- Email: [email protected]
Infection control capacity building in European countries with limited resources: issues and priorities
Accepted Manuscript Infection control capacity building in European countries with limited resources: issues and priorities Monica Licker, Luminiţa Bădiţoiu, Diana Lungeanu, Rossitza Dobrevska, Emese Szilagy, Lul Raka, Ljiljana Markovic-Denic, Silvio Brusaferro PII:
S0195-6701(17)30005-1
DOI:
10.1016/j.jhin.2016.12.024
Reference:
YJHIN 5001
To appear in:
Journal of Hospital Infection
Received Date: 26 October 2016 Accepted Date: 30 December 2016
Please cite this article as: Licker M, Bădiţoiu L, Lungeanu D, Dobrevska R, Szilagy E, Raka L, MarkovicDenic L, Brusaferro S, Infection control capacity building in European countries with limited resources: issues and priorities, Journal of Hospital Infection (2017), doi: 10.1016/j.jhin.2016.12.024. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Infection control capacity building in European countries with limited resources:
issues and priorities Monica LICKER1,2, Luminiţa BĂDIŢOIU1, Diana LUNGEANU1*, Rossitza DOBREVSKA3,
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Emese SZILAGY4, Lul RAKA5, Ljiljana MARKOVIC-DENIC6, Silvio BRUSAFERRO7
“Victor Babes” University of Medicine and Pharmacy Timisoara, Romania
2
“Pius Branzeu” Emergency, Clinical, County Hospital Timisoara, Romania
3
Bulgarian Association on Infection Prevention and Control "BulNoso", Bulgaria
4
Hungarian Society for Infection Control, Hungary
5
National Institute of Public Health, Kosovo
6
Faculty of Medicine, University of Belgrade, Institute of Epidemiology, Serbia
7
Department of Medical and Biological Sciences, University of Udine, Italy
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Running head: Infection control capacity set-up priorities
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Keywords: infection control, healthcare associated infection, patient safety
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Corresponding author: Diana LUNGEANU
„Victor Babes” University of Medicine and Pharmacy, Timisoara P-ta Eftimie Murgu 2, 300041-Timisoara, Romania Email: [email protected]
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Summary: We report the results of a panel investigation aimed at assessing the critical aspects regarding healthcare associated infections in European countries with limited resources and pinpointing the highest priority issues that need to be addressed for effective infection control. Questionnaires were designed and information collected from national EUNETIPS representatives in Bulgaria, Hungary, Kosovo, Romania, and Serbia. Based on the data collected, we concluded that rigorous implementation of existing law, standardized training, and political commitment constitute
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a common relevant background and provide the lessons to be learnt for aligning healthcare systems
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in this area with internationally recommended standards of infection control.
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Introduction
Hundreds of millions of patients are affected by healthcare associated infections (HCAI) worldwide each year, leading to significant mortality and financial losses for healthcare systems. Of every 100 hospitalized patients, between seven (in developed countries) and ten (in developing ones) suffer at least one HCAI, with a significantly higher endemic burden of HCAI for patients admitted to high
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risk departments such as intensive care units (ICU).1 While urinary tract infection (UTI) is the most frequent HCAI in high-income countries, surgical site infection (SSI) is the leading infection in areas with only limited resources, affecting up to one-third of the operated patients, i.e. the level being up to nine times higher than in developed countries.1 In the 21st century, infection control (IC) and hospital hygiene activities face new challenges: a lack of funds for specific HCAI,
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insufficient resources, and increasing pressure for publicly reporting surveillance data. While managers and administrators too frequently fail to allocate adequate resources to IC programmes,
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there is nevertheless a huge disparity in the availability of resources between countries and even between national centres.2 A critical leading role in HCAI prevention and control is played by European Institutions, i.e. DG SANCO, ECDC, European Food Safety Authority (EFSA), European professional and scientific networks, like EUropeanNETwork to promote Infection Prevention for Patient Safety (EUNETIPS), or World Health Organization (WHO). Moreover, they are key players
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in effectively preventing and controlling the spread of antimicrobial resistance (AMR).3-6 In this context, we aimed to identify or confirm common critical issues in HCAI control in SouthEastern European countries which have limited resources to invest in healthcare. These issues should be top-priority targets for these countries healthcare policies and for know-how transfer from
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Methods
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high income European countries.
A panel investigation was conducted between January and March 2016. Based on WHO technical papers and previous reports regarding HCAI in developing countries, a 30-item questionnaire was designed and feed-back was collected from the national EUNETIPS representatives of Bulgaria, Hungary, Kosovo, Romania, and Serbia. The countries were chosen based on geographical area and on their shared cultural and historical background as former communist regimes. All responses were the opinions of experts who agreed to participate in the panel and no verification was requested. Both open-ended and closed-ended questions were asked. The latter were either dichotomous (0 for absence or not a cause; 1 for presence or agreement) or ranking on a four-point scale (0 for absence, the least degree, or never encountered situation; 1 – sometimes encountered; 2 – often or frequently encountered; 3 – always encountered, certainty, or required/guaranteed by law). For the closed3
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ended questions, statistics consisting of frequency counts were provided. Responses to the fourpoint scale questions were considered as ordinal variables when enough variability among the five respondents was present. The open-ended questions underwent a separate thematic analysis based on the Braun and Clarke's six-phase guide.7 An inductive approach was employed, aimed to identify any supplementary emergent theme and help in interpreting the overall results.
