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BRIEF COMMUNICATION
Year : 2018  |  Volume : 36  |  Issue : 4  |  Page : 577-581
 

National survey of infection control programmes in South Asian association for Regional Cooperation countries in the era of patient safety


1 Dr. R. P. Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Hospital Administration, All India Institute of Medical Sciences, New Delhi, India
3 Department of Infectious Diseases, Alfred Health and Central Clinical School, Monash University, Melbourne, Australia
4 Department of Hospital Administration, Armed Forces Medical College, Pune, Maharashtra, India
5 Medical Superintendent, School of Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
6 Children's National Health System, Department of Pediatrics, Global Health and Epidemiology, George Washington University, Washington, USA

Date of Web Publication18-Mar-2019

Correspondence Address:
Dr. Vijaydeep Siddharth
Department of Hospital Administration, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmm.IJMM_18_82

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 ~ Abstract 

Background: The implementation of hospital infection prevention and control (IPC) in south Asia is not well described. We aimed to assess IPC programmes in hospitals in this region and explore opportunities for improvement. Methods: Attendees from hospitals in the South Asian Association for Regional Cooperation (SAARC) region who were at one of four National Initiative for Patient Safety workshops organised by All India Institute of Medical Sciences (New Delhi) from 2009 to 2012 were invited to complete a semi-structured questionnaire. The survey addressed six main components of IPC programmes. Results: We received responses from 306 participants from 82 hospitals. Five key opportunities for improvement emerged: (1) lack of healthcare epidemiologists, (2) relative infrequency of antibiotic guidelines (53%) and prescribing audits (33%) (3) lack of awareness of needle stick injury rates (84%) (4) only 47% of hospitals were prepared for surge capacity for patients with infectious diseases, and (5) limited coordination of hospital infection control personnel with other support services (55%-66%). Conclusion: These results outline IPC challenges in the SAARC region and may be useful to guide future quality improvement initiatives.


Keywords: Healthcare-associated infection, infection control, infection prevention, patient safety


How to cite this article:
Gupta SK, Siddharth V, Belagere MR, Stewardson AJ, Kant S, Singh S, Singh N. National survey of infection control programmes in South Asian association for Regional Cooperation countries in the era of patient safety. Indian J Med Microbiol 2018;36:577-81

How to cite this URL:
Gupta SK, Siddharth V, Belagere MR, Stewardson AJ, Kant S, Singh S, Singh N. National survey of infection control programmes in South Asian association for Regional Cooperation countries in the era of patient safety. Indian J Med Microbiol [serial online] 2018 [cited 2019 Sep 16];36:577-81. Available from: http://www.ijmm.org/text.asp?2018/36/4/577/254403



 ~ Introduction Top


Patient safety is at the heart of healthcare delivery. Patients in South Asian Association for Regional Cooperation (SAARC) countries have inequitable access to healthcare and the potential for high out-of-pocket expenses.[1] Healthcare-associated infections (HAI) are associated with increased morbidity (longer hospitalisation), mortality and cost of healthcare. The burden of HAI in low- and middle-income countries (LMIC) is estimated to be high.[2] The World Health Organization (WHO) has described a paucity of published data from LMIC. The burden of healthcare-associated infections was also recently highlighted in southeast Asian countries.[3]

India launched a series of workshops as part of the National Initiative for Patient Safety (NIPS).[4] Our survey was conducted as a part of these workshops. The objective of this study was to assess infection control programmes at the participating hospitals and explore opportunities for improvement.


 ~ Materials and Methods Top


Three-day workshops were conducted by All India Institute of Medical Sciences (AIIMS), New Delhi, that introduced four aspects of patient safety relevant to all hospitals in the SAARC countries (India, Nepal, Bhutan and Maldives): (1) infection prevention and control of HAIs; (2) communication and patient handovers; (3) medication management error and reconciliation and (4) surgical safety checklist. From 2009 to 2012, participants from 82 hospitals and medical colleges across SAARC countries were trained. These healthcare organisations were asked to nominate a multidisciplinary team to represent key drivers of hospital infection prevention and control (IPC) programmes, with representation by general surgeons or subspeciality surgeons, internal medicine specialists or paediatricians, microbiologists, anaesthesiologists, hospital administrators and nursing administrators. During the second and third year of the programme, 60 teams were given the survey questionnaire regarding the IPC programme at their organisation. Participants were invited to voluntarily participate in the survey and only those who consented were included. The study did not involve humans as subjects and hence ethical clearance was not required. The survey instrument was developed by the organisers and faculty of the NIPS programme and it addressed six components of a hospital IPC programme: (1) organisation of infection control programme, (2) infection prevention and control guidelines, (3) infection prevention and control education and training, (4) surveillance of healthcare-associated infections, (5) monitoring and evaluation and (6) assessment of environment and equipment for infection control.[4] Each of these components specifically addressed 16 questions [Table 1].
Table 1: Results of survey on infection control programme

