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Table 1 Summary of IPC core components and key remarks

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

Core component

Recommendation or good practice statement

Key remarks

Strength of recommendation and quality of evidence

1. IPC programmes

1a. The panel recommends that an IPC programme with a dedicated, trained team should be in place in each acute health care facility for the purpose of preventing HAI and combating AMR through IPC good practices.

• The organization of IPC programmes must have clearly defined objectives based on local epidemiology and priorities according to risk assessment and functions that align with and contribute to the prevention of HAI and the spread of AMR in health care.

• It is critical for a functioning IPC programme to have dedicated, trained professionals in every acute care facility. A minimum ratio of one full-time or equivalent infection preventionist (nurse or doctor) per 250 beds should be available. However, there was a strong opinion that a higher ratio should be considered, for example, one infection preventionist per 100 beds, due to increasing patient acuity and complexity, as well as the multiple roles and responsibilities of the modern preventionist.

• Good quality microbiological laboratory support is a very critical factor an effective IPC programme.

Strong, very low quality

1b. Active, stand-alone, national IPC programmes with clearly defined objectives, functions and activities should be established for the purpose of preventing HAI and combating AMR through IPC good practices. National IPC programmes should be linked with other relevant national programmes and professional organizations.

• The organization of national IPC programmes must be established with clear objectives, functions, appointed infection preventionists and a defined scope of responsibilities. Minimum objectives should include:

â–ª goals to be achieved for endemic and epidemic infections

â–ª development of recommendations for IPC processes and practices that are known to be effective in preventing HAI and the spread of AMR

• The IHR (2005) and the WHO Global Action Plan on AMR (2015) support national level action on IPC as a central part of health systems’ capacity building and preparedness. This includes the development of national plans for preventing HAI, the development or strengthening of national policies and standards of practice regarding IPC activities in health facilities, and the associated monitoring of the implementation of and adherence to these national policies and standards.

• The organization of the programme should include (but not be limited to) at least the following components:

â–ª appointed technical team of trained infection preventionists, including medical and nursing professionals

â–ª the technical teams should have formal IPC training and allocated time according to tasks

â–ª the team should have the authority to make decisions and to influence field implementation

â–ª the team should have a protected and dedicated budget according to planned IPC activity and support by national authorities and leaders

• The linkages between the national IPC programme and other related programmes are key and should be established and maintained.

• An official multidisciplinary group, committee or an equivalent structure should be established to interact with the IPC technical team.

Good practice statement

2. IPC guidelines

The panel recommends that evidence-based guidelines should be developed and implemented for the purpose of reducing HAI and AMR. The education and training of relevant health care workers on the guideline recommendations and the monitoring of adherence with guideline recommendations should be undertaken to achieve successful implementation.

Health care facility

• Appropriate IPC expertise is necessary to write or adapt and adopt a guideline both at the national and health care facility level. Guidelines should be evidence-based and reference international or national standards. Adaptation to local conditions should be considered for the most effective uptake and implementation.

• Monitoring adherence to guideline implementation is essential.

National level

• Developing relevant evidence-based national IPC guidelines and related implementation strategies is one of the key functions of the national IPC programme.

• The national IPC programme should also ensure that the necessary infrastructures and supplies to enable guideline implementation are in place.

• The national IPC programme should support and mandate health care workers’ education and training focused on the guideline recommendations.

Strong, very low quality

3. IPC education and training

3a. The panel recommends that IPC education should be in place for all health care workers by utilizing team- and task-based strategies that are participatory and include bedside and simulation training to reduce the risk of HAI and AMR.

• IPC education and training should be a part of an overall health facility education strategy, including new employee orientation and the provision of continuous educational opportunities for existing staff, regardless of level and position (for example, including also senior administrative and housekeeping staff).

• Three categories of human resources were identified as targets for IPC training and requiring different strategies and training contents: IPC specialists, all health care workers involved in service delivery and patient care, and other personnel that support health service delivery (administrative and managerial staff, auxiliary service staff, cleaners, etc.).

• Periodic evaluations of both the effectiveness of training programmes and assessment of staff knowledge should be undertaken on a routine basis.

Strong, moderate quality

3b. The national IPC programme should support the education and training of the health workforce as one of its core functions.

• The IPC national team plays a key role to support and make IPC training happen at the facility level.

• To support the development and maintenance of a skilled, knowledgeable health workforce, national pregraduate and postgraduate IPC curricula should be developed in collaboration with local academic institutions.

• In the curricula development process, it is advisable to refer to international curricula and networks for specialized IPC programmes and to adapt these documents and approaches to national needs and local available resources.

