Core components of infection prevention and control programs at the facility level in Georgia: key challenges and opportunities

Background

The Georgia Ministry of Labor, Health, and Social Affairs is working to strengthen its Infection Prevention and Control (IPC) Program, but until recently has lacked an assessment of performance gaps and implementation challenges faced by hospital staff.

Methods

In 2018, health care hospitals were assessed using a World Health Organization (WHO) adapted tool aimed at implementing the WHO’s IPC Core Components. The study included site assessments at 41 of Georgia’s 273 hospitals, followed by structured interviews with 109 hospital staff, validation observations of IPC practices, and follow up document reviews.

Results

IPC programs for all hospitals were not comprehensive, with many lacking defined objectives, workplans, targets, and budget. All hospitals had at least one dedicated IPC staff member, 66% of hospitals had IPC staff with some formal IPC training; 78% of hospitals had IPC guidelines; and 55% had facility-specific standard operating procedures. None of the hospitals conducted structured monitoring of IPC compliance and only 44% of hospitals used IPC monitoring results to make unit/facility-specific IPC improvement plans. 54% of hospitals had clearly defined priority healthcare-associated infections (HAIs), standard case definitions and data collection methods in their HAI surveillance systems. 85% hospitals had access to a microbiology laboratory. All reported having posters or other tools to promote hand hygiene, 29% had them for injection safety. 68% of hospitals had functioning hand-hygiene stations available at all points of care. 88% had single patient isolation rooms; 15% also had rooms for cohorting patients. 71% reported having appropriate waste management system.

Conclusions

Among the recommended WHO IPC core components, existing programs, infrastructure, IPC staffing, workload and supplies present within Georgian healthcare hospitals should allow for implementation of effective IPC. Development and dissemination of IPC Guidelines, implementation of an effective IPC training system and systematic monitoring of IPC practices will be an important first step towards implementing targeted IPC improvement plans in hospitals.

Inadequate infection prevention and control (IPC) practices in healthcare hospitals are a main driver of increasing rates of antimicrobial resistance (AMR) and healthcare-associated infections (HAIs) [5, 9, 15] and are a growing concern for health care and for public health worldwide [20]. Studies estimate that one in 18 hospitalized patients in Europe and one in 25 hospitalized patients in the United States has a HAI on any given day [17, 33].

While HAI data in Georgia are limited, studies suggest transmission of HAIs is an important problem [7, 14, 16]. Georgia has a high prevalence of hepatitis C virus (HCV) infection associated with healthcare exposures due to inadequate infection control [11, 23]. In response to the high HCV prevalence and growing concerns around AMR, the Georgia Ministry of Labor, Health, and Social Affairs (MoLHSA) instituted the National Strategy for Combating Antimicrobial Resistance and the Hepatitis C Elimination Program, which includes a focus on strengthening IPC and reducing healthcare transmission.

Healthcare transmission of AMR and HAIs can be prevented through comprehensive and robust IPC programs [4, 31, 32]. To support countries’ efforts to strengthen IPC, the World Health Organization (WHO) released their new evidence-based guidelines on IPC core components in 2017 [32, 36]. These guidelines cover eight areas of IPC and include 14 recommendations and best practice statements.

A number of MoLHSA decrees exist that describe facility-level IPC requirements and are treated as National IPC guidelines. However, the decrees are fragmented and only provide general IPC recommendations. Information about necessary infrastructure and implementation of IPC at Georgian healthcare hospitals is limited and only covers the built environment or HAI epidemiology and etiology. To address these gaps, ICAP at Columbia University in close collaboration with the U.S. Centers for Disease Control and Prevention (U.S. CDC), and WHO used a modified version of the draft WHO IPC Assessment Framework (IPCAF) tool to conduct a systematic assessment of IPC practices in Georgia. This study is the first formal and systematic assessment of IPC core components at the facility level in Georgia.

Study protocol

The study protocol was approved by the Institutional Review Boards (IRB) of Georgia’s National Center for Disease Control and Public Health (NCDC) and Columbia University Medical Center. This project was reviewed in accordance with the U.S. CDC human research protection procedures and was determined to be non-research. Participation in the study was voluntary and informed consent was sought from all participants, with the option to withdraw consent at any time. Respondents were informed that results of the assessment would be presented to the MoLHSA in the form of a summarized report with no data on individual hospitals included. There were no refusals to participate in the study. No compensation for participation was provided.

Hospital selection

A random sample of inpatient hospitals, stratified by geographic region and service status (i.e. public, private), was selected to ensure proportional representation. Three multi-specialty hospitals from hospital networks not included in the random sample were added to ensure representation of all private hospital networks. Small hospitals, defined as multi-specialty hospitals with less than 20 beds and specialty hospitals with less than 10 beds, were excluded. Hospitals providing only psychiatric services or tuberculosis treatment were also excluded because of the specialized care and unique IPC issues.

Pilot study and data collection

The assessment tool used was adapted from the IPCAF issued by WHO in 2018 to support the implementation of the WHO Guidelines on Core Components of IPC Programs at the National and Acute Health Care Facility Level [37, 38]. A study published in 2020 highlights that effective utilization of the IPCAF tool requires a deep understanding of the WHO terminology and underlying concepts to avoid misinterpretation and misreporting of data [34]. To improve quality of data and avoid biased reporting, the team adapted the IPCAF tool for the situational assessment in Georgia. For that, the study team conducted several meetings with local specialists involved in IPC and external IPC experts from the U.S. CDC and WHO to review the questions, select those that were relevant to Georgia, and add additional questions providing more details or verification. The revised questionnaires (Annex 2) were then transferred into ICAP’s online survey data collection system (e-Survey) and piloted at two hospitals located in the capital Tbilisi, not included in the study sample. Results of the pilot were used to revise the questionnaires and data collection procedures.

Data were collected during March 2018 by a team of local specialists involved in IPC implementation, monitoring, and training. All data collectors received a two-day training by ICAP at Columbia University in protocol implementation, interviewing techniques and ethical considerations. All healthcare facility assessments were conducted during a one-day visit by two study team members. The first part of the assessment consisted of key informant interviews, conducted in Georgian, with hospital managers and the facility IPC teams, and included a review of the facility’s available IPC-related documents. Individual and small group structured interviews were conducted at 41 hospitals and included 109 facility staff, including 51 facility managers and 58 IPC team members (i.e., nurses, epidemiologists, physicians). Disagreements around answers to the same questions for the same hospital were resolved by facilitating a discussion among hospital IPC team members to reconcile discrepancies until a final answer was agreed upon and recorded. During the second part of the assessment, the study team conducted a facility walk-through using observations to verify answers provided during the interviews. Data were entered into a tablet computer using e-Survey. Answers to open-ended questions were audio recorded and then transcribed in Georgian and translated into English for analysis.

Data analysis and reporting

Descriptive analysis was conducted for categorical data using frequency analysis and cross-tabulation. Qualitative data from key informant interviews were grouped into meaningful patterns and/or themes through content and thematic analysis using NVivo^©. Further analysis of each theme was undertaken using a three-step approach, “describe, compare, relate” [6]. Data from individual interviews were either linked with data from the document review and facility observations to allow for multidimensional descriptions of IPC core components at the facility level or integrated with each other to produce a fuller picture of IPC core components at the facility level [21].

A final written report was shared with the MoLHSA. A national IPC stakeholder meeting, which included national and facility leaders, was conducted by the MoLHSA in collaboration with the U.S. CDC and WHO. The meeting included a presentation of preliminary survey findings, expert opinion on interpretation of the data, and open discussions on the need to strengthen IPC and develop partnership between all levels to improve IPC implementation in Georgia.

The assessment included 41 hospitals (31 multi-specialty hospitals and 10 specialized hospitals), covering 15% of all hospitals in Georgia. Among these hospitals, the average bed capacity was 73 beds per facility (range 10–230 beds). Key assessment findings related to facility-level IPC system characteristics as recommended by WHO are discussed in the text below. Detailed assessment results are presented in Annex 1.

IPC program components

Of the 41 hospitals participating in the assessment, 38 (93%) had an IPC program. However, none of the IPC programs had all the WHO-recommended elements including clearly defined objectives based on local epidemiology, annual IPC workplans, adequate improvement measures and targets, and a specified IPC budget.

All hospitals included in the assessment had an IPC team, 32 (78%) hospitals had more than one IPC team member and 34 (83%) hospitals had at least one full-time IPC specialist. At least one IPC team member in 27 hospitals (66%) had received some formal IPC training. During interviews, absence of dedicated, full-time IPC nurses, lack of IPC certified courses and limited professional development opportunities for IPC personnel were cited as key barriers to adhering to the WHO Core Component recommendations.

Of the hospitals included in the assessment, 39 (95%) hospitals reported having an IPC committee consisting of a multidisciplinary group that advises the IPC team. IPC committees at every facility included senior leadership (e.g., administrative director, the chief executive officer, medical director) and senior clinical staff (e.g., chief physician, chief of nursing). Additionally, IPC committees at 28 of the 39 hospitals (72%) included facility management staff, such as biosafety, water, sanitation, and hygiene (WASH) staff. Thirty-eight of the 39 hospitals (93%) reported their committee met at least once in the past 12 months. However, documentation of IPC committee meetings, as evidenced by meeting notes, was available at only in 19 of 38 (50%) hospitals.

Thirty-five (84%) of the 41 hospitals had access to microbiology laboratory within or outside of the facility for day-to-day use. Hospitals located in urban areas had more access to microbiology laboratories compared to rural hospitals, (77% vs. 23%).

IPC training

Thirty-seven (90%) of 41 hospitals had conducted IPC trainings in the previous 12 months. Most hospitals trained clinical and non-clinical staff on IPC, however, ongoing IPC annual training for clinical staff was required at 54% of hospitals. Nine (22%) of 41 hospitals conducted IPC trainings for all clinical staff as part of new employee orientation in addition to mandatory refresher trainings at least annually. Eight (20%) of 41 hospitals conducted IPC trainings for all non-clinical staff during orientation as well as regular mandatory refresher trainings at least annually. During individual interviews, IPC focal persons mentioned lack of regular IPC training for clinicians and the need for technical assistance to develop IPC training programs at their facility as challenges to implementing IPC.

IPC monitoring and audit

Seven (17%) hospitals had an IPC monitoring/audit plan available, however none of these plans had all the necessary elements, such as clear goals and objectives, tools to systematically collect data, clearly defined roles and responsibilities, and a work plan or schedule. Thirty-two of 41 (78%) hospitals reported conducting internal monitoring/audits in the last 3 months, 20 of 41 (49%) hospitals surveyed provided documentation of these monitoring/audits. Among these 20 hospitals, none conducted internal monitoring/audits at least once a month for each category of IPC practices. Only 17 (41%) conducted monitoring/audit in the past 12 months and shared the results with all cadres of facility staff, including clinical and non-clinical staff, IPC committee and facility management.

HAI surveillance

Thirty-one of 41 (76%) hospitals reported conducting HAI surveillance. However, none of the hospitals reported having a system that include all HAI surveillance components recommended by WHO including a list of priority HAIs, standardized case definitions, standardized data collection and review methods, and clearly defined roles and responsibilities.

IPC guidelines

Thirty-one (76%) of the 41 hospitals had IPC guidelines available, including 26 (63%) that used national guidelines, two (5%) that used international guidelines translated into Georgian, and three (7%) that used internal guidelines developed by their own facility staff. Of the total sample, 18 (44%) reported training their clinical staff on the IPC guidelines. Thirty-three (80%) hospitals had IPC SOPs available, 18 (55%) of which had facility-specific SOPs adapted by IPC personnel and clinical staff.

Multimodal strategies

Facility use of multimodal strategies for hand hygiene (HH) and injection safety were assessed. Injection safety was specifically targeted given the high prevalence of HCV in Georgia. While all hospitals reported having reminders, posters, or other tools to promote hand hygiene, only 19 (46%) hospitals displayed them at all hand hygiene stations. Four (10%) hospitals used additional methods to improve team communication for hand hygiene across units. Twelve (29%) of hospitals reported having reminders, posters, or other tools to promote injection safety with only four hospitals (10%) had visible reminders, posters, or other tools to raise awareness of injection safety at all stations. Managers showed visible support and served as role models for hand hygiene in 23 (56%) hospitals and for injection safety in 21 (51%) hospitals.

IPC infrastructure and supplies

Most hospitals reported having the basic infrastructure and supplies needed to conduct IPC including building features, such as energy and water supply (100%), bed occupancy limited to one patient per bed in all units (100%), adequate spacing (at least 1 m) ensured between beds in all units (88%), and functioning environmental ventilation available in all patient care areas (98%). Thirty-six hospitals (88%) had single rooms available for individual isolation. Thirty-seven hospitals (90%) had dedicated decontamination area and/or sterile supply department available and functioning, and 40 hospitals (98%) reported to have sterile and disinfected equipment ready for use every day and of sufficient quantity.

However, for many hospitals, responses to interview questions were inconsistent with infrastructure and supply observations. For example, 21(51%) hospitals reported having a daily record of cleaning, but the daily record was verified by data collectors’ observations in 13 (32%) hospitals. Similarly, 37 (90%) hospitals reported having functioning hand hygiene stations available at all points of care, but data collectors were only able to verify through their observations in 28 (68%) hospitals. Almost all hospitals (98%) reported having functional waste collection containers available at all waste generation points, however these were observed in only 29 (71%) hospitals.

