key: cord-0015525-i3s0ysgf
authors: Deryabina, Anna; Lyman, Meghan; Yee, Daiva; Gelieshvilli, Marika; Sanodze, Lia; Madzgarashvili, Lali; Weiss, Jamine; Kilpatrick, Claire; Rabkin, Miriam; Skaggs, Beth; Kolwaite, Amy
title: Core components of infection prevention and control programs at the facility level in Georgia: key challenges and opportunities
date: 2021-02-24
journal: Antimicrob Resist Infect Control
DOI: 10.1186/s13756-020-00879-3
sha: 0de6b6c40f5254c6d4dbd0b142b2a0f554c2dac2
doc_id: 15525
cord_uid: i3s0ysgf

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 Open Access *Correspondence: annaderyabina@icap.kz; anna@deryabina.com 1 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.

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 nonresearch. 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.

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.

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.

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 MoL-HSA 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.

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 fulltime 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%).

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.

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. Thirtytwo 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.

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.

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 facilityspecific SOPs adapted by IPC personnel and clinical staff.

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.

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 wellfunctioning 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 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.

Authors' 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.

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.

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.

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.

Not applicable.

Authors have no competing interests to disclose. 

Clear goals and objectives 1 (2) Tools to collect data in a systematic way 3 (7) Clearly defined roles and responsibilities 0

Work plan or schedule 6 (15) Monitoring results were used to make unit/facility-specific plans to improve IPC practices 18 (44)

At least once within the past 3 months 32 (78) At least once within the past 6 months 1 (2) At least once within the past 12 months 0

More than 12 months ago or never 8 (20) Conducted and documented internal monitoring/auditing within the past 12 months 20 (49)

Hand Hygiene compliance 2 (5)

Consumption/usage of alcohol-based hand rub or soap 1 (2)

Injection safety 1 (2) Waste management 1 (2) Cleaning of ward environment 3 (7) Disinfection and sterilization of medical equipment/instruments 2 (5)

Transmission-based precautions, isolation and cohorting (grouping) of patients 0 

List of priority HAIs which are major causes of morbidity and mortality in the facility 15 (37) Standardized case-definitions (defined numerator and denominator) 13 (32) Standardized data collection methods 14 (34) Processes to review data quality 6 (15) Clearly defined roles and responsibilities of staff involved in surveillance 6 (15) Annual work plan and schedule 3 (7) Surveillance system includes none of the above components 7 (22) IPC guidelines

International guidelines that have not been adapted to facility context (translated into Georgian) 2 (5)

National guidelines 26 (63) Facility develops own guidelines 3 (7)

Trainings included interactive sessions 14 (34) Multimodal strategies

System change Interventions to ensure the necessary infrastructure and continuous availability of supplies 33 (80) Interventions to ensure optimal use and accessibility and prevent human error 10 (24) Education and training on IPC practices Written information and/or oral instruction/e-learning 28 (68) Interactive training sessions 21 (51) Monitoring of compliance and feedback Audits of hand hygiene conducted 12 (29) Audit results shared and discussed with HCWs and key players 5 (12) Communication and reminders Reminders, posters, or other tools used to promote or raise awareness of hand hygiene 41 (100)

Additional methods/initiatives to improve team communication across units/specialties 4 (10)

Safety climate and culture change Managers/leaders show visible support and act as champions/role models 23 (56) Facility staff are empowered to participate in hand hygiene improvement activities 10 (24)

System change Interventions to ensure the necessary infrastructure and continuous availability of supplies 38 (93) Interventions to ensure optimal use and accessibility and prevent human error 9 (22) Education and training on IPC practices Written information and/or oral instruction/e-learning 31 (76)

Interactive training sessions 14 (34) Monitoring of compliance and feedback Audits of injection safety conducted 5 (12) Audit results shared and discussed with HCWs and key players 2 (5) Communication and reminders Reminders, posters, or other tools used to promote or raise awareness of injection safety 12 (29) Additional methods/initiatives to improve team communication across units/specialties 0 

One role of the IPC team is to monitor or audit IPC practices, and provide feedback to staff in order to improve the quality of care and practice. An example of this is conducting hand hygiene observations to monitor staff compliance with appropriate hand hygiene practices.

Does this facility have an internal IPC monitoring/audit plan with any of the following?

Please verify the answer based on the available documents. Only select options that were verified by the document review.

1. No facility monitoring/audit plan available 2. Yes with clear goals and objectives 3. Yes with tools to collect data in a systematic way (for example checklists) 4. Yes with clearly defined roles and responsibilities 5. Yes with work plan or schedule 24 When was the last time there was an internal IPC monitoring/audit to assess compliance of any IPC practices at your facility? Choose one answer During the past 12 months, how often did you conduct monitoring/auditing of different IPC practices listed below in questions 25A-J? Choose one answer for each of the following questions 25A-J Please verify the answers based on the available documents.

