discuss four potential domains of technology in IPC and AMR: 1) role and potential contribution of microbiome research; 2) whole genome sequencing; 3) effectiveness and benefit of antimicrobial environmental surfaces; and 4) future research in hand hygiene.

Results

Research on the microbiome could expand understanding of antimicrobial use and also the role of probiotics or even faecal transplantation for therapeutic purposes. Whole genome sequencing will provide new insights in modes of transmission of infectious diseases. Although it is a powerful tool for public health epidemiology, some challenges with interpretation and costs still need to be addressed. The effectiveness and cost-effectiveness of antimicrobially coated or treated environmental high-touch surfaces requires further research before they can be recommended for routine use. Hand hygiene implementation can be advanced, where technological enhancement of surveillance, technique and compliance are coupled with reminders for healthcare professionals.

Conclusions

The four domains of technological innovation contribute to the prevention of HAI and AMR at different levels. Microbiome research may offer innovative concepts for future prevention, whole genome sequencing could detect new modes of transmission and become an additional tool for effective public health epidemiology, antimicrobial surfaces might help to decrease the environment as source of transmission but continue to raise more questions than answers, and technological innovation may have a role in improving surveillance approaches and supporting best practice in hand hygiene.

Creation of a national infection prevention and control programme in Sierra Leone, 2015

Prior to the 2014–2016 Ebola epidemic, Sierra Leone’s Ministry of Health and Sanitation had no infection prevention and control programme. High rates of Ebola virus disease transmission in healthcare facilities underscored the need for infection prevention and control in the healthcare system. The Ministry of Health and Sanitation led an effort among international partners to rapidly stand up a national infection prevention and control programme to decrease Ebola transmission in healthcare facilities and strengthen healthcare safety and quality. Leadership and ownership by the Ministry of Health and Sanitation was the catalyst for development of the programme, including the presence of an infection prevention and control champion within the ministry. A national policy and guidelines were drafted and approved to outline organisation and standards for the programme. Infection prevention and control focal persons were identified and embedded at public hospitals to manage implementation. The Ministry of Health and Sanitation and international partners initiated training for new infection prevention and control focal persons and committees. Monitoring systems to track infection prevention and control implementation were also established. This is a novel example of rapid development of a national infection prevention and control programme under challenging conditions. The approach to rapidly develop a national infection prevention and control programme in Sierra Leone may provide useful lessons for other programmes in countries or contexts starting from a low baseline for infection prevention and control.

Broadening the infection prevention and control network globally; 2017 Geneva IPC-think tank (part 3)

Background

Healthcare-associated infection (HAI) is a major challenge for patient safety worldwide, and is further complicated by antimicrobial resistance (AMR) due to excessive antimicrobial use in both humans and animals. Existing infection prevention and control (IPC) networks must be strengthened and adapted to better address the global challenges presented by emerging AMR.

Methods

In June 2017, 42 international experts convened in Geneva, Switzerland, to discuss two key areas for strengthening the global IPC network: 1) broadening collaboration in IPC; and 2) how to bring the fields IPC and AMR control together.

Results

The US Centers for Disease Prevention and Control, the European Centre for Disease Prevention and Control, and the World Health Organization (WHO) convened together with international experts to discuss collaboration and networks, demonstrating the participating organizations’ commitment to close collaboration in IPC. The challenge of emerging AMR can only be addressed by strengthening this collaboration across international organisations and between public health and academia. The WHO SAVE LIVES: Clean Your Hands initiative is an example of a successful collaboration between multiple global stakeholders including academia and international public health organisations; it can be used as a model. IPC-strategies are included within the four pillars to combat AMR: surveillance, IPC, antimicrobial and diagnostic stewardship, research and development. The prevention of transmission of multidrug-resistant microorganisms is a patient safety issue, and must be strengthened in the fight against AMR.

Conclusions

The working group determined that international organisations should take the lead in creating new networks, which will in turn attract academia and other stakeholders to join. At the same time, they should invest in bringing existing IPC and AMR networks under one umbrella. Transmission of multidrug-resistant microorganisms in hospitals and in the community threatens the success of antimicrobial stewardship programmes, and thus, research and development in IPC should be addressed as an enhanced global priority.

PO 8194 OPTIMISED INFORMED CONSENT FOR PARTICIPANTS IN A RANDOMISED CONTROLLED TRIAL IN RURAL UGANDA: A COMPARATIVE PROSPECTIVE COHORT STUDY

Background

Poor participant understanding of research information can be a problem in community interventional studies in rural African women where levels of illiteracy, dependency and compliance are high. We assessed the impact of alternative consent models on participants’ understanding of the clinical trial information and its contribution to the informed consent process in rural Uganda.

Methods

This was a prospective comparative cohort, nested within a pilot study of community distribution of alcohol-based hand rub to prevent neonatal sepsis (BabyGel). As part of the informed consent process, information about the trial was presented using one of three consent methods: standard researcher-read information; a ‘slide show’ using illustrated text on a flip chart; and a video showing the patient information sheet (PIS) being read as if by a newsreader in either English or the local language. In addition, all women received a written PIS in their preferred language. Each information method was used for 1 week of recruitment. Two days after recruitment, women’s understanding of the clinical trial was evaluated.

Results

A total of 30 pregnant women from 13 villages in Mbale participated in this study. Majority 90% (27/30) were assessed for recall of trial information within planned 48 hours. The slide-show was the most popular, with a mean score not less than 4.2 highest [mean (sd) range: 4.8 (0.6) [4–5]] by women who had been recruited using any of the three models. The slide show was preferred by 63% of the women (19/30), compared with 17% (5/30) and 20% (6/30) who preferred the standard and video show message, respectively. Reasons given included the benefits of having pictures to aid understanding, and the logical progression of the information.

Conclusion

Our results suggest that a slide-show message is an effective and popular alternative way of presenting trial information to women in rural Uganda, many of whom had little or no literacy.

BabyGel pilot: a pilot cluster randomised trial of the provision of alcohol handgel to postpartum mothers to prevent neonatal and young infant infection-related morbidity in the community

BACKGROUND

Alcohol-based hand rub (ABHR) is widely used in both health and social facilities to prevent infection, but it is not known whether supplying it for regular perinatal use can prevent newborn sepsis in African rural homes. Our study piloted a cluster randomised trial of providing ABHR to postpartum mothers to prevent neonatal infection-related morbidity in the communities.

METHODS

We conducted a pilot parallel cluster randomised controlled trial across ten villages (clusters) in rural Eastern Uganda. Pregnant women of over 34 weeks' gestation were recruited over a period of 3 months. Both clusters received the standard of care of antenatal health education, Maama Kit, and clinic appointments. In addition, women in the intervention villages received ABHR, instructions on ABHR use, a poster on the 'three moments of hand hygiene', and training. We followed up each mother-baby pair for 3 months after birth and measured rates of consent, recruitment, and follow-up (our target rate was more than 80%). Other measures included ABHR use (the acceptable use was more than four times a day) and its mode of distribution (village health workers (VHWs) or pharmacy), acceptability of study protocol and electronic data capture, and the use of WHO Integrated Management of Childhood Illness (IMCI) tool to screen for newborn infection.

RESULTS

We selected 36% (10/28) of villages for randomisation to either intervention or control. Over 12 weeks, 176 pregnant women were screened and 58.5% (103/176) were eligible. All, 100% (103/103), eligible women gave consent and were enrolled into the trial (55 intervention and 48 control). After birth, 94.5% (52/55) of mothers in the intervention and 100% (48/48) of mothers in the control villages were followed up within 72 h. Most, 90.9% (50/55), of the mothers in the intervention villages (96.2% of live births) and 95.8% (46/48) of mothers in the control villages (95.9% of live births) were followed up at 3 months. In intervention villages, the average hand rub use was 6.6 times per day. VHWs accounted for all ABHR stock, compared to the pharmacy that could not account for 5 l of ABHR. The screening tool was positive for infection among a third of babies, i.e. 29.2% (14/48) in the intervention villages versus 31.4% (16/51) in the control villages.VHWs completed the first four questions of IMCI screening tool with ease and accuracy. There were no adverse reactions with the ABHR.