In interviews, several facility managers from rural hospitals cited poor infrastructure (i.e., lack of rooms, need for complete renovation of premises, broken sewage systems) and absence of funding to improve infrastructure as leading factors preventing effective IPC implementation at their hospitals.

Overall, this study showed that the presence of an IPC program in Georgia does not directly correlate to a well-functioning facility-level IPC system where core IPC components are present.

Specifically, we found challenges in IPC-related staffing and training. While most hospitals had a sufficient number of designated IPC staff, nurses were part of the IPC team at only 78% of hospitals, despite recommendations for all IPC teams to include nurses [24]. In addition, IPC staff had received formal training at only 66% of hospitals surveyed; less than a third of hospitals routinely trained all new clinical and non-clinical staff as well as conducted mandatory IPC training at least annually. Only 76% of hospitals surveyed had any IPC guidelines, most were using national IPC guidelines that were not locally adapted, and only 58% of hospitals with IPC guidelines conducted related trainings. These findings correlate with research conducted previously at nine Georgian maternity hospitals showing that less than 70% of clinical staff received any type of training on HAI and that trainings conducted were limited to short seminars or ad hoc presentations [8]. Lack of effective capacity building for the healthcare workforce in Georgia is not unique to IPC,several other reviews have found inadequate training of healthcare providers to be a key challenge to quality health care services (Akhvlediani, Akhvlediani, & Kuchuloria, 2016; [16, 22, 29]. Suboptimal IPC education and training is also not unique to Georgia, as similar shortcomings were demonstrated during surveys conducted in high-income settings like Germany and Austria [1, 2].

Our findings also show that very few hospitals in Georgia used any systematic tools to routinely monitor IPC practices. Regular monitoring of IPC practices and timely feedback to all relevant staff is critical to prevent and control HAI at the facility-level [36]. Evidence shows a relationship between monitoring of hand-hygiene practices and reduced rates of HAI [10, 13, 25, 39], and WHO recommends monitoring all critical aspects of IPC, such as interventions to prevent catheter-related bloodstream infections and ventilator-associated pneumonia, as well as auditing of environmental cleaning procedures. Sharing of information with relevant facility staff was also rare. This is consistent with a 2016 review noting that due to limited training and monitoring, medical staff often neglected proper hand washing and use of personal protection equipment [3].

To our knowledge, this is the first systematic assessment of WHO’s IPC core components at Georgian health hospitals. Previously published studies focused on HAI and AMR epidemiology, including neonatal blood stream infections [16, 30], multi-drug resistant tuberculosis [19, 35], and specific pathogens such as antibiotic resistant Staphylococcus aureus, Pseudomonas aeruginosa, and Enterococcus spp. [26]. None of the published studies, however, used a systematic approach to evaluate the organization and implementation of IPC at the facility level.

There are limitations to this assessment. Hospitals were randomly selected to include those of different geographic locations, types, and sizes. Although the response rate for the selected facilities was 100%, specialized hospitals for treatment of psychiatric conditions and tuberculosis, specialized hospitals with less than 10 beds, and general hospitals with less than 20 beds were excluded from the study, therefore, the results cannot be considered nationally representative. While data collectors informed participants that results would not be used to evaluate individual hospitals and would not result in punitive actions, staff may have been reluctant to share deficiencies. For areas where direct observations were not made, the assessment team verified the answers by cross-checking the available hospital documentation, however, over-reporting of presence of certain IPC components still likely occurred. Despite efforts to provide contextual information to participants, confusion about new or unfamiliar concepts may have affected the accuracy of their answers.

Strengths of this assessment include its focus on the gap between IPC policy and IPC implementation, as well as its relatively large sample size and systematic approach to data collection. This survey highlights that the presence of an IPC committee or policy do not always translate into functioning IPC activities at hospitals in Georgia. The results also highlight the challenges that can occur even in a country with a national IPC strategy. They highlight the need for ongoing systems strengthening at both the facility level and the national level. Development and dissemination of IPC Guidelines, implementation of an effective IPC training system and systematic monitoring of IPC practices will contribute to improved IPC in the country.