• The national IPC programme should provide guidance and recommendations for in-service training to be rolled out at the facility level according to detailed IPC core competencies for health care workers and covering all professional categories listed in core component 3a.

Good practice statement

4. Surveillance

4a. The panel recommends that facility-based HAI surveillance should be performed to guide IPC interventions and detect outbreaks, including AMR surveillance with timely feedback of results to health care workers and stakeholders and through national networks.

• Surveillance of HAI is critical to inform and guide IPC strategies.

• Health care facility surveillance should be based on national recommendations and standard definitions and customized to the facility according to available resources with clear objectives and strategies. Surveillance should provide information for:

â–ª describing the status of infections associated with health care (that is, incidence and/or prevalence, type, aetiology and, ideally, data on severity and the attributable burden of disease).

â–ª identification of the most relevant AMR patterns.

â–ª identification of high risk populations, procedures and exposures.

â–ª existence and functioning of WASH infrastructures, such as a water supply, toilets and health care waste disposal.

â–ª early detection of clusters and outbreaks (that is, early warning system).

â–ª Evaluation of the impact of interventions.

• Quality microbiology and laboratory capacity is essential to enable reliable HAI surveillance.

• The responsibility for planning and conducting surveillance and analysing, interpreting and disseminating the collected data remains usually with the IPC committee and the IPC team.

• Methods for detecting infections should be active. Different surveillance strategies could include the use of prevalence or incidence studies.

• Hospital-based infection surveillance systems should be linked to integrated public health infection surveillance systems.

• Surveillance reports should be disseminated in a timely manner to those at the managerial or administration level (decision-makers) and the unit/ward level (frontline health care workers).

• A system for surveillance data quality assessment is of the utmost importance.

Strong, very low quality

4b. The panel recommends that national HAI surveillance programmes and networks that include mechanisms for timely data feedback and with the potential to be used for benchmarking purposes should be established to reduce HAI and AMR.

• National HAI surveillance systems feed in to general public health capacity building and the strengthening of essential public health functions. National surveillance programmes are also crucial for the early detection of some outbreaks in which cases are described by the identification of the pathogen concerned or a distinct AMR pattern. Furthermore, national microbiological data about HAI aetiology and resistance patterns also provide information relevant for policies on the use of antimicrobials and other AMR-related strategies and interventions.

• Establishing a national HAI surveillance programme requires full support and engagement by governments and other respective authorities and the allocation of human and financial resources.

• National surveillance should have clear objectives, a standardized set of case definitions, methods for detecting infections (numerators) and the exposed population (denominators), a process for the analysis of data and reports and a method for evaluating the quality of the data.

• Clear regular reporting lines of HAI surveillance data from the local facility to the national level should be established.

• International guidelines on HAI definitions are important, but it is the adaptation at country level that is critical for implementation.

• Microbiology and laboratory capacity and quality are critical for national and hospital-based HAI and AMR surveillance. Standardized definitions and laboratory methods should be adopted.

• Good quality microbiological support provided by at least one national reference laboratory is a critical factor for an effective national IPC surveillance programme.

• A national training programme for performing surveillance should be established to ensure the appropriate and consistent application of national surveillance guidelines and corresponding implementation toolkits.

• Surveillance data is needed to guide the development and implementation of effective control interventions.

Strong, very low quality

5. Multimodal strategies

5a. The panel recommends that IPC activities using multimodal strategies should be implemented to improve practices and reduce HAI and AMR.

• Successful multimodal interventions should be associated with an overall organizational culture change as effective IPC can be a reflector of quality care, a positive organizational culture and an enhanced patient safety climate.

• Successful multimodal strategies include the involvement of champions or role models in several cases

• Implementation of multimodal strategies within health care institutions needs to be linked with national quality aims and initiatives, including health care quality improvement initiatives or health facility accreditation bodies.

Strong, low quality

5b. The panel recommends that national IPC programmes should coordinate and facilitate the implementation of IPC activities through multimodal strategies on a nationwide or subnational level.

• The national approach to coordinating and supporting local (health facility level) multimodal interventions should be within the mandate of the national IPC programme and be considered within the context of other quality improvement programmes or health facility accreditation bodies.

• Ministry of health support and the necessary resources, including policies, regulations and tools, are essential for effective central coordination. This recommendation is to support facility level improvement.

• Successful multimodal interventions should be associated with overall cross-organizational culture change as effective IPC can be a reflector of quality care, a positive organizational culture and an enhanced patient safety climate.