CONCLUSION

It is feasible to conduct a cluster-randomised controlled trial (cRCT) of the provision of ABHR to postpartum mothers to prevent neonatal infection-related morbidity in the community in resource-poor settings. Our results indicate that home recruitment promotes excellent follow-up and retention of participants in community trials. The intervention was safe. This pilot study informed the substantial changes necessary in the larger cRCT, including a change in the primary outcome to a composite outcome considering multiple methods of infection detection. A large BabyGel cluster randomised controlled trial is now required.

TRIAL REGISTRATION

ISRCTN67852437, registered March 02, 2015.

TRIAL FUNDING

Medical Research Council/WellcomeTrust/DfID (Global Health Trials Scheme).

Optimising informed consent for participants in a randomised controlled trial in rural Uganda: a comparative prospective cohort mixed-methods study

BACKGROUND

Poor participant understanding of research information can be a problem in community interventional studies with rural African women, whose levels of illiteracy are high. This study aimed to improve the informed consent process for women living in rural eastern Uganda. We assessed the impact of alternative consent models on participants' understanding of clinical trial information and their contribution to the informed consent process in rural Uganda.

METHODS

The study applied a parallel mixed-methods design for a prospective comparative cohort, nested within a pilot study on the community distribution of an alcohol-based hand rub to prevent neonatal sepsis (BabyGel pilot trial). Women of at least 34 weeks' pregnancy, suitable for inclusion in the BabyGel pilot trial, were recruited into this study from their homes in 13 villages in Mbale District. As part of the informed consent process, information about the trial was presented using one of three consent methods: standard researcher-read information, a slide show using illustrated text on a flip chart or a video showing the patient information being read as if by a newsreader in either English or the local language. In addition, all women received the patient information sheet in their preferred language. Each information-giving method was used in recruitment for 1 week. Two days after recruitment, women's understanding of the clinical trial was evaluated using the modified Quality of Informed Consent (QuIC) tool. They were also shown the other two methods and their preference assessed using a 5-point Likert scale. Semi-structured interviews were administered to each participant. The interviews were audio-recorded, transcribed and translated verbatim, and thematically analysed.

RESULTS

A total of 30 pregnant women in their homes participated in this study. Their recall of the trial information within the planned 48 h was assessed for the majority (90%, 27/30). For all three consent models, women demonstrated a high understanding of the study. There was no statistically significant difference between the slide-show message (mean 4.7; standard deviation, SD 0.47; range 4-5), video message (mean 4.9; SD 0.33; range 4-5) and standard method (mean 4.5; SD 0.53; range 4-5; all one-way ANOVA, p = 0.190). The slide-show message resulted in the most objective understanding of question items with the highest average QuIC score of 100 points. For women who had been recruited using any of the three models, the slide show was the most popular method, with a mean score for all items of not less than 4.2 (mean 4.8; SD 0.6; range 4-5). Most women (63%, 19/30) preferred the slide-show message, compared with 17% (5/30) and 20% (6/30) for the standard and video messages, respectively. The reasons given included the benefits of having pictures to aid understanding and the logical progression of the information.

CONCLUSION

Our results from this small study suggest that slide-show messages may be an effective and popular alternative way of presenting trial information to women in rural Uganda, many of whom have little or no literacy.

TRIAL REGISTRATION

ISRCTN, ISRCTN67852437 . Registered on 18 March 2018.

Preventing neonatal sepsis in rural Uganda: a cross-over study comparing the tolerance and acceptability of three alcohol-based hand rub formulations

BACKGROUND

Neonatal sepsis causes 0.5 million deaths annually, mostly in low resource settings. Babies born in African rural homes without running water or toilet facilities are especially vulnerable. Alcohol-based hand rub (ABHR) may be used by mothers and carers as an alternative to hand washing with soap to prevent neonatal infection. However, no definite study has established the preferred formulation of hand rub for the mothers. This study aimed to assess the effects of addition of bitterants and perfume towards the acceptability of the alcohol-based hand rubs by the mothers in their homes after childbirth.

