The core components of infection

prevention and control programs:

from guidelines to implementation
in real life

Benedetta Allegranzi
IPC Global Unit, WHO HQ
 Why IPC is so important for patient
outcomes

http://www.who.int/infection-prevention/en/
http://www.who.int/infection-prevention/en/
 AMR survey 2017

• 58.4%: national IPC programme or operational plan and national IPC guidelines
• 14.9%: compliance and effectiveness evaluated and reported
 WHO Guidelines on Core Components of IPC
Programmes at the National and
Acute Health Care Facility Level

Focus on
preventing
HAIs and
combating
AMR
• http://www.who.int/infection-prevention/publications/ipc-components-guidelines/en/
• Zingg W et al. TLID 2015
• Storr J et al. ARIC 2017
• Presley L et al. TLID 2017
 WHO core components for
The guideline recommendations
effective IPC programmes
 8 Core components
– 8 Facility level
– 6 National level

 11 evidence*-based
recommendations

 3 good practice
statements
* Evidence from LMICs:
• 7 high-quality studies
• 22 lower quality

R= recommendation; GPS: good practice statement

 Core component 1: IPC programmes

Evidence from 2 studies shows that IPC programmes including

dedicated, trained professionals are effective in reducing HAIs in
acute care facilities
 Clearly defined objectives, functions and annual action plans
 Dedicated, trained IPC professionals (1 IPO/250 beds) &
multidisciplinary team
 Budget & support from the senior management leadership
 Good quality microbiological laboratory
 Critical linkages with other programmes

TB/HIV Surveillance
Waste Hep B/C
management

Community
AMR engagement

IPC
Patient
Safety / Occupational
health
Quality

Media
WASH
Policies &
guidelines
 Core component 2: IPC guidelines

Evidence from 6 studies shows that guidelines on the most

important IPC good practices and procedures implemented in
combination with health care workers’ education and training
are effective to reduce HAI
 Expertise required
 Local prioritization
 Providing resources for implementation
 HCWs education on recommended practices
 Monitoring implementation
 Core Component 2: IPC Guidelines
Key remarks

 The basic set of IPC guidelines should include the following:

– Standard precautions (see core component 1)
– Transmission-based precautions, including patient identification,
placement and the use of personal protective equipment.
– Aseptic technique for invasive procedures (including surgery) and
device management for clinical procedures, according to the scope
and type of care delivered at the facility level.
– Specific guidelines to prevent the most prevalent HAIs (for example,
catheter-associated urinary tract infection, SSI, central line-associated
bloodstream infection, ventilator-associated pneumonia) depending on
the context and complexity of care.
 Recent WHO IPC global guidelines

http://www.who.int/infection-prevention/en/
 Core component 3: IPC education & training

Evidence (15 studies at facility level) shows that IPC education that
involves frontline health care workers in a practical, hands-on
approach and incorporates individual experiences is associated
with decreased HAI and increased hand hygiene compliance
 Pre-graduate, post-graduate, in-service training
 Evaluations of training impact
 Collaboration with local academic institutions and
professional organizations
 WHO IPC Training Package
 Leadership and IPC program management
• Slides deck
 Prevention of urinary tract infections
• Trainer’s manual
 Prevention of catheter-associated bloodstream infections • Student’s handbook
 Prevention of respiratory tract infections • Videos
• E-learning module
 Prevention of surgical site infections
 Reprocessing of medical devices
 Outbreak management in healthcare
settings
 IPC to control antibiotic resistance
 HAI surveillance
 Injection safety
 Core component 4: HAI surveillance

Evidence (13 studies at facility level, 1 at national level) shows that HAI
surveillance leads to a decrease in HAI (including central line-
associated bloodstream infections, ventilator-associated pneumonia, SSI,
catheter-related urinary tract infections and catheter-related bloodstream
infections), and that timely feedback of results is influential in the
implementation of effective IPC actions
 Budget, leadership support and linkages to other surveillances and health
information systems needed
 Standardized definitions, appropriate methods, good quality laboratory support,
quality control needed
 Training and expertise needed
 Timely reporting and use of data to plan IPC are crucial
New protocol for surgical site infection
surveillance based on SUSP testing

http://www.who.int/infection-prevention/tools/surgical/SSI-
surveillance-protocol.pdf?ua=1
 Core component 5: Multimodal strategies

