Minimum requirements for infection prevention and control programmes

MINIMUM REQUIREMENTS for infection prevention and control programmes The starting point for implementing the World Health Organization core components of infection prevention and control programmes at the national and health care facility level Minimum requirements for infection prevention and control programmes ISBN 978-92-4-151694-5 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Graphic design by Maraltro, Italy. Printed in Switzerland Acknowledgements Abbreviations and acronyms Glossary of key terms and definitions Key to symbols Part 1. Introduction 1.1 Purpose of the document 1.2 Target audience 1.3 Document development structure 1.4 The role of the minimum requirements in achieving effective infection prevention and control 1.5 References Part 2. Executive summary of the minimum requirements by core component Part 3: In-depth review of the minimum requirements 3.1 Core component 1: Infection prevention and control programmes 3.2 Core component 2: Infection prevention and control guidelines 3.3 Core component 3: Infection prevention and control education and training 3.4 Core component 4: Health care-associated infection surveillance 3.5 Core component 5: Multimodal strategies 3.6 Core component 6: Monitoring, audit and feedback of infection prevention and control practices 3.7 Core component 7: Workload, staffing and bed occupancy at the facility level 3.8 Core component 8: Built environment, materials and equipment for infection prevention and control at the facility level Part 4. Annex 4. 1 Summaries of the results of a systematic review and inventory of available infection prevention and control minimum standards 4.1.1 Overview of the results of the systematic literature review on minimum standards for infection prevention and control 4.1.2 Summary of the global inventory on infection prevention and control minimum standards 4.1.3 References II IV V X 1 2 2 3 5 10 13 23 23 27 31 34 38 41 44 46 51 51 51 52 53 CONTENTS II ACKNOWLEDGEMENTS The Department of Integrated Health Services of the World Health Organization (WHO) gratefully acknowledges the contributions that many individuals and organizations have made to the development of the infection prevention and control (IPC) minimum requirements, based on the WHO core components for IPC programmes at the national and health care facility level. OVERALL COORDINATION, WRITING AND DESIGN OF THE DOCUMENT Benedetta Allegranzi (Department of Integrated Health Services, WHO) coordinated and led the development and writing of this document and contributed to the systematic review. Anthony Twyman and Alessandro Cassini (Department of Integrated Health Services, WHO) significantly contributed towards the writing of this document and to the systematic review. Julie Storr (IPC consultant, United Kingdom) and Molly Patrick (Centers for Disease Control and Prevention [CDC] international IPC team, United States of America [USA]) also contributed to the writing of this document. Joost Hopman (Radboud University Hospital and Médecins Sans Frontières/Doctors Without Borders, The Netherlands) contributed to the strategic development of this document and conducted a systematic review on the minimum standards for IPC programmes together with Daniël Urlings (Radboud University Hospital, The Netherlands); Anthony Twyman made a global inventory of available guidance on IPC minimum standards. Thomas Allen (Library and Information Networks for Knowledge, WHO) provided assistance with the search for the systematic review. Rosemary Sudan provided professional editing assistance. Laura Pearson (Department of Integrated Health Services, WHO) and Alice Simniceanu (Antimicrobial Resistance Division, WHO) supported the finalisation of the designed document. Maraltro provided the professional graphic design of the document. EXPERT CONTENT DEVELOPMENT GROUP Consensus on the contents of this document and the IPC minimum requirements was first gathered in a technical expert consultation in Addis Ababa, Ethiopia, in April 2019 with the participation of the following experts: ACKNOWLEDGEMENTS III Fahmi Ahmed (WHO Country Office for Ethiopia); Romella Abovyan (National Center for Disease Prevention and Control, Armenia); Anucha Apisarnthanarak (Thammasat University Hospital, Thailand); Batyrbek Aslanov (North-Western State Medical University, Russia); Sofonias Asrat (WHO Country Office for Ethiopia); Mekdim Ayana (WHO Regional Office for Africa); Gertrude Avortri (WHO Regional Office for Africa); Anjana Bhushan (WHO Regional Office for South-East Asia); Roderick Chen Camano (Caja Seguro Social Hospital, Panama); Christiana Agnes Conteh (Ministry of Health and Sanitation, Sierra Leone); Ana Paula Coutinho-Rehse (WHO Regional Office for Europe); Nizam Damani (IPC consultant, United Kingdom); Nino Dayanghirang (WHO Regional Office for Africa); Lamine Dhidah (Sahloul University Hospital, Tunisia); Molla Godif Fisehatsion (Ministry of Health, Ethiopia); Corey Forde (Queen Elizabeth Hospital, Barbados); Ghada Abdelwahed Ismail (Supreme Council of University Hospitals, Egypt); Nordiah Awang Jalil (Hospital Universiti Kebangsaan, Malaysia); Kushlani Jayatilleke (Sri Jayewardenapura General Hospital, Sri Lanka); Ejaz Khan (Shifa International Hospital, Pakistan); Amy Kolwaite (CDC international IPC team, USA); Thabang Masangane (Ministry of Health, Eswatini); Guy Mbayo (WHO Regional Office for Africa); Huynh Tuan Minh (University Medical Center, Viet Nam); Awa Ndir (WHO Regional Office for Africa); Babacar Ndoye (WHO Regional Office for Africa); Fernando Otaiza (Ministry of Health, Chile); Atika Swar (Federal Ministry of Health, Sudan); Maha Talaat (WHO Regional Office for the Eastern Mediterranean); Shaheen Mehtar (Infection Control Network Africa, South Africa); Benjamin Park (CDC international IPC team, USA); Molly Patrick (CDC international IPC team, USA); Lul Raka (University of Prishtina, Kosovo); Julie Storr (IPC consultant, United Kingdom); Lekilay G. Tehmeh (Ministry of Health, Liberia); Le Thi Anh Thu (Infection Control Society, Viet Nam); Roselyne M.E. Toby (Hôpital Central de Yaoundé, Cameroon); Sarah Tomczyk (Robert Koch Institute, Germany); Winifrey Ukponu (Nigeria Centre for Disease Control, Nigeria); Jay Varma (Africa CDC, Ethiopia); Daiva Yee (CDC international IPC team, USA). The content was further developed with the substantial contribution and/or review by the following experts: Fahmi Ahmed (WHO Country Office for Ethiopia); Anjana Bhushan (WHO Regional Office for South-East Asia); Ana Paula Coutinho-Rehse (WHO Regional Office for Europe); Nino Dayanghirang (WHO Regional Office for Africa); Corey Forde (Queen Elizabeth Hospital, Barbados); Amy Kolwaite (CDC international IPC team, USA); Babacar Ndoye (WHO Regional Office for Africa); Maha Talaat (WHO Regional Office for the Eastern Mediterranean); Shaheen Mehtar (Infection Control Network Africa, South Africa); Molly Patrick (CDC international IPC team, USA); Julie Storr (IPC consultant, United Kingdom); Sarah Tomczyk (Robert Koch Institute, Germany); Jay Varma (Africa CDC, Ethiopia). EXTERNAL PEER REVIEW GROUP Emine Alp (Ministry of Health, Turkey); April Baller (World Health Emergencies, WHO); Richard Gelting (CDC, USA); Margaret Montgomery (Water, Sanitation, Hygiene and Health Unit, WHO); Rob Quick (CDC, USA); Wing Hong Seto (University of Hong Kong, Hong Kong SAR, China); Nalini Singh (George Washington University Schools of Medicine and Health Sciences and Public Health and Children’s National, USA); João Toledo (Pan American Health Organization). ACKNOWLEDGEMENTS OF FINANCIAL AND OTHER SUPPORT WHO gratefully acknowledges the technical and strategic contributions by CDC (USA) and Africa CDC for the accomplishment of this project and thanks Africa CDC for hosting the technical expert consultation in its premises in Addis Ababa, Ethiopia. Funding for the development of this document was provided by the CDC (USA), in addition to WHO core funds. However, the views expressed in the manual do not necessarily reflect the official policies of the CDC. ACKNOWLEDGEMENTS IV ABBREVIATIONS AND ACRONYMS ABBREVIATIONS AND ACRONYMS ABHR AMR CDC CP CPE EQAS HAI HCW IPC IPCAF IPCAT PPE SOP UNICEF USA WASH WASH FIT WHO alcohol-based handrub antimicrobial resistance Centers for Disease Control and Prevention (USA) carbapenemase-producing carbapenemase-producing Enterobacteriaceae external quality assurance system health care-associated infection health care worker infection prevention and control infection prevention and control assessment framework infection prevention and control assessment tool personal protective equipment standard operating protocols United Nations Children’s Fund United States of America water, sanitation and hygiene water, sanitation and hygiene facility improvement tool World Health Organization VGLOSSARY OF KEY TERMS AND DEFINITIONS Alcohol-based handrub: An alcohol-based preparation designed for application to the hands to inactivate microorganisms and/or temporarily suppress their growth. Such preparations may contain one or more types of alcohol and other active ingredients with excipients and humectants. Source: WHO Guidelines on hand hygiene in health care. 2009 (https://www.who.int/gpsc/5may/tools/9789241597906/en/, accessed 29 October 2019). Antimicrobial stewardship: A coherent set of actions which promote the responsible use of antimicrobials. This definition can be applied to actions at the individual level, as well as the national and global level, and across human health, animal health and the environment. Source: Dyar OJ, Huttner B, Schouten J, Pulcini C. What is antimicrobial stewardship? Clin Microbiol Infect. 2017;23(11):793–8. OR The primary goal of antimicrobial stewardship is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms (such as Clostridium difficile) and the emergence of resistance. Source: Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44(2):159–77. Cleaners (also known as environmental cleaning staff or environmental services’ technicians): individuals responsible for performing environmental cleaning in health care facilities who play a key role in maintaining a clean and/or hygienic environment that facilitates practices related to the prevention and control of HAI. Cohorting: Grouping of patients who are colonized or infected with the same resistant organism with the aim to confine their care to one area and prevent contact with other susceptible patients (for example, all patients infected or colonized with a carbapenem-resistant Enterobacteriaceae in a specific cohort and all patients colonized with methicillin- resistant Staphylococcus aureus in a different cohort). Cohorts are created based on clinical diagnosis, microbiological confirmation with available epidemiology, and the mode of transmission of the infectious agent. Cohorting is reserved for situations where there are insufficient single rooms or where the cohorting of patients colonized or infected with the same pathogen is a more efficient use of hospital rooms and resources. Dedicated equipment, toilets and staff should be used for patients within the cohorted area for the required time duration. Sources: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings (http:// www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf, accessed 29 October 2019). WHO. Guidelines for the prevention and control of carbapenem- resistant Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa in health care facilities. 2017 (https:// www.who.int/infection-prevention/publications/guidelines-cre/ en/, accessed 29 October 2019). Carbapenem resistance (including carbapenemase-producing [CP]): Carbapenem resistance among Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa may be due to a number of mechanisms. Some strains may be innately resistant to carbapenems, while others contain mobile genetic elements (for example, plasmids, transposons) that result in the production of carbapenemase enzymes (carbapenemases), which break down most beta-lactam antibiotics, including carbapenems. Frequently, CP genes are co-located with other resistance genes, which can result in cross-resistance to many other antibiotic drug classes (1-3). Thus, while carbapenem- resistant strains of these pathogens are frequently CP (CP- Enterobacteriaceae [CPE], CP-A. baumannii, CP-P. aeruginosa), they may have other carbapenem resistance mechanisms that GLOSSARY OF KEY TERMS AND DEFINITIONS VI make them equally difficult to treat and manage clinically. Thus, the term “carbapenem-resistant Enterobacteriaceae” includes all strains that are carbapenem-resistant, including CPE. For this reason, infection prevention and control actions should focus on all strains of carbapenem-resistant Enterobacteriaceae, A. baumannii and P. aeruginosa, regardless of their resistance mechanism. Adequate infection prevention and control measures are essential in both outbreak and endemic settings. Source: WHO. Guidelines for the prevention and control of carbapenem-resistant Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa in health care facilities. 2017 (https://www.who.int/infection-prevention/ publications/guidelines-cre/en/, accessed 29 October 2019). Decontamination of medical devices: Removes soil and pathogenic microorganisms from objects so they are safe to handle, subject to further processing, use or discard (see also Reprocessing). Source: United States Centers for Disease Control and Prevention. Guidelines for disinfection and sterilization in healthcare facilities. 2008 (https://www.cdc.gov/ infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf, accessed 29 October 2019). Hand hygiene: A general term referring to any action of hand cleansing, that is, the action of performing hand hygiene for the purpose of physically or mechanically removing dirt, organic material, and/or microorganisms. Source: WHO guidelines on hand hygiene in health care. 2009 (https://www.who.int/gpsc/5may/tools/9789241597906/en/, accessed 29 October 2019). HEALTH CARE FACILITIES’ CLASSIFICATION Primary health care facilities: Facilities that provide outpatient services, family planning, antenatal care, maternal, newborn and child health services (including delivery), for example, health centres, health posts and small district hospitals. Source: WHO. Water and sanitation for health facility improvement tool (WASH FIT). 2017 (https://apps.who.int/iris/ bitstream/handle/10665/254910/9789241511698-eng. pdf;jsessionid=0A60107AA8F5A27C5FD16B0823D3F4FA?se- quence=1, accessed 29 October 2019). PRIMARY, SECONDARY AND TERTIARY HOSPITALS Primary-level hospital: Few specialties—mainly internal medicine, obstetrics and gynaecology, paediatrics and general surgery, or just general practice; limited laboratory services available for general, but not specialized, pathological analysis. Secondary-level hospital: Highly differentiated by its function with 5 to 10 clinical specialties; size ranges from 200 to 800 beds; often referred to as a provincial or district hospital. Tertiary-level hospital: Highly specialized staff and technical equipment, for example, cardiology, intensive care unit and specialized imaging units; clinical services highly differentiated by function; may have teaching activities; size ranges from 300 to 1500 beds; often referred to as a teaching or university or regional hospital. Source: WHO. Disease control priorities in developing countries. 2008 (https://www.who.int/management/facility/ ReferralDefinitions.pdf, accessed 29 October 2019). Improved sanitation facilities: Toilet facilities that hygienically separate human excreta from human contact. Examples include flush/pour flush to a piped sewer system, septic tank or pit latrine, ventilated pit latrine, pit latrine with slab or composting toilet. Source: WHO/UNICEF. Core questions and indicators for monitoring WASH in health care facilities in the Sustainable Development Goals. 2018 (https://apps.who.int/iris/bitstream/ handle/10665/275783/9789241514545-eng.pdf?ua=1, accessed 29 October 2019). Improved water source: Defined by the WHO/UNICEF Fund Joint Monitoring Programme as a water source that by its nature of construction adequately protects the source from outside contamination, particularly faecal matter. Examples include: public taps or standpipes; protected dug wells; tube wells; or boreholes. Source: WHO/UNICEF. Progress on sanitation and drinking water. 2015 update and Millennium Development Goals assessment (https://www.unicef.org/publications/ index_82419.html, accessed 29 October 2019). GLOSSARY OF KEY TERMS AND DEFINITIONS VII Infection prevention and control (IPC) minimum requirements: IPC standards that should be in place at both national and health facility level to provide minimum protection and safety to patients, health care workers and visitors, based on the WHO core components for IPC programmes. The existence of these requirements constitutes the initial starting point for building additional critical elements of the IPC core components according to a stepwise approach based on assessments of the local situation. Source: Definition used in this document and developed by the expert group. IPC professional: Health care professional trained in a certified postgraduate IPC course or a nationally recognized course. Source: WHO. Infection prevention and control assessment framework tool (IPCAF) (http://www.who.int/infection- prevention/tools/core-components/en/, accessed 29 October 2019). IPC focal point: Professional (nurse, doctor, or other) appointed to be in charge of IPC at the national or facility level who has a specific professional background, that is, formal postgraduate training in IPC leading to the successful achievement of a certificate or diploma. Source: WHO. IPCAF (http://www.who.int/infection-prevention/ tools/core-components/en/, accessed 29 October 2019). IPC link professional: Nurse or doctor in a ward or facility who has been trained in IPC (using a nationally approved in-service training package; no postgraduate certificate/diploma required) and links to an IPC focal point/team at a higher level in the organization (for example, IPC focal point/team in the facility or at the district level). IPC is not the primary assignment of this professional but, among others, he/she may undertake the following tasks: support implementation of IPC practices; provide mentorship to colleagues; undertake monitoring activities; and alert on possible infectious risks. IPC committee: A multidisciplinary group with interested stakeholders across the facility, which interacts with and advises the IPC team. For example, the IPC committee could include senior facility leadership; senior clinical staff; leads of other relevant complementary areas, such as biosafety, pharmacy, microbiology or clinical laboratory, waste management, water, sanitation and hygiene services and quality and safety, where in place. Source: WHO. IPCAF (http://www.who.int/infection-prevention/ tools/core-components/en/, accessed 29 October 2019). IPC structural indicators: Appropriate clean and hygienic environment, water, sanitation and hygiene services and availability of materials and equipment for IPC, in particular for hand hygiene, including financial, human and information resources compatible with standards set out by government authorities or other bodies responsible for the control and prevention of health care-associated infections. Source: WHO. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. 2016 (https://www.who.int/infection- prevention/publications/core-components/en/, accessed 29 October 2019). IPC process indicators: Measurement of compliance with IPC activities currently used within the facility and the presence of IPC policies, procedures and protocols. Hand hygiene is an essential process indicator to be monitored. Source: WHO. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. 2016 (https://www.who.int/infection- prevention/publications/core-components/en/, accessed 29 October 2019). Multimodal strategy: A multimodal strategy comprises several components or elements (three or more, usually five) 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 five most common elements include: (i) system change (availability of the appropriate infrastructure and supplies to enable infection prevention and control good practices); (ii) education and training of health care workers and key players (for example, managers); (iii) monitoring infrastructures, practices, processes, outcomes and providing data feedback; (iv) reminders in the workplace/communications; and (v) culture change within the establishment or the strengthening of a safety climate. GLOSSARY OF KEY TERMS AND DEFINITIONS VIII Source: WHO. Improving infection prevention and control at the health facility. 2018 (https://www.who.int/infection-prevention/ tools/core-components/facility-manual.pdf, accessed 29 October 2019). Negative pressure mechanical ventilation system: A mechanical ventilation system in which the exhaust airflow rate is greater than the supply airflow rate. The room will be at a lower pressure than the surrounding areas. Source: WHO. WHO guidelines on tuberculosis infection prevention and control. 2019 (https://apps.who.int/iris/ bitstream/handle/10665/311259/9789241550512-eng. pdf?ua=1, accessed 29 October 2019). Patient zone: Concept related to the ‘geographical’ visualization of key moments for hand hygiene. It contains the patient X and his/her immediate surroundings. This typically includes the intact skin of the patient and all inanimate surfaces that are touched by or in direct physical contact with the patient, such as the bed rails, bedside table, bed linen, infusion tubing and other medical equipment. It also contains surfaces frequently touched by health care workers while caring for the patient, such as monitors, knobs and buttons, and other ‘high frequency’ touch surfaces. Source: WHO Guidelines on hand hygiene in health care. 2009 (https://www.who.int/gpsc/5may/tools/9789241597906/en/, accessed 29 October 2019). Personal protective equipment: Specialized clothing or equipment worn to protect the health care worker or any other person from infection. These usually consist of standard precautions: gloves, mask and gown. If bloodborne or airborne infections, these will include face protection, goggles and mask or face shield, gloves, gown or coverall, head cover and rubber boots. Source: WHO. Medical devices. 2014 (https://www.who.int/ medical_devices/meddev_ppe/en/, accessed 29 October 2019). Point of care: The place where three elements come together: the patient, the health care worker and care or treatment involving contact with the patient or his/her surroundings (within the patient zone). Source: WHO Guidelines on hand hygiene in health care. 2009 (https://www.who.int/gpsc/5may/tools/9789241597906/en/, accessed 29 October 2019). Positive pressure mechanical ventilation system: A mechanical ventilation system in which the supply airflow rate is greater than the exhaust airflow rate. The room will be at a higher pressure than the surrounding areas. Source: WHO. Natural ventilation for infection control in health- care settings. 2009 (https://www.who.int/water_sanitation_ health/publications/natural_ventilation.pdf, accessed 29 October 2019). Protocol: Detailed plan of a scientific or medical experiment, treatment or procedure. Reprocessing of medical devices: All steps that are necessary to make a contaminated reusable medical device ready for its intended use. These steps may include cleaning, functional testing, packaging, labelling, disinfection and sterilization. Source: WHO. Decontamination and reprocessing of medical devices for health care facilities. 2016 (https://www.who.int/ infection-prevention/en/, accessed 29 October 2019). Standard operating procedure: Set of step-by-step instructions compiled by an organization to help workers carry out routine operations in the most effective manner. Standard precautions: A set of activities designed to prevent the transmission of organisms between patients/staff for the prevention of health care-associated infection. They must be applied to ALL patients who require health care, by ALL health workers in ALL health settings. They include: hand hygiene; use of personal protective equipment; handling and disposal of waste and sharps; handling and management of clean and used linen; environmental cleaning; and decontamination of equipment. Source: The Northern Ireland Regional Infection and Prevention Control Manual. Standard precautions. Updated 2015 (https:// www.niinfectioncontrolmanual.net/standard-precautions, accessed 29 October 2019). Transmission-based precautions: Additional measures focused on the particular mode of transmission of the microrganism and GLOSSARY OF KEY TERMS AND DEFINITIONS IX always used in addition to standard precautions. They are grouped into categories according to the route of transmission of the infectious agent. Transmission-based precautions should be applied when caring for patients with known infection, patients who are colonized with an infectious organism, and asymptomatic patients who are suspected of/under investigation for colonization or infection with an infectious microorganism. Source: The Northern Ireland Regional Infection and Prevention Control Manual. Transmission-based precautions. Updated 2015 (https://www.niinfectioncontrolmanual.net/transmission- based-precautions, accessed 29 October 2019). Water quality: The quality of water is affected by microbial, chemical and radiological aspects, with microbial aspects constituting the principle concern for infection control in health care settings. Water in health care facilities should not present a risk to health from pathogens and should be protected from contamination inside the health care setting itself. Water for drinking, cooking, personal hygiene, medical activities, cleaning and laundry must be safe for the purpose intended. ‘Safe’ water is water that meets national and/or WHO water quality guidelines, including zero Escherichia coli or thermotolerant coliform bacteria in any 100-millilitre sample of drinking water. Source: WHO. Drinking water quality guidelines. 2017 (https:// www.who.int/water_sanitation_health/publications/drinking- water-quality-guidelines-4-including-1st-addendum/en/, accessed 29 October 2019). GLOSSARY OF KEY TERMS AND DEFINITIONS XKEY TO SYMBOLS Visual representation of the WHO core components of infection prevention and control (IPC) programmes at the national and health care facility level. Visual representation of minimum versus full requirements of the core components to achieve effective IPC programmes. Key people to be involved in an activity. Process undertaken to develop the document. How the document is structured. Achieving the effective implementation of the IPC core components. Content relevant for the national level. Content relevant for the health care facility level. KEY TO SYMBOLS

1PART 1. INTRODUCTION Why should health systems have strong infection prevention and control (IPC) programmes? Preventing harm to patients, health workers and visitors due to infection in health care facilities is fundamental to achieve quality care, patient safety, health security and the reduction of health care-associated infections (HAIs) and antimicrobial resistance (AMR). Similarly, preventing and reducing the transmission of infectious diseases that pose global threats, such as pandemic influenza, Ebola virus disease and other viral haemorrhagic fevers, is paramount. Clean, safe care is a patient right and should also be the duty and pride of all those working in the health care sector. Supported by many stakeholders in the field of IPC, WHO has issued recommendations and specifications for effective IPC programmes. These are included in the evidence-based WHO Guidelines on core components of IPC programmes (1) and the approach for their implementation is presented in associated manuals for both the national and facility levels (2, 3). 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. The implementation of all WHO recommendations on core components is required to build functioning programmes leading to the effective reduction of HAIs and AMR. However, fulfilment of all IPC core components takes time. For some countries, it may be a demanding journey that will need to build upon a realistic, stepwise approach. In particular for countries where IPC is limited or inexistent, it is critical to start by ensuring that at least minimum requirements for IPC are in place as soon as possible, both at the national and facility level, and to gradually progress to the full achievement of all requirements of the IPC core components according to local priority plans. Patients and health care workers (HCWs) need to be safe and protected at all times, no matter where and irrespective of the context. The eight core components of IPC are the ‘wheels of the cart’ that will ensure patients have a safe journey while in a health care facility. PART 1. INTRODUCTION 21.2 TARGET AUDIENCE The main target audience of this document are IPC and AMR focal points/leads, policy-makers, senior managers and other professionals with the mandate of or interested in developing or strengthening IPC programmes at the national, sub-national and facility level. IPC teams and committees are also the critical target audience of this document. Key players in addressing each of the minimum requirements are also indicated in the specific chapters related to each core component. The document could also be helpful to other stakeholders, such as those responsible for health care quality improvement, patient safety, health facility accreditation/regulation, public health, infectious disease control and surveillance, water, sanitation and hygiene (WASH), occupational 1.1 PURPOSE OF THE DOCUMENT The purpose of this document is to present and promote the minimum requirements for IPC programmes at the national and health care facility level, identified by expert consensus according to available evidence and in the context of the WHO core components. The minimum requirements are defined as: IPC standards that should be in place at the national and facility level to provide minimum protection and safety to patients, HCWs and visitors, based on the WHO core components for IPC programmes. PART 1. INTRODUCTION What are the minimum requirements for IPC programmes? Who should implement the minimum requirements for IPC programmes? 3How was this document developed? health, antimicrobial stewardship programmes, clinical microbiology and environmental health interventions, as well as additional categories of health care professionals involved in care delivery. WHO staff, partners in nongovernmental organizations and donors involved in supporting the development or implementation of IPC and WASH capacity building, AMR national action plans and, the core capacities of the International Health Regulations at country level (4), will also benefit from using this document. Of note, IPC implementation is the responsibility of all HCWs and not the sole responsibility of the IPC teams or policy-makers. Therefore, it is important that all HCWs are made aware of the IPC minimum requirements. Consideration should be given to providing an active orientation on IPC minimum requirements (for example, pre-service training, updates within annual in- service training, etc.) to health workers, based on the different areas of work and functions. 1.3 DOCUMENT DEVELOPMENT AND STRUCTURE A group of international experts and professionals working at national and facility levels in the field of IPC was convened by WHO, with support by the United States Centers for Disease Control and Prevention and the Africa Centre for Disease Control and Prevention. Plenary sessions were held to identify the objectives and scope of the project and to define the concept of minimum requirements. Working groups were formed to identify minimum requirements for each IPC core component at the national and the health facility levels, based on existing IPC and WASH recommendations and standards. For the purpose of this work, health facilities were categorized as primary health care facilities, secondary health care facilities (including primary and secondary hospitals) and tertiary health care facilities (tertiary hospitals). Based on proposals by the working groups, all participants expressed their opinion on the minimum requirements by voting. Only those identified with >70% consensus was accepted and included in this document. The cut-off of 70% was based on evidence from studies on consensus building to ensure a high consensus rate among the expert group (5-7). Mention is made of requirements with a lower level of consensus in the rationale (‘why’) sections of each minimum requirements’ chapter. A second round of review of the minimum requirements’ content and language was undertaken with the participants after the international meeting. Finally, international experts and WHO staff not participating in the meeting were asked to provide an external review and input to the final draft document. PART 1. INTRODUCTION 4The document includes four parts. Part 1 is an introduction that includes sections of paramount importance to understand the remaining content of the document and the minimum requirements for IPC programmes. The minimum requirements are summarized in Part 2 of this document, together with the WHO evidence-based recommendations for each IPC core component (1). Part 3 is an in-depth review exploration of each core component and its minimum requirements for the national and health care facility levels (Box 1). Part 4 includes summaries of the results of a systematic review and inventory of available pubblications IPC minimum standards, used as the evidence basis for the development of this document. How is this document structured? WHAT WHO HOW WHY FULLREQUIREMENTS Minimum requirements Is responsible for action To measure progress Rationale and additional details on the minimum requirements Full core component requirements Text of the minimum requirements for each IPC core component identified by expert consensus according to national and health care facility level and based on existing IPC and WASH recommendations and standards. Identification of those who have the mandate to ensure that the minimum requirements are put in place and sustained or can play a role. Indicators to be used to track implementation and progress for each minimum requirement are available from different WHO monitoring tools. Explanations about the reasons for selecting the agreed minimum requirements (rationale) and additional details explaining their content and importance. Comprehensive list of the actions and requirements* to achieve full implementation of each IPC core component. Note that these exist only for acute care hospitals because the WHO recommendations on IPC core components apply mainly to these facilities and not specifically to primary care facilities. * Note that in some cases, there are no major differences compared to the minimum requirements. STRUCTURE OF THE MINIMUM REQUIREMENTS (PART 3)BOX 1 PART 1. INTRODUCTION 5How can the minimum requirements help achieve effective implementation of the IPC core components? 1.4 ROLE OF THE MINIMUM REQUIREMENTS It is important to note that the gold standard in any country is to achieve the full implementation of all requirements of the WHO core components of IPC programmes (Fig. 1) (1). For this reason, governments and facilities should take steps to work towards this goal, including in the context of national action plans for AMR, quality of care and health security. Fig. 1 Visual representation of the WHO core components of IPC programmes. PART 1. INTRODUCTION MU LTIMODAL S TR ATE GIES EDUCATION AND TRAINING GUIDELINES MONITORING, AUDIT AND FEEDBACK SURVEILLANCE ENABLING ENVIRONMENT BUILT ENVIRONMENT, MATERIALS AND EQUIPMENT WORKLOAD, STAFFING, AND BED OCCUPANCY and all relevant programme linkages IPC PROGRAMMES 6The approach to facilitate implementation of the WHO core components, together with real-life examples from countries and facilities around the world, is described in the WHO practical manuals developed for the national and facility levels (2, 3). Anyone interested in understanding and implementing the minimum requirements should read the WHO Guidelines on core components of IPC programmes (1) and the manuals supporting their implementation at the national and facility levels (2, 3). However, it is recognized that countries may be at different levels of progress, with different capacities, available opportunities and resources. Thus, the minimum requirements represent the starting point for undertaking the journey to build strong and effective IPC programmes at the national and facility level (Fig. 2) and SHOULD be in place for all countries and health care facilities to support further progress towards full implementation of all core components. Fig. 2 Minimum versus full requirements to achieve effective IPC programmes. PART 1. INTRODUCTION 7Whether applying the minimum requirements or full requirements, the implementation of the IPC core components should always be tackled using a stepwise approach, based on a careful assessment of the status of the IPC programme and activities locally. A country or a health facility may not be able to aim at putting in place all core components or even all minimum requirements at the same time. Therefore, when preparing to improve IPC, it is essential to start by using standardized tools and indicators developed and validated for assessing the status of the core components at the national or health facility in any country worldwide, regardless of the geographical location and level of income. Depending on the strengths (core component requirements/features already in place) and the gaps (requirements/features not available or in place) identified through the assessment, a prioritization exercise can then help to identify which core components and minimum or full requirements need to be targeted through an improvement action plan tailored to the local context, expertise and resources available. To undertake this process, WHO proposes a five-step cycle of implementation (Fig. 3 and Box 2) to support any IPC improvement intervention or programme as described further in the practical manuals (2, 3, 8). Fig. 3 The five-step cycle to IPC improvement. PART 1. INTRODUCTION Step 5 Sustaining the programme over the long term Step 1 Preparing for action Step 2 Baseline assessment Step 3 Developing and executing an action plan Step 4 Evaluating impact Multimodal improvement strategy embedded within each step in the cycle of continuous improvement 8Type of tool and purpose Structure Who should complete it Standardized assessment tool designed to determine the IPC core components already in place (existing strengths) and to identify gaps or weaknesses at the national level. The main purpose of IPCAT2 is to support implementation, thereby providing a road map to guide IPC actions. IPCAT2 includes six sections correspond- ing to the six core component recommen- dations targeted at the national level, with an associated scoring system. The tool is intended to be used for self-assessment by the national IPC team and/or committee, but it can also be used for joint assessments with external experts or external assessments. STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 Preparing for action Baseline assessment Developing and executing an action plan Assessing impact Sustaining the programme over the long term This step aims to ensure that all of the prerequisites that need to be in place for the success of an IPC intervention or programme are considered. These include starting to think about the identification of key players and their roles and responsibilities, as well as the necessary resources (human and financial), infrastructure/s, planning and coordination of activities. Of note, the preparations made can be refined through step 3 after conducting step 2. Conducting an objective baseline assessment of the current situation of the IPC core components and minimum requirements is critical for the identification of existing strengths and gaps. Standardized and validated assessment indicators and tools available from WHO are listed in Part 3. The national and facility level standardized tools to assess the IPC core components and WASH are described in Boxes 3-5. Developing a tailor- made action plan that addresses the local reality and focuses on the priority areas for improvement identified through the baseline assessment. The development and execution of an action plan should be based upon a multimodal improvement strategy and supported by a dedicated budget. Conducting a follow- up assessment using the same tools as in step 2 is crucial to determine the effectiveness of the plan and achievement of the minimum requirements. Further review of the long term impact and acceptability of the ongoing action plan, and ensuring its sustainability, are important steps in the cycle of improvement. This allows also an evaluation of the next steps and priorities for implementation of all minimum requirements and the IPC core components in full. THE FIVE-STEP CYCLE TO INFECTION PREVENTION AND CONTROL IMPROVEMENT NATIONAL INFECTION PREVENTION AND CONTROL ASSESSMENT TOOL 2 (IPCAT2) (9) BOX 2 BOX 3 PART 1. INTRODUCTION 9Type of tool and purpose Structure Who should complete it Validated assessment tool designed to measure the IPC situation of a health care facility and determine the core components already in place (existing strengths) and to identify gaps or weaknesses to guide action planning. Structured, closed-formatted questionnaire with an associated scoring system, which includes eight sections corresponding to the eight core component recommendations targeted at the facility level. The tool is meant to be completed by health care professionals responsible for organising and implementing IPC measures and who have in-depth knowledge of IPC at the facility level (IPC focal point or team or committee), but it can also be used for joint assessments with or external assessments by external experts. Type of tool and purpose Structure Who should complete it Improvement tool to be used on a continuous and regular basis to help health care facility staff and administrators prioritize and improve WASH and health care waste management infrastructures and services in facilities in low- and middle-income countries; and to inform broader district, regional and national efforts to improve quality health care. WASH FIT complements the IPCAF and provides a greater depth of information on the built environment. WASH FIT covers four broad areas: water, sanitation (including health care waste management), hygiene (hand hygiene and environmental cleaning) and management. The tool is meant to be used by health care facility managers and staff including the chief medical officer, the financial administrator, doctors, nurses and persons in charge of managing water and waste. Other people outside the facility may also be involved, such as local, district and regional WASH and/or public works authorities, representatives from the community, local and regional government authorities involved in implementing national quality health care, IPC and maternal, newborn and child health strategies, donors, and nongovernmental organizations (NGOs). FACILITY INFECTION PREVENTION AND CONTROL ASSESSMENT FRAMEWORK (IPCAF) (10) WASH FIT (11) BOX 4 BOX 5 PART 1. INTRODUCTION 10 1.5 REFERENCES 1. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016 (http://www.who.int/infection-prevention/ publications/ipc-components-guidelines/en/, accessed 29 October 2019). 2. Interim Practical Manual supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. Geneva: World Health Organization; 2017 (http://www.who.int/ infection-prevention/tools/core-components/cc-implementation-guideline. pdf, accessed 29 October 2019). 3. 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 (http://www.who.int/infection-prevention/tools/ core-components/facility-manual.pdf, accessed 29 October 2019). 4. International Health Regulations (2005). Assessment tool for core capacity requirements at designated airports, ports and ground crossings. Geneva: World Health Organization; 2009 (https://www.who.int/ihr/ports_airports/ PoE/en/, accessed 29 October 2019). 5. Vogel C ZS, Griffiths C, Hobbs M, Henderson E, Wilkins E. A Delphi study to build consensus on the definition and use of big data in obesity research. Int J Obesity 2019; Jan 17 [Epub ahead of print]. 6. Slade SC, Dionne CE, Underwood M, Buchbinder R. Standardised method for reporting exercise programmes: protocol for a modified Delphi study. BMJ Open. 2014: e006682. 7. Diamond IR, Grant CR, Feldman BM, Pencharz PB, Ling SC, Moore AM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67:401–09. 8. Infection prevention and control: core components for IPC - implementation tools and resources. Geneva: World Health Organization; 2019 (https://www. who.int/infection-prevention/tools/core-components/en, accessed 29 October 2019). 9. Infection prevention and control assessment tool (IPCAT2). Geneva: World Health Organization; 2017 (http://www.who.int/infection-prevention/tools/ core-components/IPCAT2.xls, accessed 29 October 2019). 10. Infection prevention and control assessment framework. Geneva: World Health Organization; 2018 (https://www.who.int/infection-prevention/tools/ core-components/IPCAF-facility.PDF, accessed 29 October 2019). 11. Water and sanitation for health facility improvement tool (WASH FIT). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/ bitstream/handle/10665/254910/9789241511698-eng.pdf?sequence=1, accessed 29 October 2019). PART 1. INTRODUCTION

13 Active, stand-alone, national IPC programmes with clearly defined objectives, functions and activities should be established for the purpose of preventing HAI, promoting patient safety and combating AMR through IPC good practices. National IPC programmes should be linked with other relevant national programmes and professional organizations. A functional IPC programme should be in place, including at least: • one full-time focal point trained in IPC. • a dedicated budget for implementing IPC strategies/plans. The panel recommends that an IPC programme with a dedicated, trained team should be in place in each acute health care facility for the purpose of preventing HAI and combating AMR through IPC good practices. PRIMARY CARE: IPC trained health care officer • Trained IPC link person, with dedicated (part-) time in each primary health care facility. • One IPC-trained health care officer at the next administrative level (for example, district) to supervise the IPC link professionals in primary health care facilities. SECONDARY CARE: functional IPC programme • Trained IPC focal point (one full-time trained IPC Officer [nurse or doctor]) as per the recommended ratio of 1:250 beds with dedicated time to carry out IPC activities in all facilities (for example, if the facility has 120 beds, one 50% full-time equivalent dedicated officer). • Dedicated budget for IPC implementation. TERTIARY CARE: functional IPC programme • At least one full-time trained IPC focal point (nurse or doctor) with dedicated time per 250 beds. • IPC programme aligned with the national programme and with a dedicated budget. • Multidisciplinary committee/team. • Access to microbiology laboratory. MINIMUM REQUIREMENTS PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT CORE COMPONENT 1: IPC PROGRAMMES NATIONAL LEVEL FACILITY LEVEL CORE COMPONENT RECOMMENDATION 14 The panel recommends that evidence-based guidelines should be developed and implemented for the purpose of reducing HAI and AMR. The education and training of relevant HCWs on the guideline recommendations and the monitoring of adherence with guideline recommendations should be undertaken to achieve successful implementation. National IPC guidelines • Evidence-based, ministry-approved guidelines adapted to the local context and reviewed at least every five years. PRIMARY CARE: facility-adapted standard operating procedures (SOPs) and their monitoring • Evidence-based facility-adapted SOPs based on the national IPC guidelines. • At a minimum, the facility SOPs should include: ‐ hand hygiene ‐ decontamination of medical devices and patient care equipment ‐ environmental cleaning ‐ health care waste management ‐ injection safety ‐ HCW protection (for example, post- exposure prophylaxis, vaccinations) ‐ aseptic techniques ‐ triage of infectious patients ‐ basic principles of standard and transmission-based precautions. • Routine monitoring of the implementation of at least some of the IPC guidelines/ SOPs. SECONDARY AND TERTIARY CARE: all requirements as for the primary health care facility level, with additional SOPs on: • standard and transmission-based precautions (for example, detailed, specific SOPs for the prevention of airborne pathogen transmission); • aseptic technique for invasive procedures, including surgery; • specific SOPs to prevent the most prevalent HAIs based on the local context/ epidemiology; • occupational health (specific detailed SOP). CORE COMPONENT RECOMMENDATION MINIMUM REQUIREMENTS CORE COMPONENT 2: IPC GUIDELINES PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT NATIONAL LEVEL FACILITY LEVEL NATIONAL LEVEL AND FACILITY LEVEL 15 The national IPC programme should support education and training of the health workforce as one of its core functions. National training policy and curriculum • National policy that all HCWs are trained in IPC (in-service training). • An approved IPC national curriculum aligned with national guidelines and endorsed by the appropriate body. • National system and schedule of monitoring and evaluation to check on the effectiveness of IPC training and education (at least annually). The panel recommends that IPC education should be in place for all HCWs by using team- and task-based strategies that are participatory and include bedside and simulation training to reduce the risk of HAI and AMR. PRIMARY CARE: IPC training for all front-line clinical staff and cleaners upon hiring • All front-line clinical staff and cleaners must receive education and training on the facility IPC guidelines/SOPs upon employment. • All IPC link persons in primary care facilities and IPC officers at the district level (or other administrative level) need to receive specific IPC training. SECONDARY CARE: IPC training for all front-line clinical staff and cleaners upon hire • All front-line clinical staff and cleaners must receive education and training on the facility IPC guidelines/SOPs upon employment. • All IPC staff need to receive specific IPC training. TERTIARY CARE: IPC training for all front-line clinical staff and cleaners upon hire and annually • All front-line clinical staff and cleaners must receive education and training on the facility IPC guidelines/SOPs upon employment and annually. • All IPC staff need to receive specific IPC training. MINIMUM REQUIREMENTS CORE COMPONENT 3: IPC EDUCATION AND TRAINING PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT NATIONAL LEVEL FACILITY LEVEL CORE COMPONENT RECOMMENDATION 16 PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT MINIMUM REQUIREMENTS CORE COMPONENT 4: HAI SURVEILLANCE The panel recommends that national HAI surveillance programmes and networks that include mechanisms for timely data feedback and with the potential to be used for benchmarking purposes should be established to reduce HAI and AMR. IPC surveillance and a monitoring technical group • Establishment by the national IPC focal point of a technical group for HAI surveillance and IPC monitoring that: ‐ is multidisciplinary; ‐ develops a national strategic plan for HAI surveillance (with a focus on priority infections based on the local context) and IPC monitoring. The panel recommends that facility-based HAI surveillance should be performed to guide IPC interventions and detect outbreaks, including AMR surveillance, with timely feedback of results to HCWs and stakeholders and through national networks. PRIMARY CARE • HAI surveillance is not required as a minimum requirement at the primary facility level, but should follow national or sub-national plans, if available (for example, detection and reporting of outbreaks affecting the community is usually included in national plans). SECONDARY CARE • HAI surveillance should follow national or sub-national plans. TERTIARY CARE: functional HAI surveillance • Active HAI surveillance should be conducted and include information on AMR: ‐ enabling structures and supporting resources need to be in place (for example, dependable laboratories, medical records, trained staff), directed by an appropriate method of surveillance; ‐ the method of surveillance should be directed by the priorities/plans of the facility and/or country. • Timely and regular feedback needs to be provided to key stakeholders in order to lead to appropriate action, in particular to the hospital administration. NATIONAL LEVEL FACILITY LEVEL CORE COMPONENT RECOMMENDATION 17 PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT The panel recommends that national IPC programmes should coordinate and facilitate the implementation of IPC activities through multimodal strategies on a nationwide or sub- national level. Multimodal improvement strategies for IPC interventions • Use of multimodal strategies to implement IPC interventions according to national guidelines/SOPs under the coordination of the national IPC focal point (or team, if existing). The panel recommends that IPC activities using multimodal strategies should be implemented to improve practices and reduce HAI and AMR. PRIMARY CARE: multimodal strategies for priority IPC interventions • Use of multimodal strategies – at the very least to implement interventions to improve hand hygiene, safe injection practices, decontamination of medical instruments, devices and environmental cleaning. SECONDARY CARE: multimodal strategies for priority IPC interventions • Use of multimodal strategies – at the very least to implement interventions to improve each one of the standard and transmission-based precautions, and triage. TERTIARY CARE: multimodal strategies for all IPC interventions • Use of multimodal strategies to implement interventions to improve each one of the standard and transmission-based precautions, triage, and those targeted at the reduction of specific infections (for example, surgical site infections or catheter-associated infections) in high- risk areas/patient groups, in line with local priorities. MINIMUM REQUIREMENTS CORE COMPONENT 5: MULTIMODAL STRATEGIES NATIONAL LEVEL FACILITY LEVEL CORE COMPONENT RECOMMENDATION 18 MINIMUM REQUIREMENTS CORE COMPONENT 6: MONITORING, AUDITING AND FEEDBACK NATIONAL LEVEL FACILITY LEVEL The panel recommends that a national IPC monitoring and evaluation programme should be established to assess the extent to which standards are being met and activities are being performed according to the programme’s goals and objectives. Hand hygiene monitoring with feedback should be considered as a key performance indicator at the national level. IPC surveillance and monitoring technical group • Establishment by the national IPC focal point of a technical group for HAI surveillance and IPC monitoring that: ‐ is multidisciplinary; ‐ develops a national strategic plan for HAI surveillance and IPC monitoring and, for IPC indicators monitoring: · develops recommendations for minimum indicators (for example, hand hygiene); · develops an integrated system for the collection and analysis of data (for example, protocols, tools) · provides training at the facility level to collect and analyse these data. The panel recommends that regular monitoring/ audit and timely feedback of health care practices according to IPC standards should be performed to prevent and control HAI and AMR at the health care facility level. Feedback should be provided to all audited persons and relevant staff. PRIMARY CARE • Monitoring of IPC structural and process indicators should be put in place at primary care level, based on IPC priorities identified in the other components. This requires decisions at the national level and implementation support at the sub- national level. SECONDARY AND TERTIARY CARE • A person responsible for the conduct of the periodic or continuous monitoring of selected indicators for process and structure, informed by the priorities of the facility or the country. • Hand hygiene is an essential process indicator to be monitored. • Timely and regular feedback needs to be provided to key stakeholders in order to lead to appropriate action, particularly to the hospital administration. CORE COMPONENT RECOMMENDATION PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT 19 The panel recommends that the following elements should be adhered to in order to reduce the risk of HAI and the spread of AMR: (1) bed occupancy should not exceed the standard capacity of the facility; (2) HCW staffing levels should be adequately assigned according to patient workload. PRIMARY CARE • To reduce overcrowding: a system for patient flow, a triage system (including referral system) and a system for the management of consultations should be established according to existing guidelines, if available. • To optimize staffing levels: assessment of appropriate staffing levels, depending on the categories identified when using WHO/national tools (national norms on patient/staff ratio), and development of an appropriate plan. SECONDARY AND TERTIARY CARE • To standardize bed occupancy: ‐ establish a system to manage the use of space in the facility and to establish the standard bed capacity for the facility; ‐ hospital administration enforcement of the system developed; ‐ no more than one patient per bed; ‐ spacing of at least one metre between the edges of beds; ‐ overall occupancy should not exceed the designed total bed capacity of the facility. • To reduce overcrowding and optimizing staffing levels: same minimum requirements as for primary health care. MINIMUM REQUIREMENTS CORE COMPONENT 7: WORKLOAD, STAFFING AND BED OCCUPANCY (FACILITY LEVEL ONLY*) * The national health system, IPC programme and any other relevant body should coordinate and support the implementation of this core component at the facility level. FACILITY LEVEL* CORE COMPONENT RECOMMENDATION PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT 20 Patient care activities should be undertaken in a clean and hygienic environment that facilitates practices related to the prevention and control of HAI, as well as AMR, including all elements around WASH infrastructure and services and the availability of appropriate IPC materials and equipment. The panel recommends that materials and equipment to perform appropriate hand hygiene should be readily available at each point of care. PRIMARY CARE: • Water should always be available from a source on the premises (such as a a deep borehole or a treated, safely managed piped water supply) to perform basic IPC measures, including hand hygiene, environmental cleaning, laundry, decontamination of medical devices and health care waste management according to national guidelines. • A minimum of two functional, improved sanitation facilities should be available on-site, one for patients and the other for staff; both should be equipped with menstrual hygiene facilities. • Functional hand hygiene facilities should always be available at points of care/toilets and include soap, water and single-use towels (or if unavailable, clean reusable towels) or alcohol-based handrub (ABHR) at points of care and soap, water and single-use towels (or if unavailable, clean reusable towels) within 5 metres of toilets. • Sufficient and appropriately labelled bins to allow for health care waste segregation should be available and used (less than 5 metres from point of generation); waste should be treated and disposed of safely via autoclaving, high temperature incineration, and/or buried in a lined, protected pit. • The facility layout should allow adequate natural ventilation, decontamination of reusable medical devices, triage and space for temporary cohorting/isolation/physical separation if necessary. • Sufficient and appropriate IPC supplies and equipment (for example, mops, detergent, disinfectant, personal protective equipment (PPE) and sterilization) and power/energy (for example, fuel) should be available for performing all basic IPC measures according to minimum requirements/SOPs, including all standard precautions, as applicable; lighting should be available during working hours for providing care. SECONDARY AND TERTIARY CARE: • A safe and sufficient quantity of water should be available for all required IPC measures and specific medical activities, including for drinking, and piped inside the facility at all times - at a minimum to high-risk wards (for example, maternity ward, operating room/s, intensive care unit). • A minimum of two functional, improved sanitation facilities that safely contain waste available for outpatient wards should be available and one per 20 beds for inpatient wards; all should be equipped with menstrual hygiene facilities. • Functional hand hygiene facilities should always be available at points of care, toilets and service areas (for example, the decontamination unit), which include ABHR and soap, water and single-use towels (or if unavailable, clean reusable towels) at points of care and service areas, and soap, water and single-use towels (or if unavailable, clean reusable towels) within 5 metres of toilets. • Sufficient and appropriately labelled bins to allow for health care waste segregation should be available and used (less than 5 metres from point of generation) and waste should be treated and disposed of safely via autoclaving, incineration (850° to 1100°C), and/or buried in a lined, protected pit. MINIMUM REQUIREMENTS FACILITY LEVEL CORE COMPONENT 8: BUILT ENVIRONMENT, MATERIALS AND EQUIPMENT FOR IPC (FACILITY LEVEL ONLY*) * The national health system, IPC programme and any other relevant body should coordinate and support the implementation of this core component at the facility level. CORE COMPONENT RECOMMENDATION PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT 21 PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT • The facility should be designed to allow adequate ventilation (natural or mechanical, as needed) to prevent transmission of pathogens. • Sufficient and appropriate supplies and equipment and reliable power/energy should be available for performing all IPC practices, including standard and transmission-based precautions, according to minimum requirements/SOPs; reliable electricity should be available to provide lighting to clinical areas for providing continuous and safe care, at a minimum to high-risk wards (for example, maternity ward, operating room/s, intensive care unit). • The facility should have a dedicated space/area for performing the decontamination and reprocessing of medical devices (that is, a decontamination unit) according to minimum requirements/SOPs. • The facility should have adequate single isolation rooms or at least one room for cohorting patients with similar pathogens or syndromes, if the number of isolation rooms is insufficient

23 CORE COMPONENT 1: IPC PROGRAMMES A functional IPC programme should be in place, including at least: • one full-time focal point trained in IPC; • a dedicated budget for implementing IPC strategies/plans. • Minister of health or other assigned senior authority within the ministry of health (for example, Director General of Health Services) at national and/or state level. • Minister of finances may also have an important role in allocating a dedicated budget for IPC. • Leads of other programmes where links can be useful for synergistic action (for example, HAI, AMR, WASH). • National IPC committee or technical working group, depending on the country situation as in some countries the committee exists, but there is no national IPC focal point or team to take action. Thus, the IPC committee can have a critical role in advocating for establishing a national IPC focal point. • IPC technical partners have an important role in advocating for and supporting (also financially in some cases) the establishment of an IPC focal point (for example, WHO country office, WHO Regional Office, UNICEF, United States Centers for Disease Control and Prevention [CDC], and other organizations with competence and activities in the field of IPC). PRIMARY CARE IPC-trained link person and health care officer • Trained IPC link person, with dedicated (part-) time in each primary health care facility. • One IPC-trained health care officer at the next administrative level (for example, district) to supervise the IPC link professionals in primary health care facilities. SECONDARY CARE Functional IPC programme • Trained IPC focal point (one full-time trained IPC Officer [nurse or doctor]) as per the recommended ratio of 1:250 beds with dedicated time to carry out IPC activities in all facilities (for example, if the facility has 120 beds, one 50% full-time equivalent dedicated officer). • Dedicated budget for IPC implementation. TERTIARY CARE Functional IPC programme • At least one full-time trained IPC focal point (nurse or doctor) with dedicated time per 250 beds. • IPC programme aligned with the national programme and with a dedicated budget. • Multidisciplinary committee/team. • Access to microbiology laboratory. • All key players mentioned at the national level can influence and/ or mandate the establishment of IPC link persons, IPC focal points and IPC committees at the health care facility level and of IPC officers at the next administrative level. • Directors of health or health management teams (or other decision-making role) at the district or province or state level (or other administrative level depending on the country). • At secondary and tertiary health care facility level, hospital director, medical director, chief nurse and finance office director have a critical role in the decision to establish the minimum requirements for core component 1. • Existing IPC committee (or similar) at the facility or next administrative level. • Local partners have an important role in advocating for and supporting (also financially in some cases) the establishment of IPC minimum requirements at the facility level. WHAT (minimum requirements) WHO (is responsible for action) PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS NATIONAL LEVEL FACILITY LEVEL NATIONAL LEVEL FACILITY LEVEL 24 NATIONAL LEVEL SOURCES AND RESOURCES1 FACILITY LEVEL SOURCES AND RESOURCES • IPC assessment tool 2 (IPCAT2) – 1.1.1: an active national IPC programme exists. • IPCAT2 – 1.1.2: an appointed infection prevention focal person in charge of the IPC programme can be identified. • IPCAT2 – 1.1.4: the appointed infection prevention focal person has undergone training in IPC in the prevention of HAI. • IPCAT2 – 1.1.7: there is a dedicated budget allocated to the IPC programme. Sources • IPCAT2 results (where available; use the autogenerated results and graphics available in the Excel file of IPCAT2); https://www.who. int/infection-prevention/tools/core-components/en/. • WHO. State Party Self-assessment Annual Reporting Tool. International Health Regulations (2005). 2018; https://www.who. int/ihr/publications/WHO-WHE-CPI-2018.16/en/. • WHO. Joint External Evaluation (JEE) report (where available) 2nd edition, 2018; https://www.who.int/ihr/procedures/joint-external- evaluations/en/. • Food and Agriculture Organization of the United Nations; Organisation for Animal Health; WHO. Global monitoring of country progress on antimicrobial resistance (AMR): Tripartite AMR country self-assessment survey (TrACSS), version 3.0, report (where available). 2018; https://www.who.int/antimicrobial- resistance/global-action-plan/Tripartite-antimicrobial-resistance- country-self-assessment-questionnaire-2018-EN.pdf?ua=1. Sources • IPCAF results report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/ core-components/IPCAF-template.pdf?ua=1. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level. 2016; https://www. who.int/infection-prevention/publications/core-components/en/. • WHO. 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. 2018; https://www.who.int/infection- prevention/tools/core-components/facility-manual.pdf. • Twinning partnerships for improvement; https://www.who.int/ servicedeliverysafety/twinning-partnerships/en/. PRIMARY CARE • A trained IPC link person, with dedicated time is available in each primary health care facility. • IPC interventions included in the facility annual plan. • A trained IPC health care officer is available at the next administrative level (for example, district) to supervise the IPC link professionals. SECONDARY CARE • Infection prevention and control assessment framework tool (IPCAF) – 1.1: an IPC programme exists. • IPCAF – 1.3: at least one full-time trained IPC focal person (nurse or doctor) is in place per 250 beds. • IPCAF – 1.4: the IPC focal point has dedicated time for IPC activities in all facilities regardless of the number of beds. • IPCAF – 1.9: there is a dedicated budget specifically for the IPC programme, that is, covering IPC activities, including salaries. TERTIARY CARE • IPCAF – 1.1: an IPC programme exists. • IPCAF – 1.3: at least one full-time trained IPC focal person (nurse or doctor) is in place per 250 beds. • IPCAF – 1.6: there is a multidisciplinary IPC committee actively supporting the IPC team. • IPCAF – 1.9: there is a dedicated budget specifically for the IPC programme, that is, covering IPC activities, including salaries. • IPCAF – 1.10: the IPC programme has access to a microbiological laboratory, either present on- or off-site for routine day-to-day use. HOW (to measure progress) 1 Sources refers here to possible information that may be available from existing sources that can be used to extract relevant information in order to address each indicator. Resources lists available relevant implementation tools and resources. PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS NATIONAL LEVEL INDICATORS (YES/NO) FACILITY LEVEL INDICATORS (YES/NO) 25 Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core-components/en/. • WHO. Interim practical manual supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. • Association for Professionals in Infection Control and Epidemiology (APIC). HAI cost calculator; https://apic.org/ resources/cost-calculators/. • European Centre for Disease Prevention and Control. Core competencies for infection control and hospital hygiene professionals in the European Union. 2013; https://ecdc.europa. eu/sites/portal/files/media/en/publications/Publications/ infection-control-core-competencies.pdf. • At least one professional (nurse or doctor) must be given the responsibility of IPC at the national level. He/she should have at least basic knowledge and training on IPC (ideally, an IPC postgraduate certificate) and some practical experience. • Once the person is in place, having some resources (budget) is essential to operate. • Based on this, the objectives, functions and activity plan will be developed by the IPC focal point in collaboration with other national programmes and institutions, as well as external partners. PRIMARY CARE • The primary health care level is the first main point of entry of infectious pathogens to the health system and it is where IPC is usually weakest. • It is critical to establish at least a basic level of IPC and triage in primary care (that is, the minimum requirements) to avoid infection and AMR spread through the health system, including health care- associated outbreaks caused by human-to-human transmission of emerging or re-remerging pathogens. • It is important to have professionals in charge of IPC at different levels (facility and at the next administrative level) to support a programmatic approach based on coordination, supervision and accountability through monitoring and evaluation. • The existence of an IPC programme and practices at the primary care level will contribute to patient safety and quality of care and facilitate linkages to the community and dissemination of basic prevention principles among families, as well as patient and family engagement. • The link person should be a staff member at the primary health care facility level, trained in IPC and with dedicated time (part-time). • In facilities with more than 10 HCWs, the IPC link person should be in charge of the following functions: advising on procurement and maintenance of equipment and consumables for IPC; monitoring and supervising IPC activities; liaising with the relevant next administrative level IPC coordinators on the implementation of IPC activities; liaising with the regular disease notification system for the reporting of unusual events. • In facilities with less than 10 HCWs, the link person could have some of the above-mentioned functions but, overall, more support from the district officer will be needed, especially for monitoring activities. SECONDARY AND TERTIARY CARE • A comprehensive and functioning IPC programme should be in place in all acute health care facilities because evidence demonstrates a large effect on HAI reduction. • The existence of an IPC focal point and budget are necessary conditions for building an IPC programme with objectives and plans, and the necessary premise for any IPC action. • The number of staff needed depends on patient acuity and the complexity of care in the facility, as well as the multiple roles and responsibilities of IPC professionals. WHY (rationale and additional details on the minimum requirements) PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS NATIONAL LEVEL FACILITY LEVEL 26 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • Active, stand-alone, national IPC programme with clearly defined objectives, functions and activities. • Technical trained IPC team (medical and nursing professionals) with allocated time, budget and authority to make decisions. • Strong linkages of the national IPC programmes with other relevant national programmes and professional organizations. • Supported by at least one national external quality assurance system (EQAS) microbiological reference laboratory. • Supported by an official multidisciplinary IPC committee. PRIMARY CARE Not applicable. SECONDARY AND TERTIARY CARE • IPC programmes with clearly defined objectives based on local epidemiology and priorities according to risk assessment and functions that align with and contribute to the prevention of HAI and the spread of AMR in health care. • Dedicated, trained professionals in every acute care facility. • A minimum ratio of one full-time or equivalent IPC professional (nurse or doctor) per 250 beds or a higher ratio (one IPC professional per 100 beds) due to increased patient acuity and complexity, as well as the multiple roles and increasing responsibilities of the IPC professional. • External quality control system support of the microbiological laboratory is important for an effective IPC programme. Full core component requirements NATIONAL LEVEL FACILITY LEVEL 27 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS CORE COMPONENT 2: IPC GUIDELINES National IPC guidelines • Evidence-based, nationally-approved guidelines adapted to the local context and reviewed at least every five years. • National IPC focal point (and IPC team or committee, if existing) as guideline development and implementation are key activities in their mandate. • In a country where the IPC focal point/team is newly established and has limited experience/expertise, consider external IPC technical support as needed for initial guideline development/ review. • Another national responsible body (for example, the national centre for disease control, institute of public health) or an academic institution collaborating with the ministry of health may also play an important role in developing IPC guidelines/SOPs. PRIMARY CARE Facility-adapted SOPs and their monitoring • Evidence-based facility-adapted SOPs based on the national IPC guidelines. • At a minimum, the facility SOPs should include: ‐ hand hygiene ‐ decontamination of medical devices and patient care equipment ‐ environmental cleaning ‐ health care waste management ‐ injection safety ‐ HCW protection (for example, at least post-exposure prophylaxis, vaccinations) ‐ aseptic techniques ‐ triage of infectious patients ‐ basic principles of standard and transmission-based precautions. • Routine monitoring of the implementation of at least some of the IPC guidelines/SOPs. SECONDARY AND TERTIARY CARE all requirements as for the primary health care facility level, with additional SOPs on: • standard and transmission-based precautions (for example, detailed, specific SOPs for the prevention of airborne pathogen transmission); • aseptic technique for invasive procedures, including surgery; • specific SOPs to prevent the most prevalent HAIs based on local context/epidemiology; • occupational health (detailed). PRIMARY CARE • Trained IPC link person, with dedicated (part-) time and/or support from an appointed IPC person at the next administrative level. • If the expertise at the facility and next administrative level is limited, external support should be sought. SECONDARY AND TERTIARY CARE • The IPC focal point is responsible for writing and adapting the SOPs, promoting their adoption and monitoring adherence. If the expertise of the IPC focal point is limited, external support should be sought. • The development and implementation of the SOPs requires a functioning IPC programme and associated expertise to ensure that local recommended procedures refer to national or WHAT (minimum requirements) WHO (is responsible for action) NATIONAL LEVEL FACILITY LEVEL NATIONAL LEVEL FACILITY LEVEL 28 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • IPCAT2 – 2.1.1: the national IPC focal point has a mandate to work with key players to produce guidelines for the prevention and control of HAI. • IPCAT2 – 2.1.6: the national IPC focal point actively addresses guideline adaptation to reflect local conditions. • IPCAT2 – 2.1.3: the guidelines are reviewed at least every 5 years and updated to reflect the current evidence base. PRIMARY CARE • IPCAF – 2.2: facility-adapted SOPs are available for hand hygiene, decontamination of medical devices and patient care equipment, environmental cleaning, health care waste management, injection safety, HCW protection (for example, at least post-exposure prophylaxis, vaccinations), aseptic techniques, triage, basic principles of standard and transmission-based precautions. • IPCAF – 2.3: The guidelines/SOPs are consistent with national/ international IPC guidelines (if they exist). • IPCAF – 2.8: Routine monitoring of the implementation of at least some of the guidelines/SOPs is undertaken. SECONDARY AND TERTIARY CARE • IPCAF – 2.2: facility-adapted SOPs/guidelines are available for hand hygiene, decontamination of medical devices and patient care equipment, environmental cleaning, health care waste management, injection safety, HCW protection (for example, at least post-exposure prophylaxis, vaccinations), aseptic technique for invasive procedures, including surgery, triage, standard and transmission-based precautions, specific SOPs to prevent the most prevalent HAIs based on local context/epidemiology, and occupational health. • IPCAF – 2.3: the guidelines/SOPs are consistent with national/ international IPC guidelines (if they exist). • IPCAF – 2.8: routine monitoring of the implementation of at least some of the SOPs is undertaken. NATIONAL LEVEL INDICATORS (YES/NO) FACILITY LEVEL INDICATORS (YES/NO) international evidence-based guidelines and standards and are adapted to the context. • Relevant stakeholders (for example, link nurse or doctors, leading doctors, nurses, health care facility managers, champions, quality managers) should be involved in the development and adaptation of the SOPs. • Involvement of front-line HCWs should be considered in the development and implementation of SOPs. • The IPC focal point should also be responsible for organizing staff training on the SOPs and for monitoring adherence to the recommended procedures, in collaboration with others who may be in charge of training and assessment at the local level. HOW (to measure progress) NATIONAL LEVEL SOURCES AND RESOURCES FACILITY LEVEL SOURCES AND RESOURCES Source • IPCAT2 results (where available; use the autogenerated results and graphics available in the Excel file of IPCAT2); https://www.who.int/ infection-prevention/tools/core-components/en/. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core-components/en/. • WHO. Improving infection prevention and control at the health facility. Interim practical manual supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. Sources • IPCAF results report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/ core-components/IPCAF-template.pdf?ua=1. • Primary Health Care Performance Initiative. Primary health care progression model assessment tool report (where available). 2018; https://improvingphc.org/primary-health-care-progression-model. Tools and resources • WHO Guidelines on core components of IPC programmes at the national and acute health care facility level; https://www.who.int/ infection-prevention/publications/core-components/en/. • WHO. Improving infection prevention and control at the health facility: Interim practical manual supporting implementation of the WHO guidelines on core components of infection prevention 29 and control programmes. 2018; https://www.who.int/infection- prevention/tools/core-components/facility-manual.pdf. • CDC IPC guidelines library; https://www.cdc.gov/infectioncontrol/ guidelines/index.html. • APIC: list of IPC guidelines; https://apic.org/Professional-Practice/ Scientific-guidelines. • Asia Pacific Society for Infection Control IPC guidelines; http:// apsic-apac.org/guidelines-and-resources/apsicguidelines/. PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • The availability of national guidelines contributes to a reduction in the risk of HAIs and AMR, especially when implemented in combination with HCW education and training. • The development of IPC guidelines/protocols/SOPs and related implementation strategies is a key function of the national IPC focal point (or IPC team/programme if they exist). • National guidelines are necessary to indicate the IPC standards and measures that should be adhered to and monitored, including the appropriate training of HCWs at all levels. • National IPC guidelines should be evidence-based (that is, based on systematic reviews of the scientific literature and other existing guidelines) and ideally refer to/adapted from international standardized guidelines, if available. • Guideline content should be prioritized locally, based on the most frequent practices and/or types of HAI and adapted to local circumstances (for example, use of indwelling catheters and other devices, surgery and other invasive procedures). However, at a minimum, the guidelines should cover the following topics: ‐ hand hygiene ‐ decontamination of medical devices and patient care articles ‐ environmental cleaning ‐ health care waste management ‐ transmission-based precautions ‐ injection safety ‐ HCW protection ‐ aseptic techniques ‐ triage ‐ development and implementation of strategies for training on and dissemination of the IPC guidelines are part of the minimum requirements. • Regular updates (that is, at least every 5 years) are required to ensure that the guidelines reflect current evidence and remain topical and practical to the evolution of health care delivery. PRIMARY CARE • At the facility level, it is not necessary to have the expertise required to develop evidence-based guidelines. It is important to develop SOPs for the implementation and monitoring of available national or international guidelines. • IPC link professionals at the facility level should work with the IPC focal points at the next administrative level (for example, district) to develop adapted SOPs based on the national (or international) guidelines for primary care. • Monitoring adherence to SOP implementation is essential to evaluate its adoption and effectiveness to achieve the desired outcomes and to assist with adjustments and improvements of the implementation strategies. IPC monitoring and supervision should be assured by the health care officer in charge of IPC at the next administrative level (for example, district). • Adaptation to local conditions should be considered for the most effective uptake and implementation. SECONDARY AND TERTIARY CARE • See all points indicated for the primary health care facility level. • A higher level of IPC expertise is required to develop SOPs in secondary and tertiary health care facilities due to the increase in acuity and complexity of care provided. • Facility-adapted SOPs should be prioritized locally, based on the most frequent practices and/or with practices associated with an increase in the risk of HAI and adapted to local circumstances (for example, use of indwelling catheters and other devices, surgery and other invasive procedures). WHY (rationale and additional details on the minimum requirements) NATIONAL LEVEL FACILITY LEVEL • Development of national guidelines and related implementation strategies are a function of the national IPC team or focal point and require IPC expertise. Requirements (which are under the responsibility of the national programme) for developing and implementing effective national IPC guidelines: ‐ IPC expertise for development or adaptation; ‐ local prioritization; ‐ providing resources, infrastructures and supplies for enabling implementation; PRIMARY CARE Not applicable. SECONDARY AND TERTIARY CARE No major differences to be noted compared to the minimum requirements. Full core component requirements NATIONAL LEVEL FACILITY LEVEL 30 ‐ HCW education on recommended practices; ‐ monitoring implementation and adherence; ‐ regular updates. • To fully accomplish core component 2, guidelines on all the following topics should be developed at the national level (either in one main guideline or in specific guidelines, as feasible and appropriate according to the local context): ‐ standard precautions: · hand hygiene · use of PPE · sterilization and medical device decontamination · safe handling of linen and laundry · health care waste management · patient placement · respiratory hygiene and cough etiquette · environmental cleaning · injection safety · HCW protection, safety and post-exposure prophylaxis. ‐ transmission-based precautions; ‐ aseptic technique and device management for clinical procedures; ‐ specific guidelines to prevent the most prevalent HAIs (for example, catheter-associated urinary tract infection, surgical site infection, central line-associated bloodstream infection, ventilator-associated pneumonia), depending on the context and complexity of care. • Early engagement and participation of stakeholders in the development and production of guidelines is vital to ensure consensus and better buy-in. PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS 31 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS CORE COMPONENT 3: IPC EDUCATION AND TRAINING National training policy and curriculum • National policy that all HCWs are trained in IPC (in-service training). • An approved IPC national curriculum aligned with national guidelines and endorsed by the appropriate body. • National system and schedule of monitoring and evaluation to check on the effectiveness of IPC training and education (at least annually). PRIMARY CARE IPC training for all frontline clinical staff and cleaners upon hire • All front-line clinical staff and cleaners must receive education and training on the facility IPC guidelines/SOPs upon employment. • All IPC link persons in primary care facilities and IPC officers at the district level (or other administrative level) need to receive specific IPC training. SECONDARY CARE IPC training for all front-line clinical staff and cleaners upon hire: • All front-line clinical staff and cleaners must receive education and training on their IPC guidelines/SOPs upon employment. • All IPC staff need to receive specific IPC training. TERTIARY CARE IPC training for all front-line clinical staff and cleaners upon employment and annually • All front-line clinical staff and cleaners must receive education and training on the facility IPC guidelines/SOPs upon employment and annually. • All IPC staff need to receive specific IPC training either on-line or participate in courses. WHAT (minimum requirements) NATIONAL LEVEL FACILITY LEVEL • IPC focal point (and IPC team or committee if they exist) at the ministry of health or other national responsible body as IPC education and training are key activities in their mandate. • Senior leads in key positions at the ministry level, including ministries of health and education. • Local academic institutions, including universities and others with a mandate on health workforce education, have a key role in curricula development and endorsement, and in training delivery. • It is important to include all other relevant programmes and national actors and identify key joint areas of work across education and training efforts. • In a country where the IPC focal point/team is newly established and has limited experience/expertise, consider external IPC technical support as needed for initial IPC curriculum development and implementation. PRIMARY CARE • Trained IPC officer at the next administrative level (for example, district) is responsible for training IPC link persons, front-line HCWs and cleaners in primary care facilities, according to a plan and strategy developed at the national level. • IPC officers at the next administrative level (for example, district) should be trained by the national or sub-national level. • IPC expertise is required to lead IPC training. • If the expertise at the next administrative level is limited, external support should be sought. • IPC link persons should provide on-the-job supervision/ mentorship to HCWs and cleaners in their facility. SECONDARY AND TERTIARY CARE • The IPC focal point (or IPC team if it exists) is responsible for training front-line HCWs and cleaners. • IPC expertise is required to lead IPC training. • If the expertise of the IPC focal point is limited, external support should be sought, for example, at the regional or national level. • In addition, non-IPC personnel with adequate skills (for example, link nurses/practitioners or champions and opinion leaders) could play a role of mentorship to refresh IPC principles and champion IPC practices at the ward level. WHO (is responsible for action) NATIONAL LEVEL FACILITY LEVEL 32 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • IPCAT2 – 3.1.1: the national IPC programme provides guidance and recommendations for in-service training at the facility level (for example, frequency, expertise required, requirements for new employee orientation, monitoring and evaluation approaches). • IPCAT2 – 3.1.2: the national IPC programme provides content and support for IPC training of all HCWs at the facility level. • IPCAT2 –3.2.5: IPC training is integrated into continuing medical, nursing and allied health professional education and training. • IPCAT2 – 3.3.1: a national system and schedule of monitoring and evaluation is in place to check on the effectiveness of training and education, for example, at least annually. Possible additional indicators • National policy on HCW training developed. • National IPC curriculum for HCWs developed, approved and endorsed by an appropriate professional society/body. PRIMARY CARE • All new front-line HCWs receive orientation education and training on IPC guidelines/SOPs. • All new cleaning staff receive orientation education and training on IPC guidelines/SOPs. • Specific IPC training/education is offered for IPC link professionals in primary care facilities. • Specific IPC training/education is offered for IPC staff at the district level. SECONDARY CARE • IPCAF – 3.3: all new front-line HCWs receive orientation education and training on IPC guidelines/SOPs. • IPCAF – 3.4: all new cleaning staff receive orientation education and training on IPC guidelines/SOPs. • IPCAF – 3.10: specific IPC training/education is offered for IPC professionals. TERTIARY CARE • IPCAF – 3.3: all new front-line HCWs receive orientation and at least annual education and training on IPC guidelines/SOPs. • IPCAF – 3.4: all new cleaning staff receive orientation and at least annual education and training on IPC guidelines/SOPs. • IPCAF – 3.10: specific IPC training/education is offered for IPC professionals. NATIONAL LEVEL INDICATORS (YES/NO) FACILITY LEVEL INDICATORS (YES/NO) HOW (to measure progress) NATIONAL LEVEL SOURCES AND RESOURCES FACILITY LEVEL SOURCES AND RESOURCES Sources • IPCAT2 results (where available; use the autogenerated results and graphics available in the Excel file of IPCAT2); https://www.who. int/infection-prevention/tools/core-components/en/. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core-components/en/. • WHO. Improving infection prevention and control at the health facility: Interim practical manual supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. Source • IPCAF results report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/ core-components/IPCAF-template.pdf?ua=1. Tools and resources • WHO Guidelines on core components of IPC programmes at the national and acute health care facility level (2016) for more information; https://www.who.int/infection-prevention/ publications/core-components/en/. • WASH FIT; https://apps.who.int/iris/bitstream/hand le/10665/254910/9789241511698-eng.pdf?sequence=1. • WHO. 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. 2018; https://www.who.int/infection- prevention/tools/core-components/facility-manual.pdf. • When coupled with national IPC guidelines, training contributes to a reduction in HAI and AMR and a more skilled health workforce. • Supporting and facilitating training at all levels should be considered an important indicator for assessing the impact of IPC programmes. PRIMARY CARE • IPC education and training are critical to developing a competent and skilled workforce. At a minimum, an emphasis on a basic level of IPC and triage in primary care to avoid infection and AMR spread through the health system, including health care-associated outbreaks. WHY (rationale and additional details on the minimum requirements) NATIONAL LEVEL FACILITY LEVEL 33 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • The IPC focal point/team should be specifically trained on the use of multimodal strategies for implementing IPC interventions. • Training and curricula content should be based on the national guidelines and SOPs and then prioritized locally, based on the most frequent practices and/or types of HAI. • Basic concepts of multimodal strategies implementation should be included in the training of IPC link professionals and IPC staff. • Ensuring an orientation upon employment will provide a baseline knowledge to all front-line staff and cleaners, while recognizing that ongoing educational opportunities are the gold standard. • Patient and visitor education remains an important consideration. In particular, whenever family members assume care activities, they should receive tailored IPC training in order to protect themselves and their loved ones and thus minimize any possibility of cross- transmission. Patient and family education at the facility level can also stimulate the use of appropriate hygiene measures in the community, such as handwashing with soap. SECONDARY AND TERTIARY CARE • IPC education that involves front-line HCWs in a practical, hands-on approach and incorporates individual experiences is associated with decreased HAI and increased hand hygiene compliance. • Three categories of human resources were identified as targets for IPC training and requiring different strategies and training content: IPC specialists; all HCWs involved in service delivery and patient care; and other personnel that support health service delivery (administrative and managerial staff, auxiliary service staff, cleaners, etc.). • The IPC focal person/team should be specifically trained on the use of multimodal strategies for implementing IPC interventions. • Patient and family education remains an important consideration (see above). • In particular for tertiary care facilities, providing training refreshers annually is a minimum requirement. • The national IPC programme should: ‐ develop IPC pre- and postgraduate and in-service curricula in collaboration with local academic institutions for: · IPC specialists · all HCWs involved in service delivery and patient care · other personnel (administrative and managerial staff, auxiliary service staff, cleaners); ‐ develop some standardized training tools to support curricula implementation, aligned with national technical guidelines and international IPC standards. • In addition to the curricula and tool development, appropriate steps should be undertaken for the approval, adoption and roll-out of the curricula by all health faculties (for example, medicine, nursing, midwifery, dentistry, laboratory, etc.). • Clear career pathways for IPC professionals should be established at the national level. • Consideration should be given to the teaching methods and modalities and grounded in adult education principles. The following training methods could be included: problem-based learning; hands-on workshops; focus groups; peer-to-peer training; classroom-based simulation; and bedside training. PRIMARY CARE Not applicable. SECONDARY AND TERTIARY CARE • Mandatory IPC training should be ensured for all HCWs, including those providing direct patient care (for example, doctors, nurses, nurse aides, midwives, attendants, personal support workers, etc.) and administrative and managerial staff, auxiliary service staff, and cleaners, based on their functions and facility-adapted SOPs. This includes: ‐ new employee orientation ‐ continuous educational opportunities for existing staff (at least annually). • In-service training should be practical and complementary to WASH and other training areas (for example, quality improvement). • IPC education and training should be a part of an overall health facility education strategy, including new employee orientation and the provision of continuous educational opportunities for existing staff, regardless of level and position (for example, including also senior administrative and housekeeping staff). • IPC staff should be trained on specific IPC functions specific to the tertiary care level and in line with facility-adapted IPC SOPs. Periodic evaluations of both the effectiveness of training programmes and assessment of staff knowledge should be undertaken on a routine basis. Full core component requirements NATIONAL LEVEL FACILITY LEVEL 34 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS CORE COMPONENT 4: HAI SURVEILLANCE IPC surveillance and monitoring technical group • Establishment by the national IPC focal point of a technical group for HAI surveillance and IPC monitoring that: ‐ is multidisciplinary ‐ develops a national strategic plan for HAI surveillance (with a focus on priority infections based on the local context) and IPC monitoring. PRIMARY CARE • HAI surveillance is not required as a minimum requirement at the primary facility level, but should follow national or sub- national plans, if available (for example, detection and reporting of outbreaks affecting the community is usually included in the national plans). SECONDARY CARE • HAI surveillance should follow national or sub-national plans. TERTIARY CARE • Active HAI surveillance should be conducted and include information on AMR. • Enabling structures and supporting resources need to be in place (for example, dependable laboratories, medical records, trained staff), directed by an appropriate method of surveillance. • The method of surveillance should be directed by the priorities/ plans of the facility and/or country (for example, point prevalence studies to gather a quick snapshot of the situation, or longitudinal prospective surveillance of surgical site infection if this was identified as a problem). • Timely and regular feedback needs to be provided to key stakeholders in order to lead to appropriate action, in particular to the hospital administration. WHAT (minimum requirements) NATIONAL LEVEL FACILITY LEVEL • The national IPC lead/focal point (and IPC technical team or committee, if existing) at the ministry of health or national body responsible for IPC should take action to convene the technical group for HAI surveillance and IPC monitoring. • Ideally, the technical group should include microbiologists, clinicians, laboratory technicians, epidemiologists, professionals working in other surveillance systems, statisticians, data managers and information technology experts, and monitoring and evaluation experts. • Linkage to other relevant surveillance programmes should be established, in particular alignment with surveillance of AMR. PRIMARY AND SECONDARY CARE • If HAI surveillance is conducted, a trained IPC link person/focal point, according to national or sub-national plans. TERTIARY CARE • The IPC focal point (or IPC team/committee if existing) is responsible for putting together a team for HAI/AMR surveillance, and then planning and conducting surveillance, and analysing, interpreting and disseminating the collected data. • The team should be multidisciplinary, ideally including epidemiologists, statisticians, infection control, data managers and information technology experts with the appropriate capacity. At least some of this expertise should be available. • The IPC focal point should be trained in basic epidemiology and surveillance methods. • Linkage to other relevant surveillance programmes should be established, in particular alignment with surveillance of AMR. WHO (is responsible for action) NATIONAL LEVEL FACILITY LEVEL 35 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • A multidisciplinary technical group for HAI surveillance is established at the national level. • A national strategic plan for HAI surveillance (with a focus on priority infections based on the local context) is in place. • IPCAT2 – 4.1.3: the national IPC programme (or collaborating partner) leads are designated to coordinate the national HAI surveillance programme and network. PRIMARY CARE • Note: HAI surveillance is not required, but should follow national or sub-national plans, if available. • If conducted, HAI surveillance is undertaken in accordance with national plans (yes/no/not applicable). SECONDARY CARE • HAI surveillance is undertaken in accordance with national plans. TERTIARY CARE • IPCAF – 4.1: active surveillance is a defined component of the IPC programme • IPCAF – 4.2: do you have personnel responsible for surveillance activities? • IPCAF – 4.3: staff responsible for surveillance activities have been trained in basic epidemiology, surveillance and IPC (that is, capacity to oversee surveillance methods, data management and interpretation). • IPCAF – 4.5: a prioritization exercise is used to determine the method of surveillance according to the local context (that is, identifying infections that are major causes of morbidity and mortality in the facility). • IPCAF – 4.8: reliable surveillance case definitions (defined as numerator and denominator according to international definitions, for example, CDC National Healthcare Safety Network/European Centre for Disease Prevention and Control) are used or adapted through an evidence-based adaptation process and expert consultation. • IPCAF – 4.14: timely and regular feedback (for example, quarterly/half-yearly/annually) is provided to key stakeholders in order to lead to appropriate action, in particular to the hospital administration. • Enabling structures and supporting resources (for example, EQAS microbiological reference laboratory, medical records with sufficient clinical information to determine HAI case definitions, dedicated staff time) are in place to support HAI surveillance. • Active surveillance is conducted for colonization or infections caused by multidrug-resistant pathogens according to the local epidemiological data. NATIONAL LEVEL INDICATORS (YES/NO) FACILITY LEVEL INDICATORS (YES/NO) HOW (to measure progress) NATIONAL LEVEL SOURCES AND RESOURCES FACILITY LEVEL SOURCES AND RESOURCES Source • IPCAT2 results (where available; use the autogenerated results and graphics available in the Excel file of IPCAT2); https://www.who. int/infection-prevention/tools/core-components/en/. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level for more information. 2016; https://www.who.int/infection-prevention/publications/ core-components/en/. • WHO. Improving infection prevention and control at the health facility: Interim practical manual supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. Source • IPCAF results report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/ core-components/IPCAF-template.pdf?ua=1. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level for more information. 2016; https://www.who.int/infection-prevention/publications/core- components/en/. • WHO. 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. 2018; https://www.who.int/infection- prevention/tools/core-components/facility-manual.pdf. 36 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • HAI surveillance is the first step (minimum requirement) to assess the magnitude of the burden of disease by the systematic collection of data in targeted wards/unit. As a first step, when a HAI surveillance system is not in place, a multidisciplinary technical group should develop a plan for surveillance. • This group will have the task of identifying: ‐ priorities and methods for surveillance; ‐ a comprehensive surveillance plan for HAIs and IPC monitoring; ‐ a centralized, national reporting mechanism; ‐ a minimum set of data (outcomes, indicators or other information) for surveillance, including providing a baseline assessment; ‐ roles and responsibilities for the implementation of HAI surveillance at facility level. • Prioritization should not only be based on vertical systems (for example, human immunodeficiency virus, tuberculosis, malaria, influenza, Salmonella spp., etc.), but should consider essential targets of HAI prevention, for example, reduction of the number of surgical site or bloodstream infections. • The national level could also consider the development of a policy/ regulations to mandate HAI surveillance in facilities, according to the minimum requirements specified below. • Surveillance of HAIs should be aligned with the priorities of the AMR national action plan. PRIMARY CARE • The detection and reporting of outbreaks affecting the community to national authorities should be included in national or sub-national plans. SECONDARY CARE • Given the low level of specialized care, HAI surveillance in secondary care was not strictly considered by expert consensus as a minimum requirement; monitoring of IPC indicators was considered more important. • Some secondary facilities may decide to conduct surveillance of relevant HAIs, such as surgical site infections, depending on the type of care delivered and the facility’s capacity and prioritization of the core components. • Reporting outbreaks in the health care facility or affecting the community to national authorities should be included in national or sub-national plans. TERTIARY CARE • HAIs and AMR are a burden in intensive care units and other highly specialized units/wards where invasive interventions carry more risks for HAIs and patients have a higher risk of death due to these infections. • For this reason, targeted HAI surveillance is necessary at tertiary health care level. • To ensure implementation of the national surveillance plan, a HAI surveillance team should be in place in every tertiary hospital. • Prioritization is also the responsibility of the IPC team, and a prioritization exercise should be conducted in line with national recommendations. • The team should develop a surveillance strategic plan according to present capacities including: ‐ purpose; ‐ target sample and infection outcomes; ‐ identification of a national reference laboratory and quality assurance capacities; ‐ development/careful adaptation of case definitions. • Timely feedback to hospital leadership and front-line HCWs is considered as one the most critical parts of surveillance and monitoring. Facilities should consider defining the timeliness of feedback (for example, monthly or bi-monthly). • The IPC focal team should tailor its surveillance methodology to available resources and priorities in line with national recommendations. WHY (rationale and additional details on the minimum requirements) NATIONAL LEVEL FACILITY LEVEL • A national HAI surveillance programme and networks that include mechanisms for the timely feedback of monitoring and evaluation data feedback should be established, with the potential to be used for benchmarking purposes. • Surveillance programmes should be supported by: ‐ engaged governments and other respective authorities; ‐ allocated human and financial resources; ‐ microbiology and laboratory capacity (at least one national PRIMARY CARE Not applicable. SECONDARY AND TERTIARY CARE • Facility-based HAI surveillance should be performed to guide IPC interventions and detect outbreaks, including AMR. • Hospital-based infection surveillance systems should be linked to integrated public health infection surveillance systems. Full core component requirements NATIONAL LEVEL FACILITY LEVEL 37 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS reference laboratory), with standardized definitions and laboratory methods; ‐ an informatics system for data collection and analysis. • Surveillance programmes should meet the following criteria: ‐ demonstrate clear objectives, a standardized set of case definitions, methods for detecting HAIs (numerators) and the exposed population (denominators), including a process for the analysis of data and reports and a method for evaluating the quality of the data; ‐ establish clear regular reporting lines of HAI surveillance data from the local facility to the national level; ‐ adapt international guidelines on HAI definitions at country level before implementing them; ‐ include a national training programme for performing surveillance to ensure the appropriate and consistent application of national surveillance guidelines and protocols; ‐ provide data to guide the development and implementation of effective control interventions. • The surveillance programme should provide data on infections: ‐ that may become epidemic in the health care facility (early detection of outbreaks); ‐ commonly observed in vulnerable populations (for example, neonates, burn patients, patients in intensive care units and immunocompromised hosts); ‐ that may cause severe outcomes, such as high case fatality and patient morbidity and suffering; ‐ caused by resistant microorganisms with an emphasis on multidrug- resistant pathogens; ‐ associated with selected invasive devices or specific procedures, such as the use of intravascular devices, indwelling urinary catheters and surgery; ‐ that may affect HCWs (for example, hepatitis B and C and human immunodeficiency virus). • Feedback of results to HCWs and stakeholders through national networks should be timely. • Surveillance should be based on national recommendations and standard definitions and customized to the facility, according to available resources with clear objectives and strategies. • Methods for detecting infections should be active. Different surveillance strategies could include the use of prevalence or incidence rates of HAI and AMR pathogens. A system for surveillance data quality assessment should be in place. • Surveillance should be based on clinical and/or microbiology data and supported by laboratory capacity with EQAS • The IPC committee and IPC team are responsible for planning and conducting HAI surveillance and analysing, interpreting and disseminating the data collected. For this reason, surveillance activities should be conducted by trained staff (ideally full-time) able to plan, collect and manage the data and convene meetings with the team, the committee and other key players. • Surveillance should provide information for: ‐ describing the status of infections associated with health care (that is, incidence and/or prevalence, type, aetiology and, ideally, data on severity and the attributable burden of disease); ‐ identification of the most relevant AMR susceptibility patterns; ‐ identification of high-risk populations, procedures and exposures; ‐ early detection of clusters and outbreaks (that is, early warning system); ‐ evaluation of the impact of interventions. 38 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS CORE COMPONENT 5: MULTIMODAL STRATEGIES Multimodal improvement strategies for IPC interventions • Use of multimodal strategies to implement IPC interventions according to national guidelines/SOPs, under the coordination of the national IPC focal point (or team, if existing). PRIMARY CARE Multimodal strategies for priority IPC interventions • Use of 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. SECONDARY CARE Multimodal strategies for priority IPC interventions • Use of multimodal strategies – at the very least to improve each item of standard and transmission-based precautions and triage. TERTIARY CARE Multimodal strategies for all IPC interventions • Use of multimodal strategies to implement interventions to improve each item of standard and transmission-based precautions, triage, and those targeted at the reduction of specific infections (for example, surgical site or catheter- associated infections) in high-risk areas/patient groups, according to local priorities. WHAT (minimum requirements) NATIONAL LEVEL FACILITY LEVEL • The IPC focal point (and IPC technical team or committee, if existing) at the ministry of health or national body responsible for IPC, as multimodal interventions are key activities in their mandate. • Senior leads in key positions at the ministry level. Convincing high level senior managers and key professionals of the value of employing multimodal strategies at the national and facility level is important and dependent on effective communication and advocacy. • Key members and teams of all other relevant programmes and national actors who will be responsible for the implementation of the IPC programme, including possible joint areas of work. • National and local experts on implementation science, as well as those from the fields of behavioural science and communication. PRIMARY, SECONDARY AND TERTIARY CARE • Trained IPC link person and IPC focal point with the support of an IPC-trained health care officer at the next administrative level are responsible for using a multimodal approach for the implementation of IPC interventions/SOPs. • Successful multimodal strategies include the involvement of champions or role models. • Collaboration with colleagues in quality improvement and patient safety to develop and promote multimodal strategies should be addressed. WHO (is responsible for action) NATIONAL LEVEL FACILITY LEVEL • IPCAT2 – 5.1.1: the appointed IPC focal point is trained and competent in implementation science and multimodal behaviour change strategies. PRIMARY CARE • IPCAF – 5.1: multimodal strategies are used to implement priority IPC interventions (at the very least to improve hand NATIONAL LEVEL INDICATORS (YES/NO) FACILITY LEVEL INDICATORS (YES/NO) HOW (to measure progress) 39 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • IPCAT2 – 5.1.2: promotion of multimodal strategies through the inclusion of the approach in the development of IPC guidelines, education and training. hygiene, safe injection practices, decontamination of medical instruments and devices and environmental cleaning). SECONDARY CARE • IPCAF – 5.1: multimodal strategies are used to implement priority IPC interventions (at the very least to implement interventions to improve standard and transmission-based precautions and triage). TERTIARY CARE • IPCAF – 5.1: multimodal strategies are used to implement all IPC interventions and to improve standard and transmission- based precautions, triage, and those targeted at the reduction of specific infections in high-risk areas/vulnerable patient groups, in line with local health priorities. NATIONAL LEVEL SOURCES AND RESOURCES FACILITY LEVEL SOURCES AND RESOURCES Source • IPCAT2 results (where available; use the autogenerated results and graphics available in the Excel file of IPCAT2); https://www.who. int/infection-prevention/tools/core-components/en/. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core-components/en/. • WHO. Improving infection prevention and control at the health facility: Interim practical manual supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. Source • IPCAF results report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/ core-components/IPCAF-template.pdf?ua=1. Tools and resources • WHO Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www.who.int/infection-prevention/publications/core- components/en/. • WHO. 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. 2018; https://www.who.int/infection- prevention/tools/core-components/facility-manual.pdf. • WHO multimodal improvement strategy leaflet; https://www. who.int/infection-prevention/publications/ipc-cc-mis.pdf?ua=1. • According to the available scientific evidence, multimodal strategies are the most effective approach to implement hand hygiene programmes and other IPC interventions (for example, to reduce central line-associated bloodstream infections and surgical site infections) in order to achieve the key elements for success that support IPC progress and, ultimately, a measurable impact that benefits patients and HCWs, such as system change, creation of an enhanced patient safety climate and HCW behavioural change. • The IPC focal point/team should be specifically trained on the use of multimodal strategies for the implementation of IPC interventions. • Multimodal strategies for implementing IPC interventions should be explicitly indicated in the national IPC action plans, including all 5 key elements identified by WHO as needed for each IPC intervention selected and according to the local context. • The national IPC focal person or team should develop a national multimodal strategy framework to facilitate implementation of the prioritized IPC interventions at facility level in the context of quality improvement. PRIMARY CARE • Multimodal strategies should be used for any IPC intervention at all levels of the health care system because their effectiveness is supported by strong evidence. • However, it is recognized that multimodal strategies are complex approaches to be put in place. Thus, the interventions included in the minimum requirements are the priority ones among those that should be included in SOPs and training for the primary health care level (see minimum requirements for core components 2 and 3). SECONDARY AND TERTIARY CARE • Multimodal strategies should be used for any IPC intervention at all levels of the health care system in order to provide safe and effective health care delivery. • Complexity of care and human resources (including in the IPC team) vary across secondary and tertiary care facilities and the scope of the minimum requirements may vary according to the local context. • Specialized/complex services are provided in tertiary care facilities. • In tertiary care facilities, there is an increased potential for transmission of infection due to prolonged hospital stay, more WHY (rationale and additional details on the minimum requirements) NATIONAL LEVEL FACILITY LEVEL 40 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS complex procedures being performed and the admission of high-risk vulnerable populations. • Compelling evidence is available on the effectiveness of multimodal strategies to reduce infections in high-risk areas/patient groups. • It is the mandate of the national IPC programme to ensure that all IPC interventions are implemented using multimodal strategies. • The national IPC programme should facilitate the use of multimodal strategies by ensuring that the following elements are in place to support their use: ‐ expertise and necessary resources including policies, regulations and tools; ‐ overall organizational culture change to achieve an enhanced patient safety climate; ‐ coordination and teamwork; ‐ linkages with quality improvement initiatives and health facility accreditation; ‐ local adaptation. PRIMARY CARE Not applicable. SECONDARY AND TERTIARY CARE • Multimodal strategies must be used for implementing any IPC intervention at all levels of the health care system. • Overall organizational culture change is a key element to prioritize within multimodal strategies as effective IPC can be a reflector of quality care, a positive organizational culture, and an enhanced patient safety climate. • Successful multimodal strategies include the involvement of champions or role models. • Implementation of multimodal strategies within health care institutions needs to be linked to national quality aims and initiatives, including health care quality improvement initiatives or health facility accreditation bodies. Full core component requirements NATIONAL LEVEL FACILITY LEVEL 41 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS CORE COMPONENT 6: MONITORING, AUDIT AND FEEDBACK IPC surveillance and monitoring technical group • Establishment by the national IPC focal point of a technical group for HAI surveillance and IPC monitoring that: ‐ is multidisciplinary; ‐ develops a national strategic plan for HAI surveillance and IPC monitoring; ‐ develops an integrated system for the collection and analysis of data (for example, protocols, tools); ‐ provides training at the facility level to collect and analyse these data; ‐ develops recommendations for minimum process indicators (for example, hand hygiene). PRIMARY CARE • Monitoring of IPC structural and process indicators should be put in place at primary care level, based on IPC priorities identified in the other components. This requires decisions at the national level and implementation support at the sub-national level. SECONDARY AND TERTIARY CARE • A person responsible for the conduct of the periodic or continuous monitoring of selected indicators for process and structure, informed by the priorities of the facility or the country. • Hand hygiene is an essential process indicator to be monitored. • Timely and regular feedback needs to be provided to key stakeholders in order to lead to appropriate action, particularly to the hospital administration. WHAT (minimum requirements) NATIONAL LEVEL FACILITY LEVEL • The IPC lead/focal point (and IPC technical team or committee at the ministry of health or national body responsible for IPC) should take action to convene the technical group for HAI surveillance and IPC monitoring (same group as for core component 4). • Ideally, the technical group should include microbiologists, laboratory technicians, epidemiologists, professionals working in other surveillance systems, statisticians, data managers and information technology experts and monitoring and evaluation experts. • Liaison should be ensured with: ‐ senior leads in key positions at the ministry level; ‐ team members of all other relevant programmes and national actors who are involved in the implementation and monitoring of the IPC programme, including national quality and patient safety leaders. PRIMARY, SECONDARY AND TERTIARY CARE • Trained IPC link person/focal point/ IPC officer (or IPC committee/team if existing) are responsible for audit and feedback and should be trained in auditing technique plans. WHO (is responsible for action) NATIONAL LEVEL FACILITY LEVEL • A multidisciplinary technical group for IPC monitoring is established at the national level. • IPCAT2 – 6.2: A well-defined plan focusing on IPC outcomes, processes and strategies, with clear goals, targets and operational plans is in place. • IPC indicators integrated with national monitoring systems, for example, health management information systems. PRIMARY CARE • IPCAF – 6.2: a well-defined monitoring plan with clear goals/ objectives, targets and activities focused on IPC structural and process indicators (including tools to collect data in a systematic way) is in place based on IPC priorities identified in the other components and, importantly, informed by decisions at the national level and implementation support at the sub-national level. NATIONAL LEVEL INDICATORS (YES/NO) FACILITY LEVEL INDICATORS (YES/NO) HOW (to measure progress) 42 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • A mechanism to train national and local auditors is in place. • Hand hygiene compliance monitoring and feedback is identified as a minimum indicator, at the very least for reference hospitals. SECONDARY AND TERTIARY CARE • IPCAF – 6.1: A trained person responsible for conducting periodic or continuous monitoring/audit of selected indicators for process (for example, hand hygiene) and structure is in place and informed by the priorities of the facility or country. • Monitoring of hand hygiene compliance is undertaken using the WHO hand hygiene observation tool or equivalent. • IPCAF – 6.4: monitoring of hand hygiene strategies is undertaken using the WHO Hand Hygiene Self-Assessment Framework Survey. • IPCAF – 6.5: timely and regular feedback of auditing reports (for example, feedback on hand hygiene compliance data or other processes) on the state of IPC activities/performance is provided to key stakeholders, in order to lead to appropriate action, particularly to the hospital management and senior administration. • Setting up national monitoring of indicators of IPC practices, processes and infrastructures is usually more feasible than establishing HAI surveillance as a first step for gathering data to inform IPC action. • The technical group indicated as the minimum requirement for core component 4 should be the same group responsible for core component 6. • Monitoring IPC practices and providing feedback to concerned stakeholders are critical to achieve behaviour change or other process modifications that improve the quality of care and reduce HAIs and AMR. • Monitoring and feedback are also aimed at engaging stakeholders, creating partnerships and developing working groups and networks. • Consideration should be given to policies that create incentives (positive or negative) tied to indicators in order to generate buy-in from hospital administrators. • Data from existing data sources (for example, Joint External PRIMARY CARE • IPC monitoring is critical to identify improvement action needed and should be in line with national recommendations and priorities. • Monitoring of indicators of IPC practices, processes and infrastructures should be feasible at the primary care level, whereas HAI surveillance is not applicable. • Hand hygiene infrastructure (for example, hand hygiene stations at the point of care or ABHR consumption) could be considered as a first step to monitoring. • Hand hygiene compliance monitoring according to the WHO observation method is considered the gold standard. • In many primary care facilities, one person responsible for the monitoring of indicators should be identified and this activity requires support at the sub-national level (for example, district). • The selection of indicators to be monitored should be driven at national level, with input at regional/sub-national level. • Any decision should be in line with decisions on other core components. WHY (rationale and additional details on the minimum requirements) NATIONAL LEVEL FACILITY LEVEL NATIONAL LEVEL SOURCES AND RESOURCES FACILITY LEVEL SOURCES AND RESOURCES Source • IPCAT2 results (where available; use the autogenerated results and graphics available in the Excel file of IPCAT2); https://www.who. int/infection-prevention/tools/core-components/en/. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core-components/en/. • WHO. Improving infection prevention and control at the health facility: Interim practical manual supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. • WHO hand hygiene monitoring and feedback tools (updated in 2009); https://www.who.int/gpsc/5may/tools/evaluation_ feedback/en/. Source • IPCAF results report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/ core-components/IPCAF-template.pdf?ua=1. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core-components/ en/. • WHO. 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. 2018; https://www.who.int/infection- prevention/tools/core-components/facility-manual.pdf. • WHO hand hygiene monitoring and feedback tools (updated in 2009); https://www.who.int/gpsc/5may/tools/evaluation_ feedback/en/. • WHO Hand Hygiene Self-Assessment Framework; https://www. who.int/gpsc/5may/hhsa_framework/en/. 43 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS Evaluation or Service Availability and Readiness Assessment) should be considered, particularly at the beginning when identifying priorities. • If possible, integration with existing national health information systems and routine facility monitoring would be critical for streamlining data collection and making linkage/correlations. • Hand hygiene (including compliance monitoring and/or infrastructure indicators) is considered a crucial indicator according to WHO recommendations. This activity should be decided upon at national level according to the highest standards to avoid any misrepresentation of compliance levels. • Surveillance of other structure and process indicators should be considered, prioritizing those that drive action. • Other indicators to be monitored should also provide information on IPC enablers (for example, related to WASH, availability of structures) and be considered as basic essentials for IPC. • Data gathered through IPC monitoring should guide priority setting in the national IPC strategic plan. • Based on all these considerations, a plan for regular monitoring at the facility level should be developed at the national level, including plans for feedback and for supervision to assist in the development and implementation of improvement plans. SECONDARY AND TERTIARY CARE • IPC monitoring is critical to identify improvement action and should be combined with HAI surveillance and in line with national recommendations and priorities. • Principles and minimum requirements for monitoring and auditing should not change between secondary and tertiary care; more indicators might be monitored in tertiary care. • It is important to monitor both process indicators (prone to limitations related to observation bias) and infrastructure indicators. • Hand hygiene (including compliance monitoring and/or infrastructure indicators) is considered a crucial indicator according to WHO recommendations. This activity should be decided upon at national level and according to the highest standards to avoid any misrepresentation of compliance levels. • Timely feedback to hospital leadership and front-line HCWs is one of the most effective parts of surveillance and monitoring. Facilities should consider defining the timeliness of feedback. • Establishment of a national IPC monitoring and evaluation programme with goals, objectives and defined performance indicators for: ‐ IPC standards ‐ IPC activities ‐ hand hygiene compliance monitoring and feedback (strongly recommended as a national performance indicator). • National level monitoring and evaluation should have mechanisms in place that: ‐ provide regular reports on the state of national goals (outcomes and processes) and strategies; ‐ regularly monitor and evaluate the WASH services, IPC activities and structure of the health care facilities through audits or other officially recognized means; ‐ promote the evaluation of the performance of local IPC programmes in a non-punitive institutional culture. PRIMARY CARE Not applicable. SECONDARY AND TERTIARY CARE • Regular monitoring/auditing of practices and other indicators should be according to IPC standards and include timely feedback to: ‐ all audited persons and relevant staff (individual change); ‐ hospital management and senior administration (organizational change); ‐ IPC team and committee (or quality of care committees). • Monitoring extends to the evaluation of the facility IPC programme to: ‐ assess if objectives are met; ‐ assess if goals/objectives are accomplished; ‐ assess whether the IPC activities are being performed according to requirements; ‐ identify aspects that may need improvement. • Important information that may be used for this purpose includes: ‐ the results of the assessment of compliance with IPC practices; ‐ other process indicators (for example, training activities); ‐ dedicated time by the IPC team; ‐ resource allocation. • Monitoring should include regular assessments of staff knowledge about IPC. Full core component requirements NATIONAL LEVEL FACILITY LEVEL 44 CORE COMPONENT 7: WORKLOAD, STAFFING AND BED OCCUPANCY (FACILITY LEVEL ONLY*) WHAT (minimum requirements) WHO (is responsible for action) HOW (to measure progress) PRIMARY CARE • To reduce overcrowding: a system for patient flow, a triage system (including referral system) and a system for the management of consultations according to existing guidelines should be established. • To optimize staffing levels: assessment of appropriate staffing levels, depending on the categories seen when using WHO/national tools (national norms on patient/staff ratio), and development of an appropriate plan. SECONDARY AND TERTIARY CARE • To standardize bed occupancy: ‐ establish a system to manage the use of space in the facility and establish the standard bed capacity for the facility; ‐ hospital administration enforcement of the system developed; ‐ no more than one patient per bed; ‐ spacing of at least 1 metre between the edges of beds; ‐ overall occupancy should not exceed the designed total bed capacity of the facility. • To reduce overcrowding and optimize staffing levels: same minimum requirements as for primary health care. PRIMARY, SECONDARY AND TERTIARY CARE • Decisions regarding workload, staffing and bed occupancy are not directly within the responsibility of the IPC link person, focal point or programme, but rather lie with senior managers and directors. Nevertheless, the IPC link nurse, officer or programme should understand the evidence supporting this core component in order to be able to help influence decision-makers at the facility and ministry level, with the assistance of an IPC-trained health care officer at the next administrative level. Therefore, the development of IPC skills in negotiation and advocacy are important considerations. • The successful implementation of this core component should be supported by a national plan for human resource development. PRIMARY CARE • Systems are in place to reduce overcrowding (for example, a system for patient flow, a triage system including a referral system, and a system for the management of consultations) according to existing guidelines/SOPs. • IPCAF – 7.3: appropriate staffing levels are assessed according to patient workload using national/international standards or staffing needs assessment tools and action plans developed based on results. SECONDARY AND TERTIARY CARE • IPCAF – 7.3: appropriate staffing levels are assessed according to patient workload using national/international standards or staffing needs assessment tools and action plans developed based on results. • IPCAF – 7.4: the design of wards is in accordance with international standards regarding bed capacity. • IPCAF – 7.5: bed occupancy in the facility is kept to one patient per bed. • IPCAF – 7.7: adequate spacing of more than 1 metre between patient beds is ensured in the facility. • IPCAF – 7.8: a system is in place, including clear lines of responsibility, to assess and respond when adequate bed capacity exceeds the designed total bed capacity of the facility (for example, the hospital administration/management assume responsibility). * Facility level only. However, the national health system, IPC programme and any other relevant body should coordinate and support the implementation of this core component at the facility level. PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS INDICATORS (YES/NO) 45 SOURCES AND RESOURCES Source • IPCAF report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/core-components/IPCAF- template.pdf?ua=1. Tools and resources • WHO Guidelines on core components of IPC programmes at the national and acute health care facility level. 2016; https://www.who.int/ infection-prevention/publications/core-components/en/. • WHO. 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. 2018; https://www.who.int/infection-prevention/tools/core-components/ facility-manual.pdf. • WHO Essential environmental health standards in health care. 2008; https://www.who.int/water_sanitation_health/publications/ehs_hc/en/. • WHO. Workload indicators of staffing need (WISN). 2015; https://www.who.int/hrh/resources/wisn_user_manual/en/. WHY (rationale and additional details on the minimum requirements) Full core component requirements PRIMARY CARE • Overcrowding and lack of triage and patient flow systems are recognized as a public health issue that can lead to disease transmission. SECONDARY AND TERTIARY CARE • Bed occupancy exceeding the standard capacity of the facility is associated with an increased risk of HAI in acute care facilities, in addition to inadequate HCW staffing levels. • Intended capacity may vary from original designs and across facilities and countries. For these reasons, the original ward/unit design regarding bed capacity should be adhered to and in accordance with standards. • In exceptional circumstances where bed capacity is exceeded, hospital management should act to ensure appropriate staffing levels that meet patient demand and an adequate distance between beds. These principles apply to all units and departments with inpatient beds, including emergency departments. • The WHO Workload Indicators of Staffing Need method provides health managers with a systematic way to determine how many HCWs of a particular type are required to cope with the workload of a given health facility and decision making. • It is recognized that in special circumstances, adherence to this recommendation may need to be balanced against the immediate need to provide clinical care to as many patients as possible. PRIMARY CARE Not applicable. SECONDARY AND TERTIARY CARE Same as for minimum requirements. PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS 46 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS CORE COMPONENT 8: BUILT ENVIRONMENT, MATERIALS AND EQUIPMENT FOR IPC AT THE FACILITY LEVEL (FACILITY LEVEL ONLY*) WHAT (minimum requirements) PRIMARY CARE • Water should always be available from an improved source on the premises to perform basic IPC measures, including hand hygiene, environmental cleaning, laundry, decontamination of medical devices and health care waste management. • A minimum of two functional, improved sanitation facilities should be available on-site, one for patients and one for staff; both should be equipped with menstrual hygiene facilities. • Functional hand hygiene facilities should always be available at points of care/toilets and include soap, water and single-use towels (or if unavailable, clean reusable towels) or ABHR at points of care and soap, water and single-use towels (or if unavailable, clean reusable towels) within 5 metres of toilets. • Sufficient and appropriately labelled bins to allow for health care waste segregation should be available (less than 5 metres from point of generation); waste should be treated and disposed of safely via autoclaving, incineration, and/or buried in a lined, protected pit. • The facility layout should allow adequate natural ventilation, decontamination of reusable medical devices, triage and space for temporary cohorting/isolation/physical separation if necessary. • Sufficient and appropriate IPC supplies and equipment (for example, mops, detergent, disinfectant, PPE and sterilization) and power/energy (for example, fuel) should be available for performing all basic IPC measures according to minimum requirements/SOPs, including all standard precautions, as applicable; lighting should be available during working hours (usually, 8 am-5 pm) for providing care. SECONDARY AND TERTIARY CARE • A safe and sufficient quantity of water should be available for all required IPC measures and specific medical activities, including for drinking, and piped inside the facility at all times, at a minimum to high-risk wards (for example, maternity ward, operating room/s, intensive care unit). • A minimum of two functional, improved sanitation facilities that safely contain waste should be available for outpatient wards and one per 20 beds for inpatient wards should be available; all should be equipped with menstrual hygiene facilities. • Functional hand hygiene facilities should always be available at points of care, toilets and service areas (for example, the decontamination unit), which include ABHR and soap, water and single-use towels (or if unavailable, clean reusable towels) at points of care and service areas, and soap, water and single-use towels (or if unavailable, clean reusable towels) within 5 metres of toilets. • Sufficient and appropriately labelled bins to allow for health care waste segregation (including for needle and sharps disposal) should be available and used (less than 5 metres from point of generation) and waste should be treated and disposed of safely via autoclaving, incineration (850° to 1100°C), and/or buried in a lined, protected pit. • The facility should be designed to allow adequate ventilation (natural or mechanical, as needed) to prevent transmission of infectious pathogens. • Sufficient and appropriate supplies and equipment and reliable power/energy should be available for performing all IPC practices, including standard and transmission-based precautions, according to minimum requirements/SOPs; reliable electricity should be available to provide lighting to clinical areas for providing continuous and safe care, at a minimum to high-risk wards (for example, maternity ward, operating room/s, intensive care unit). • The facility should have a dedicated space/area for performing decontamination and reprocessing of reusable medical devices (that is, a decontamination unit) according to minimum guidelines/SOPs. • The facility should have adequate single isolation rooms or at least one room for cohorting patients with similar pathogens, if the number of isolation rooms is insufficient. WHO (is responsible for action) PRIMARY • Trained IPC link person/focal point (see minimum requirements for core component 1), as well as facility manager/in-charge and ancillary staff (for example, cleaning staff, incinerator operators). SECONDARY AND TERTIARY CARE • Trained IPC link person/focal point (see minimum requirements for core component 1) and district/local WASH environmental health officer. • Facilities manager and ward or department leads/in-charge staff. • Additionally, at the national level, the IPC lead/focal point (and IPC technical team or committee, if existing) at the ministry of health or national body responsible for IPC, as well as the national body (for example, ministry of water or ministry of the environment or ministry of rural development) and the technical team or committee responsible for WASH (if separate), should take action to convene a technical group for the implementation of IPC and WASH requirements for all health care facilities and implementation tools. • Ideally, the technical group should include clinicians, engineers, environmental health officers and procurement managers. • Financial manager at the facility and the next administrative level (for example, district), and the ministry of finances at the national level. * Facility level only. However, the national health system, IPC programme and any other relevant body should coordinate and support the implementation of this core component at the facility level. 47 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS HOW (to measure progress) PRIMARY CARE • IPCAF – 8.1: water services available at all times and of sufficient quantity for all uses (for example, hand washing, drinking, personal hygiene, medical activities, sterilization, decontamination, cleaning and laundry). • IPCAF – 8.3: functioning hand hygiene stations (that is, ABHR or soap and water and clean single-use towels) available at all points of care. • IPCAF – 8.4: there are more than or equal to four toilets or improved latrines available for outpatient settings or more than or equal to one per 20 users for inpatient settings. • Modified IPCAF – 8.5: sufficient energy/power supply available at least during working hours for all uses (for example, pumping and boiling water, sterilization and decontamination, incineration or alternative treatment technologies, electronic medical devices, general lighting of areas where health care procedures are performed to ensure safe provision of health care and lighting of toilet facilities and showers). • IPCAF – 8.6: functioning environmental ventilation (natural or mechanical) available in patient care areas. • IPCAF – 8.8: appropriate and well-maintained materials for cleaning (for example, detergent, mops, buckets, etc.) available. • IPCAF – 8.9: single patient rooms or rooms for the cohorting/physical separation of patients with similar pathogens or syndrome if the number of isolation rooms is insufficient (for example, tuberculosis, measles, cholera, Ebola, severe acute respiratory syndrome). • IPCAF – 8.10: PPE is available at all times and in sufficient quantity for all uses for all HCWs. • IPCAF – 8.11: functional waste collection containers for non-infectious (general) waste, infectious waste and sharps waste in close proximity to all waste generation points. • IPCAF – 8.15: a dedicated decontamination area and/or sterile supply department (either present on- or off-site and operated by a licensed decontamination management service) for the decontamination and sterilization of medical devices and other items/equipment. • IPCAF – 8.16: sterile and disinfected equipment ready for use and reliably available. SECONDARY AND TERTIARY CARE (in addition to primary care indicators above) (from the water and sanitation for health facility improvement tool (WASH FIT**): • Hygiene – 3.1: essential indicator 1. Functioning hand hygiene stations are available at all points of care (yes/no). Stations present, but no water and/or soap or ABHR present (yes/no). • Hygiene – 3.2: essential indicator 2. Hand hygiene promotion materials clearly visible and understandable at key places (yes/at some places, but not all/none). • Hygiene – 3.3: advanced indicator 1. Functioning hand hygiene stations are available in service areas (yes/stations present, but no water and/ or soap or ABHR present). • Hygiene – 3.4: advanced indicator 2. Functioning hand hygiene stations available in waste disposal area (yes/stations present, but no water and/or soap present). • Hygiene – 3.5: advanced indicator 3. Hand hygiene compliance activities are undertaken regularly (yes/compliance activities in facility policy, but not carried out with any regularity/no compliance activities). INDICATORS (YES/NO) SOURCES AND RESOURCES Sources • IPCAF results report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/core-components/ IPCAF-template.pdf?ua=1. • WASH FIT results report (where available). https://www.who.int/water_sanitation_health/publications/water-and-sanitation-for-health- facility-improvement-tool/en/. Tools and resources • WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene. Joint Monitoring Programme definitions of improved water/sanitation. 2019; https://www.unwater.org/publication_categories/whounicef-joint-monitoring-programme-for-water-supply-sanitation- hygiene-jmp/. • WHO. Guidelines on sanitation and health. 2018; https://www.who.int/water_sanitation_health/publications/guidelines-on-sanitation-and- health/en/. • WHO. Essential environmental health standards in health care. 2008; https://www.who.int/water_sanitation_health/publications/ehs_hc/en/. • WHO. Safe management of wastes from health care. 2014; https://www.who.int/water_sanitation_health/publications/wastemanag/en/ • WHO and Pan American Health Organization. Decontamination and reprocessing of medical devices for health-care facilities. 2016; https://www. who.int/infection-prevention/publications/decontamination/en/. • WHO. Guidelines on tuberculosis infection prevention and control. 2019 update; https://www.who.int/tb/publications/2019/guidelines- tuberculosis-infection-prevention-2019/en/. • WHO. Natural ventilation for infection control in health-care settings. 2009; https://www.who.int/water_sanitation_health/publications/natural_ ventilation/en/. • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level. 2016; https://www.who.int/ infection-prevention/publications/core-components/en/. ** NOTE: most of these indicators have three possible responses, not simply ‘yes/no’. 48 • WHO. 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. 2018; https://www.who.int/infection-prevention/tools/core-components/ facility-manual.pdf. • WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene. WASH in health care facilities: global baseline report. 2019; https://www.unwater.org/publications/wash-in-health-care-facilities-global-baseline-report-2019/. • WHO. WASH in health care facilities: practical steps to achieve universal access to quality care. Actions and solutions. 2019; https://www.who. int/water_sanitation_health/publications/wash-in-health-care-facilities/en/. WHY (rationale and additional details on the minimum requirements) PRIMARY CARE • Adequate infrastructures and availability of adequate WASH support are essential to perform any health care services and IPC activities (for example, water is absolutely critical for hand hygiene, cleaning and key services such as delivery). • Improved water sources are those which by nature of their design and construction have the potential to protect water from external contamination (for example, microorganisms, dirt). While drinking water is not required for basic IPC measures, water from improved sources may better facilitate performing IPC measures according to guidelines/SOPs, for example, water from groundwater sources that is non-turbid can generally enable the effective preparation of disinfectant solutions for environmental cleaning and decontamination of medical devices. The chlorine concentration in all disinfectant solutions should be regularly monitored and the dose adjusted as necessary to meet chlorine concertation targets. • Improved sanitation facilities are those designed to hygienically separate human excreta from human contact, which is critical for reducing the transmission risk from enteric pathogens and, in addition to menstrual hygiene facilities, help maintain a hygienic environment; separate toilets for patients and staff also helps to minimize indirect contact between patients and staff that may pose an infection risk. • When there is a risk of soiling, ABHR is not a substitute for soap and water for hand hygiene after toileting or when hands are visibly soiled (for example, while assisting childbirth). • If ABHRs are available, it is essential to have these accessible at all points of care, given the proven advantages of ABHRs over soap and water, but it is also essential that soap, water and single-use towels are available in clinical services. • Adequate ventilation throughout the facility contributes to maintaining a hygienic environment and can be minimally accomplished via the presence of functional windows (preferably equipped with insect traps) and doors, that allow at least 6-8 air changes per hour for natural ventilation (for example, by opening opposite windows). • Sufficient energy/power and a stand-by ‘back-up’ arrangement (including solar, wind, stand-by generator or others) and fuel should be available on- site for lighting clinical practices and basic IPC measures (for example, for performing decontamination of medical devices, if needed). • If the facility performs any procedures (for example, deliveries or other basic gynaecological procedures) requiring reusable medical devices (for example, vaginal specula), at a minimum it is essential to create dedicated areas that allow proper workflow from dirty to clean for performing the decontamination and reprocessing of medical devices. • A small space to assess patients regarding the disease/reason for accessing the facility (that is, triage), including any infectious disease transmission risk, and to allow them to be directed to different areas according to priority and type of disease can be accomplished with minimal resources. • Adequate space for temporary cohorting/isolation can also be accomplished with minimal resources by the creation of a physical separation or barrier between suspected/infected patients and other patients, staff and visitors, and is critical for ensuring transmission-based precautions. If resources allow, a room should be designated for this function. SECONDARY AND TERTIARY CARE • It is critical for water to be available 24 hours on-site from an improved source and piped into the facility to clinical areas, at a minimum to high-risk wards (for example, maternity ward, operating room/s, intensive care unit), points of care and service areas (for example, sterile services department) as patients in these areas may require 24-hour clinical care where water-related IPC is critical (for example, hand hygiene, environmental cleaning, reprocessing of medical devices). • The use of safe water (according to WHO drinking-water quality standard, that is, no Escherichia coli detectable in 100 mL and/or 0.5 mg/L free chlorine residual) for water-related IPC interventions minimizes the risk of direct and indirect exposure to water-related pathogens of enteric and environmental origin (for example, Pseudomonas, Legionella) and should be available for all clinical services; at a minimum, it should be provided to high-risk wards where the burden of HAI and AMR are high. • Sufficient quantities of water are required to ensure that all water-related IPC interventions can be performed. This quantity varies and is dependent on the particular service or ward. To avoid any frequent service gaps/water shortages, it is required that there be sufficient on-site water storage capacity to provide services for a minimum of 48 hours. • Ensuring an adequate quantity of toilets for inpatient users to prevent crowding and overuse and ensuring regular cleaning are critical to maintain a hygienic environment and minimize the transmission risk from enteric pathogens, at a minimum in the ratio defined previously. • Positive mechanical ventilation is needed for clean areas such as operating rooms and clean areas in decontamination units and the sterile services department, while negative pressure ventilation may be required for isolation facilities, for example, multidrug-resistant tuberculosis (see tuberculosis references in ‘resources’). The requirement for mechanical ventilation is most applicable to tertiary care facilities. • Reliable power means that a constant (that is, 24-hour) source of power and/or back-up power is available for high-risk wards (for example, maternity ward, operating room/s, intensive care unit). Without reliable power, it is not possible to operate decontamination (sterilization) equipment and waste treatment equipment when needed, or to have lighting in clinical areas in order to provide continuous and safe care. • Reliable power can be achieved via an on-site source of energy/power and fuel (for example, wind, solar, stand-by generator/s) to provide back-up as needed. • Given the increased risk for HAIs and AMR at secondary and tertiary health care facilities, there should be at least one isolation room per 20-bedded ward in secondary care facilities, and 1:10 in the tertiary level as a minimum. • Cohorting can be carried out in a dedicated area of a general ward. It can be done in any well-ventilated area as long as hand hygiene and transmission-based precautions are strictly adhered to. PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS 49 • As improving access to WASH services and IPC materials and equipment is resource intensive, the first step (minimum requirement) is to establish a multidisciplinary technical group to develop standards and implementation tools. • This group will have the task of: ‐ reviewing the requirements for WASH services, environmental hygiene, and IPC materials and equipment, according to the national context; ‐ developing a monitoring plan and reporting mechanism for assessing and improving WASH services and IPC materials and equipment in all health care facilities against national standards; use of existing tools (for example, WASH FIT or WHO/UNICEF JMP indicators for WASH in health care facilities) may be of help in these efforts; ‐ identifying roles and responsibilities for the implementation and management of WASH services, environmental hygiene and IPC materials and equipment at the facility level at all health care facilities. • The national level could also consider the development of a policy/regulations to mandate WASH services in facilities, according to the minimum requirements specified above. Full core component requirements ALL HEALTH CARE FACILITIES • Central government and national IPC and WASH programmes should develop standards and national action plans to ensure adequate WASH services, a hygienic environment, and the availability of IPC materials and equipment in all health care facilities, including primary care. • Ensuring an adequate hygienic environment should be the responsibility of senior facility managers and local authorities. • To implement the full requirements of the core component 8, all health care facilities should provide the following: ‐ water from an improved source located on premises with sufficient water available at all times for drinking, hand washing, food preparation, personal hygiene, medical activities, cleaning and laundry; ‐ improved sanitation facilities located on premises that are functional with safe management of sewage/faecal waste, including the use of well- managed septic tanks and leach fields, disposal into functioning sewers or off-site removal, and include at least one toilet designated for women/ girls to manage menstrual hygiene needs, at least one separated for staff, and at least one meeting the needs of people with limited physical disabilities; also, sanitation facilities for infants and children that are adapted for their use (with for example, smaller seats, child-sized bed pans), segregated by sex for older children, appropriately lit and accessible to people with limited mobility; ‐ adequate drainage of storm and wash water to prevent vector breeding; ‐ continuous access to hand hygiene facilities equipped with ABHRs and (where appropriate) with water, soap and disposable or clean towels at the point of care, within 5 metres of toilets, and other areas such as the sterile services departments, laboratories and mortuaries; ‐ continuous adequate supply of sharps’ containers and containers for segregating other types of health care waste and equipment to ensure that health care waste is treated and disposed of safely, including autoclaving, incineration or removal for off-site treatment; ‐ continuous adequate supplies to ensure regular cleaning of examination rooms, waiting areas, surfaces and toilets; ‐ continuous adequate supply of appropriate PPE for both clinical care and health care waste handling and cleaning; ‐ adequate ventilation to meet comfort requirements and reduce the risk of transmission of airborne pathogens; ‐ adequate power for sterilization, incineration and medical devices; sufficient energy for pumping water, sterilization and operating health care waste equipment (that is, incinerators); well-lit areas where health care procedures are performed and in toilet facilities, including at night. • The IPC team or committee should be involved in planning all these activities and systems and in the design of buildings and infrastructures and construction in health care facilities. • Practical actions to improve WASH in health care facilities should include: ‐ conduct situational analysis and assessment ‐ define roadmap and set targets ‐ establish national standards and accountability mechanisms ‐ improve and maintain infrastructure ‐ monitor and review data ‐ develop health workforce ‐ engage communities and ‐ conduct operational research and learning. SECONDARY AND TERTIARY CARE (in addition to primary care) • A dedicated centralized decontamination area and/or sterile supply department for the decontamination and sterilization of medical devices and other items/equipment should be available and supplied with sufficient water and power. • A dedicated clean storage area for patient care items and equipment, including sterile material, and a separate area for the storage of clean linen should be available as outlined in the WHO manual on decontamination and reprocessing of medical devices for health-care facilities (see ‘resources’). • An adequate number of single rooms (with private toilet facilities and including some rooms with negative pressure mechanical ventilation system) and/or rooms suitable for patient cohorting for the isolation of suspected /infected patients, including those with tuberculosis, other airborne pathogens and multidrug-resistant organisms, should be available to prevent transmission to other patients, staff and visitors. • Proper ventilation systems should be available in general and in the operating room, including either negative or positive air pressure conditions, depending on the situation. • Risk assessment systems and measures should be developed to ensure protection during building and renovation work for patients, their families and staff, especially in high-risk areas, such as units where severely immunocompromised patients (transplant, patients with profound neutropenia, etc.) are managed, as well as in intensive care, neonatal and burn units and operating rooms. PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS

51 PART 4. ANNEX PART 4. ANNEX 4.1 Annex 1. Summaries of the results of a systematic review and inventory on available IPC minimum standards 4.1.1 Overview of the results of the systematic literature review on minimum standards for IPC The systematic review on IPC minimum standards was conducted as a basis for the expert consultation on the IPC minimum requirements. It focused on the question: “What are the minimum standards of effective IPC programmes aimed at reducing health care-associated infections at the national and health care levels?” The Cumulative Index of Nursing and Allied Health Literature (CIHAHL), PubMed, GIM (WHO Global Index Medicus) and EMBASE databases were searched to identify reported minimum standards. IPC interventions were categorized as either horizontal (for example, IPC programme, education) or vertical (for example, prevention of surgical site infections). Hand hygiene, injection safety and education are examples of horizontal IPC interventions, while the prevention of surgical site infections, hospital-associated pneumonia and catheter-related bloodstream infections were categorized as vertical IPC interventions. Horizontal interventions were more frequently mentioned compared to vertical interventions as being a minimum requirement (Fig. 1). Hand hygiene (91%), transmission-based precautions (including triage) (87%), surveillance (85%), education/training (81%) and the built environment/infrastructure (77%) were the five most frequently mentioned horizontal critical IPC measures, followed by guidelines (70%), decontamination (70%) and monitoring/audits/feedback (66%). To p 5 ho riz on ta l i nt er ve nt io ns Facility level Hand hygiene 91% Transmission-based precautions 87% Surveillance 85% Education/training 81% Built environment/infrastructure 77% Pr ev en tio n of C R- BS I 3 6% Pr ev en tio n of M RS A 32 % Pr ev en tio n of V AP /H AP 2 6% Pr ev en tio n of S SI 2 1% Pr ev en tio n of C AU TI o r C RO 1 9% Top 5 vertical interventionsFig. 1 Top 5 horizontal and vertical interventions mentioned as a minimum requirement at the facility level. ABBREVIATIONS CR-BSI, catheter-related bloodstream infection; MRSA, methicillin-resistant Staphylococcus aureus; VAP/HAP, ventilator-associated pneumonia/hospital- acquired pneumonia; SSI, surgical site infection; CAUTI, catheter-associated urinary tract infection; CRO, carbapenem-resistant organisms. 52 PART 4. ANNEX Compliance with standard precautions is usually low and it is therefore important to investigate implementation strategies to improve this key measure. Existing competencies of IPC practitioners, as well as existing indicators, will be useful to define minimum standards. It will be critical to draw on lessons learned from the past and to engage hospital leadership in further discussions regarding the importance of implementation of IPC programmes. The review also highlighted the low quality of studies reviewed (systematic reviews and before-after studies), a very great number of studies from high- income countries, a high percentage of systematic reviews on methicillin- resistant Staphylococcus aureus and Clostridium difficile from high-income countries, and an elevated number of facility-based studies. 4.1.2 Summary of the global inventory on IPC minimum standards The aim of developing the global inventory of IPC minimum standards was to produce a catalogue of already available guidance on these standards (especially from the perspective of low-resource settings) from WHO regional and country offices, other organizations and countries directly. This was to complement the systematic review and country experiences gathered previously and to provide insights into what could be considered as ‘minimum standards’ for IPC at the national and facility level. A global call was made to relevant networks, as well as a search for any publicly available IPC-related documents. The database used for the guidelines on the core components of IPC was also searched for any relevant documents. A total of 23 documents were reviewed in full (1-23), but only nine included approved national IPC standards defined as ‘minimum’ for health care facilities (1-9). Overall, these documents provided validation of the WHO guidelines on core components for IPC programmes as all reviewed documents could be categorized and related to the eight core components. Most notably, core components 1 (IPC programmes), 3 (education and training) and 8 (built environment) were the most referred to, while core component 7 (workload, staffing and bed occupancy) was the least reported. The limitations of the final inventory had already been acknowledged as it was taken from direct submissions and those that were publicly available. However, despite some countries specifically identifying IPC minimum standards, the majority lacked any standard definition of minimum standards and their approach remained broad with a lack of specificity. 53 PART 4. ANNEX 4.1.3 References 1. Ethiopian hospital services transformation guidelines, volume 2. Ethiopian hospitals management initiative. Addis Ababa: Federal Democratic Republic of Ethiopia Ministry of Health; 2016. 2. Ministry of Health Social Services Namibia. Hospital standards and criteria, 1st edition (Draft 2). 2018 (http:// www.mhss.gov.na/documents/119527/659098/ MoHSS+Namibia+Hospital+Standards+and+Criteria+DRAFT. pdf/13271616-e30e-4a0d-b3d9-54d17c283eeb, accessed 29 October 2019). 3. Infection Prevention and Control (IPAC) Canada. Infection Prevention and Control (IPAC) Program Standard. Can J Infect Control. 2016; 30(Suppl):1-97 (https://ipac-canada.org/photos/custom/CJIC/ Vol31No4supplement.pdf, accessed 29 October 2019). 4. Swaziland standards authority. 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Ministerio de Salud Publica del Ecuador; 2006 (https://aplicaciones.msp. gob.ec/salud/archivosdigitales/documentosDirecciones/dnn/archivos/ manual%20de%20normas%20de%20infecciones%20nosocomiales.pdf, accessed 29 October 2019). 14. Société Française de Hygiène Hospitalière. Surveillance and prevention of healthcare-associated infections. HygièneS. 2010; 18(4): 3-175 (https:// sf2h.net/wp-content/uploads/2016/04/SF2H_surveillance-and-prevention- guidelines-2010.pdf, accessed 29 October 2019). 15. Personelle und organisatorische Voraussetzungen zur Prävention nosokomialer Infektionen Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention [Personnel and organizational requirements for the prevention of nosocomial infections: recommendations from the Commission for Hospital Hygiene and Infection Prevention]. Bundesgesundheitsbl [German Federal Health Bulletin] 2009;52:951–962 [in German] (https://www.rki.de/DE/ Content/Infekt/Krankenhaushygiene/Kommission/Downloads/Rili_ Hygmanagement.pdf?__blob=publicationFile, accessed 30 October 2019). 16. Hospital infection control manual for small healthcare organizations. New Delhi (India): National Accreditation Board for Hospitals and Healthcare Providers (https://nabh.co/Images/PDF/HIC_Guidebook.pdf, accessed 29 October 2019). 17. National infection prevention and control guidelines for health care services in Kenya. Nairobi: Kenya: Ministry of Public Health and Sanitation and Ministry of Medical Services, Republic of Kenya; December 2010 (http://www.ashcott.com/images/IPC_GUIDELINES.pdf, accessed 29 October 2019). 18. American University of Beirut Medical Centre. Standard precautions. 2015. 19. Rapid evaluation guide for hospital programs for prevention and control of nosocomial infections. Washington (DC): Pan American Health Organization; 2011 (https://www.paho.org/hq/dmdocuments/2011/HAI- 55 Evaluation-guide-2011-ENG.pdf, accessed 29 October 2019). 20. Ministère de la Santé et l’Action Sociale du Sénégal. Programme national de lutte contre les infections nosocomiales (PRONALIN). Fiche de supervision. 2011. 21. Sri Lanka College of Microbiologists. Empirical and prophylactic use of antimicrobials. National guidelines. 2016 (http://slmicrobiology.lk/ download/National-Antibiotic-Guidelines-2016-Web.pdf, accessed 30 October 2019). 22. National Institute for Health and Care Excellence (United Kingdom). Infection prevention and control. Quality standard (QS61). April 2014 (https://www.nice.org.uk/guidance/qs61/chapter/Introduction, accessed 30 October 2019). 23. United States of America Centers for Disease Prevention and Control. Core infection prevention and control practices for safe healthcare delivery in all settings – recommendations of the Healthcare Infection Control Practices Advisory Committee. 2017 (https://www.cdc.gov/hicpac/ recommendations/core-practices.html, accessed 29 October 2019). ISBN 978-92-4-151694-5

MINIMUM REQUIREMENTS for infection prevention and control programmes The starting point for implementing the World Health Organization core components of infection prevention and control programmes at the national and health care facility level Minimum requirements for infection prevention and control programmes ISBN 978-92-4-151694-5 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Graphic design by Maraltro, Italy. Printed in Switzerland Acknowledgements Abbreviations and acronyms Glossary of key terms and definitions Key to symbols Part 1. Introduction 1.1 Purpose of the document 1.2 Target audience 1.3 Document development structure 1.4 The role of the minimum requirements in achieving effective infection prevention and control 1.5 References Part 2. Executive summary of the minimum requirements by core component Part 3: In-depth review of the minimum requirements 3.1 Core component 1: Infection prevention and control programmes 3.2 Core component 2: Infection prevention and control guidelines 3.3 Core component 3: Infection prevention and control education and training 3.4 Core component 4: Health care-associated infection surveillance 3.5 Core component 5: Multimodal strategies 3.6 Core component 6: Monitoring, audit and feedback of infection prevention and control practices 3.7 Core component 7: Workload, staffing and bed occupancy at the facility level 3.8 Core component 8: Built environment, materials and equipment for infection prevention and control at the facility level Part 4. Annex 4. 1 Summaries of the results of a systematic review and inventory of available infection prevention and control minimum standards 4.1.1 Overview of the results of the systematic literature review on minimum standards for infection prevention and control 4.1.2 Summary of the global inventory on infection prevention and control minimum standards 4.1.3 References II IV V X 1 2 2 3 5 10 13 23 23 27 31 34 38 41 44 46 51 51 51 52 53 CONTENTS II ACKNOWLEDGEMENTS The Department of Integrated Health Services of the World Health Organization (WHO) gratefully acknowledges the contributions that many individuals and organizations have made to the development of the infection prevention and control (IPC) minimum requirements, based on the WHO core components for IPC programmes at the national and health care facility level. OVERALL COORDINATION, WRITING AND DESIGN OF THE DOCUMENT Benedetta Allegranzi (Department of Integrated Health Services, WHO) coordinated and led the development and writing of this document and contributed to the systematic review. Anthony Twyman and Alessandro Cassini (Department of Integrated Health Services, WHO) significantly contributed towards the writing of this document and to the systematic review. Julie Storr (IPC consultant, United Kingdom) and Molly Patrick (Centers for Disease Control and Prevention [CDC] international IPC team, United States of America [USA]) also contributed to the writing of this document. Joost Hopman (Radboud University Hospital and Médecins Sans Frontières/Doctors Without Borders, The Netherlands) contributed to the strategic development of this document and conducted a systematic review on the minimum standards for IPC programmes together with Daniël Urlings (Radboud University Hospital, The Netherlands); Anthony Twyman made a global inventory of available guidance on IPC minimum standards. Thomas Allen (Library and Information Networks for Knowledge, WHO) provided assistance with the search for the systematic review. Rosemary Sudan provided professional editing assistance. Laura Pearson (Department of Integrated Health Services, WHO) and Alice Simniceanu (Antimicrobial Resistance Division, WHO) supported the finalisation of the designed document. Maraltro provided the professional graphic design of the document. EXPERT CONTENT DEVELOPMENT GROUP Consensus on the contents of this document and the IPC minimum requirements was first gathered in a technical expert consultation in Addis Ababa, Ethiopia, in April 2019 with the participation of the following experts: ACKNOWLEDGEMENTS III Fahmi Ahmed (WHO Country Office for Ethiopia); Romella Abovyan (National Center for Disease Prevention and Control, Armenia); Anucha Apisarnthanarak (Thammasat University Hospital, Thailand); Batyrbek Aslanov (North-Western State Medical University, Russia); Sofonias Asrat (WHO Country Office for Ethiopia); Mekdim Ayana (WHO Regional Office for Africa); Gertrude Avortri (WHO Regional Office for Africa); Anjana Bhushan (WHO Regional Office for South-East Asia); Roderick Chen Camano (Caja Seguro Social Hospital, Panama); Christiana Agnes Conteh (Ministry of Health and Sanitation, Sierra Leone); Ana Paula Coutinho-Rehse (WHO Regional Office for Europe); Nizam Damani (IPC consultant, United Kingdom); Nino Dayanghirang (WHO Regional Office for Africa); Lamine Dhidah (Sahloul University Hospital, Tunisia); Molla Godif Fisehatsion (Ministry of Health, Ethiopia); Corey Forde (Queen Elizabeth Hospital, Barbados); Ghada Abdelwahed Ismail (Supreme Council of University Hospitals, Egypt); Nordiah Awang Jalil (Hospital Universiti Kebangsaan, Malaysia); Kushlani Jayatilleke (Sri Jayewardenapura General Hospital, Sri Lanka); Ejaz Khan (Shifa International Hospital, Pakistan); Amy Kolwaite (CDC international IPC team, USA); Thabang Masangane (Ministry of Health, Eswatini); Guy Mbayo (WHO Regional Office for Africa); Huynh Tuan Minh (University Medical Center, Viet Nam); Awa Ndir (WHO Regional Office for Africa); Babacar Ndoye (WHO Regional Office for Africa); Fernando Otaiza (Ministry of Health, Chile); Atika Swar (Federal Ministry of Health, Sudan); Maha Talaat (WHO Regional Office for the Eastern Mediterranean); Shaheen Mehtar (Infection Control Network Africa, South Africa); Benjamin Park (CDC international IPC team, USA); Molly Patrick (CDC international IPC team, USA); Lul Raka (University of Prishtina, Kosovo); Julie Storr (IPC consultant, United Kingdom); Lekilay G. Tehmeh (Ministry of Health, Liberia); Le Thi Anh Thu (Infection Control Society, Viet Nam); Roselyne M.E. Toby (Hôpital Central de Yaoundé, Cameroon); Sarah Tomczyk (Robert Koch Institute, Germany); Winifrey Ukponu (Nigeria Centre for Disease Control, Nigeria); Jay Varma (Africa CDC, Ethiopia); Daiva Yee (CDC international IPC team, USA). The content was further developed with the substantial contribution and/or review by the following experts: Fahmi Ahmed (WHO Country Office for Ethiopia); Anjana Bhushan (WHO Regional Office for South-East Asia); Ana Paula Coutinho-Rehse (WHO Regional Office for Europe); Nino Dayanghirang (WHO Regional Office for Africa); Corey Forde (Queen Elizabeth Hospital, Barbados); Amy Kolwaite (CDC international IPC team, USA); Babacar Ndoye (WHO Regional Office for Africa); Maha Talaat (WHO Regional Office for the Eastern Mediterranean); Shaheen Mehtar (Infection Control Network Africa, South Africa); Molly Patrick (CDC international IPC team, USA); Julie Storr (IPC consultant, United Kingdom); Sarah Tomczyk (Robert Koch Institute, Germany); Jay Varma (Africa CDC, Ethiopia). EXTERNAL PEER REVIEW GROUP Emine Alp (Ministry of Health, Turkey); April Baller (World Health Emergencies, WHO); Richard Gelting (CDC, USA); Margaret Montgomery (Water, Sanitation, Hygiene and Health Unit, WHO); Rob Quick (CDC, USA); Wing Hong Seto (University of Hong Kong, Hong Kong SAR, China); Nalini Singh (George Washington University Schools of Medicine and Health Sciences and Public Health and Children’s National, USA); João Toledo (Pan American Health Organization). ACKNOWLEDGEMENTS OF FINANCIAL AND OTHER SUPPORT WHO gratefully acknowledges the technical and strategic contributions by CDC (USA) and Africa CDC for the accomplishment of this project and thanks Africa CDC for hosting the technical expert consultation in its premises in Addis Ababa, Ethiopia. Funding for the development of this document was provided by the CDC (USA), in addition to WHO core funds. However, the views expressed in the manual do not necessarily reflect the official policies of the CDC. ACKNOWLEDGEMENTS IV ABBREVIATIONS AND ACRONYMS ABBREVIATIONS AND ACRONYMS ABHR AMR CDC CP CPE EQAS HAI HCW IPC IPCAF IPCAT PPE SOP UNICEF USA WASH WASH FIT WHO alcohol-based handrub antimicrobial resistance Centers for Disease Control and Prevention (USA) carbapenemase-producing carbapenemase-producing Enterobacteriaceae external quality assurance system health care-associated infection health care worker infection prevention and control infection prevention and control assessment framework infection prevention and control assessment tool personal protective equipment standard operating protocols United Nations Children’s Fund United States of America water, sanitation and hygiene water, sanitation and hygiene facility improvement tool World Health Organization VGLOSSARY OF KEY TERMS AND DEFINITIONS Alcohol-based handrub: An alcohol-based preparation designed for application to the hands to inactivate microorganisms and/or temporarily suppress their growth. Such preparations may contain one or more types of alcohol and other active ingredients with excipients and humectants. Source: WHO Guidelines on hand hygiene in health care. 2009 (https://www.who.int/gpsc/5may/tools/9789241597906/en/, accessed 29 October 2019). Antimicrobial stewardship: A coherent set of actions which promote the responsible use of antimicrobials. This definition can be applied to actions at the individual level, as well as the national and global level, and across human health, animal health and the environment. Source: Dyar OJ, Huttner B, Schouten J, Pulcini C. What is antimicrobial stewardship? Clin Microbiol Infect. 2017;23(11):793–8. OR The primary goal of antimicrobial stewardship is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms (such as Clostridium difficile) and the emergence of resistance. Source: Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44(2):159–77. Cleaners (also known as environmental cleaning staff or environmental services’ technicians): individuals responsible for performing environmental cleaning in health care facilities who play a key role in maintaining a clean and/or hygienic environment that facilitates practices related to the prevention and control of HAI. Cohorting: Grouping of patients who are colonized or infected with the same resistant organism with the aim to confine their care to one area and prevent contact with other susceptible patients (for example, all patients infected or colonized with a carbapenem-resistant Enterobacteriaceae in a specific cohort and all patients colonized with methicillin- resistant Staphylococcus aureus in a different cohort). Cohorts are created based on clinical diagnosis, microbiological confirmation with available epidemiology, and the mode of transmission of the infectious agent. Cohorting is reserved for situations where there are insufficient single rooms or where the cohorting of patients colonized or infected with the same pathogen is a more efficient use of hospital rooms and resources. Dedicated equipment, toilets and staff should be used for patients within the cohorted area for the required time duration. Sources: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings (http:// www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf, accessed 29 October 2019). WHO. Guidelines for the prevention and control of carbapenem- resistant Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa in health care facilities. 2017 (https:// www.who.int/infection-prevention/publications/guidelines-cre/ en/, accessed 29 October 2019). Carbapenem resistance (including carbapenemase-producing [CP]): Carbapenem resistance among Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa may be due to a number of mechanisms. Some strains may be innately resistant to carbapenems, while others contain mobile genetic elements (for example, plasmids, transposons) that result in the production of carbapenemase enzymes (carbapenemases), which break down most beta-lactam antibiotics, including carbapenems. Frequently, CP genes are co-located with other resistance genes, which can result in cross-resistance to many other antibiotic drug classes (1-3). Thus, while carbapenem- resistant strains of these pathogens are frequently CP (CP- Enterobacteriaceae [CPE], CP-A. baumannii, CP-P. aeruginosa), they may have other carbapenem resistance mechanisms that GLOSSARY OF KEY TERMS AND DEFINITIONS VI make them equally difficult to treat and manage clinically. Thus, the term “carbapenem-resistant Enterobacteriaceae” includes all strains that are carbapenem-resistant, including CPE. For this reason, infection prevention and control actions should focus on all strains of carbapenem-resistant Enterobacteriaceae, A. baumannii and P. aeruginosa, regardless of their resistance mechanism. Adequate infection prevention and control measures are essential in both outbreak and endemic settings. Source: WHO. Guidelines for the prevention and control of carbapenem-resistant Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa in health care facilities. 2017 (https://www.who.int/infection-prevention/ publications/guidelines-cre/en/, accessed 29 October 2019). Decontamination of medical devices: Removes soil and pathogenic microorganisms from objects so they are safe to handle, subject to further processing, use or discard (see also Reprocessing). Source: United States Centers for Disease Control and Prevention. Guidelines for disinfection and sterilization in healthcare facilities. 2008 (https://www.cdc.gov/ infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf, accessed 29 October 2019). Hand hygiene: A general term referring to any action of hand cleansing, that is, the action of performing hand hygiene for the purpose of physically or mechanically removing dirt, organic material, and/or microorganisms. Source: WHO guidelines on hand hygiene in health care. 2009 (https://www.who.int/gpsc/5may/tools/9789241597906/en/, accessed 29 October 2019). HEALTH CARE FACILITIES’ CLASSIFICATION Primary health care facilities: Facilities that provide outpatient services, family planning, antenatal care, maternal, newborn and child health services (including delivery), for example, health centres, health posts and small district hospitals. Source: WHO. Water and sanitation for health facility improvement tool (WASH FIT). 2017 (https://apps.who.int/iris/ bitstream/handle/10665/254910/9789241511698-eng. pdf;jsessionid=0A60107AA8F5A27C5FD16B0823D3F4FA?se- quence=1, accessed 29 October 2019). PRIMARY, SECONDARY AND TERTIARY HOSPITALS Primary-level hospital: Few specialties—mainly internal medicine, obstetrics and gynaecology, paediatrics and general surgery, or just general practice; limited laboratory services available for general, but not specialized, pathological analysis. Secondary-level hospital: Highly differentiated by its function with 5 to 10 clinical specialties; size ranges from 200 to 800 beds; often referred to as a provincial or district hospital. Tertiary-level hospital: Highly specialized staff and technical equipment, for example, cardiology, intensive care unit and specialized imaging units; clinical services highly differentiated by function; may have teaching activities; size ranges from 300 to 1500 beds; often referred to as a teaching or university or regional hospital. Source: WHO. Disease control priorities in developing countries. 2008 (https://www.who.int/management/facility/ ReferralDefinitions.pdf, accessed 29 October 2019). Improved sanitation facilities: Toilet facilities that hygienically separate human excreta from human contact. Examples include flush/pour flush to a piped sewer system, septic tank or pit latrine, ventilated pit latrine, pit latrine with slab or composting toilet. Source: WHO/UNICEF. Core questions and indicators for monitoring WASH in health care facilities in the Sustainable Development Goals. 2018 (https://apps.who.int/iris/bitstream/ handle/10665/275783/9789241514545-eng.pdf?ua=1, accessed 29 October 2019). Improved water source: Defined by the WHO/UNICEF Fund Joint Monitoring Programme as a water source that by its nature of construction adequately protects the source from outside contamination, particularly faecal matter. Examples include: public taps or standpipes; protected dug wells; tube wells; or boreholes. Source: WHO/UNICEF. Progress on sanitation and drinking water. 2015 update and Millennium Development Goals assessment (https://www.unicef.org/publications/ index_82419.html, accessed 29 October 2019). GLOSSARY OF KEY TERMS AND DEFINITIONS VII Infection prevention and control (IPC) minimum requirements: IPC standards that should be in place at both national and health facility level to provide minimum protection and safety to patients, health care workers and visitors, based on the WHO core components for IPC programmes. The existence of these requirements constitutes the initial starting point for building additional critical elements of the IPC core components according to a stepwise approach based on assessments of the local situation. Source: Definition used in this document and developed by the expert group. IPC professional: Health care professional trained in a certified postgraduate IPC course or a nationally recognized course. Source: WHO. Infection prevention and control assessment framework tool (IPCAF) (http://www.who.int/infection- prevention/tools/core-components/en/, accessed 29 October 2019). IPC focal point: Professional (nurse, doctor, or other) appointed to be in charge of IPC at the national or facility level who has a specific professional background, that is, formal postgraduate training in IPC leading to the successful achievement of a certificate or diploma. Source: WHO. IPCAF (http://www.who.int/infection-prevention/ tools/core-components/en/, accessed 29 October 2019). IPC link professional: Nurse or doctor in a ward or facility who has been trained in IPC (using a nationally approved in-service training package; no postgraduate certificate/diploma required) and links to an IPC focal point/team at a higher level in the organization (for example, IPC focal point/team in the facility or at the district level). IPC is not the primary assignment of this professional but, among others, he/she may undertake the following tasks: support implementation of IPC practices; provide mentorship to colleagues; undertake monitoring activities; and alert on possible infectious risks. IPC committee: A multidisciplinary group with interested stakeholders across the facility, which interacts with and advises the IPC team. For example, the IPC committee could include senior facility leadership; senior clinical staff; leads of other relevant complementary areas, such as biosafety, pharmacy, microbiology or clinical laboratory, waste management, water, sanitation and hygiene services and quality and safety, where in place. Source: WHO. IPCAF (http://www.who.int/infection-prevention/ tools/core-components/en/, accessed 29 October 2019). IPC structural indicators: Appropriate clean and hygienic environment, water, sanitation and hygiene services and availability of materials and equipment for IPC, in particular for hand hygiene, including financial, human and information resources compatible with standards set out by government authorities or other bodies responsible for the control and prevention of health care-associated infections. Source: WHO. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. 2016 (https://www.who.int/infection- prevention/publications/core-components/en/, accessed 29 October 2019). IPC process indicators: Measurement of compliance with IPC activities currently used within the facility and the presence of IPC policies, procedures and protocols. Hand hygiene is an essential process indicator to be monitored. Source: WHO. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. 2016 (https://www.who.int/infection- prevention/publications/core-components/en/, accessed 29 October 2019). Multimodal strategy: A multimodal strategy comprises several components or elements (three or more, usually five) 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 five most common elements include: (i) system change (availability of the appropriate infrastructure and supplies to enable infection prevention and control good practices); (ii) education and training of health care workers and key players (for example, managers); (iii) monitoring infrastructures, practices, processes, outcomes and providing data feedback; (iv) reminders in the workplace/communications; and (v) culture change within the establishment or the strengthening of a safety climate. GLOSSARY OF KEY TERMS AND DEFINITIONS VIII Source: WHO. Improving infection prevention and control at the health facility. 2018 (https://www.who.int/infection-prevention/ tools/core-components/facility-manual.pdf, accessed 29 October 2019). Negative pressure mechanical ventilation system: A mechanical ventilation system in which the exhaust airflow rate is greater than the supply airflow rate. The room will be at a lower pressure than the surrounding areas. Source: WHO. WHO guidelines on tuberculosis infection prevention and control. 2019 (https://apps.who.int/iris/ bitstream/handle/10665/311259/9789241550512-eng. pdf?ua=1, accessed 29 October 2019). Patient zone: Concept related to the ‘geographical’ visualization of key moments for hand hygiene. It contains the patient X and his/her immediate surroundings. This typically includes the intact skin of the patient and all inanimate surfaces that are touched by or in direct physical contact with the patient, such as the bed rails, bedside table, bed linen, infusion tubing and other medical equipment. It also contains surfaces frequently touched by health care workers while caring for the patient, such as monitors, knobs and buttons, and other ‘high frequency’ touch surfaces. Source: WHO Guidelines on hand hygiene in health care. 2009 (https://www.who.int/gpsc/5may/tools/9789241597906/en/, accessed 29 October 2019). Personal protective equipment: Specialized clothing or equipment worn to protect the health care worker or any other person from infection. These usually consist of standard precautions: gloves, mask and gown. If bloodborne or airborne infections, these will include face protection, goggles and mask or face shield, gloves, gown or coverall, head cover and rubber boots. Source: WHO. Medical devices. 2014 (https://www.who.int/ medical_devices/meddev_ppe/en/, accessed 29 October 2019). Point of care: The place where three elements come together: the patient, the health care worker and care or treatment involving contact with the patient or his/her surroundings (within the patient zone). Source: WHO Guidelines on hand hygiene in health care. 2009 (https://www.who.int/gpsc/5may/tools/9789241597906/en/, accessed 29 October 2019). Positive pressure mechanical ventilation system: A mechanical ventilation system in which the supply airflow rate is greater than the exhaust airflow rate. The room will be at a higher pressure than the surrounding areas. Source: WHO. Natural ventilation for infection control in health- care settings. 2009 (https://www.who.int/water_sanitation_ health/publications/natural_ventilation.pdf, accessed 29 October 2019). Protocol: Detailed plan of a scientific or medical experiment, treatment or procedure. Reprocessing of medical devices: All steps that are necessary to make a contaminated reusable medical device ready for its intended use. These steps may include cleaning, functional testing, packaging, labelling, disinfection and sterilization. Source: WHO. Decontamination and reprocessing of medical devices for health care facilities. 2016 (https://www.who.int/ infection-prevention/en/, accessed 29 October 2019). Standard operating procedure: Set of step-by-step instructions compiled by an organization to help workers carry out routine operations in the most effective manner. Standard precautions: A set of activities designed to prevent the transmission of organisms between patients/staff for the prevention of health care-associated infection. They must be applied to ALL patients who require health care, by ALL health workers in ALL health settings. They include: hand hygiene; use of personal protective equipment; handling and disposal of waste and sharps; handling and management of clean and used linen; environmental cleaning; and decontamination of equipment. