1 Background

The field of Infection Prevention and Control (IPC) encompasses a systematic and evidence-based strategy aimed at reducing the occurrence of infections among healthcare professionals, patients, and the wider population. The implementation of this technique is mandated for all health facilities and healthcare practitioners [1]. The inadequate implementation of IPC measures contributes to the occurrence of healthcare-associated infections (HAIs) [1]. This, in turn, exacerbates the problem of antimicrobial resistance (AMR), leading to increased rates of mortality and morbidity and placing a financial burden on both governments and individuals in the healthcare sector [2]. Furthermore, inadequate execution of IPC measures has been demonstrated to make healthcare professionals more susceptible to the occurrence of newly developing and recurring diseases, such as the coronavirus disease of 2019 (COVID-19) [3].

Compliance with IPC in hospitals in low- and middle-income countries (LMICs) has been shown in various studies to be inadequate, for example, in Philippines [4], and in Nigeria [5]; calling for a tailored implementation focused on a particular LMICs context [6]. Over the course of the previous ten years, it has been observed that the implementation of IPC recommendations and standards in Tanzanian hospitals has been insufficient [7]. In 2018, the Ministry undertook a revision of the National IPC Guidelines, followed by a revision of the IPC standards in 2020. Presently, there are continuing nationwide endeavours to disseminate, train, and monitor the execution of these guidelines and standards across all levels [8]. However, there is a scarcity of information regarding the responses of hospitals towards ongoing efforts implemented by the Ministry of Health (MoH) on adherence of IPC core components to various functional units [9]. Each Regional Referral Hospital has about twenty functional units based on services provided namely; intensive care unit (ICU); dental unit; eye unit; care and treatment clinic (CTC); labour ward; medical wards; paediatric wards; laboratory; obstetrics and gynaecology (ObGy) wards; outpatient department (OPD); administration; radiology; casualty; pharmacy; surgical wards; laundry; operating theatre; health care waste management (HCWM); blood transfusion; central sterilization and supply department (CSSD); and mortuary. During COVID 19 pandemic every HCW and clients at each functional unit at Health facility were at risk of health care associated COVID 19 infections. Since COVID 19 patients were in need of intensive care services which were mostly available at referral hospitals in Tanzania, it was paramount that these referral hospitals should adhere to all IPC measures for safety of both HCWs and their clients. Therefore, objective of the study was to provide a comprehensive description of the implementation of IPC measures within the various functional units of 26 Regional Referral Hospitals.

2 Methodology

Tanzania has implemented the standards-based management and recognition strategy as part of its national initiatives and efforts to promote IPC in all regional referral hospitals. This strategy aims to enhance the quality and safety of services provided in these healthcare facilities. During COVID-19 pandemic, MoH took efforts to improve IPCpractices in Health facilities using the strategy in which assessment were conducted annually to track progess.The Annual IPC assessment utilized the National IPC standards tool for hospitals, which is one of the checklists available in the MoH Tanzania’s digitalized system known as the Afya Supportive Supervision System (AfyaSS) [10]. AfyaSS is a platform for supportive supervision where checklists for various country health interventions are configured including National IPC assessment tool. The structure of data captured are according to the individual checklist.This study was a retrospective analysis of secondary data from Tanzania IPC 2021 annual implementation report from Regional Referral Hospitals extracted from AfyaSS after seeking permision.

The national IPC assessment tool is composed of all minimum IPC standard precautions requirements to be adhered to by all healthcare workers in Hospital settings all the time such as hand hygiene, personal protective equipment utilization, instrument processing and decontamination, housekeeping, medical waste management, and handling of sharps. The tool was developed with verification criteria which need some IPC standard precautions to be measured by observation, interviews, and document review. The review of documents involved documents available at a functional unit such as the availability of guidelines, standards operating procedures, checklists, and bundles at the working site in order to evaluate the performance of health institutions across many functional units. There are 28 regional referral hospitals in 26 regions of Tanzania Mainland in which three of them are in Dar es Salaam Region [11]. Therefore, in 2021 an IPC assessment was conducted on 26 regional referral hospitals that were fully functioning. The remaining two were in construction and shifting to new buildings. In addition to that, the assessment involved all healthcare service delivery units available at the Hospital that were functional.

The AfyaSS computed the scores for each functional unit by dividing the total number of standards reached by that unit by the total number of standards that the functional unit was expected to meet and then multiplying the result by 100. The facility score was determined by dividing the total score of each functional unit by the total score required to be achieved at that facility level and then multiplying the result by 100. Tool range 0–59% as poor performance, (60–79)% as moderate performance, and (80–100)% as outstanding performance.

Extraction and cleaning of data were done followed by data analysis which was done using STATA version 15.0 in order to calculate the weighted median with interquartile range (IQR) for each functional unit score for the year 2021.

3 Results

Table 1 below displays the weighted median ratings for each functional unit in 26 regional referral hospitals in 2021. The overall weighted median IPC compliance for all 26 regional referral hospitals was 50% (41–60) N = 26, with the lowest score being 24% and the best score being 72%. IPC compliance was as follows in each functional unit across all 26 regional referral hospitals: The best-performing unit was the Adult ICU at 71.4% (46.4–78.6), with the highest hospital scoring at 85.7% and the lowest facility scoring 17.9%. Mortuary was the lowest-performing functional unit, scoring 47.4% (36.8–57.9) N = 24, with the lowest score of 5.3% and the greatest IPC compliance of 79%. CSSD scored 47.4% (40–50) N = 24, with the lowest score being 10.5% and the highest being 65%, making it another functional unit that performed poorly. In addition, the blood transfusion unit received a dismal score of 47.6% (38.1–61.9) out of a possible 19 points, with the lowest score being 9.5% and the best being 81%.

Table 1 Infection Prevention and Control scores per functional unit in 26 Regional Referral Hospitals
Full size table

4 Discussion

4.1 Main findings in the context of previous research

The findings of this study indicate that there was a poor level of compliance with the weighted median IPC standards across all 26 regional referral hospitals. Additionally, the study assessed the performance of all functional units within these facilities. The ICU for adults demonstrated the highest level of performance across all units, whereas the mortuary, CSSD, and blood transfusion units showed the lowest levels of performance across all 26 regional referral hospitals. The relatively low level of adherence to IPC protocols seen at these referral hospitals continues to present a potential hazard to healthcare workers (HCWs) and patients seeking medical treatment at these establishments, particularly in light of the ongoing prevalence of newly developing and recurring diseases. The performance of HCWM may have also been contributed by previous quality improvement interventions in these hospitals such as the use of 5S-KAIZEN-TQM approach [12]. Also, some studies have reported inadequate HCWM handling in these hospitals [13, 14]. In Zambia, a study by Leonard and colleagues reported inadequate practices in HCWM handling [15].

The study presented findings on the outstanding performance of the ICU at the regional referral hospital in the domain of IPC for adult patients. These results stand in contrast to a previous study that highlighted the elevated risk of infection rates in ICUs located in developing nations [16]. The observed disparity may be attributed to insufficient monitoring measures implemented at the 26 regional referral hospitals, resulting in a lack of comprehensive data regarding the effectiveness of IPC policies. In Ethiopia, monthly training for HCWs, supportive supervision, and routine monitoring have been reported to contribute to improvement in HCWs’ compliance with IPC practices in neonatal ICUs in two hospitals [17].

In addition to that, the study reported that the lowest-performing units at 26 regional referral hospitals were mortuary, CSSD, and blood transfusion. The results of this study align with other prior investigations that have documented suboptimal interprofessional communication within hospital settings which limit skills and knowledge sharing among all HCWs in all functional units [18, 19]. Hence, it is also possible that inadequate space assigned to a certain functional unit to these regional referral hospitals especially CSSD, mortuaries limited its adherence to IPC standards. In addition to that, inadequate knowledge, and a lower level of awareness about the anticipation of risks, may account for this disparity of compliance to IPC in these functional units. Nevertheless, it could be due to the negligence of HCWs working in units not directly touching patients towards adhering to all IPC standards when compared to HCWs working in units that involve direct patient contact and the use of invasive devices.

4.2 Policy implications

The findings of our study have important policy implications for improving the quality and safety of services delivered in regional referral hospitals. The MoH needs to strengthen regular monitoring of the implementation of IPC practices in these hospitals, focusing on the various functional units. Secondly, the management teams of these hospitals need to strengthen the Work Improvement Teams, which are usuallyhealth quality champions in the functional units to perform their roles and regularly report quality initiatives implementation to the hospital's quality improvement team and the management team. Such team-based efforts will make IPC part of every health worker’s business on a daily basis in a way that will help to ensure hospital resilience to any future outbreaks and pandemics [20].

4.3 Study limitation and mitigation

A major limitation of this study is its design, which is a retrospective study using secondary data. Incompleteness of data and missing functional units in some hospitals were foreseen. This was due to the fact that the majority of regional referral hospitals had ongoing construction and renovation of buildings to expand the service delivery. To mitigate the problem, the study focused heavily on all available data after data cleaning, and regional referral hospitals with more than half of functional units were taken for analysis. For the Functional unit analysed,the results can be generalized to other hospitals with similar level. However, we recommend another prospective study to be conducted to come up with the actual situation of all functional units in all regional referral hospitals.

5 Conclusion and recomendations

The assessment of IPC practices in 26 regional referral hospitals using the National IPC checklist revealed that IPC performance is low in mortuary, CSSD, and blood transfusion units, but high in ICUs. We anticipate that the mentored HCWs and those who received comprehensive training will be able to further strengthen IPC practices in their units at all hospitals visited. In addition, the MoH will need to strengthen HAIs surveillance as well as IPC indicators monitoring and evaluation through protocol dissemination,training and ensure of utilization of digitals tools.. In addition, it is suggested that all hospital quality improvement leaders and healthcare workers at all hospital functional units [21, 22] make IPC a priority and have active IPC programs in order to implement IPC guidelines and conduct HAIs surveillance to improve patient safety at all functional units. Also, the leaders need to facilitate sharing among staff between the functional units in order to solve various challenges faced and improve facility compliance with IPC practices [23]. Lastly, In addressing the issue of missing data the MoH, should strengthens the data quality assessment to all Healthcare facilities [24].