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Reliability analysis was conducted on meaningful sub-scales of closed-ended questions, by employing the Cronbach's alpha. The standardized Cronbach's alpha was provided as well, as an indication of non-redundancy when the two values were close. Two questions (Q17 and Q27) had the coding reversed for this analysis. For sub-scales with at least acceptable consistency
The statistical analysis was performed with SPSS v20.0.
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Results
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(Cronbach's alpha over 0.6) the inter-item correlation matrix was provided and further discussed.
The full questionnaire together with the answers received is presented in the Annex. Table I provides a general description and the results of reliability analysis for the closed-ended questions to which it was applicable. For the meaningful and reliable sub-scales, the inter-item correlation analysis was applied (Table II).
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Regarding resources, all the five panel contributors reported staff shortages (Q17, Q18), a general lack of capacity associated with a lack of both supply services and of adequate staff training (strongly correlated Q4 a, e, f). Shortcomings in supplying services, drugs, and training also correlated positively (Q4 c, d, f). Strong negative correlations in Q4-items were found between
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technology and a lack of human resources and supply services (b with a, c, f). A lack of policies correlated strongly and positively with human resources, adequate training, drugs, and supply
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services (Q4 g with a, d, e, f).
Regarding standards and procedures, a negative strong correlation was found between Q14 and Q15. Answers to Q26 and Q27 were inconsistent. The sub-scale of antibiotics issues was consistent (high alpha value), with strong positive inter-item correlation (Q21−24). The answers to open-ended questions (Q29-30) were collated into three main themes: (1) lack of financial resources is a critical aspect: (2) lack of trained human resources is a critical aspect but can be improved with limited resources; (3) poor health policies and mis-articulated political commitment is a critical aspect, though things can be improved with limited financial investment.
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Discussion
Raka and Mulliqi-Osmani have highlighted limited resources, poor infrastructure, insufficient equipment, together with a lack of national guidelines and policies as key difficulties in combating antibiotic resistance and IC successful implementation in the region, solely based on microbiology laboratory support.3 According to Rodrigues-Bano et al., agreement on the minimum requirements
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for adequate IC should be reached as institutional priority, with clear programmes including objectives, indicators, periodical evaluations, multidisciplinary IC teams, and education for ward staff in IC-related issues.2 We actually found that all the five countries experienced serious staff shortages, correlating with deficiencies in staff training and supply services. Unsurprisingly, in 2016, technology appeared as pervasive but it could not compensate for the lack of human resources
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and supply services. There was a general negative perception regarding all resources, except for technology.
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In terms of challenges, lack of adherence to standard precautions in health care facilities remains a formidable obstacle, due to insufficient educational efforts and awareness building. Surveillance for HCAI outbreaks and bacterial resistance, together with the systematic assessment of compliance with infection-prevention and control (IPC) practices play an essential part in developing any IC policy and measuring the success.4 Meanwhile, adopting and implementing European strategies for
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patient safety and HCAI prevention and control is in progress.5,6,8 Indeed, the result this panel revealed was of a strong positive correlation between rigorous procedures in place for monitoring the quality of sterilization/ disinfection and the existence of institutional guidelines and protocols for HCAI prevention and control. However, there was zero correlation with the application of
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national standards, even when they did exist, though hospitals did make efforts at training the staff. Harmonisation of training programmes in terms of IC, through engagement of professionals and
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training organizations, has already been identified as an important mechanism for improving the quality of healthcare throughout Europe.9,10 The actual answers to the antibiotics sub-scale showed the awareness of the medical personnel regarding the importance of screening and reliable microbiological diagnosis in timely implementation of antimicrobial therapy and also in patient prognosis. Overall, across the sub-scales analysed and the answered open-ended questions, the common denominator and perceived top-priority target proved to be national-level adequate training coupled with political commitment.
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Conclusions
The novel contribution of this expert panel report consists in bringing under a common umbrella the shared problems and concerns from countries in the South-Eastern part of Europe. Despite the differences across the countries and their limited resources, there are common issues to be realistically addressed in order to obtain better results in infection control, as well as valuable
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lessons to learn from countries with more resources available and higher levels of performance in preventing HCAI.
Funding sources: this research did not receive any specific grant from funding agencies in the
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public, commercial, or not-for-profit sectors.
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Conflict of interest statement: none declared.
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References
1. WHO. Health care-associated infections FACT SHEET. Available athttp://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf [Accessed August 2016]. 2. Rodrigues-Bano J, del Toro MD, Lopez-Mendez J, et al. Minimum requirements in infection control. Clin Microbiol Infect 2015; 21(12): 1072-1076.
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3. Raka L, Mulliqi-Osmani G. Infection Control in Developing World. In: Sudhakar C, editor. Infection Control – Updates, InTech; 2012. p. 65-78. DOI: 10.5772/33282. 4. WHO. Infection prevention and control in health care: time for collaborative action. Available at http://applications.emro.who.int/docs/EM_RC57_6_en.pdf?ua=1 [Accessed August 2016].
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5. Brusaferro S. Improving infection control and hospital hygiene in Europe: Professional networks and European programs. 2015/C 151/01; Available athttp://eunetips.eu/pdf/eunetips.2015.06.26.brusaferro.pdf [Accessed August 2016].
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6. European Union Council Recommendation on patient safety, including the prevention and control of healthcare associated infections. 2009; Available at http://ec.europa.eu/health/patient_safety/docs/council_2009_en.pdf[Accessed August 2016]. 7. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3(2): 77101.
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8. Allegranzi B, Begheri Nejad S, Combescure C, et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. The Lancet 2011; 377: 228241. 9. Brusaferro S, Arnoldo L, Cattani G, et al. Harmonizing and supporting infection control training in Europe, J Hosp Infect. 2015;89: 351–346.
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10. Brusaferro S, Cookson B, Kalenic S, et al.Training infection control and hospital hygiene professionals in Europe, 2010: agreed core competencies among 33 European countries. Euro Surveill, 2014; 19: 45-54.
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Table I. General description and reliability analysis for closed-ended questions.
Resources (Q1 – Q4)
Cronbach's alpha (Std Cronbach's alpha)
Description
Q1-Q3 were country-specific Yes/No questions with 0.77 (0.779) almost no overlapping across countries − no further statistics were calculated. Q4 was a 7-item sub-scale with binary options, aimed at identifying most critical areas where resources are lacking (4a. Human resources; 4b. Technologies; 4c. Medical devices; 4d. Drugs; 4e. Supply services (cleaning, sterilization, etc.); 4f. Training; 4g. Policies).
Four-rank questions were aimed at identifying infrastructure and organizational issues in hospitals (e.g. availability of isolation rooms, toilets, antiseptic solutions, disinfectants), with no country-specificity.
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Infrastructure (Q6 – Q10)
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Cronbach's alpha was calculated.
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Factors or issues investigated
0.063 (0.114)
Cronbach's alpha was calculated and answers ended in low reliability. These items were not included in the interitem correlation analysis. Two- and four-rank questions seeking to determine degree of availability of national standards, local rigorous procedures and their application, standardized training, guidelines and protocols.
0.625 (0.643)
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Standards and procedures (Q11 – Q16; Q19, Q20)
Yes/No questions, no variance (i.e. all five countries experience serious staff shortages).
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Staff shortages (Q17, Q18)
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Some data ended in no variance, with all negative answers− no further statistics were calculated for Q12, Q13, and Q19. Composite scale was constructed including Q11, Q14, Q15, Q16, Q20. For this scale, Cronbach's alpha was calculated. –
No further statistics were calculated.
Antibiotics issues Q21 – Q24)
Four-rank questions seeking for the degree of in-practice application of therapeutic protocols, capacity of antimicrobial resistance phenotypes identification, HCAI reporting by the microbiology laboratories, routine screening for antimicrobial resistant germs carriers.
0.924 (0.943)
Cronbach's alpha was calculated. Pathology surveillance (Q25)
Four answers for "passive and active detection"; one country (Hungary) mostly relies on active detection. No further statistics were calculated.
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HCAI reporting (Q26, Q27)
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Yes/No questions regarding sanction applied for hospitals with high HCAI prevalence vs. under-reporting the HCAI pathology.
0.571 (0.58)
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Cronbach's alpha was calculated − resulted in contradictory national policies, with low reliability of answers.
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Table II. Inter-item correlation matrix for reliable scale statistics: (a) question 4, regarding the most critical areas where resources are lacking; (b) sub-scale regarding the availability and application of standards, procedures, guidelines, and protocols; (c) sub-scale regarding antibiotics issues*. (a) Resources Q4a Q4b Q4a 1.000 - 0.612 Q4b 1.000 − Q4c − − Q4d − − Q4e − − Q4f − − Q4g − − (b) Standards and procedures Q11 Q14 Q15 Q16 Q20 (c) Antibiotics issues
Q4d Q4e 0.250 1.000 0.612 - 0.612 0.612 0.408 1.000 0.250 1.000 − − − − − Q14 Q15 0 0.324 1.000 - 0.927 1.000 − − − − − Q21 Q22 Q21 1.000 0.873 Q22 1.000 − Q23 − − Q24 − − * items with zero variance were removed from all sub-scale analyses
Q4f 0.612 - 0.167 0.667 0.408 0.612 1.000 − Q16 0.816 - 0.333 0.662 1.000 − Q23 0.764 0.786 1.000 −
Q4g 0.408 0.167 0.167 0.612 0.408 0.667 1.000 Q20 0.853 0.174 0.208 0.870 1.000 Q24 0.913 0.896 0.598 1.000
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Q4c 0.408 0.167 1.000 − − − − Q11 1.000 − − − −
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Annex
Kosovo, Romania, and Serbia. Factors or issues investigated 1
Have new hospitals been built in your country during the past 10 years?
0 – no; 1 – yes
4 no (exception Bulgaria)
2
Has significant refurbishing of existing hospitals intended to reduce the incidence of HCAI been conducted in your country during the past 10 years?
0 – no; 1 – yes
4 yes (exception Hungary, no answer)
3
Do the current (i.e. 2016) available resources in your country cover the requirements for the prevention and control of HCAI?
0 – no; 1 – partially;
4 partial covering (exception Kosovo, no cover)
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Coding
4
2 – yes
If resources are insufficient, which are the most critical areas where resources are lacking in IC/HH?
0 – no, not the case; 1 – yes, this is lacking
between 1 and 7 areas of resource lacking; 4 yes for human resources (exception Hungary) and 1 respondent (Kosovo) checking all the 7 areas;
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4a. Human resources; 4b. Technologies; 4c. Medical devices; 4d. Drugs; 4e. Supply services (cleaning, sterilization, etc.); 4f. Training; 4g. Policies; 4h. Other (please specify...) 5
−
6
Are there sufficient isolation rooms in hospitals in your country (especially for HCAI high risk departments)?
0 – no; 1 – only in few hospitals;
Q6, Q7 each – 3 "only in few hospitals"; none for "all hospitals";
7
Do the hospital rooms in your country have private bathrooms/ toilets?
2 – in the majority of hospitals;
Q8 – 4 "in all hospitals" (exception Bulgaria, in the majority);
8
Is there a sink in each hospital ward in your country?
