key: cord-1012400-b3gt6lob
authors: Choi, Ui Yoon; Kwon, Young Mi; Kang, Hye Jeong; Song, Jae Hoon; Lee, Hae Yeoun; Kim, Mi Sook; Kahm, Se Hoon; Kwon, Ji Young; Kim, Sang Hoon; Lee, Sang-Hwa; Choi, Jung Hyun; Lee, Jehoon
title: Surveillance of the infection prevention and control practices of healthcare workers by an infection control surveillance-working group and a team of infection control coordinators during the COVID-19 pandemic
date: 2021-01-30
journal: J Infect Public Health
DOI: 10.1016/j.jiph.2021.01.012
sha: 94b9f1d5ee519f967e04c16320cf1d85efb6bfc0
doc_id: 1012400
cord_uid: b3gt6lob

BACKGROUND: During the ongoing coronavirus disease (COVID-19) pandemic, hospitals have strengthened their guidelines on infection prevention and control (IPC), and a rigorous adherence to these guidelines is crucial. An infection control surveillance-working group (ICS-WG) and infection control coordinators (ICCs) team were created to monitor the IPC practices of the healthcare workers (HCWs) in a regional hospital in Korea. This study analyzed the surveillance results and aimed to identify what IPC practices needed improvement. METHODS: During phase 1 (March to April 2020), the ICS-WG performed random audits, recorded incidences of improper IPC practices, and provided advice to the violators. During phase 2 (April to July), the ICCs inspected the hospital units and proposed practical ideas about IPC. The surveillance and proposals targeted the following practices: patient screening, usage of personal protective equipment (PPE), hand and respiratory hygiene, equipment reprocessing, environmental cleaning, management of medical waste, and social distancing. RESULTS: In phase 1, of the 127 violations observed, most (32.3%) corresponded to hand and respiratory hygiene. In phase 2, the highest proportion of violation per category was observed in the management of medical waste (37.8%); among these, a higher proportion of violation (71.4%) was observed in the collection of medical waste. Of the 106 proposals made by the ICCs, the most addressed practice was patient screening (28.3%). No case of nosocomial infection was reported during the study period. CONCLUSION: Adherence to proper hand and respiratory hygiene was inadequate at the early stage of the COVID-19 pandemic. The results indicate that more attention and further training are needed for the management of medical waste, particularly medical waste collection, and that continuous upgrading of the strategies for patient screening is essential. These results will be useful in helping other healthcare facilities to establish their IPC strategies.

The pandemic of coronavirus disease 2019 (COVID- 19) is ongoing, and the World Health Organisation (WHO) has warned that this crisis will not end soon [1, 2] . In Korea, the first case of COVID-19 was reported on January 20, 2020. The infection rate overwhelmed the country in February and March but then started to decrease [3] . However, incidence spikes followed by cluster infections have been constantly occurring. As of October 17, there had been 25,698 cases, with 455 deaths [4] .

Hospitals are high-risk environments for nosocomial exposure and infection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the coronavirus that causes COVID-19 [5, 6] . There is increasing evidence that individuals with COVID-19 who are either asymptomatic or exhibit mild non-specific symptoms, such as fever or cough, are highly contagious. These patients may introduce the virus to hospitals, thereby causing clusters of nosocomial infection [7, 8] . To minimize the risk of SARS-CoV-2 exposure and nosocomial infection, hospitals have strengthened their guidelines on infection prevention and control (IPC) practices [9] [10] [11] . Rigorous adherence to these guidelines is crucial to maintain the standards of IPC practices at high levels, and surveillance alongside continuous training of healthcare workers (HCWs) greatly contributes to this end.

This study presents the activities of the infection control surveillance-working group (ICS-WG) and the infection control coordinators (ICCs)'s team at Eunpyeong St. Mary's Hospital, Seoul, Korea. The two programs were created during the COVID-19 pandemic to reinforce the monitoring on IPC practices. This hospital is a regional referral hospital and generally hosts a considerable number of patients immunocompromised due to organ transplantation, hematologic diseases, or chemotherapy. With the outbreak of COVID-19, Eunpyeong St. Mary's Hospital was also designated as COVID-19 testing and treatment hospital. Consequently, the hospital established guidelines on the following categories of IPC practices: patient screening and triage, personal protective equipment (PPE) usage, hand and J o u r n a l P r e -p r o o f respiratory hygiene, equipment reprocessing, environmental cleaning, management of medical waste, and social distancing. These guidelines were notified to all the HCWs of the hospital. The ICS-WG and ICCs were assigned to monitor the IPC practices of the HCWs, particularly for any improper IPC practice that is in violation of the guidelines.

