Table 1 Frequent (≥ 3 occurrences) themes concerning IPC implementation lessons learned in low-resource settings according to each WHO core component

Core Component 1: IPC programme

Need an approach to maintain “continuous” advocacy (n = 15)

Set up regular meetings with senior leadership/managers

10

IPC should be a part of routine meetings, presentations, or rounds

5

May first need external technical assistance (n = 13)

National level should first support selected professionals to receive external IPC training and these professionals can then act as trainers in-country

9

External IPC experts should first review initial materials to ensure they meet IPC standards

4

Use a stepwise approach to build required resources (n = 10)

Start with a small group of committed staff in addition to link nurses and regional staff

6

Need at least a small budget in the beginning for recognition

4

Use specific activities or opportunities as “catalysts” for advocacy (n = 6)

Use of data (process or outcome measures) can help convince leadership of IPC’s importance, i.e. avoid "no data, no problem"

3

Publicize starting examples, e.g. hand hygiene, surgical site infections

3

Promote linkages with health system (n = 6)

Link IPC personnel and team with the quality management team

3

Link IPC personnel and team with AMR team

3

National IPC association can drive IPC improvement (n = 6)

National IPC association can be active in providing expert input and assisting with local adaption of materials

6

May need normative actions to convince stakeholders (n = 4)

Need legislation for recognition

4

Core Component 2: IPC guidelines

Consider specific approaches to operationalize guidelines (n = 16)

Link guidelines directly to training and workshops

6

Link guidelines directly to monitoring indicators

4

Set guideline dissemination plan early during planning

3

Designate dedicated multidisciplinary guideline implementation leads

3

Use specific strategies for adaption of guidelines (n = 15)

Schedule ongoing meetings to review guidelines and regularly update them based on current evidence and practice

5

National IPC association can drive guidance development and adaption

4

Meet with other public health programmes (e.g. maternal and child health, HIV, tuberculosis) and identify joint guideline themes and actions

3

Develop a plan to collect local evidence to inform guidelines

3

May first need external technical assistance (n = 12)

Hire external IPC expert for initial development and then locally adapt

8

Adapt international standard guidelines, e.g. WHO, ECDC, US CDC

4

Core Component 3: IPC education and training

Consider specific training methods (n = 19)

Select 1–2 master trainers to first receive IPC expert training outside of the country

5

Consider multidisciplinary training, i.e. different staff together, to remove hierarchy

4

Use a train-the-trainers structure

4

May need initial IPC expert technical consultant and then can locally adapt training

3

Ensure regular in-service workshops

3

Promote linkages with health system and sustainability (n = 9)

Create an IPC career path, e.g. accreditation

5

Harmonize trainings across programmes, e.g. maternal and child health, HIV, tuberculosis

4

Foster local IPC leadership during trainings (n = 7)

Require mandatory trained IPC hospital leads who can play an integral role in trainings

4

Identify local champion trainers and trainees at the facility level

3

Core Component 4: HAI surveillance

Prioritise feasible but high-impact starting points or pilots (n = 30)

Start with surgical site infection (e.g. post caesarean-section, 30-day follow-up) pilot

8

Start with device-associated infection, e.g. urinary or bloodstream, pilot

5

Start with severe acute respiratory infection pilot

5

Use a stepwise fashion to slowly scale-up surveillance in a careful way

5

Can start with paper-based system but develop transition plan for electronic surveillance

4

Start with pilot in intensive care units

3

Ensure multidisciplinary collaboration, mentorship (n = 26)

Conduct regular surveillance training and feedback, e.g. yearly seminars

6

Conduct site support visits, e.g. assessment of case finding, forms, denominator data

5

Advocate for integration of HAI surveillance with AMR and stewardship efforts

4

Create a technical working group on surveillance in National IPC or AMR committees

4

Ensure that one hospital is effectively trained in surveillance and can provide leadership to other hospitals

4

Promote frequent informal mentorship

3

Carefully consider definitions and data quality processes (n = 22)

Conduct a careful structured discussion on adaption of case definitions, maintaining standards, consistency and predictive value

7

Reference US National Healthcare Safety Network (NHSN) definitions

7

First identify who can collect, clean, and analyse data, i.e. invest in statisticians

4

Decide early on how to regularly evaluate data quality

4

Promote “data for action” (n = 7)

Leverage quality improvement programme/activities

7

Core Component 5: Multidmodal strategies for implementation of IPC interventions

Promote activities to clearly communicate and advocate for multimodal strategies (n = 16)

Need leadership buy-in to obtain resources, e.g. awareness workshop, regular meetings

7

Many cannot explain what multimodal strategies so communicate a clear definition

6

Identify multidisciplinary champions for multimodal strategies

3

Put focus on certain elements of multimodal strategies (n = 16)

Monitoring, audit, feedback, scoring and accountability mechanisms are key elements

8

Guidelines and training are key elements

4

Promotion of safety culture is a key element, e.g. organizational culture questionnaire, team communication mechanisms, mentorship activities

4

Prioritise feasible but high-impact starting points or pilots (n = 14)

Start with hand hygiene pilot

8

Start with device-associated infections, e.g. urinary or bloodstream, pilot

3

Start with surgical site infection pilot

3

Core Component 6: Monitoring/audit of IPC practices and feedback

Promote “data for action” (n = 17)

Present at IPC committee meetings, during hospital workshops, and in staff emails to build political will for change

6

Recognize performance with incentives, e.g. centre of excellence, ward/personnel awards

6

Publish scores for staff, e.g. device-associated infection-free days, hand hygiene practices

5

Prioritise feasible but high-impact starting points or pilots (n = 12)

Monitoring/audit and feedback should be part of IPC implementation from the beginning

5

Start with hand hygiene pilot

4

Start small to show “the problem”

3

Put focus on certain methods (n = 6)

Communicate positive audit and feedback culture, i.e. not punitive

3

Integrate with national health monitoring and information systems (HMIS)

3

Core Component 7: Workload, staffing and bed occupancy

Need the participation of national level actors (n = 11)

National level actors should set standards, e.g. for nurse-patient ratio

6

Long-term advocacy with national level actors is essential

5

Put focus on certain methods (n = 3)

Need to show data and local research to set staffing and bed occupancy standards

3

Core Component 8: Built environment, materials and equipment for IPC

IPC professionals should be actively involved in facility construction (n = 8)

Conduct regular meetings between construction and IPC teams to ensure that facility design, construction, modifications and renovations meet IPC standards

8

Put focus on certain elements of a multimodal strategy (n = 5)

Start with procuring equipment for hand hygiene

5

Promote long-term advocacy and integration with health system (n = 3)

Long-term WASH advocacy is needed for leadership buy-in and need phased in approach

3