3 – in all hospitals
Q9 – 3 "in the majority"; none for zero availability;
9
Are antiseptic solutions for the hands of the medical staff being provided in sufficient quantities in hospitals in your country?
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Infrastructure (Q6 – Q10)
Answers (N total =5 respondents)
Question
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Resources (Q1 – Q4)
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Questionnaire used in the HAI panel investigation and answers collected from the national EUNETIPS representatives of Bulgaria, Hungary,
Q10 – 4 "in the majority"; 1 (Hungary) "in all hospitals";
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11
Are there rigorous procedures (written evidence and recording, routine use of indicators, etc.) in place for monitoring the quality of sterilization and disinfection of medical instruments/devices/ equipments in hospitals in your country?
0 – no; 1 – only in few hospitals;
12
Are the hospital cleaning plans coherent with what is recommended by the literature?
0 – no; 1 – yes
13
Are there standards defined at national level on the required number and qualifications of the medical and nursing staff?
4 "in the majority" or "all hospitals"; 1 (Kosovo) "only in few"
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Are disinfectants and current decontamination products provided in sufficient quantities in hospitals in your country?
2 – in the majority of hospitals;
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3 – in all hospitals
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Standards and procedures (Q11 – Q16)
10
0 – no; 1 – only in few hospitals;
4 yes (exception Hungary, no answer) – zero variance 5 "in all hospitals" – zero variance
2 – in the majority of hospitals; 3 – in all hospitals
If standards exist, are these standards applied?
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14
Staff shortages (Q17, Q18)
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Are the members of the healthcare staff regularly and efficiently trained on prevention and control of HCAI?
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15
0 – no; 1 – only in few hospitals;
3 no; 1 "only in few hospitals"; 1 no answer (Hungary)
2 – in the majority of hospitals; 3 – in all hospitals 0 – no; 1 – only in few hospitals;
4 "in the majority" or "all hospitals"; 1 no (Romania)
2 – in the majority of hospitals; 3 – in all hospitals
16
Is there a standardized training plan?
0 – no; 1 – yes
4 no (exception Bulgaria, standardized training plan does exist)
17*
Did your health system suffer in the last five years from significant staff losses?
0 – no; 1 – in very few hospitals, not significant;
no negative answer
2 – yes in some specialties, e.g. ICU;
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3 – yes 0 – no; 1 – yes
no positive answer
19
Are there legal requirements in your country in the field of HCAI? Please specify.
0 – no; 1 – yes
5 yes – zero variance
20
Are there institutional guidelines and protocols for the prevention and control of HCAI implemented in hospitals in your country?
0 – no; 1 – only in few hospitals;
2 "only in few"; 2 "in the majority"; 1 (Hungary) "in all hospitals"
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If the answer for Q17 is yes - Are there specific measures taken to prevent members of the healthcare staff from leaving the system?
2 – in the majority of hospitals;
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Laws, guidelines (Q19, Q20)
18
3 – in all hospitals
21
Are antibiotics prescribed according to therapeutic protocols?
0 – no; 1 – only in few cases;
5 "in the majority" or "all hospitals"
2 – in the majority of cases;
23
Are laboratory capacities in hospitals adequate for the identification of antimicrobial resistance phenotypes?
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3 – in all cases
Do hospital microbiology laboratories report HCAI outbreaks in a timely manner?
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Antibiotics issues (Q21 – Q24)
24
Are patients admitted in high risk hospital departments in your country routinely screened to detect carriers of antimicrobial resistant germs (MRSA, ESBL production, MDR, etc?)
0 – no; 1 – only in few hospitals;
4 "in the majority" or "all hospitals"; 1 "only in few hospitals" (Romania)
2 – in the majority of hospitals; 3 – in all hospitals 0 – no; 1 – only in few hospitals;
2 "only in few hospitals"; 2 "in the majority"; 1 "in all hospitals" (Hungary)
2 – in the majority of hospitals; 3 – in all hospitals 0 – no; 1 – only in few hospitals; 2 – in the majority of hospitals;
2 no; 1 "only in few hospitals"; 2 "in the majority"
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3 – in all hospitals 25
The hospital acquired pathology surveillance system in your country mostly relies on:
0 – no detection; 1 – passive detection;
4 answers for "passive and active detection"; 1 (Hungary) mostly relies on active detection
2 – passive and active detection;
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Pathology surveillance (Q25)
3 – active detection Are there sanctions applied in your country for hospitals with a high prevalence of HCAI?
0 – no; 1 – yes
27*
Are there sanctions taken against hospitals which under-report HCAI pathology?
0 – no; 1 – yes
28
Please indicate your position
29
30
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4 no (exception Romania, i.e. with sanctions for high prevalence of HAI) 3 no; 2 yes (Bulgaria and Hungary)
all respondents in leading positions and national representatives in EUNETIPS
What are the five most critical aspects in your country which can affect an effective prevention and control of HCAI? (please rank them from the first to the fifth)
Open ended
Theme 1 (Q29): lack of financial resources
What are the aspects you think can be improved in IC/HH in your country even with a limited amount of resources?
Open ended
What can be learnt by a high income country from the IC/HH experiences in countries with limited resources? Please specify.