Although many studies have recently reported on experiences with IPC practices against COVID-19, systematically analyzed data are limited. This study assessed the observations of the ICS-WG and ICCs on the IPC practices of the HCWs in a regional referral hospital during the pandemic and aimed to determine which practice is the most challenging to execute in compliance with the guidelines and thus needs improvement. The results will be useful in providing the HCWs with feedback and proper training on IPC practices, and in establishing IPC strategies at other healthcare facilities Methods J o u r n a l P r e -p r o o f Checklist A detailed checklist was developed to maintain adherence to proper IPC practice and distributed to the managers of the hospital units or teams, who shared it with their members.

This checklist, which reflected the guidelines issued by the Korea Disease Control and Prevention Agency [12] , is presented in Table 1 . The ICS-WG or ICC monitored for the presence of the required elements, the performance of HCWs, and evidence of IPC practices including the body temperature checking note and HCW's working note. The following presents criteria for compliance briefly (no or incomplete presentation/performance was considered as noncompliant).

· Patient Screening and Triage -Present completely (e.g.: posters, hand sanitizer, triage, isolation room) was considered as compliant.

-Performed completely (e.g.: checking body temperature) was considered as compliant · PPE usage of HCW -Present completely (e.g.: prepared PPE, room for PPE doffing, instruction poster) was considered as compliant.

-Performed completely (e.g.: wearing PPE, providing surgical mask) was considered as compliant.

· Hand and respiratory hygiene J o u r n a l P r e -p r o o f -Present completely (e.g.: poster, sanitizer, all of people wearing facial mask) was considered as compliant.

· Equipment Reprocessing -Present completely (e.g.: manual for cleaning equipment, disinfectant) was considered as compliant.

-Performed completely (e.g.: wearing PPE during cleaning equipment) was considered as compliant.

· Environmental cleaning -Performed completely (e.g.: cleaning), was considered as compliant.

· Management of medical waste -Present (e.g.: container for medical waste) in necessary places, was considered as compliant.

-Present completely (e.g.: disposal vinyl bags are placed in container, not overfilled, lid is closed), was considered as compliant.

-Performed completely (wearing of specified PPE during handling, segregated properly-not mixed with nonmedical waste), was considered as compliant.

· Social distancing -Present completely (e.g.: poster, social distancing), was considered as compliant. 

During phase 1, the incidences of noncompliance with the guidelines were recorded for all the IPC categories, and the distribution by each IPC category was assessed. During phase 2, the proportion of compliance and noncompliance per category among the total inspections were evaluated. In addition, the distribution of each category addressed in the proposals made by the ICCs was evaluated.

Descriptive statistics and frequency distributions were generated for all variables.

Fisher's exact test or the chi-square test was performed to compare the incidence or proportions of the variables. All the statistical analyses were performed using IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, NY, USA). P < 0.05 was considered statistically significant. 

The results of this study showed that, during phase 1, the most frequent (32.3%) noncompliance with the IPC guidelines were related to hand and respiratory hygiene practices. In other words, these practices appear to be the most improperly performed IPC practices in a hospital setting during the early stage of the COVID-19 pandemic. Additionally, during phase 1, the ICS-WG often identified patients or visitors without any or properly worn facial masks. Thus, it seems that the awareness of the usage of facial masks was not high during the early stage of the COVID-19 pandemic.

During phase 2, the highest proportion (37.8%) of noncompliance observed was related to the management of medical waste compared with other IPC categories. The overall high proportions of compliance in IPC categories during phase 2 indicate that the HCWs were careful about IPC practices, except for the management of medical waste. Among the management of medical waste items, the highest proportion (71.4%) of noncompliance was observed with the collection of medical waste ( Table 2 ). ICCs found cases of overfilled bins or their lids being opened. The containers for medical waste disposal are foot operated; however there were cases of faults with the pedal or arbitrarily fixed to open, for convenience (not needing to pedal every time). In the observation of the preparation of containers for medical waste disposal in necessary places (e.g., inpatient wards, outpatient clinics), 10% noncompliance was identified. In the observation of handling (PPE worn when handling, medical waste segregated properly (not mixed with nonmedical waste)), 30% noncompliance was identified. It seemed that the preparation or handling of containers by the HCWs was important and was considered to have a high risk of contamination, whereas the collection of medical waste was less important, with a low risk of contamination. However, overfilling can lead to contaminated surfaces in the environment where SARS-CoV-2 could survive for more than 5 days and could be the medium of transmission [13] . The faults with the pedals or the arbitrary opening of the containers could lead to touching of the containers. These behaviors J o u r n a l P r e -p r o o f increase the risk of contamination with SARS-CoV-2, particularly in the wards where COVID-19 patients are hospitalized and places where COVID-19 testing is performed [14] .