Evidence (44 studies at facility, 14 at national level) shows that

implementing IPC activities at facility level using multimodal
strategies is effective to improve IPC practices and reduce HAI
(particularly hand hygiene compliance, central line-associated bloodstream
infections, ventilator-associated pneumonia, infections caused by MRSA and C.
difficile)

A multimodal strategy comprises several elements or components (3 or more; usually 5)

implemented in an integrated way with the aim of improving an outcome and changing
behaviour. It includes tools, such as bundles and checklists, developed by multidisciplinary
teams that take into account local conditions.
The key approach for IPC
implementation
 WHO hand hygiene strategy impact

• All intervention strategies

Meta-analysis from 22 studies confirmed
that the WHO hand hygiene strategy indicated improvement in
is effective at increasing health care
workers compliance and results of 19
compliance with hand hygiene
studies showed reduction of health • WHO-5 & WHO 5+ were more
care associated infections
effective
• Allegranzi B et al, Lancet ID 2013
• Luangasanatip N et al, BMJ 2015
Multimodal thinking
Multimodal thinking…
Multimodal thinking…
Multimodal thinking…
Multimodal thinking…
Multimodal thinking…
National & facility manuals for practical
implementation support
 Core component 6: Monitoring/audit of IPC
practices & feedback

Evidence (6 studies at facility level, 1 at national level) showed that

regular monitoring/auditing of IPC practices paired with regular
feedback (individually and/or team/unit) is effective to increase
adherence to care practices and to decrease overall HAI
 To achieve behaviour change or other improvements
 To document progress and impact
 Essential: timely feedback and data interpretation for action
 Integration/alignment with other monitoring systems needed
 Core Component 7: Workload, staffing & bed
occupancy (facility level)

Evidence from 19 studies shows that bed occupancy exceeding

the standard capacity of the facility is associated with increased
risk of HAI in acute care facilities, in addition to inadequate health
care worker staffing levels
 Overcrowding recognized as being a public health issue that can lead to
disease transmission
 Standards for bed occupancy should be one patient per bed with adequate
spacing between beds (at least 1 metre)
 HCWs staffing levels should be adequately assigned according to patient
workload
WHO Workload Indicators of Staffing Need (WISN) method
(http://www.who.int/hrh/resources/wisn_user_manual/en/)
 Core Component 8: Built environment,
materials & equipment for IPC (facility level)

Evidence from 11 studies shows that availability of equipment and products at

the point of care leads to increased compliance with good practices and
reduction of HAI.
In 6/11 studies, the intervention consisted of the ready availability and optimal
placement of hand hygiene materials and equipment in areas designated for
patient care or where other health care procedures are performed and led to a
significant increase of hand hygiene compliance.

 Appropriate clean and hygienic environment, WASH services

and materials and equipment for IPC, in particular for HH
 Core Component 8: Built environment,
materials & equipment for IPC
8a. Key Remarks (1)
 An appropriate environment, WASH services and materials and
equipment for IPC are a core component of effective IPC programmes
at health care facilities.
 Ensuring an adequate hygienic environment is the responsibility of
senior facility managers and local authorities.
 The central government and national IPC and WASH programmes
also play an important role in developing standards and recommending
their implementation regarding adequate WASH services in health care
facilities, the hygienic environment, and the availability of IPC materials
and equipment at the point of care.
 WHO standards for drinking water quality, sanitation and
environmental health in health care facilities should be implemented.
 Core Component 8: Built environment,
materials & equipment for IPC
8b. Key Remarks
 WHO standards* for the adequate number and
appropriate position of hand hygiene facilities should be
implemented in all health care facilities.