• Strong consideration should be given to country adaptation of implementation strategies reported in the literature, as well as to feedback of results to key stakeholders and education and training to all relevant persons involved in the implementation of the multimodal approach.

Strong, low quality

6. Monitoring/audit of IPC practices and feedback

6a. The panel recommends that regular monitoring/audit and timely feedback of health care practices according to IPC standards should be performed to prevent and control HAI and AMR at the health care facility level. Feedback should be provided to all audited persons and relevant staff.

• The main purpose of auditing/monitoring practices and other indicators and feedback is to achieve behaviour change or other process modification to improve the quality of care and practice with the goal of reducing the risk of HAI and AMR spread. Monitoring and feedback are also aimed at engaging stakeholders, creating partnerships and developing working groups and networks.

• Sharing the audit results and providing feedback not only with those being audited (individual change), but also with hospital management and senior administration (organizational change) are critical steps. IPC teams and committees (or quality of care committees) should also be included as IPC care practices are quality markers for these programmes.

• IPC programmes should be periodically evaluated to assess the extent to which the objectives are met, the goals accomplished, whether the activities are being performed according to requirements and to identify aspects that may need improvement identified via standardized audits. Important information that may be used for this purpose includes the results of the assessment of compliance with IPC practices, other process indicators (for example, training activities), dedicated time by the IPC team and resource allocation.

Strong, low quality

6b. The panel recommends that a national IPC monitoring and evaluation programme should be established to assess the extent to which standards are being met and activities are being performed according to the programme’s goals and objectives. Hand hygiene monitoring with feedback should be considered as a key performance indicator at the national level.

• Regular monitoring and evaluation provides a systematic method to document the progress and impact of national programmes in terms of defined indicators, for example, tracking hand hygiene improvement as a key indicator, including hand hygiene compliance monitoring.

• National level monitoring and evaluation should have in place mechanisms that:

â–ª Provide regular reports on the state of the national goals (outcomes and processes) and strategies.

â–ª Regularly monitor and evaluate the WASH services, IPC activities and structure of the health care facilities through audits or other officially recognized means.

â–ª Promote the evaluation of the performance of local IPC programmes in a non- punitive institutional culture.

Strong, moderate quality

7. Workload, staffing and bed occupancy (acute health care facility only)

The panel recommends that the following elements should be adhered to in order to reduce the risk of HAI and the spread of AMR:

(1) bed occupancy should not exceed the standard capacity of the facility;

(2) health care worker staffing levels should be adequately assigned according to patient workload.

• Standards for bed occupancy should be one patient per bed with adequate spacing between patient beds and that this should not be exceeded.

• Intended capacity may vary from original designs and across facilities and countries. For these reasons, it was proposed that ward design regarding bed capacity should be adhered to and in accordance with standards. In exceptional circumstances where bed capacity is exceeded, hospital management should act to ensure appropriate staffing levels that meet patient demand and an adequate distance between beds. These principles apply to all units and departments with inpatient beds, including emergency departments.

• The WHO Workload Indicators of Staffing Need method provides health managers with a systematic way to determine how many health workers of a particular type are required to cope with the workload of a given health facility and decision-making (http://www.who.int/hrh/resources/wisn_user_manual/en/).

• Overcrowding was recognized as being a public health issue that can lead to disease transmission.

Strong, very low quality

8. Built environment, materials and equipment for IPC at the facility level (acute health care facility only)

8a. Patient care activities should be undertaken in a clean and/or hygienic environment that facilitates practices related to the prevention and control of HAI, as well as AMR, including all elements around the WASH infrastructure and services and the availability of appropriate IPC materials and equipment.

• An appropriate environment, WASH services and materials and equipment for IPC are a core component of effective IPC programmes at health care facilities.

• Ensuring an adequate hygienic environment is the responsibility of senior facility managers and local authorities. However, the central government and national IPC and WASH programmes also play an important role in developing standards and recommending their implementation regarding adequate WASH services in health care facilities, the hygienic environment, and the availability of IPC materials and equipment at the point of care.

• WHO standards for drinking water quality, sanitation and environmental health in health care facilities should be implemented.

Good practice statement

8b. The panel recommends that materials and equipment to perform appropriate hand hygiene should be readily available at the point of care.

• WHO standards for the adequate number and appropriate position of hand hygiene facilities should be implemented in all health care facilities.

Strong, very low quality

  1. HAI health care-associated infection, AMR antimicrobial resistance, IPC infection prevention and control, IHR International Health Regulations, WASH water, sanitation and health, NA not applicable