The WHO IPCAF was based on the WHO CCs , which is an evidence-based guideline on the implementation of essential components for IPC programs in terms of effectiveness in reducing HCAI at the facility level. The 8 essential CCs address the complex nature of IPC, encompassing technical guidelines, human resources, surveillance, and the built environment. Therefore, analysis of the national survey in comparison to the WHO IPCAF allowed a comprehensive exploration of the status and gaps in IPC programs in Korean hospitals.
Much evidence shows that an IPC structure, composed of a dedicated IPC team and relevant in-house governance, reduces HCAIs and is thus the single most important component in an institution’s IPC capacity [7, 8]. In general, the results of this study show that these essential IPC structures are well in place in most tertiary and general hospitals in Korea. This may be partly due to relevant legislative measures, such as the Korean Medical Service Act, which mandated the requirement for an IPC committee and an IPC team in all general hospitals and hospitals with more than 150 beds. Studies show that countries with similar legislative regulations have a more robust implementation of IPC structures compared to countries that do not, suggesting that the influence of relevant legislation is critical in the establishment of IPC components in healthcare facilities [9, 10]. However, it is worth noting that in Korea, such legislative measures were coupled with various policy measures to promote the quality of care in IPC. For example, implementation of IPC programs was included or expanded in performance evaluation programs such as the Korean Healthcare Accreditation System and healthcare quality evaluation. Also, a novel reimbursement scheme was developed within the National Health Insurance in 2016 that pays hospitals a certain amount of fee per patient’s admission day provided that the hospital meets specified criteria, which include the operation of an IPC team with a designated number of full-time, trained IPC staff and the development of an IPC program, etc. It is assumed that a combined effect of legislation and such quality-driven approaches has resulted in a generally high percentage of IPC teams and programs in tertiary and general hospitals in Korea.
On the other hand, the percentage of IPC team availability was relatively low among long-term care hospitals (6.3%) and hospitals (22.1%). These hospital groups were not subject to the mandatory implementation of IPC teams and committees at the point of the survey, which may partly explain the low percentage of IPC teams and other CC1 components. Long-term care hospitals in Korea, which are mostly privately owned and offer health services related to chronic diseases and other geriatric illnesses, are not required by law to have IPC teams. This legal exemption is primarily due to the operational difficulties of long-term care hospitals, mainly related to insufficient budget and manpower . However, given that recent research indicates that long-term hospitals are vulnerable to HCAI , it is clear that stronger policy support is required to empower long-term hospitals in infection control.
It is interesting to note that despite the high percentage of hospitals with an established IPC team and committee, their actual operations were quite heterogeneous and suboptimal in many hospitals, implying that the installation of these IPC structures does not instantly guarantee effective execution of IPC activities. One example is shown through the data on the IPC committee meeting. IPC committee meetings, albeit being the main decision-making process concerning IPC policies in hospitals, are not actively carried out or not considered helpful in 61.8% of the hospitals. Similar results were revealed in another study, in which 23% of hospitals answered that the IPC committee was not supported by senior staff . It is considered that further technical support, such as training and education targeting hospital executives, is warranted for such essential IPC structures to effectively function.
IPC education and training has proven to be effective in reducing HCAI if conducted effectively to achieve behavior change [13,14,15]. In addition, as IPC is relevant to all healthcare workers, IPC education has to target not only the IPC specialists and frontline workers but also all general staff in the facility. Results of this study reveal that IPC education targeting IPC specialists was one of the components with generally high compliance, possibly owing to the Korean Medical Service Act that stipulates mandatory education of at least 16 h for members of the IPC team. The Act mandates that official IPC education to IPC team members should be provided by the government, government-funded institutions (e.g., Korea Human Resource Development Institute for Health and Welfare), professional associations, and/or academic societies. The Act also specifies specific training topics and subjects to guarantee the quality of education provided.
On the other hand, IPC education targeting the general staff in the facility is currently roughly regulated as one of the responsibilities of the hospital manager and/or IPC teams in the hospital. Therefore, convenient, one-way oral instruction was more frequently applied compared to interactive training in all hospital groups. Previous studies conducted among hospitals in Austria and Germany also showed that interactive training was the least utilized mode of training [9, 10]. Evidence suggests that participatory, interactive IPC education involving task-based strategies and simulation is associated with decreased HCAI and is therefore strongly recommended through the WHO IPC CC guideline [2, 13,14,15]. Future policies should aim to support IPC education targeting all staff in the facility and also strengthen various modes of effective training, such as interactive learning.