* This requires that a hand hygiene product (for example,

alcohol-based hand rub, if available) be easily accessible
and as close as possible – within arm’s reach of where
patient care or treatment is taking place. Point-of-care
products should be accessible without having to leave the
patient zone. The WHO Guidelines on hand hygiene in
health care state: “minimum sink-to-bed ratio 1:10 and 1:1 in
isolation rooms”
 Implementation of the IPC Core
Components
 The WHO CC are a road map to indicate how IPC can
effectively prevent harm due to HAI and AMR
 Implementation, including effective leadership, is key to
translate guidelines into practices
– not always easy and takes time
– multimodal/multidisciplinary strategies
– monitoring approaches
– patient-centred
– integrated within clinical procedures
– innovative and locally adapted
– tailored to specific cultures and resource level
 Main challenges to implement IPC
in low- and middle-income countries
 HAIs and IPC not on the top of the national health agenda
 Gap between policy and actual implementation
 Lack of reliable data on HAIs (poor laboratory support and
surveillance systems)
 Limited access to qualified and trained IPC professionals
 Limited human resources (understaffing)
 Inadequate budgets
 WASH and infrastructure gaps
 Supplies procurement challenges
 Need for adaptation or tailoring to the cultural setting and
local context, and according to available resources
• Allegranzi B et al. The Lancet 2011;377:228-41
• National and facility manuals supporting the implementation resources of the WHO IPC Core Components Guidelines
(http://www.who.int/infection-prevention/tools/core-components/en/)
• M. Licker et al. J Hosp Infect 2017; 85e88
 IPC implementation: implications for
low- and middle-income countries
However:
 Resources invested are worth the net gain, irrespective of
the context and despite the costs incurred
 Not all solutions require additional resources
 Some solutions can likely be low cost and local production
(e.g. alcohol-based hand rubs) should be encouraged
 Partnerships or partners’ collaborations could assist in the
achievement of the core components delivery and funding
 Making improvement
with limited resources
• Damani highlights three approaches to
improve IPC in settings with limited
resources:
– focus on improving no-cost practices
• focus on improving low-cost practices
• stop wasteful and unnecessary
practices.

• These three approaches have the potential

to save money, time and improve the
quality and safety of health care.

Damani N. Simple measures save lives: an approach to infection control in countries

with limited resources. J Hosp Infect. 2007;65(Suppl. 2):151-154.
Reflections on IPC core components -
Region of the Americas
Major challenges in providing IPC support and making progress

Core Component Comment

• Political commitment for IPC in MoH
1 – IPC programmes • Organized and functional IPC program at the hospital level
• Weak National IPC program
2 – IPG guidelines
• Implementation science and knowledge transfer
3 – IPC education and training
• Surveillance data – lack of standards and trendlines
• Laboratory support
4 – Surveillance • readiness
• “outbreaks of SCN” (data misinterpretation)
• The AMR Agenda and Pillar 3
5 – Multimodal strategies • Not understood
6 – Monitoring/ audit of IPC • M&E of IPC Program
practices and feedback • M&E culture / environment
7 – Workload, staffing and bed • Trained Human Resources – National and Hospital –
occupancy • High turnover of HCW
8 – Built environment, materials and
• Funds not allocated
equipment for IPC at the facility level
25/09/2018 | Title of the presentation 39
Translating guidelines to action
Implementation resources for the WHO
IPC Core Components Guidelines

http://www.who.int/infection-prevention/tools/core-
http://www.who.int/infection-prevention/tools/core-components/en/
components/en/
 The implementation approach