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 ~ Results Top


We received responses from 305 of 306 healthcare professionals from 59 hospitals. Sixty interdisciplinary teams from 59 hospitals were administered the questionnaire [Figure 1]. Of these organisations, 36 (60%) were academic institutions from both public and private sectors. Out of 59 hospitals, 24 (40.67%) had <501 beds, 19 (32.2%) had 501–1000 beds, 11 (18.64%) had 1001–1500 beds and five (10.2%) had more than 1500 beds. Of these respondents, 225 (74%) were from teaching hospital and 80 (26%) from non-teaching hospital. The participating healthcare professionals included 56 (19%) hospital administrator/managers, 54 (18%) surgeons, 50 (16%) nursing personnel, 49 (16%) microbiologists, 47 (15%) physicians, 46 (15%) anaesthesiologist, 3 others and 1 missing.
Figure 1: Geographical distribution of participating healthcare facilities

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Responses of the participants of the NIPS workshop to IPC core components are shown in [Table 1]. Some participants, i.e., 291–305 (95%–99%) responded to the questions. Five most important findings emerged which are as follows: (1) Healthcare epidemiologist that were trained in IPC programme were present in only 40% of the hospitals, (2) IPC guidelines specifically antibiotic policy was reported only about half, i.e., 53% of the respondents and antibiotic-prescribing audits were reported by third, i.e., 33%, (3) majority, i.e., 84% were not aware of needle stick injury rates in their hospital, (4) half of the hospitals, i.e., 47% were prepared for surge capacity for patients with infectious diseases and (5) coordination of hospital infection control (HIC) personnel with different support services was limited, i.e., 55%–65%.


 ~ Discussion Top


Our national survey describes the first extensive description of core components of IPC in SAARC countries. It is also unique that described the healthcare system broadly in that respondents provided information about a diverse range of organisations including non-teaching and teaching; private and not-for-profit and accredited and non-accredited hospitals. The survey identifies the areas of where improvement in hospital IPC programmes are required and can be used to inform organisation-and country-level policy makers in SAARC countries.

Our survey findings are similar to that which have been reported from different studies both in developed and developing countries.[5],[6],[7] It is much easier to constitute an infection control committee but difficult to ensure its effective functioning. Training and content of training curriculum is another area of concern in developing countries. Only 61% of the hospitals in our study provide training on HIC to their healthcare personnel.

Although surveillance for HAI-CLABSI, CAUTI, VAP and SSIs was being done by 70% of the hospitals while only half of the hospitals have antibiotic policy guiding appropriate use of antimicrobial in place. Antimicrobial resistance (AMR) is a current and increasing threat and challenge to global health and development of all countries with different consequences regarding hospital-acquired and community-acquired infections.[8] It is a critical situation in South East Asia when it comes to antimicrobial resistance.[9] Continuous efforts are being made in this direction; recently, WHO SEARO countries made a declaration known as 'Jaipur Declaration on Antimicrobial Resistance'.[10]

In India, HIC is a critical domain of patient safety which has not been adequately addressed by the health policymakers until very recently when WHO has required countries to develop national action plan for surveillance of antimicrobial pathogens.[11]

Infection control teams are confronted with many challenges with regard to resource allocation, human resources (especially infection control nurses), guidelines and education and training. This is a major issue which public sector hospitals are faced with.[12] HIC needs support from administrators and more cooperation from medical personnel.[13] Organisational mechanisms for supporting training, appraisal and clinical governance are important determinants of effective practice and successful change.[14] Given the effect of healthcare-associated infection on patient care and economy, there is a need of enacting rules/regulations/laws/national programme for hospital hygiene and infection control as has been done by not only developed countries but also developing countries.[15],[16] Furthermore, many national and international healthcare facility accrediting bodies/agencies have integrated component of infection control in their set of standards, given its significant impact on infection control.[17] There is a need for an international strategy that would establish standards, procedures and methods for HAI surveillance, prevention and control and promote their implementation at national level.[18]

This study has few limitations. It was assumed that respondents had adequate knowledge regarding HIC policies and procedures in their hospitals. Due to logistic constraints, it was not feasible to validate responses by site visits, given wide geographic distribution of participating sites.


 ~ Conclusion Top


From the study findings, it can be concluded that half of the hospitals had a HIC programme in place; but, it is on ground implementation and effectiveness needs to be studied. The study has also identified several key areas of concern, which Indian hospital needs to be worked on. It includes recognising epidemiologist, as an important member of infection control team, guidelines/SOP formulation for HIC, antibiotic-prescribing audit as a strategy to thwart AMR and capacity building needs to be strengthened. Infection control in developing countries differs markedly from that in developed countries; therefore, it is important to take these differences into account when formulating policies for the developing countries. The study also hints that national aureditation board for hospitals and healthcare providers (NABH) and/or joint commission internationa (JCI)-certified hospitals in India have better HIC than other hospitals, as HIC being an important component of accreditation standards. Hence, there is a need for country-level coordination though legislation, guidelines and policies.

Acknowledgement

The authors thanks Dr. Pankaj Arora, Department of Hospital Administration, PGIMER, Chandigarh, India; Dr. ShaliniBhalla, Fortis Hospital, Delhi, India and Dr. Parmeshwar Kumar, Department of Hospital Administration, AIIMS, Delhi, India in conducting NIPS workshops.

List of Institutions participated in NIPS

India: AIIMS, New Delhi; AIMS, Kochi; MAMC, New Delhi; CMC, Vellore; St. John's, Bengaluru; SMS Jaipur; GMC, Jammu; NIMS, Jaipur; AFMC, Pune; KGMU Lucknow; SSIMS, Putapatty; Fortis Hospital, Chandigarh; JIIPMER, Puducherry; PMCH, Patna; GMCH, Chandigarh; FMMC, Mangalore; MGIMS, Sevagram; RPGMC, Tanda; AMC Hospital, Dibrugarh; R&R Hospital, Delhi; Sir SGH, Baroda; DMCH, Ludhiana; KMC, Manipal; MS Ramaiah Medical College, Bengaluru; LRS Hospital, Delhi; Pt. B. D. Sharma PGIMS, Rohtak; GMC, Goa; LHMC, Delhi; SCTIMST, Trivandrum; GMC, Aurangabad; CMC, Ludhiana; Mizoram; Max Hospital, Delhi; NEIGRIHMS, Shillong, West Bengal; Breach Candy Hospital Trust, Mumbai, Maharashtra; RIMS, Imphal; B L Kapur Hospital, Delhi; Dr. L. H. Hiranandani Hospital, Mumbai; Sir Gangaram Hospital, Delhi; Rainbow Children's Hospital, Hyderabad; Shalby Hospital, Ahemdabad; AIMS, Gurgaon; Smt NHL Municipal Medical College, Ahemdabad; RNT Medical College, Udaipur; Care Institute, Ahemdabad; HIMS, Dehradun; Steriling Hospital, Ahemdabad; KJSMC, Mumbai; MLBMCH, Jhansi, Uttar Pradesh; MMIMCR, Ambala; Hinduja Hospital, Mumbai; Saifee Hospital, Mumbai; SKIMS, Srinagar; UCMS and GTB Hospital, Delhi; Maharaja Agrasen Hospital, Delhi; Apollo Hospital, Bhubaneshwar; DDU Hospital, Delhi; RGCI, Delhi; MMC, Karnataka; Batra Hospital, Delhi; Armed Forces, DGMSs (Air & Navy); B. M. Birla, Kolkata; JNIMS, Imphal; RMC, Loni, Maharashtra; NBMCH, Siliguri; GMC, Amritsar; GSMCH, Patiala; Pushpanjali Crosslay, Ghaziabad.

Nepal: B P Koirala Institute of Health Sciences, Dharan.

Bhutan: Jigme Dorji Wangchuk National Referral Hospital, Thimpu.

Maldives: Indira Gandhi Memorial Hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 ~ References Top

1.
Allegranzi B, Bagheri Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L, et al. Burden of endemic health-care-associated infection in developing countries: Systematic review and meta-analysis. Lancet 2011;377:228-41.  Back to cited text no. 1
    
2.
Weinshel K, Dramowski A, Hajdu Á, Jacob S, Khanal B, Zoltán M, et al. Gap analysis of infection control practices in low- and middle-income countries. Infect Control Hosp Epidemiol 2015;36:1208-14.  Back to cited text no. 2
    
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Guidelines on Core Components of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level. Available from: http://www.wipo.int/amc/en/mediation/rules. [Last accessed on 2017 Sep 30].  Back to cited text no. 3
    
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eHEALTH. India surges ahead for patient safety: an initiative by AIIMS. Available from: http://www.ehealth.eletsonline.com/2010/05/india-surges-ahead-for-patient-safety-an-initiative-by-aiims/. [Last accessed on 2017 Sep 26].  Back to cited text no. 4
    
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Danchaivijitr S, Supchutikul A, Waitayapiches S, Kachintorn K. Quality of nosocomial infection control in Thailand. J Med Assoc Thai 2005;88 Suppl 10:S145-9.  Back to cited text no. 5
    
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Struelens MJ, Wagner D, Bruce J, MacKenzie FM, Cookson BD, Voss A, et al. Status of infection control policies and organisation in European hospitals, 2001: The ARPAC study. Clin Microbiol Infect 2006;12:729-37.  Back to cited text no. 6
    
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Mori-Yoshikawa N, Ohmagari N, Kirikae T. Organization of nosocomial infection control measures and local networks for infectious disease control in middle-scale hospitals in Japan. Jpn J Infect Dis 2014;67:379-81.  Back to cited text no. 7
    
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Berlin Declaration of the G20 Health Ministers Together Today for a Healthy Tomorrow; 2017. Avaialble from: https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/G/G20-Gesundheitsministertreffen/G20_Health_Ministers_Declaration_engl.pdf. [Last accessed on 2017 Sep 26].  Back to cited text no. 8
    
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Singh PK. One Health approach to tackle antimicrobial resistance in South East Asia. BMJ 2017;358:j3625. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28874363. [Last accessed on 2017 Sep 26].  Back to cited text no. 9
    
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World Health Organization. Jaipur Declaration in WHO South East Asia Region. World Health Organization; 2011. Available from: http://www.searo.who.int/entity/antimicrobial_resistance/rev_jaipur_declaration_2014.pdf?ua=1. [Last accessed on 2017 Sep 26].  Back to cited text no. 10
    
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Government of India. National Action Plan on Antimicrobial Resistance (NAP-AMR 2017-2021); 2017. Available from: http://cseindia.org/userfiles/inap_amr_20170420.pdf. [Last accessed on 2017 Sep 27].  Back to cited text no. 11
    
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Talaat M, Kandeel A, Rasslan O, Hajjeh R, Hallaj Z, El-Sayed N, et al. Evolution of infection control in Egypt: Achievements and challenges. Am J Infect Control 2006;34:193-200.  Back to cited text no. 12
    
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Buachum S, Soparat P, Yimyaem S, Jariyasethpong T, Danchaivijitr S. Nosocomial infection control in regional and provincial hospitals. J Med Assoc Thai 2005;88 Suppl 10:S124-7.  Back to cited text no. 13
    
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Griffiths P, Renz A, Hughes J, Rafferty AM. Impact of organisation and management factors on infection control in hospitals: A scoping review. J Hosp Infect 2009;73:1-4.  Back to cited text no. 14
    
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Ider BE, Clements A, Adams J, Whitby M, Muugolog T. Organisation of hospital infection control in Mongolia. J Hosp Infect 2010;75:209-13.  Back to cited text no. 15
    
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Oh HS, Chung HW, Kim JS, Cho SI. National survey of the status of infection surveillance and control programs in acute care hospitals with more than 300 beds in the republic of Korea. Am J Infect Control 2006;34:223-33.  Back to cited text no. 16
    
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Sekimoto M, Imanaka Y, Kobayashi H, Okubo T, Kizu J, Kobuse H, et al. Impact of hospital accreditation on infection control programs in teaching hospitals in Japan. Am J Infect Control 2008;36:212-9.  Back to cited text no. 17
    
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Lazzari S, Allegranzi B, Concia E. Making hospitals safer: The need for a global strategy for infection control in health care settings. World Hosp Health Serv 2004;40:32, 34, 36-42.  Back to cited text no. 18
    


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