Further education is needed to increase awareness on the collection of medical waste. During the study period, the hospital constantly had inpatient undergoing treatment for COVID-19 and the positive rate for COVID-19 testing (104/4735; 2.2%) was higher than the J o u r n a l P r e -p r o o f nationwide positive rate of 0.5% [15, 16] . However, no case of nosocomial infection was reported during the study period.

During the COVID-19 pandemic, it has become clear that more ID physicians and ICNs are needed in Korea as well as other countries. This need seems to be higher in developing countries, small cities, or non-hospital healthcare facilities [17, 18] . In many countries, including Korea, infection control units with an ID physician and ICN are mandatory for hospitals [19] . However, during the COVID-19 pandemic, infection control units should constantly revise their programs and implement updated strategies in the hospital according to the newly issued governmental policies to accommodate the dynamics of COVID-19. It is virtually impossible to rely on these units for monitoring the IPC practices throughout the hospital. In this study, most of the members of the ICS-WG and ICCs were not ID physicians or ICNs but performed their surveillance using a checklist. For the ICS-WG and ICCs to be effective, not all of their members need to be ID physicians or ICNs as long as they know the essential steps of IPC practices and there is interactive communication among ICCs, ICS-WG, and hospital executives. An ideal ICS-WG member or ICC should be enthusiastic, keen, and with a special interest in infection control [19] .

Reporting through PowerPoint presentations was also helpful. Recently, self-checklists have increasingly been used in monitoring ICP practices, but a check mark is used to record compliance, rather than a parameter that grades the performance [20, 21] . PowerPoint presentations explicitly describe a situation and can include photographs of any case of noncompliance, thereby increasing the efficacy of the ICCs in their surveillance. Additionally, these presentations enabled making effective proposals and were useful in creating an interactive environment with eagerness to devise constructive strategies.

Although this study had the above-mentioned merits, it also had some limitations. fixing an unannounced surveillance on the pair's unit was not enforced because of the concern that the ICCs may be overburdened since they also had routine responsibilities as HCWs. Fourth, the study period was relatively short. Although the ICS-WG and ICCs are still operating, it is paramount to share experiences and strategies as soon as possible during a pandemic. Thus, a short study period was inevitable.

In conclusion, the results of this study indicate the need for awareness and further training of HCWs on the management of medical waste, particularly collection of waste, at Eunpyeong St. Mary's Hospital. In addition, it is essential to update the guidelines on patient screening and triage periodically. This study also demonstrated that the hand and respiratory hygiene practices were inadequate during the early stage of the COVID-19 pandemic. The findings of this study will be useful in providing feedback to the HCWs at Eunpyeong St.

Mary's Hospital and in the future training of these personnel. The results can also serve as reference data for other healthcare facilities in formulating their own IPC strategies. We 

No funding sources.

None declared.

Not required. 

World Health Organization. COVID-19 pandemic

British Broadcasting Corporation. Coronavirus may never go away, World Health Organization warns

The first case of 2019 novel Coronavirus pneumonia imported into Korea from Wuhan, China: implication for infection for infection prevention and control measures

The updates of COVID-19 in Republic of Korea, as of

MERS and COVID-19 among healthcare worker: A narrative review

Apparent and occult infections of medical staff in a COVID-19 designated hospital

A SARS-CoV-2 familiar cluster infection reveals asymptomatic transmission to children

Optimizing screening strategies for coronavirus disease 2019: A study from Middle China

Effective strategies to prevent Coronavirus disease-2019 (COVID-19) outbreak in hospital

Coronavirus disease 2019 (COVID-19): A literature review

An analytical study on the awareness, attitude and practice during the COVID-19 pandemic in Riyadh, Saudi Arabia

Central Disaster and Safety Countermeasure Headquarters on COVID-19. Guidelines for Coronavirus disease 2019 for local goverment

Persistence of SARS-CoV-2 in the environment and COVID-19 transmission risk from environmental matrices and surfaces

Medical waste management practice during the 2019-2020 novel coronavirus pandemic: Experience in a general hospital

Cheongju, Korea: Korean Centers for J o u r n a l P r e -p r o o f Disease Control and Prevention

The updates of COVID-19 in Republic of Korea, as of March 9

Where is the ID in COVID-19?

Nurse staffing and Coronavirus infections in California Nursing Homes

The role of the infection control link nurse

How infection control teams can assess their own performance and enhance their prestige using activity and outcome indicators for public reporting

Impact of self-reported guideline compliance: Bloodstream infection prevention in a national collaborative

The authors thank Dr. Soon Yong Kwon, Dr. Seung Hye Choi, Fr. Chang Yeob Park and Dr. Seung Eun Jung for their encouragement to conduct this study. The authors also thank all the ICC inspectors who participated in this study.