Implementation of the core components of infection prevention and control (IPC) programmes in North Macedonia

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infection prevention and control (IPC) programmes in North Macedonia

Self-assessment summary report

June 2020

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the national and facility levels. The self-assessment paid particular attention to facilities involved in treatment of COVID-19 patients in order to identify key gaps and to provide guidance and recommendations to improve IPC practices at the national level. It built on information from a joint external evaluation of International Health Regulations core capacities in North Macedonia in 2019. This report provides summary results of the IPC core components self-assessment and sets out recommendations for next steps that need to be taken.

Keywords

INFECTION PREVENTION AND CONTROL SELF-ASSESSMENT

CORE COMPONENTS

COVID-19 BEHAVIOURAL INSIGHTS COVID-19

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Acknowledgements

The IPC core components self-assessment was implemented under the leadership of Professor Dr Katja Popovska and Professor Dr Vesna Gerasimovska from the Macedonian Association for Control of Intrahospital Infections.

The WHO Regional Office for Europe is also grateful to the hospital managers and the professionals responsible for IPC in the hospitals and health facilities where the assessment was undertaken, including:

▪ University Clinic for Infectious Diseases and Febrile Conditions

▪ General Hospital 8th September

▪ Clinic for Children’s Diseases

▪ General Hospital, Bitola

▪ General Hospital, Stip

▪ Emergency Medical Centre, Skopje

▪ Institute for Microbiology and Parasitology, Skopje

▪ Geriatric Hospital 13th November

▪ Health Centre Gjorce Petrov

▪ Department for Haemodialysis within General Hospital 8th September.

Special thanks go to staff of the WHO Country Office in North Macedonia (Dr Jihane Tawilah, Head of Office, and Ms Margarita Spasenovska, National Professional Officer) and to the team from the Clinical and Health Interventions Pillar/Incident Leadership and

Management Response at the WHO Regional Office for Europe (Mrs Ana Paula Coutinho Rehse, Dr Caroline Brown and Dr Regmi Jetri), as well as the WHO international consultants Professor Rossitza Vatcheva-Dobrevska, Ms Tamara Curtin and Ms Unarose Hogan).

The IPC core components self-assessment was conducted with financial support from the United States Agency for International Development (USAID).

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Introduction

According to WHO, defective infection prevention and control (IPC) practices during

everyday health care delivery cause harm to hundreds of millions of patients worldwide every year (1). Health care-associated infections (HAIs), including those resistant to antimicrobials, are among the most common complications of hospital stays. No country or health system – even the most developed or sophisticated – can claim to be free from HAIs.

Although significant progress has been made to reduce HAIs in many parts of the world, several emerging events have underlined the need to support countries in developing and strengthening IPC, with the objective of achieving resilient health systems, at both the national and facility levels. In recent years, the spread of Middle East respiratory syndrome coronavirus and the Ebola virus disease outbreaks have revealed gaps in IPC measures applied by the countries concerned. Furthermore, the International Health Regulations (IHR) (2) and the WHO global action plan on antimicrobial resistance (AMR) (3) call for IPC strengthening across nations.

In consideration of these factors, in 2016 WHO published the new guidelines on the core components of IPC programmes (4), with the aim of strengthening IPC capacities at the national and facility levels. The guidelines address eight areas (IPC programmes; evidence- based guidelines; education and training; surveillance; multimodal strategies; monitoring, audit and feedback; workload, staffing and bed occupancy and the built environment, materials and equipment). They comprise 11 recommendations and three good practice statements. The objectives of the WHO guidelines are:

▪ to provide evidence-based recommendations on the core components of IPC programmes that are required to be in place at the national and acute facility level to prevent HAIs and to combat AMR through IPC practices;

▪ to support countries and health care facilities to develop or strengthen IPC programmes and strategies through the provision of evidence- and consensus-based guidance that can be adapted to the local context, while taking account of available resources and public health needs.

Status of IPC programmes in North Macedonia

According to the joint external evaluation of IHR core capacities of North Macedonia in 2019 (5), a national IPC programme is not in place in the country. Hand hygiene campaigns have been conducted regularly since 2014 and educational materials are available. Training materials and visuals are distributed to all hospitals and are available on the Institute of Public Health website. A national commission for control of HAIs is in place, underpinned by the necessary laws and regulations. National and local commissions are in place for control of HAIs, along with a person responsible for IPC. All public health centres prepare annual plans for IPC measures and all hospitals should have internal hospital HAI commissions.

The joint external evaluation made the following recommendations.

▪ A national IPC programme should be developed and implemented.