Open ended
* coding was reversed for internal consistency
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Open ended
Two major themes across Q29 and Q30. Theme 2: lack of trained human resources Theme3: poor health policies and mis-articulated political commitment inconsistent answers; most probably due to question misunderstanding
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31
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26
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HAI reporting (Q26, Q27)
EUNETIPS – EUropean NETwork to promote Infection prevention for Patient Safety; HCAI – Healthcare Associated Infection; IC/HH – Infection Control and Hospital Hygiene; ICU – Intensive Care Unit; SSI – Surgical Site Infection; UTI – Urinary Tract Infection
S0195-6701(17)30005-1
DOI:
10.1016/j.jhin.2016.12.024
Reference:
YJHIN 5001
To appear in:
Journal of Hospital Infection
Received Date: 26 October 2016 Accepted Date: 30 December 2016
Please cite this article as: Licker M, Bădiţoiu L, Lungeanu D, Dobrevska R, Szilagy E, Raka L, MarkovicDenic L, Brusaferro S, Infection control capacity building in European countries with limited resources: issues and priorities, Journal of Hospital Infection (2017), doi: 10.1016/j.jhin.2016.12.024. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Infection control capacity building in European countries with limited resources:
issues and priorities Monica LICKER1,2, Luminiţa BĂDIŢOIU1, Diana LUNGEANU1*, Rossitza DOBREVSKA3,
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Emese SZILAGY4, Lul RAKA5, Ljiljana MARKOVIC-DENIC6, Silvio BRUSAFERRO7
“Victor Babes” University of Medicine and Pharmacy Timisoara, Romania
2
“Pius Branzeu” Emergency, Clinical, County Hospital Timisoara, Romania
3
Bulgarian Association on Infection Prevention and Control "BulNoso", Bulgaria
4
Hungarian Society for Infection Control, Hungary
5
National Institute of Public Health, Kosovo
6
Faculty of Medicine, University of Belgrade, Institute of Epidemiology, Serbia
7
Department of Medical and Biological Sciences, University of Udine, Italy
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Running head: Infection control capacity set-up priorities
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Keywords: infection control, healthcare associated infection, patient safety
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Corresponding author: Diana LUNGEANU
„Victor Babes” University of Medicine and Pharmacy, Timisoara P-ta Eftimie Murgu 2, 300041-Timisoara, Romania Email: [email protected]
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ACCEPTED MANUSCRIPT
Summary: We report the results of a panel investigation aimed at assessing the critical aspects regarding healthcare associated infections in European countries with limited resources and pinpointing the highest priority issues that need to be addressed for effective infection control. Questionnaires were designed and information collected from national EUNETIPS representatives in Bulgaria, Hungary, Kosovo, Romania, and Serbia. Based on the data collected, we concluded that rigorous implementation of existing law, standardized training, and political commitment constitute
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a common relevant background and provide the lessons to be learnt for aligning healthcare systems
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M AN U
SC
in this area with internationally recommended standards of infection control.
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Introduction
Hundreds of millions of patients are affected by healthcare associated infections (HCAI) worldwide each year, leading to significant mortality and financial losses for healthcare systems. Of every 100 hospitalized patients, between seven (in developed countries) and ten (in developing ones) suffer at least one HCAI, with a significantly higher endemic burden of HCAI for patients admitted to high
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risk departments such as intensive care units (ICU).1 While urinary tract infection (UTI) is the most frequent HCAI in high-income countries, surgical site infection (SSI) is the leading infection in areas with only limited resources, affecting up to one-third of the operated patients, i.e. the level being up to nine times higher than in developed countries.1 In the 21st century, infection control (IC) and hospital hygiene activities face new challenges: a lack of funds for specific HCAI,
SC
insufficient resources, and increasing pressure for publicly reporting surveillance data. While managers and administrators too frequently fail to allocate adequate resources to IC programmes,
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there is nevertheless a huge disparity in the availability of resources between countries and even between national centres.2 A critical leading role in HCAI prevention and control is played by European Institutions, i.e. DG SANCO, ECDC, European Food Safety Authority (EFSA), European professional and scientific networks, like EUropeanNETwork to promote Infection Prevention for Patient Safety (EUNETIPS), or World Health Organization (WHO). Moreover, they are key players
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in effectively preventing and controlling the spread of antimicrobial resistance (AMR).3-6 In this context, we aimed to identify or confirm common critical issues in HCAI control in SouthEastern European countries which have limited resources to invest in healthcare. These issues should be top-priority targets for these countries healthcare policies and for know-how transfer from
AC C
Methods
EP
high income European countries.
A panel investigation was conducted between January and March 2016. Based on WHO technical papers and previous reports regarding HCAI in developing countries, a 30-item questionnaire was designed and feed-back was collected from the national EUNETIPS representatives of Bulgaria, Hungary, Kosovo, Romania, and Serbia. The countries were chosen based on geographical area and on their shared cultural and historical background as former communist regimes. All responses were the opinions of experts who agreed to participate in the panel and no verification was requested. Both open-ended and closed-ended questions were asked. The latter were either dichotomous (0 for absence or not a cause; 1 for presence or agreement) or ranking on a four-point scale (0 for absence, the least degree, or never encountered situation; 1 – sometimes encountered; 2 – often or frequently encountered; 3 – always encountered, certainty, or required/guaranteed by law). For the closed3
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ended questions, statistics consisting of frequency counts were provided. Responses to the fourpoint scale questions were considered as ordinal variables when enough variability among the five respondents was present. The open-ended questions underwent a separate thematic analysis based on the Braun and Clarke's six-phase guide.7 An inductive approach was employed, aimed to identify any supplementary emergent theme and help in interpreting the overall results.
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Reliability analysis was conducted on meaningful sub-scales of closed-ended questions, by employing the Cronbach's alpha. The standardized Cronbach's alpha was provided as well, as an indication of non-redundancy when the two values were close. Two questions (Q17 and Q27) had the coding reversed for this analysis. For sub-scales with at least acceptable consistency
The statistical analysis was performed with SPSS v20.0.