Hand Hygiene Compliance (using any observation tools) If monitoring tools are not available (checklist and schedule), but facility staff claim to conduct monitoring frequently, mark "Periodically but no regular schedule" 

A national survey on the implementation of key infection prevention and control structures in German hospitals: results from 736 hospitals conducting the WHO Infection Prevention and Control Assessment Framework (IPCAF)

Evaluating infection prevention and control programs in Austrian acute care hospitals using the WHO Infection Prevention and Control Assessment Framework

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Global infection prevention and control priorities 2018-22: a call for action

Healthcare-associated infections in intensive care units: epidemiology and infection control in low-to-middle income countries

Integrating analyses in mixed methods research. Thousand Oaks: Sage

Prevalence and predictors of surgical site infection in Tbilisi, Republic of Georgia

Knowledge of health care-associated infections among Georgian obstetricians and gynecologists

The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs

Monitoring and feedback of hand hygiene compliance and the impact on facility-acquired methicillin-resistant Staphylococcus aureus

National progress toward hepatitis C elimination-Georgia

Relationship of hospital organizational culture to patient safety climate in the Veterans Health Administration

Cost-effectiveness of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial

Nosocomial Infections in Georgia; a retrospective study of microbiological data from four major tertiary care hospitals in Tbilisi, capital of Georgia

Antibiotic resistance-the need for global solutions

Etiology of neonatal blood stream infections in Tbilisi, Republic of Georgia

Multistate point-prevalence survey of health care-associated infections

The patient safety chain: transformational leadership's effect on patient safety culture, initiatives, and outcomes

High prevalence of multidrug-resistant tuberculosis in Georgia

Antimicrobial resistance in hospital-acquired gram-negative bacterial infections

Qualitative data analysis. Thousand Oaks: Sage

Barriers to accessing adequate maternal care in Georgia: a qualitative study

Launch of a nationwide hepatitis C elimination program-Georgia

The critical role of the staff nurse in antimicrobial stewardship-unrecognized, but already there

Effectiveness of a hospital-wide programme to improve compliance with hand hygiene

Genetic background and antibiotic resistance of Staphylococcus aureus strains isolated in the Republic of Georgia

Decreasing catheter-associated urinary tract infections in the neurological intensive care unit: one unit's success

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An overview of the health care system in Georgia: expert recommendations in the context of predictive, preventive and personalised medicine

High mortality among patients with positive blood cultures at a children's hospital in Tbilisi, Georgia

Redefining infection prevention and control in the new era of quality universal health coverage

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European Centre for Disease Prevention and Control. Point prevalence survey of healthcare associated infections and antimicrobial use in European acute care hospitals

Testing of the WHO Infection Prevention and Control Assessment Framework at acute healthcare facility level

The potential of a multiplex high-throughput molecular assay for early detection of first and second line tuberculosis drug resistance mutations to improve infection control and reduce costs: a decision analytical modeling study

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Transmission-based precautions, isolation and cohorting (grouping) of patients to prevent the spread of multidrug resistant organisms (MDRO) If monitoring tools are not available (checklist and schedule), but facility staff claim to conduct monitoring frequently, mark "Periodically but no regular schedule" 1. Discharge diagnosis data 2. Voluntary notification from physicians or nurses 3. Ward-based assessments (e.g., chart review, discussion with nurses or physicians, patient exam) 4. Laboratory-based assessment (e.g., review of blood cultures) 5. None of these types of surveillance 32 Have staff conducting HAI surveillance been trained in basic epidemiology, surveillance and IPC (i.e. capacity to oversee surveillance methods and manage/analyze/interpret data)? 

The term multimodal strategy refers to the implementation of several elements or components in an integrated way with the aim of improving an outcome and changing behavior. This multimodal strategy includes components such as system change which is the availability of infrastructure and supplies to enable IPC practices; education and training of healthcare workers and other hospital staff; monitoring of infrastructure, practices, processes, outcomes, and providing data feedback; reminders in the workplace; and culture change within the facility. In other words, the strategy involves "building" the right system, "teaching" the right things, "checking" the right things, "selling" the right messages, and ultimately "living" IPC throughout the entire health system.

For hand hygiene (HH) improvement activities, does your facility have any or all of the following elements listed in questions 46A-E? SELECT ALL THAT APPLY for questions 46A-E 

Are water services available at all times and of sufficient quantity for all uses (e.g., hand washing, drinking, personal hygiene, medical activities, sterilization, decontamination, cleaning and laundry)? Choose one answer 1. No, available on average < 5 days per week 2. Yes, available on average ≥ 5 days per week or every day but not of sufficient quantity 3. Yes, every day and of sufficient quantity 51Is a reliable safe drinking water station present and accessible for staff, patients and families at all times and in all locations/wards? Choose one answer Are at least two pairs of household cleaning gloves and one pair of overalls or apron and boots in a good state and available for each cleaning and waste disposal staff member? Choose one answer 1. No, not available 2. Yes, available but in poor condition 3. Yes, in good condition 67Is wastewater safely managed using on-site treatment (for example, septic tank followed by drainage pit) or sent to a functioning sewer system? Choose one answer