▪ A strategy for control and prevention of HAIs should be developed and implemented. This should include the stipulation that the national commission for control of HAIs should

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develop defined goals and a strategy, and that hospital commissions are functioning everywhere.

▪ All hospitals should have professionals trained in the prevention and control of HAIs on their staff, and a relevant national training programme should be developed.

▪ A system should be established to measure implementation of hand hygiene.

▪ Guidelines for improving biosecurity should be strengthened.

North Macedonia participated in the point prevalence survey of HAIs and antimicrobial use in long-term care facilities in the European Union and European Economic Area, led by the European Centre for Disease Prevention and Control in 2016–2017 (6). The National Institute of Public Health coordinated the data collection and analysis in four long-term care facilities, including 294 residents. The results revealed that 3.4% of residents in North Macedonia had at least one HAI at the time of the survey.

Self-assessment of implementation of the core components of IPC programmes in North Macedonia

At the request of the Ministry of Health, the WHO Regional Office for Europe supported North Macedonia in conducting a self-assessment of implementation of the core components of IPC programmes at the national and facility levels, with specific focus on facilities

involved in treatment of COVID-19 patients. The self-assessment was led by Professor Dr Katja Popovska and Professor Dr Vesna Gerasimovska, of the Macedonian Association for Control of Intrahospital Infections.

The self-assessment at the national level was undertaken using the WHO national IPC assessment tool 2 (IPCAT2) (7). It was conducted in Skopje on 25–30 May 2020. The self- assessment of 10 individual facilities was undertaken using the WHO infection prevention and control assessment framework (IPCAF) (8). It was conducted on 15–20 May 2020. The members of the IPC hospital teams were instructed and advised on how to fill out the questionnaires by the team leaders of this activity.

Summary results of the self-assessment

The national team used IPCAT2 to evaluate how the six core components of the guidelines targeted at the national level were implemented in North Macedonia. The results showed an intermediate level of implementation of core component 1 (IPC programmes), but they demonstrated that further improvement was needed for core components 2 (IPC guidelines), 3 (IPC education and training), 4 (HAI surveillance), 5 (multimodal strategies) and 6

(monitoring of IPC practices and feedback) (Table 1).

Table 1. Summary results of the self-assessment at the national level

IPC core component National score

(percentage of implementation)

1. IPC programmes 43

2. IPC guidelines 17

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IPC core component National score

(percentage of implementation)

3. IPC education and training 5

4. HAI surveillance 29

5. Multimodal strategies 14

6. Monitoring of IPC practices and feedback 33

Designated representatives of 10 facilities, with the assistance of the Macedonian Association for Control of Intrahospital Infections, conducted the self-assessment of the IPC programme at the facility level. They used IPCAF to evaluate how the eight core components of the guidelines targeted at the facility level were implemented. Table 2 outlines the four IPCAF levels of IPC promotion and practice. The self-assessment covered 10 facilities (seven hospitals in Skopje, Bitola and Shtip and three primary health care facilities).

Table 2. IPC level definitions according to IPCAF score results IPC level Definition

Inadequate IPC core components implementation is deficient. Significant improvement is required.

Basic Some aspects of the IPC core components are in place, but not sufficiently implemented. Further improvement is required.

Intermediate Most aspects of the IPC core components are appropriately

implemented. The facility should continue to improve the scope and quality of implementation and focus on the development of long-term plans to sustain and further promote the existing IPC programme activities.

Advanced The IPC core components are fully implemented according to the WHO recommendations, and are appropriate to the needs of the facility.

Source: WHO (8).

The average score across all 10 facilities in North Macedonia was 392.6, corresponding to a basic level of implementation of the core components. The average score at the hospital (secondary health care) level was 440, corresponding to an intermediate level of

implementation. The average score at the primary health care level was 281.8, corresponding to a basic level of implementation (Table 3).

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Table 3. Summary results of the self-assessment at the facility level

Main recommendations

The assessment team made the following recommendations on each of the core components of IPC programmes in North Macedonia. WHO has produced a number of guidance materials that can be consulted for further information and support (10–13).

Core component 1 – IPC programmes

▪ A national IPC programme with clear goals, objectives and activities for HAI prevention should be developed, supported by a national multidisciplinary IPC team.

▪ A national IPC committee consisting of 86 multidisciplinary experts with a proven track record in the field of IPC should be established. The committee should be an advisory body to the minister of health and offer solutions and activities for implementation of the IPC programme at the national and facility levels.