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Results
SC
(Cronbach's alpha over 0.6) the inter-item correlation matrix was provided and further discussed.
The full questionnaire together with the answers received is presented in the Annex. Table I provides a general description and the results of reliability analysis for the closed-ended questions to which it was applicable. For the meaningful and reliable sub-scales, the inter-item correlation analysis was applied (Table II).
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Regarding resources, all the five panel contributors reported staff shortages (Q17, Q18), a general lack of capacity associated with a lack of both supply services and of adequate staff training (strongly correlated Q4 a, e, f). Shortcomings in supplying services, drugs, and training also correlated positively (Q4 c, d, f). Strong negative correlations in Q4-items were found between
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technology and a lack of human resources and supply services (b with a, c, f). A lack of policies correlated strongly and positively with human resources, adequate training, drugs, and supply
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services (Q4 g with a, d, e, f).
Regarding standards and procedures, a negative strong correlation was found between Q14 and Q15. Answers to Q26 and Q27 were inconsistent. The sub-scale of antibiotics issues was consistent (high alpha value), with strong positive inter-item correlation (Q21−24). The answers to open-ended questions (Q29-30) were collated into three main themes: (1) lack of financial resources is a critical aspect: (2) lack of trained human resources is a critical aspect but can be improved with limited resources; (3) poor health policies and mis-articulated political commitment is a critical aspect, though things can be improved with limited financial investment.
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Discussion
Raka and Mulliqi-Osmani have highlighted limited resources, poor infrastructure, insufficient equipment, together with a lack of national guidelines and policies as key difficulties in combating antibiotic resistance and IC successful implementation in the region, solely based on microbiology laboratory support.3 According to Rodrigues-Bano et al., agreement on the minimum requirements
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for adequate IC should be reached as institutional priority, with clear programmes including objectives, indicators, periodical evaluations, multidisciplinary IC teams, and education for ward staff in IC-related issues.2 We actually found that all the five countries experienced serious staff shortages, correlating with deficiencies in staff training and supply services. Unsurprisingly, in 2016, technology appeared as pervasive but it could not compensate for the lack of human resources
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and supply services. There was a general negative perception regarding all resources, except for technology.
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In terms of challenges, lack of adherence to standard precautions in health care facilities remains a formidable obstacle, due to insufficient educational efforts and awareness building. Surveillance for HCAI outbreaks and bacterial resistance, together with the systematic assessment of compliance with infection-prevention and control (IPC) practices play an essential part in developing any IC policy and measuring the success.4 Meanwhile, adopting and implementing European strategies for
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patient safety and HCAI prevention and control is in progress.5,6,8 Indeed, the result this panel revealed was of a strong positive correlation between rigorous procedures in place for monitoring the quality of sterilization/ disinfection and the existence of institutional guidelines and protocols for HCAI prevention and control. However, there was zero correlation with the application of
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national standards, even when they did exist, though hospitals did make efforts at training the staff. Harmonisation of training programmes in terms of IC, through engagement of professionals and
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training organizations, has already been identified as an important mechanism for improving the quality of healthcare throughout Europe.9,10 The actual answers to the antibiotics sub-scale showed the awareness of the medical personnel regarding the importance of screening and reliable microbiological diagnosis in timely implementation of antimicrobial therapy and also in patient prognosis. Overall, across the sub-scales analysed and the answered open-ended questions, the common denominator and perceived top-priority target proved to be national-level adequate training coupled with political commitment.
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Conclusions
The novel contribution of this expert panel report consists in bringing under a common umbrella the shared problems and concerns from countries in the South-Eastern part of Europe. Despite the differences across the countries and their limited resources, there are common issues to be realistically addressed in order to obtain better results in infection control, as well as valuable
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lessons to learn from countries with more resources available and higher levels of performance in preventing HCAI.
Funding sources: this research did not receive any specific grant from funding agencies in the
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public, commercial, or not-for-profit sectors.
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Conflict of interest statement: none declared.
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References
1. WHO. Health care-associated infections FACT SHEET. Available athttp://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf [Accessed August 2016]. 2. Rodrigues-Bano J, del Toro MD, Lopez-Mendez J, et al. Minimum requirements in infection control. Clin Microbiol Infect 2015; 21(12): 1072-1076.
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3. Raka L, Mulliqi-Osmani G. Infection Control in Developing World. In: Sudhakar C, editor. Infection Control – Updates, InTech; 2012. p. 65-78. DOI: 10.5772/33282. 4. WHO. Infection prevention and control in health care: time for collaborative action. Available at http://applications.emro.who.int/docs/EM_RC57_6_en.pdf?ua=1 [Accessed August 2016].
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5. Brusaferro S. Improving infection control and hospital hygiene in Europe: Professional networks and European programs. 2015/C 151/01; Available athttp://eunetips.eu/pdf/eunetips.2015.06.26.brusaferro.pdf [Accessed August 2016].
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6. European Union Council Recommendation on patient safety, including the prevention and control of healthcare associated infections. 2009; Available at http://ec.europa.eu/health/patient_safety/docs/council_2009_en.pdf[Accessed August 2016]. 7. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3(2): 77101.
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8. Allegranzi B, Begheri Nejad S, Combescure C, et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. The Lancet 2011; 377: 228241. 9. Brusaferro S, Arnoldo L, Cattani G, et al. Harmonizing and supporting infection control training in Europe, J Hosp Infect. 2015;89: 351–346.
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10. Brusaferro S, Cookson B, Kalenic S, et al.Training infection control and hospital hygiene professionals in Europe, 2010: agreed core competencies among 33 European countries. Euro Surveill, 2014; 19: 45-54.