HCAI surveillance (CC4) of Korea centers around KONIS, which is the government-led surveillance program in which hospitals participate on a voluntary basis.KONIS data reveals that major HCAI rates in Korea have been decreasing over the past decade. Urinary tract infections have decreased from 4.24 cases per 1000 patient days in 2006 to 0.88 cases per 1000 patient days in 2016. Pneumonia in ICUs has decreased from 3.68 cases per 1000 patient days in 2006 to 1.00 cases per 1000 patient days in 2016 . KONIS mainly surveys IPC rates in ICUs and surgical site infection rates, which explains the relatively high participation in the tertiary and general hospital groups that operate ICUs and operating rooms.
KONIS applies standardized data collection methods (IPCAF CC4 question 9), informatics (IPCAF CC4 question 4), protocols (IPCAF CC4 question 8), audit processes (IPCAF CC4 question 10), uniform data feed-back methods (IPCAF CC4 question 14), and governance (IPCAF CC4 question 3), which all participating hospitals share. In contrast to the high participation in tertiary and general hospitals, only a limited number of hospitals in the hospital and long-term care hospital groups participated in the KONIS, revealing the need to expand IPC surveillance in these hospital groups. The government is in the process of developing surveillance modules for these smaller-sized hospitals and long-term care hospitals .
While CC2 was a component with high mean scores in studies from other countries, this study revealed different results. The guideline for disinfection and sterilization was the most commonly available IPC guideline across all hospital types, which may be contributing to the relatively high percentage of hospitals monitoring disinfection and sterilization. On the other hand, the percentage of hospitals with antibiotic stewardship guidelines was quite low, especially in the hospital (51.5%) and long-term care hospital group (31.0%). This result, along with the relatively low percentage of hospitals performing MDR pathogen screening and isolation of MDR-positive patients (CC6), reveal that antimicrobial resistance activities in these hospital groups are suboptimal. Many previous studies have also raised issues regarding the relatively high prevalence of MDR pathogens in smaller-sized hospitals [18, 19]. As the development of the WHO CCs was in response to the global threats posed by antimicrobial resistance, this figure is quite alarming, which calls for more active policy actions regarding AMR [2, 20].
Many of the indicators in WHO CC7 and CC8, such as staffing levels, bed occupancy, power and water supplies, ventilation, waste management, sterile supply department, etc., were developed based on the standards required for healthcare in medium- and low-resource settings . The Korean Medical Service Act stipulates a wide range of basic standards on staffing and the built environment, through which the hospitals’ license to operate is strictly regulated. Therefore, it was appropriate to assume that hospitals in Korea met the minimum standards that the WHO core components suggested. Nevertheless, some indicators that were considered relevant in the local context were included in the national survey and are worth further discussion.
Hand hygiene stations (IPCAF CC8 question 3) were generally accessible to all patients, but the number of patients per station was especially high in long-term care hospitals (6.8) compared to tertiary and general hospitals. The new legal standard requiring at least one hand hygiene station per 3 patients in ICUs went into force in 2017. This standard applies to only newly established facilities, which may explain why the number of patients per station is higher than 3 in the hospital and long-term care hospital group. Such insufficiency in the built environment has been an issue in other high-income countries as well , underscoring the need for continued policy support in establishing the basic infrastructure in healthcare facilities. In contrast to this, personal protection equipment (IPCAF CC8 question 10), such as masks and hand rubs, were widely available in all hospital groups. Fluid and injections were prepared in areas other than clean rooms and dedicated preparation areas in 32.3% of general hospitals and 49.3% of long-term care hospitals. As fluids and drugs should be prepared under the strictest of conditions to prevent contamination and possible infection hazards that stem from it, more strict measures are being taken around the world regarding the preparation of pharmaceuticals in hospitals. This implies that national-level policy measures should be further developed and implemented to promote safe preparation and injection practices .
Implementation of multimodal strategies (CC5) was not effectively surveyed through the national survey. However, reflecting that CC5 was the component with the lowest mean score in other high-income countries [7, 8], it could be speculated that Korean hospitals may also have similar difficulties in the effective implementation of multimodal strategies. Whereas individual elements of multimodal strategies, e.g. education and training, could already be at work, systematically integrating them to achieve behavioral change requires a certain level of expertise in the field. Policy measures should be put forth to strengthen facilities in delivering multimodal strategies. It is also advisable that future national surveys incorporate indicators relevant to multimodal strategies to allow exploration of their status in Korean hospitals.
This study has several limitations. First of all, the national survey was conducted on a voluntary basis, and therefore, facilities with a high interest in IPC may be overrepresented. Another limitation is that although the survey was roughly pre-tested in two randomly selected hospitals, it did not go through an official pilot test due to time constraints and logistical reasons. Also, as the answers were self-administered, the data can be different from other currently available national-level data sets, such as the national health insurance data. Lastly, although many of the survey questions were similar to their IPCAF counterparts, the answering options were different and may have hampered direct comparison.