METHODS

This was a 3-way blinded cross-over study design. Mothers with children aged ≤3 months were recruited from immunisation clinics at 3 local health facilities in rural eastern Uganda and received 3-different ABHR formulations (in the order plain, bitterant and perfumed) packed in 100 ml bottles. Each ABHR was used for 5 consecutive days followed by a 2-day 'washout' period (evaluation period). Overall satisfaction with each hand rub was evaluated at the end of each week using a 7-point Likert scale.

RESULTS

A total of 43 women were recruited, whose ages ranged from 16 to 45 years (mean 26.2 years old). None of the participants normally used a hand protective lotion/cream. The three formulations were used for a mean of 5 (range 3-7) days. A significantly greater volume of the "bitterant" and "perfumed" formulations (mean 91 and 83 ml respectively) were used in comparison to the "plain" formulation (mean 64 ml). Overall satisfaction was high with all the hand rubs, but the perfumed formulation had a significantly higher overall satisfaction score [mean 6.7, range 4-7] compared with the plain [6.4, 3-7] and bitterant [6.2, 2-7] formulations.

CONCLUSIONS

All the 3 ABHR formulations were well accepted with little to choose between them. The ABHR with added perfume scored highest on overall satisfaction and was used significantly more often than plain ABHR. ABHR with bitterant additive did, however, score highly and may be a preferable choice to those with concern over alcohol misuse.

TRIAL REGISTRATION

ISRCTN67852437 , prospectively registered on 18/03/2018.

Exploring the use of entertainment-education YouTube videos focused on infection prevention and control

BACKGROUND

As a communications strategy, education entertainment has been used to inform, influence, and shift societal and individual behaviors. Recently, there has been an increasing number of entertainment-education YouTube videos focused on hand hygiene. However, there is currently no understanding about the quality of these videos; therefore, this study aimed to explore the social media content and user engagement with these videos.

METHODS

The search terms "hand hygiene" and "hand hygiene education" were used to query YouTube. Video content had to be directed at a health care professional audience. Using author designed checklists, each video was systematically evaluated and grouped according to educational usefulness and was subsequently evaluated against the categories of attractiveness, comprehension, and persuasiveness.

RESULTS

A total of 400 videos were screened, with 70 videos retained for analysis. Of these, 55.7% (n = 39) were categorized as educationally useful. Overall, educationally useful videos scored higher than noneducationally useful videos across the categories of attractiveness, comprehension, and persuasiveness. Miscommunication of the concept of My 5 Moments for Hand Hygiene was observed in several of the YouTube videos.

CONCLUSIONS

The availability of educationally useful videos in relation to hand hygiene is evident; however, it is clear that there are opportunities for contributors using this medium to strengthen their alignment with social media best practice principles to maximize the effectiveness, reach, and sustainability of their content.

Global hand hygiene improvement progress: two surveys using the WHO Hand Hygiene Self-Assessment Framework

The World Health Organization (WHO) conducted two global surveys in 2011 and 2015 using the Hand Hygiene Self-Assessment Framework. In 2011, 2119 health facilities from 69 countries participated, and in 2015, 807 health facilities from 91 countries participated. In total, 86 facilities submitted results for both surveys; their overall score increased significantly (P<0.001) from 335.1 [standard deviation (SD) 7.5] to 374.4 (SD 90.5). In terms of WHO regions, the scores for the Eastern Mediterranean, Europe and Western Pacific regions all improved significantly (P<0.01). This represents a snapshot of the current position of global hand hygiene improvement efforts, outlining facility progress and highlighting the value of such an assessment tool.

Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations

Health care-associated infections (HAI) are a major public health problem with a significant impact on morbidity, mortality and quality of life. They represent also an important economic burden to health systems worldwide. However, a large proportion of HAI are preventable through effective infection prevention and control (IPC) measures. Improvements in IPC at the national and facility level are critical for the successful containment of antimicrobial resistance and the prevention of HAI, including outbreaks of highly transmissible diseases through high quality care within the context of universal health coverage. Given the limited availability of IPC evidence-based guidance and standards, the World Health Organization (WHO) decided to prioritize the development of global recommendations on the core components of effective IPC programmes both at the national and acute health care facility level, based on systematic literature reviews and expert consensus. The aim of the guideline development process was to identify the evidence and evaluate its quality, consider patient values and preferences, resource implications, and the feasibility and acceptability of the recommendations. As a result, 11 recommendations and three good practice statements are presented here, including a summary of the supporting evidence, and form the substance of a new WHO IPC guideline.

Redefining infection prevention and control in the new era of quality universal health coverage

Universal health coverage (UHC) is a concept that is deeply rooted in the Development Agenda and is receiving increasing attention at the global level. The interconnection of infection prevention and control (IPC), UHC and quality has not been well described. We aim to present a novel and compelling case for considering IPC as a critical part of quality UHC and develop a preliminary theory of change model, informed by existing literature and emerging thinking on this evolving field. A review of published and grey literature on UHC, quality and IPC was undertaken with a view to triangulating common goals and informing a theory of change. A preliminary theory of change framework describing the potential synergy between UHC, quality and IPC in catalysing concerted action at every level of the health system has been developed. A table outlining key considerations at the policy, practice and research levels is also presented. This paper considers the extent to which the global IPC community in its widest form should better position IPC as a fundamental component of quality within the context of rapidly advancing UHC-driven health system reforms. The theory of change will be of value to the many organisations involved in supporting countries and facilities as they move towards a true focus on UHC.

Promoting patient safety in India: situational analysis and the way forward

Unsafe healthcare is a well-recognized issue internationally and is attracting attention in India as well. Drawing upon the various efforts that have been made to address this issue in India and abroad, we explore how we can accelerate developments and build a culture of patient safety in the Indian health sector. Using five international case studies, we describe experiences of promoting patient safety in various ways to inform future developments in India. We offer a roadmap for 2020, which contains suggestions on how India could build a culture of patient safety.

Development of an evaluation framework for African-European hospital patient safety partnerships

BACKGROUND

Patient safety is recognised as a significant healthcare problem worldwide, and healthcare-associated infections are an important aspect. African Partnerships for Patient Safety is a WHO programme that pairs hospitals in Africa with hospitals in Europe with the objective to work together to improve patient safety.

OBJECTIVE

To describe the development of an evaluation framework for hospital-to-hospital partnerships participating in the programme.

METHODS

The framework was structured around the programme's three core objectives: facilitate strong interhospital partnerships, improve in-hospital patient safety and spread best practices nationally. Africa-based clinicians, their European partners and experts in patient safety were closely involved in developing the evaluation framework in an iterative process.

RESULTS

The process defined six domains of partnership strength, each with measurable subdomains. We developed a questionnaire to measure these subdomains. Participants selected six indicators of hospital patient safety improvement from a short-list of 22 based on their relevance, sensitivity to intervention and measurement feasibility. Participants proposed 20 measures of spread, which were refined into a two-part conceptual framework, and a data capture tool created.

CONCLUSION

Taking a highly participatory approach that closely involved its end users, we developed an evaluation framework and tools to measure partnership strength, patient safety improvements and the spread of best practice.

Strengthening the evidence-policy interface for patient safety: enhancing global health through hospital partnerships

Strengthening the evidence-policy interface is a well-recognized health system challenge in both the developed and developing world. Brokerage inherent in hospital-to-hospital partnerships can boost relationships between “evidence” and “policy” communities and move developing countries towards evidence based patient safety policy. In particular, we use the experience of a global hospital partnership programme focused on patient safety in the African Region to explore how hospital partnerships can be instrumental in advancing responsive decision-making, and the translation of patient safety evidence into health policy and planning. A co-developed approach to evidence-policy strengthening with seven components is described, with reflections from early implementation. This rapidly expanding field of enquiry is ripe for shared learning across continents, in keeping with the principles and spirit of health systems development in a globalized world.

