Adapting infection prevention and control assessment tools for use in low- and middle-income countries

Background: There are many existing infection prevention and control (IPC) tools developed and validated by large organizations such as the World Health Organization (WHO) and the Centers for Disease Control and Prevention. These tools are generally created with little input from professionals working in low-income regions and are tested in high-income countries and/or high-level facilities in low- and middle-income countries (LMICs). Recent publications have highlighted both the disproportionate burden of surgical site infections (SSIs) in LMICs and the very limited data on surgical conditions and practices in these regions. There is a need and a desire for quality improvement in SSI/IPC/patient safety in low-level facilities in LMIC. Therefore, a logical starting point would be to adapt available tools for use in resource-limited facilities, with a strong focus on input and enthusiastic participation from local health-care workers and leadership. Our goal was to assess IPC capacity of facilities by analyzing health-care-associated infection (HAI) surveillance, hospital workforce and infrastructure, environmental cleaning, and surgical operative practices. Methods: We created an adapted survey using components from the WHO's Guideline on Core Components for IPC and Essential Surgical Care Situational Analysis Tool that addressed IPC program support, HAI surveillance, surgical preparation practices, and infrastructural support. Purposive sampling was used to identify 23 health facilities across 7 counties in Kenya. We chose to use cesarean section as a bellwether procedure because it is a high-volume procedure in LMIC. Permission to conduct the survey was solicited from facility leadership prior to the beginning of the survey. Two surveyors visited each facility to complete the adapted assessment framework. Results: All facilities had an IPC program and 22 (95.6%) reported that their program was supported by facility leadership and a professional IPC team. However, only 10 (43.5%) facilities reported a specific IPC budget. Eight (34.8%) facilities had on-site and 8 (34.8%) had off-site microbiological laboratory. Twelve (52.2%) conducted HAI surveillance, and out of those that conducted HAI surveillance, 11 (91.7%) monitored specifically for SSIs. Most had adequate and reliable water (95.6%) and power (91.3%). Fifteen (65.2%) allowed bed-sharing and 6 (26.1%) placed beds in hallways or areas other than rooms. Over 75% of facilities did not follow the WHO-recommended preoperative practices on bathing, hair removal, and skin preparation. Conclusions: This survey was a time and resource-efficient way of collecting the data needed to understand the variables associated with surgery, SSI, and IPC in low-level facilities. Clear targets for surgical practice improvement were identified, and the workforce and infrastructure data will be used to design effective and sustainable solutions.