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Table I. General description and reliability analysis for closed-ended questions.
Resources (Q1 – Q4)
Cronbach's alpha (Std Cronbach's alpha)
Description
Q1-Q3 were country-specific Yes/No questions with 0.77 (0.779) almost no overlapping across countries − no further statistics were calculated. Q4 was a 7-item sub-scale with binary options, aimed at identifying most critical areas where resources are lacking (4a. Human resources; 4b. Technologies; 4c. Medical devices; 4d. Drugs; 4e. Supply services (cleaning, sterilization, etc.); 4f. Training; 4g. Policies).
Four-rank questions were aimed at identifying infrastructure and organizational issues in hospitals (e.g. availability of isolation rooms, toilets, antiseptic solutions, disinfectants), with no country-specificity.
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Infrastructure (Q6 – Q10)
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Cronbach's alpha was calculated.
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Factors or issues investigated
0.063 (0.114)
Cronbach's alpha was calculated and answers ended in low reliability. These items were not included in the interitem correlation analysis. Two- and four-rank questions seeking to determine degree of availability of national standards, local rigorous procedures and their application, standardized training, guidelines and protocols.
0.625 (0.643)
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Standards and procedures (Q11 – Q16; Q19, Q20)
Yes/No questions, no variance (i.e. all five countries experience serious staff shortages).
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Staff shortages (Q17, Q18)
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Some data ended in no variance, with all negative answers− no further statistics were calculated for Q12, Q13, and Q19. Composite scale was constructed including Q11, Q14, Q15, Q16, Q20. For this scale, Cronbach's alpha was calculated. –
No further statistics were calculated.
Antibiotics issues Q21 – Q24)
Four-rank questions seeking for the degree of in-practice application of therapeutic protocols, capacity of antimicrobial resistance phenotypes identification, HCAI reporting by the microbiology laboratories, routine screening for antimicrobial resistant germs carriers.
0.924 (0.943)
Cronbach's alpha was calculated. Pathology surveillance (Q25)
Four answers for "passive and active detection"; one country (Hungary) mostly relies on active detection. No further statistics were calculated.
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HCAI reporting (Q26, Q27)
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Yes/No questions regarding sanction applied for hospitals with high HCAI prevalence vs. under-reporting the HCAI pathology.
0.571 (0.58)
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Cronbach's alpha was calculated − resulted in contradictory national policies, with low reliability of answers.
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Table II. Inter-item correlation matrix for reliable scale statistics: (a) question 4, regarding the most critical areas where resources are lacking; (b) sub-scale regarding the availability and application of standards, procedures, guidelines, and protocols; (c) sub-scale regarding antibiotics issues*. (a) Resources Q4a Q4b Q4a 1.000 - 0.612 Q4b 1.000 − Q4c − − Q4d − − Q4e − − Q4f − − Q4g − − (b) Standards and procedures Q11 Q14 Q15 Q16 Q20 (c) Antibiotics issues
Q4d Q4e 0.250 1.000 0.612 - 0.612 0.612 0.408 1.000 0.250 1.000 − − − − − Q14 Q15 0 0.324 1.000 - 0.927 1.000 − − − − − Q21 Q22 Q21 1.000 0.873 Q22 1.000 − Q23 − − Q24 − − * items with zero variance were removed from all sub-scale analyses
Q4f 0.612 - 0.167 0.667 0.408 0.612 1.000 − Q16 0.816 - 0.333 0.662 1.000 − Q23 0.764 0.786 1.000 −
Q4g 0.408 0.167 0.167 0.612 0.408 0.667 1.000 Q20 0.853 0.174 0.208 0.870 1.000 Q24 0.913 0.896 0.598 1.000
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Q4c 0.408 0.167 1.000 − − − − Q11 1.000 − − − −
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Annex
Kosovo, Romania, and Serbia. Factors or issues investigated 1
Have new hospitals been built in your country during the past 10 years?
0 – no; 1 – yes
4 no (exception Bulgaria)
2
Has significant refurbishing of existing hospitals intended to reduce the incidence of HCAI been conducted in your country during the past 10 years?
0 – no; 1 – yes
4 yes (exception Hungary, no answer)
3
Do the current (i.e. 2016) available resources in your country cover the requirements for the prevention and control of HCAI?
0 – no; 1 – partially;
4 partial covering (exception Kosovo, no cover)
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Coding
4
2 – yes
If resources are insufficient, which are the most critical areas where resources are lacking in IC/HH?
0 – no, not the case; 1 – yes, this is lacking
between 1 and 7 areas of resource lacking; 4 yes for human resources (exception Hungary) and 1 respondent (Kosovo) checking all the 7 areas;
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4a. Human resources; 4b. Technologies; 4c. Medical devices; 4d. Drugs; 4e. Supply services (cleaning, sterilization, etc.); 4f. Training; 4g. Policies; 4h. Other (please specify...) 5
−
6
Are there sufficient isolation rooms in hospitals in your country (especially for HCAI high risk departments)?
0 – no; 1 – only in few hospitals;
Q6, Q7 each – 3 "only in few hospitals"; none for "all hospitals";
7
Do the hospital rooms in your country have private bathrooms/ toilets?
2 – in the majority of hospitals;
Q8 – 4 "in all hospitals" (exception Bulgaria, in the majority);
8
Is there a sink in each hospital ward in your country?
3 – in all hospitals
Q9 – 3 "in the majority"; none for zero availability;
9
Are antiseptic solutions for the hands of the medical staff being provided in sufficient quantities in hospitals in your country?