▪ All hospitals should have a functioning IPC programme with a dedicated, trained IPC team for the purpose of preventing HAI and combating AMR by implementing IPC

recommendations. Teams should receive full support from educated professionals in AMR and HAI prevention.

IPC core components at the facility level

Secondary health care facilities average score

Primary health care facilities average score

All facilities average score

1. IPC programmes 57.8 22.5 46.8

2. IPC guidelines 77.5 56.7 71.3

3. IPC education and training

57.1 41.7 52.5

4. HAI surveillance 38.6 20 33

5. Multimodal strategies 15.7 16.7 16

6. Monitoring of IPC practices and feedback

43 34.2 40.5

7. Workload, staffing and bed occupancy

64.3 Not applicable to outpatient setting

47.5

8. Built environment, materials and equipment for IPC at the facility level

86 81.7 85

Average total IPC level

440/800 Intermediate

281.8/700 Basic

392.6 Basic

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▪ All primary health care institutions should establish an IPC team composed of a doctor, a nurse and a laboratory technician. The IPC team should be responsible for developing an IPC programme with clearly defined goals and performance indicators, supported by the facility management.

Core component 2 – IPC guidelines

▪ The national IPC team should update national guidelines covering the following key topics: standard and transmission-based precautions; outbreak management and

preparedness; injection safety; prevention of surgical site infection; prevention of vascular catheter-associated bloodstream infections; prevention of hospital-acquired pneumonia;

prevention of catheter-associated urinary tract infections; and prevention of transmission of multidrug-resistant pathogens.

▪ IPC teams in all hospitals should organize a system to monitor guideline implementation, supported by hospital leadership.

▪ Primary health care institutions should send experts for training on guideline development and should involve front-line health workers in the planning of IPC guidelines. They should organize training on all updated guidance and audit its implementation.

Core component 3 – IPC education and training

▪ Members of the national IPC team and IPC committee should undertake advanced IPC courses organized by international organizations (such as the European Society of Clinical Microbiology and Infectious Diseases, the European Centre for Disease Prevention and Control and WHO).

▪ The national IPC programme should introduce mandatory IPC training for all health care personnel on employment and at least annually. Training should include technical

presentations, case studies and simulation exercises, and the content of IPC standard operation procedures should be integrated into the training programme.

▪ IPC team at the facility level should develop a communication strategy to engage new and current personnel to attend IPC training, and should evaluate the effectiveness of the IPC training programme once or twice a year.

▪ Primary health care institutions should ensure all new and current personnel attend continuous training activities organized by local professional associations at least twice a year. Training activities should be evaluated routinely by the local IPC team.

Core component 4 – HAI surveillance

▪ The national IPC team should consider coordinating a pilot point prevalence survey in selected hospitals to identify HAI and AMR trends. This could involve the National Institute of Public Health, given its previous experience. This is essential to orient future surveillance and IPC interventions approaches.

▪ Hospital IPC teams, in alignment with the national approach, should establish HAI and AMR surveillance programmes based on local surveillance priorities and relevant

multidrug-resistant pathogens. Hospital management should provide IT infrastructure and professional support from trained epidemiologists or microbiologists to conduct HAI and AMR surveillance.

▪ Hospital IPC teams should analyse HAI and AMR surveillance data, and should present trends regularly to hospital departments and to the local IPC committee and management.

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▪ Local IPC teams at primary health care institutions should conduct HAI and AMR surveillance at least every six months, followed by data analysis and reporting at least once a year.

Core component 5 – multimodal strategies

▪ The national IPC team should develop a national hand hygiene strategy plan, based on the WHO multimodal hand hygiene improvement framework.

▪ Hospital IPC teams, in alignment with the national approach, should develop hand hygiene plans based on the WHO hand hygiene self-assessment framework (9).

▪ Local IPC teams at primary health care institutions should use multimodal strategies – at the very least to implement interventions to improve hand hygiene, safe injection

practices, decontamination of medical instruments and devices and environmental cleaning.

Core component 6 – monitoring of IPC practices and feedback

▪ The national IPC team should develop a monitoring and evaluation framework. It should consider requesting hospital IPC teams to implement the WHO hand hygiene self- assessment framework and the WHO IPCAF regularly.

▪ Hospital IPC teams should develop clear monitoring plans, including description of IPC practices to be monitored, frequency of monitoring and mechanisms to provide feedback.

Staff involved in monitoring activities should receive adequate training. The list of indicators for monitoring should be expanded, including antibiotic consumption and hand hygiene indicators, according to the WHO framework.