Hand hygiene--when and how should it be done?

Practising hand hygiene at the right times to prevent healthcare-associated infections is one of the most important patient care practices health professionals can undertake. However, changing behaviour to ensure staff practise appropriate hand hygiene requires a multifaceted approach. This article highlights two important aspects of the message staff need--the when and the how of hand hygiene.

Improving adherence to hand hygiene practice

Hand hygiene compliance rates continue to vary between healthcare settings and individual professionals. This article looks at how a multimodal approach to infection prevention and control, using expertise from other disciplines, can increase compliance with hand hygiene practices.

Global implementation of WHO's multimodal strategy for improvement of hand hygiene: a quasi-experimental study

BACKGROUND

Health-care-associated infections are a major threat to patient safety worldwide. Transmission is mainly via the hands of health-care workers, but compliance with recommendations is usually low and effective improvement strategies are needed. We assessed the effect of WHO's strategy for improvement of hand hygiene in five countries.

METHODS

We did a quasi-experimental study between December, 2006, and December, 2008, at six pilot sites (55 departments in 43 hospitals) in Costa Rica, Italy, Mali, Pakistan, and Saudi Arabia. A step-wise approach in four 3-6 month phases was used to implement WHO's strategy and we assessed the hand-hygiene compliance of health-care workers and their knowledge, by questionnaire, of microbial transmission and hand-hygiene principles. We expressed compliance as the proportion of predefined opportunities met by hand-hygiene actions (ie, handwashing or hand rubbing). We assessed long-term sustainability of core strategy activities in April, 2010.

FINDINGS

We noted 21,884 hand-hygiene opportunities during 1423 sessions before the intervention and 23,746 opportunities during 1784 sessions after. Overall compliance increased from 51.0% before the intervention (95% CI 45.1-56.9) to 67.2% after (61.8-72.2). Compliance was independently associated with gross national income per head, with a greater effect of the intervention in low-income and middle-income countries (odds ratio [OR] 4.67, 95% CI 3.16-6.89; p<0.0001) than in high-income countries (2.19, 2.03-2.37; p<0.0001). Implementation had a major effect on compliance of health-care workers across all sites after adjustment for main confounders (OR 2.15, 1.99-2.32). Health-care-workers' knowledge improved at all sites with an increase in the average score from 18.7 (95% CI 17.8-19.7) to 24.7 (23.7-25.6) after educational sessions. 2 years after the intervention, all sites reported ongoing hand-hygiene activities with sustained or further improvement, including national scale-up.

INTERPRETATION

Implementation of WHO's hand-hygiene strategy is feasible and sustainable across a range of settings in different countries and leads to significant compliance and knowledge improvement in health-care workers, supporting recommendation for use worldwide.

FUNDING

WHO, University of Geneva Hospitals, the Swiss National Science Foundation, Swiss Society of Public Health Administration and Hospital Pharmacists.

Cutting levels of antimicrobial resistance

The incidence of antimicrobial resistance is increasing and represents a serious threat not only to patients who have infections that do not respond to antimicrobial drugs but also to global healthcare systems. European Antibiotics Awareness Day aims to ensure health professionals and the public understand the importance of ensuring antibiotics are used correctly to minimise the spread of resistance. This article discusses the nursing role in preventing antimicrobial resistance.

Developed-developing country partnerships: benefits to developed countries?

