Having an advanced level in terms of implementing the hand hygiene program is associated with the level of infection control staffing, in particular, to achieve reasonable progress in education and for creating an institutional safety climate. The SENIC Project (Study on the Efficacy of Nosocomial Infection Control) calculated the adequate ratio of one infection control professional per 250 hospital beds more than 30 years ago [8]; this ratio was used as a reference for a long period of time. The Delphi project conducted in 2001, suggested that a ratio of 0.8–1 infection control professionals per 100 hospital beds may be needed to effectively drive improvement [9]. This is also supported by recent studies [10, 11].
In Korea, the median number of inpatient beds per infection control professionals among the hospitals which participated in KONIS in 2006 was 580; this was maintained above 300 until 2015 [12]. This was twice as high as the number in US hospitals [13]. The ratio remarkably changed after the infection control policy was introduced by the Korean Government in 2016. The median number of inpatient beds per infection control professional was 141 among hospitals which participated in KONIS in 2018. In this survey, the median number of inpatient beds per infection control professional was 309 in 2013 and 289 in 2015 and markedly decreased to 178 in 2017; this was significant in multivariable linear regression analysis. As a result, the degree of infection control activity measured by the WHO HHASF significantly improved in Korean hospitals.
The compliance of hand hygiene also improved across Korean hospitals. Since 2013 the National Hand Hygiene Promotion Campaign instigated by KCDC conducted several pilot surveillances for hand hygiene compliance in hospitals [14]. Although a simple comparison is difficult as the participating hospitals are different during each surveillance period, hand hygiene compliance was 67.2% in 35 hospitals between November 2013 and February 2014, which increased to 83% in 23 hospitals between September 2016 and January 2017, and 85.2% in 61 hospitals between February 2018 and June 2018.
Our surveys, especially the 2017 survey, presents a snapshot of the current level of implementation of hand hygiene improvement programs in Korean healthcare facilities. In the 2017 survey, most hospitals (94.1%) were at intermediate and advanced levels of progression; there were no hospitals with inadequate levels. Based on the HHSAF, the median score in the 2017 survey indicated that the level of progress was at an “advanced” level. These results mean that an appropriate hand hygiene promotion strategy is in place and the practices have improved in Korea, which was similar to the US survey for 168 facilities conducted in 2011 and the global survey for 86 facilities conducted in 2015 [11, 15].
In the 2017 survey, specific component scores were higher for system change (median 95, IQR 85–100) and evaluation and feedback (median 85, IQR 75–90). These scores had significantly improved compared to previous surveys. This result suggested that the facilities for hand hygiene, such as easy access to alcohol-based hand sanitizer, have been sufficiently improving and the activities for hand hygiene monitoring and feedback have been well established in Korean hospitals. The institutional safety climate around hand hygiene was the element of the strategy that scored the lowest in all surveys (median scores, 55–60), which did not significantly change over time. In both US and global surveys, the score for institutional safety climate was also the lowest [11, 15]. This likely reflects the challenges to convey the concept that infection control and preventive interventions can be significantly enhanced when understood in the context of a positive safety culture.
In this study, total HHSAF score was significantly associated with hospital size and teaching status. In contrast to our results, there was no association between total HHSAF score and facility size and teaching status in the survey conducted in the US [11]. This suggested that the infection control activities in Korea have been conducted mainly at large teaching hospitals and have not sufficiently permeated through to smaller sized hospitals.
Our study has several limitations. First, although the usability and reliability of the WHO HHSAF was well established [4], reporting bias may be present as the results rely on self-assessment. Second, this study results might exaggerate the actual status of hand hygiene activities in Korea because hospitals voluntarily participated in the surveys and hospitals with more hand hygiene promotion activities may have participated in the survey.