▪ Management should ask hospital IPC teams to present the results at least twice a year. In situations where institutional culture does not allow public disclosure, hospital IPC teams should provide feedback directly to the head of department.

▪ Local IPC teams at primary health care institutions should implement the WHO hand hygiene self-assessment framework as a starting-point for monitoring and evaluation of IPC practices.

Core component 7 – workload, staffing and bed occupancy

▪ All hospitals should maintain an appropriate staffing level according to the number of patients, in line with WHO standards. Hospital administrators should have a rapid response plan in case additional staff are needed (i.e. a human resources policy for management of urgent deployment of staff).

▪ Hospital managers should be engaged in mandatory annual renovation and redesign of all hospital departments, in accordance with international standards.

▪ Patients should not be accommodated in corridors or on the floor; two patients should not occupy the same bed; and the distance between beds should be at least 1 metre. Local IPC teams should inform hospital administrators about the importance of these conditions to reduce HAIs and prevent outbreaks.

▪ Local IPC teams at primary health care institutions should participate in the

development/regular updating of mechanisms for patient flow, a triage system (including a referral system) and a system for management of consultations. They should also assess staffing levels regularly and develop an appropriate rapid response plan in case additional staff are needed.

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Core component 8 – built environment, materials and equipment for IPC at the facility level

▪ Local IPC teams should establish cohort wards for unforeseen (crisis) situations. They should introduce or update existing plans and standard procedures for patient placement if isolation is required. An organized arrangement for infectious waste incineration or an alternative for emergencies should be established.

▪ Local IPC teams at primary health care institutions should ensure a regular supply of high- quality personal protective equipment.

Next steps

IPC is a cross-cutting issue in health care. Strong, effective IPC programmes have the ability to influence the quality of care, improve patient safety and protect all those providing care in the health system. Implementation of all WHO recommendations on core components is required to build functioning programmes, leading to the effective reduction of HAIs and AMR. The fulfilment of all IPC core components takes time; however, the current COVID- 19 pandemic has accelerated the development of a national IPC programme in North Macedonia.

The results of the baseline assessment should be used to develop and execute an action plan based around a multimodal improvement strategy. The action plan will identify priorities, time frames and designation of lead people and support staff for each action as necessary.

A draft action plan was developed to support implementation of the core components of IPC programmes at the national and facility levels in North Macedonia. Next steps include discussion with competent health authorities seeking official approval of the action plan, including allocation of human and financial resources.

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References

¹

1. Allegranzi B, Kilpatrick C, Storr J, Kelley E, Park BJ, Donaldson L et al. Global infection prevention and control priorities 2018–22: a call for action. Lancet Glob Health. 2017;5 (12):E1178–80. doi:10.1016/S2214-109X(17)30427-8.

2. International Health Regulations. In: World Health Organization [website]. Geneva: World Health Organization; 2020 (https://www.who.int/health-topics/international-health-

regulations#tab=tab_1).

3. Global action plan on antimicrobial resistance. Geneva: World Health Organization; 2015 (https://www.who.int/antimicrobial-resistance/publications/global-action-plan/en/).

4. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016 (https://apps.who.int/iris/handle/10665/251730).

5. Joint external evaluation of IHR core capacities of the Republic of North Macedonia:

mission report: 11–15 March 2019. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/handle/10665/325320).

6. Suetens C, Latour K, Kärki T, et al. Prevalence of healthcare-associated infections, estimated incidence and composite antimicrobial resistance index in acute care hospitals and long-term care facilities: results from two European point prevalence surveys, 2016 to 2017 [published correction appears in Euro Surveill. 2018 Nov;23(47):]. Euro Surveill.

2018;23(46):1800516. doi:10.2807/1560-7917.ES.2018.23.46.1800516

7. Instructions for the national infection prevention and control assessment tool 2 (IPCAT2).

Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/330078).

8. Infection prevention and control assessment framework at the facility level. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/330072).

9. Hand hygiene self-assessment framework 2010. Geneva: World Health Organization; 2010 (https://www.who.int/gpsc/5may/hhsa_framework/en/).

10. Interim practical manual: supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/330073).

11. Improving infection prevention and control at the health facility: interim practical manual supporting implementation of the WHO guidelines on core components of infection prevention and control programmes. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/279788).

12. Hospital readiness checklist for COVID-19: interim version February 24 2020.

Copenhagen: WHO Regional Office for Europe; 2020 (https://apps.who.int/iris/handle/10665/333972).

13. Minimum requirements for infection prevention and control programmes. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/handle/10665/330080).

1 All URLs accessed 27 November 2020.

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