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Infrastructure (Q6 – Q10)
Answers (N total =5 respondents)
Question
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Resources (Q1 – Q4)
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Questionnaire used in the HAI panel investigation and answers collected from the national EUNETIPS representatives of Bulgaria, Hungary,
Q10 – 4 "in the majority"; 1 (Hungary) "in all hospitals";
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11
Are there rigorous procedures (written evidence and recording, routine use of indicators, etc.) in place for monitoring the quality of sterilization and disinfection of medical instruments/devices/ equipments in hospitals in your country?
0 – no; 1 – only in few hospitals;
12
Are the hospital cleaning plans coherent with what is recommended by the literature?
0 – no; 1 – yes
13
Are there standards defined at national level on the required number and qualifications of the medical and nursing staff?
4 "in the majority" or "all hospitals"; 1 (Kosovo) "only in few"
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Are disinfectants and current decontamination products provided in sufficient quantities in hospitals in your country?
2 – in the majority of hospitals;
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3 – in all hospitals
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Standards and procedures (Q11 – Q16)
10
0 – no; 1 – only in few hospitals;
4 yes (exception Hungary, no answer) – zero variance 5 "in all hospitals" – zero variance
2 – in the majority of hospitals; 3 – in all hospitals
If standards exist, are these standards applied?
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Staff shortages (Q17, Q18)
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Are the members of the healthcare staff regularly and efficiently trained on prevention and control of HCAI?
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15
0 – no; 1 – only in few hospitals;
3 no; 1 "only in few hospitals"; 1 no answer (Hungary)
2 – in the majority of hospitals; 3 – in all hospitals 0 – no; 1 – only in few hospitals;
4 "in the majority" or "all hospitals"; 1 no (Romania)
2 – in the majority of hospitals; 3 – in all hospitals
16
Is there a standardized training plan?
0 – no; 1 – yes
4 no (exception Bulgaria, standardized training plan does exist)
17*
Did your health system suffer in the last five years from significant staff losses?
0 – no; 1 – in very few hospitals, not significant;
no negative answer
2 – yes in some specialties, e.g. ICU;
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3 – yes 0 – no; 1 – yes
no positive answer
19
Are there legal requirements in your country in the field of HCAI? Please specify.
0 – no; 1 – yes
5 yes – zero variance
20
Are there institutional guidelines and protocols for the prevention and control of HCAI implemented in hospitals in your country?
0 – no; 1 – only in few hospitals;
2 "only in few"; 2 "in the majority"; 1 (Hungary) "in all hospitals"
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If the answer for Q17 is yes - Are there specific measures taken to prevent members of the healthcare staff from leaving the system?
2 – in the majority of hospitals;
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Laws, guidelines (Q19, Q20)
18
3 – in all hospitals
21
Are antibiotics prescribed according to therapeutic protocols?
0 – no; 1 – only in few cases;
5 "in the majority" or "all hospitals"
2 – in the majority of cases;
23
Are laboratory capacities in hospitals adequate for the identification of antimicrobial resistance phenotypes?
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3 – in all cases
Do hospital microbiology laboratories report HCAI outbreaks in a timely manner?
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Antibiotics issues (Q21 – Q24)
24
Are patients admitted in high risk hospital departments in your country routinely screened to detect carriers of antimicrobial resistant germs (MRSA, ESBL production, MDR, etc?)
0 – no; 1 – only in few hospitals;
4 "in the majority" or "all hospitals"; 1 "only in few hospitals" (Romania)
2 – in the majority of hospitals; 3 – in all hospitals 0 – no; 1 – only in few hospitals;
2 "only in few hospitals"; 2 "in the majority"; 1 "in all hospitals" (Hungary)
2 – in the majority of hospitals; 3 – in all hospitals 0 – no; 1 – only in few hospitals; 2 – in the majority of hospitals;
2 no; 1 "only in few hospitals"; 2 "in the majority"
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3 – in all hospitals 25
The hospital acquired pathology surveillance system in your country mostly relies on:
0 – no detection; 1 – passive detection;
4 answers for "passive and active detection"; 1 (Hungary) mostly relies on active detection
2 – passive and active detection;
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Pathology surveillance (Q25)
3 – active detection Are there sanctions applied in your country for hospitals with a high prevalence of HCAI?
0 – no; 1 – yes
27*
Are there sanctions taken against hospitals which under-report HCAI pathology?
0 – no; 1 – yes
28
Please indicate your position
29
30
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4 no (exception Romania, i.e. with sanctions for high prevalence of HAI) 3 no; 2 yes (Bulgaria and Hungary)
all respondents in leading positions and national representatives in EUNETIPS
What are the five most critical aspects in your country which can affect an effective prevention and control of HCAI? (please rank them from the first to the fifth)
Open ended
Theme 1 (Q29): lack of financial resources
What are the aspects you think can be improved in IC/HH in your country even with a limited amount of resources?
Open ended
What can be learnt by a high income country from the IC/HH experiences in countries with limited resources? Please specify.
Open ended
* coding was reversed for internal consistency
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Open ended
Two major themes across Q29 and Q30. Theme 2: lack of trained human resources Theme3: poor health policies and mis-articulated political commitment inconsistent answers; most probably due to question misunderstanding
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31
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26
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HAI reporting (Q26, Q27)
EUNETIPS – EUropean NETwork to promote Infection prevention for Patient Safety; HCAI – Healthcare Associated Infection; IC/HH – Infection Control and Hospital Hygiene; ICU – Intensive Care Unit; SSI – Surgical Site Infection; UTI – Urinary Tract Infection