IPCAT2
Implementation

National
packages

5-Step
WHO implementation
Guidelines cycle
Health
facility IPCAF
 Implementation manual and assessment
tool for the national level

http://www.who.int/infection-prevention/tools/core-components/en/
http://www.who.int/infection-prevention/tools/core-components/en/
 Implementation manual and assessment
framework for the health facility level
 Based on qualitative analysis of
examples of IPC implementation in
low-resource settings
 29 interviews with IPC
professionals from low-resource
settings analysed using a
qualitative inductive thematic
approach
 Identification of common IPC
implementation themes
(appearing ≥4 times) for IPC
professionals to consider
(according to the 8 WHO IPC core
components) and lessons learned

http://www.who.int/infection-prevention/tools/core-components/en/
 New IPC facility-level assessment tool

• Structured, closed-formatted questionnaire with an associated scoring system based on the

HHSAF approach; 81 indicators
• Self- or joint-assessments
• Template for data interpretation, discussion and action planning
• Tested for usability, reliability and construct validity in a sample of 181 acute health care facilities in
46 countries across the world
45 | Department of Service Delivery and Safety
Highlights from part III
Stepwise approach
The 5-Step approach to
IPC improvement
The step-wise approach
What help you can find

CASE STUDY EXAMPLES

http://www.who.int/infection-prevention/tools/core-components/en/
Liberia: core components prioritization
Core components
prioritization
1. National IPC programme
(2016)
3. Training (2015-)
2. Guidelines (2017-18)
6. Monitoring (2015-)
8. Built environment (2016-)
4. HAI (SSI) surveillance (2018)
Liberia – all health care workers’ IPC training (2015-16)

• Keep Safe Keep Serving (KSKS) training:

40 master trainers, 2258 HCWs
• Safe & Quality Services (SQS) training:
13000 HCWs

61 Cooper et al. BMC Med 2016; 14:2

 WHO IPC Advanced Training (2017-18)
 Leadership and IPC program management Liberia: 37 facility, county &
national IPC focal persons
 Prevention of urinary tract infections
 Prevention of catheter-associated bloodstream infections
 Prevention of respiratory tract infections
 Prevention of infections in surgery
 Reprocessing of medical devices
 Outbreak management in healthcare
settings
 IPC to control antibiotic resistance
 HAI surveillance
 Injection safety
National quality policy and DRAFT

IPC guidelines (2018)

Liberia national IPC guidelines TOT
 Implementation example

Allegranzi B, et al. Lancet Infect Dis. 2018 Mar 5

The surgical unit-based safety
programme (SUSP)
Patient safety culture
improvement (CUSP):
Infection prevention
• science of safety education best practices
• staff safety assessment
• leadership + • evidence-based and
identified according to
local staff assessment
• learning from defects
• team work and
communication

Improvement of the patient Reduction of:

safety climate • SSIs
• surgical complications
Stepwise approach
Understand your current situation
What tools do you use?

Discuss the following questions from the SUSP

Perioperative Staff Safety Assessment Tool:
1. Please briefly describe the most frequent ways (list
maximum 3) in which patients may get a surgical site
infection in your surgical services/facilities
2. Please describe what you think can be done to prevent
this surgical site infection
Multidisciplinary local teams
 Tools to address the culture
Core CUSP toolkit
Created for clinicians by clinicians, the CUSP toolkit is modular and modifiable to
meet individual unit needs. Each module includes teaching tools and resources to
support change at the unit level, presented through facilitator notes that take you
step-by-step through the module, presentation slides, tools, videos.

https://www.ahrq.gov/professionals/education/curriculum-
tools/cusptoolkit/modules/index.html
https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/surgery/guide-
appcusp.html
Understanding and influencing
the local culture: tools created by
SUSP teams in African hospitals