Developing countries can generate effective solutions for today's global health challenges. This paper reviews relevant literature to construct the case for international cooperation, and in particular, developed-developing country partnerships. Standard database and web-based searches were conducted for publications in English between 1990 and 2010. Studies containing full or partial data relating to international cooperation between developed and developing countries were retained for further analysis. Of 227 articles retained through initial screening, 65 were included in the final analysis. The results were two-fold: some articles pointed to intangible benefits accrued by developed country partners, but the majority of information pointed to developing country innovations that can potentially inform health systems in developed countries. This information spanned all six WHO health system components. Ten key health areas where developed countries have the most to learn from the developing world were identified and include, rural health service delivery; skills substitution; decentralisation of management; creative problem-solving; education in communicable disease control; innovation in mobile phone use; low technology simulation training; local product manufacture; health financing; and social entrepreneurship. While there are no guarantees that innovations from developing country experiences can effectively transfer to developed countries, combined developed-developing country learning processes can potentially generate effective solutions for global health systems. However, the global pool of knowledge in this area is virgin and further work needs to be undertaken to advance understanding of health innovation diffusion. Even more urgently, a standardized method for reporting partnership benefits is needed--this is perhaps the single most immediate need in planning for, and realizing, the full potential of international cooperation between developed and developing countries.

Importance of hand hygiene during invasive procedures

Invasive devices, such as urinary catheters and peripheral and central venous catheters, can form part of essential patient care and may provide life-saving support and treatment. However, the invasive nature of these devices and the vulnerability of patients can increase the risk of acquiring a healthcare-associated infection (HCAI). This article highlights the importance of best practice in relation to insertion and management of invasive devices, incorporating hand hygiene, to reduce the risk of HCAI. Although the information can be applied to invasive devices in general, the focus is on urinary catheters.

Hand hygiene improvement in the community: a systems approach

Hand hygiene compliance, which is influenced in part by human behaviour, is central to infection prevention in all care settings. This article focuses specifically on the importance of a multimodal strategy for continued hand hygiene improvement, and its relevance to community nursing. Additionally, the article addresses the challenges and opportunities of infection prevention and control in a community context, and highlights current national and international guidelines that offer a framework and set of principles for implementation and sustainability with a specific focus on the multimodal strategy associated with the WHO Guidelines on Hand Hygiene in Health Care (2009). The authors conclude with some considerations for community nurses when addressing translation of these principles into their everyday working context.

Disney, engagement, action: the Infection Prevention Society’s strategy from development to launch

This paper details the development of the Infection Prevention Society strategic plan 2011–2016 from its inception in 2009 to its launch in September 2011 at the Infection Prevention Society’s annual conference. It aims to provide a transparent account of how the vision, mission and strategic aims of the strategy were shaped and crafted through a number of iterations that involved members at key stages.

Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study

Healthcare-associated infections (HAIs) affect at least 300,000 patients annually in the UK and represent a significant, yet largely preventable, burden to healthcare systems. Hand hygiene by healthcare workers (HCWs) is the leading prevention measure, but compliance with good practice is generally low. The UK National Patient Safety Agency surveyed the public, inpatients, and HCWs, particularly frontline clinical staff and infection control nurses, in five acute care hospitals to determine whether they agreed that a greater level of involvement and engagement with patients would contribute to increased compliance with hand hygiene and reduce HAIs. Fifty-seven percent (302/530) of the public were unlikely to question doctors on the cleanliness of their hands as they assumed that they had already cleaned them. Forty-three percent (90/210) of inpatients considered that HCWs should know to clean their hands and trusted them to do so, and 20% (42/210) would not want HCWs to think that they were questioning their professional ability to do their job correctly. Most HCWs surveyed (178/254, 71%) said that HAI could be reduced to a greater or lesser degree if patients asked HCWs if they had cleaned their hands before touching them. Inviting patients to remind HCWs about hand hygiene through the provision of individual alcohol-based hand-rub containers and actively supporting an 'It's OK to ask' attitude were perceived as the most useful interventions by both patients and HCWs. However, further work is required to refute the myth among HCWs that patient involvement undermines the doctor- or HCW-patient relationship.

Moving forward with confidence: 2009 IPS insight survey of the membership

In this paper we present the findings of the first Infection Prevention Society membership survey conducted at the end of 2009. The survey sought to identify the views of current members in relation to the future direction and services provided by the Society and the reasons for some existing members leaving the Society. Around one-third of the membership responded to the survey. The findings reveal general satisfaction with the direction of the Society and point out areas of activity that can be developed and these have informed the current work of the Board in setting the strategic aims of the Society for the next 5 years.