This survey provided a comprehensive analysis of IPC implementation in Eastern China. Overall, the participating hospitals had a median score of 682, which corresponded to an “advanced” IPC level. These results are similar to those reported in developed countries, such as Germany and Austria. Noticeably, 25.6% (32/125) of the secondary care hospitals that participated were classified as “intermediate” or “basic”. Secondary care hospitals in IPC have limited human and material resources, making some core components difficult to implement. Our results are consistent with the aforementioned phenomenon. Therefore, we should pay more attention to IPC practices in secondary care hospitals, especially IPC programme and multimodal strategies for implementation of IPC interventions.
Nosocomial infection management has been practiced in China since 1896. Over the last 30 years, IPC has made remarkable achievements in regulations and policies, particularly in the aftermath of SARS and COVID-19 pandemics [15, 16]. A median score of 85 to 100 indicated that IPC programs and guidelines are widely established in China. In this study, 96.8% of hospitals reported having an IPC committee, and three-quarters had an allocated budget, both of which were slightly higher than previously reported levels in a systematic review . This is partially explained by the widespread use of electronic HAI surveillance and IPC activities in the participating hospitals. However, further research is required to evaluate the impact of the allocated budget on IPC implementation. There are many national IPC documents, most of which are mandatory in China. Thus, it is not surprising that participating hospitals had such high scores on CC2 (IPC guidelines).
The authors of a 2017 systematic review and expert consensus recommended a ratio of one full-time or equivalent IP per 250 beds . During the COVID-19 pandemic, the National Health Commission of China recommended a ratio of one full-time IP for every 150–200 beds, two IPs for less than 100 beds, and four IPs for 100–500 beds . In our study, the average number of IPs per 100 beds was 0.5, which is lower than 1.2 in American hospitals and 0.8 in Canadian hospitals [19, 20]. There is still a significant disparity between the current staffing levels and national standards, which may be attributed to a lack of commitment by hospital leaders to infection control. Moreover, health care workers may be reluctant to work full-time on IPC due to limited career tracks and low salaries.
Infection control is a dynamic and evolving discipline. Orientation of new employees and continuous IPC education and training for healthcare workers (HCWs) are vital in hospitals. Although HCWs are aware of the risk of the transmission of infection, compliance with standard precautions was unsatisfactory . Therefore, a multifaceted approach to educate HCWs regarding compliance with standard precautions is recommended. Only about half of the participating hospitals reported using simulation-based training, an evidence-based approach that has been shown to improve hand hygiene compliance and lower HAIs, to educate their HCWs and other personnel. Additionally, our results indicated that patients and family members received less IPC training than HCWs. To prevent the transmission of HAIs and improve care quality, recommendations such as hand hygiene, couth etiquette and other IPC that can be shared with the patients to minimize the risk of HAIs were made to empower patients and family members in infection control aspects [22, 23]. Additional studies are needed to assess patient education on infection control measures to develop a validated intervention program.
Surveillance and feedback of surveillance data to frontline HCWs and other stakeholders have been a cornerstone in IPC program improvement. Almost all hospitals reported conducting HAI surveillance, because annual prevalence investigations on HAIs are mandatory in Mainland China. In 2017, the CHINET surveillance reported that the prevalence of methicillin-resistant S. aureus was 37.3%, and the prevalence of vancomycin-resistant enterococci was 2.0% . These numbers are alarming, and IPC should be empowered to prevent cross-transmission of multidrug-resistant microorganisms in hospitals.
Assessment of safety culture is still in its infancy among acute care hospitals in China. In our study, only 10.4% of the participating hospitals assessed safety cultural factors. Although the importance of adhering to IPC recommendations has been highlighted, adoption remains suboptimal in hospitals . Safety culture is recognized as a critical factor in improving IPC performance and reducing HAIs [26, 27]. It is recommended that hospitals and care units should regularly assess safety culture using the validated tools and identify areas for improvement.
Our study had certain limitations. The hospitals participated in this study were secondary and tertiary care hospitals, which have more resources for IPC implementation than primary care hospitals. Thus, the IPCAF results can only be extrapolated cautiously to secondary or above care hospitals, but cannot represent the situation of Chinese acute care facilities as a whole. Although there are many Chinese footnotes and explanations provided, some terminology of IPCAF may difficult to understand. The respondents have different educational level, background and work experience, which may lead to false reporting. Furthermore, with a response rate of 58.1%, reporting bias may be present because the results were dependent on hospitals that were interested in participating in this survey. Since this study was conducted during the COVID-19 pandemic, the relatively low response rate may be due to the busy work of IPs and unwillingness to share deficiencies. Notwithstanding these limitations, this study had numerous strengths. This is the first study to use IPCAF to evaluate the current situation of IPC resources and practices in China, which contributes to understand the gap between domestic and international IPC standards. The results highlighted that the IPCAF scores were positively correlated with hospital levels, the number of hospital beds and the number of IPs.