http://www.who.int/infection-prevention/countries/surgical/en/
System change - modified
WHO formulations
for surgical hand preparation
Formulation I Formulation II
Final concentrations: ethanol 80% Final concentrations: isopropanol 75%
wt/wt, glycerol 0.725% vol/vol, wt/wt, glycerol 0.725% vol/vol,
hydrogen peroxide 0.125% hydrogen peroxide 0.125% vol/vol.
vol/vol. Ingredients:
Ingredients: 1. isopropanol (absolute), 750 g
1. ethanol (absolute), 800 g 2. H2O2 (30%), 4.17 ml
2. H2O2 (3%), 4.17 ml 3.glycerol (98%), 7.25 ml (or 7.25 x
3.glycerol (98%), 7.25 ml (or 7.25 1.26 = 9.135 g)
x 1.26 = 9.135 g) top up to 1000 g with distilled
4.
4.top up to 1000 g with distilled or water
boiled water
Sources:
Suchomel M KM, Kundi M, Pittet D, Rotter ML. Modified World Health Organization hand rub formulations comply w ith European efficacy requirements for preoperative
surgical hand preparations. Infect Control Hosp Epidemiol. 2013; 34(3):245–250.
Allegranzi B, Aiken AM, Zeynep Kubilay N, Nthumba P, Barasa J, Okumu G et al. A multimodal infection control and patient safety intervention to reduce surgical site
infections in Africa: a multicentre, before–after, cohort study. Lancet Infect Dis. 2018; 18(5):507–515.
System change - surgical skin
preparation

Local preparation of 2% chlorhexidine isopropanol solution

1. Isopropanol: 62.7 % g/g

2. chlorhexidine 12.1% g/g taken from a 18.8% g/g

chlorhexidine digluconate water solution

3. Top up with distilled water up to 100%

Source: Allegranzi B, Aiken AM, Zeynep Kubilay N, Nthumba P, Barasa J, Okumu G et al. A multimodal infection control and patient safety intervention
to reduce surgical site infections in Africa: a multicentre, before–after, cohort study. Lancet Infect Dis. 2018; 18(5):507–515.

http://www.who.int/infection-prevention/tools/surgical/training_education/en/
Tools for monitoring impact
Peri-operative form

Post-operative form

94% of patients had ≥2 follow-up interactions (inpatient reviews, outpatient

clinic, telephone interviews); 80% had ≥3 interactions during their 30 -day
surveillance period
Impact on preventive measures

Allegranzi B, et al. Lancet Infect Dis. 2018 Mar 5

Impact on SSI
Summary of success factors
• Use of multimodal strategies (this does not mean checklists and
bundles)

• Having a step-wise action plan

• Mapping recommendations according to the surgical patient journey

• Empowering teams and involving front-line staff

• Engaging leadership

• Letting teams take the lead on adaptation

• Catalysing collective and individual ownership

• Using data to create awareness

• Awarding teams and work demonstrating a safety culture spirit

New WHO SSI Prevention
Implementation Package

WHO SSI WHO Adaptive

Prevention Tools to
Hospital Support
http://www.who.int/infection- Implementation SSI Prevention
prevention/tools/surgical/evaluation
_feedback/en/ Guide Implementation

Fact sheets on NEW IMPLEMENTATION

SSI recommendations PLATFORM
http://www.who.int/infection-prevention/tools/surgical/en/ Launching Soon!
 SAVE LIVES: Clean Your Hands - 5 May 2019
Monitoring IPC & Hand Hygiene – WHO Global Survey 2019
 Tools: IPC Assessment Framework (IPCAF)* & Hand Hygiene Self-assessment Framework
(HHSAF)**
 Timeline:
– Preparations: September-December 2018
– Survey conduct: January-March 2019
– Survey analysis: April-June 2019
 Sample:
– Open voluntary participation by health care facilities around the world
– Randomised weighted sub-sample
 Planning:
➢ Month 1: preparations
➢ Month 2: IPCAF
➢ Month 3: HHSAF
I. Tools completion on paper at HCF level II. Submission online or by email
 Report: to be issued by WHO by 2019
*http://www.who.int/infection-prevention/tools/core-components/IPCAF-facility.PDF?ua=1
**http://www.who.int/gpsc/country_work/hhsa_framework_October_2010.pdf?ua=1
 THANK YOU!!!
WHO Infection Prevention and Control
Global Unit

Learn more at:

http://www.who.int/infection-prevention/en/