Our study shows that most of Georgian hospitals we surveyed have parts of an effective IPC program, namely an IPC committee, an IPC policy, designated staff and basic infrastructure in place; however, this does not translate into functional IPC activities. Georgia is reforming their healthcare system to ensure universal health coverage (UHC) and improve the quality of healthcare services, but achieving UHC with quality health services is not possible without an effective IPC system [31]. Endorsement of this study by the MoLHSA is an important step in Georgia's commitment to improving IPC and adhering to WHO’s IPC Core Components. There are resources available which provide practical tools for strengthening IPC programs at the national and facility level, based on the WHO IPC Core Components, and addressing the gaps identified during this assessment [37, 38].

Georgia is currently updating national IPC guidelines, based on international standards, but adapted to the Georgian context. This is an initial step to establishing national IPC standards, upon which to base the development of IPC trainings and an IPC monitoring system. A comprehensive IPC monitoring system at the facility and national level is critical to ensure compliance and guide future IPC improvements. Continuous improvement will require regular monitoring and use of IPC data.

The authors are responsible for the data described in the manuscript and assure full availability of the study material upon request to the corresponding author.

AMR:

Antimicrobial resistance

DQA:

Data quality audit

HAI:

Health care-associated infections

IICP:

International Infection Control Program

IPCAF:

IPC Situational analysis Framework

IPC:

Infection prevention and control

IRB:

Institutional review board

MoLHSA:

Ministry of Labor Health and Social Affairs of Georgia

NCDC & PH:

National Centers for Disease Control & Public Health, Georgia

PI:

Principal investigator

SOP:

Standard operating procedure

U.S. CDC:

U.S. Centers for Disease Control and Prevention

WHO:

World Health Organization

This situational analysis would not have been possible without the support from the MoLHSA leadership and participation of staff from healthcare hospitals included in the assessment. In addition, the following individuals were essential to the development and implementation of the assessment: Marina Baidauri (MoLHSA), Tina Gabrichidze (Tbilisi State Medical University), Gvantsa Gasviani (MoLHSA), Eka Khabazi (NCDC & PH), Shorena Svanidze (Tbilisi Republican Hospital), Lela Tsakadze (EVEX), Sarina Dane (ICAP), Nadria Erkebaeva (ICAP), Viktor Ivakin (ICAP), Getachew Kassa (ICAP), Brenda Senyana (ICAP), Ketie Zaridze (NCDC & PH).

Disclaimer:

The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention or the WHO.

This study was funded by the U.S. Centers for Disease Control and Prevention (CDC) through the Global Technical Assistance Project, Cooperative Agreement # 5U2GGH000994-03, Year 5. Funding period 04/01/2018–03/31/2019, President’s Emergency Plan for AIDS Relief (PEPFAR). CDC staff were involved in protocol development, implementation and report writing.

Affiliations

1. ICAP, Columbia University, Almaty, Kazakhstan

   Anna Deryabina

2. International Infection Control Program, Division of Healthcare Quality Promotion, U.S. Centers for Disease Control and Prevention, Atlanta, USA

   Meghan Lyman, Daiva Yee, Jamine Weiss & Amy Kolwaite

3. South Caucasus Office, U.S. Centers for Disease Control and Prevention, Atlanta, USA

   Marika Gelieshvilli & Beth Skaggs

4. MoLHSA/NCDC&PH, Atlanta, USA

   Lia Sanodze

5. TEPHINET, Atlanta, GA, USA

   Lali Madzgarashvili

6. Consultant to the World Health Organization, Geneva, Switzerland

   Claire Kilpatrick

7. ICAP, Columbia University, New York, USA

   Miriam Rabkin

Contributions

AD contributed to the design, data collection, analysis, and interpretation of data, and drafted the article. MG, LS and LM contributed to data collection. DY contributed to data analysis. ML, JW, MR, CK, BS and AK contributed to the conception, design of the study and revised the article for content and language. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Anna Deryabina.

Ethics approval and consent to participate

The study protocol was reviewed and approved by the Columbia University Medical Center IRB, IRB of Georgia National Center for Disease Control and Public Health.

Consent for publication

Not applicable.

Competing interests

Authors have no competing interests to disclose.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Annex 1: Assessment of IPC system characteristics

Annex 2A: Questionnaires used for semi-structured interviews with health managers

Annex 2B: Questionnaires used for semi-structured interviews with IPC FOCAL POINT/TEAM

PART 1

PART 2

The checklist should be completed by the assessment team based on direct observations during a random walk around the facility. It is recommended that the random walk will include visits to one ICU (if available) and a typical ward (department). In case of hospitals that have pediatric and adult wards, the team needs to visit one adult ward and one pediatric ward. In each ward, the team must check a minor procedures room and 2–5 patient rooms.

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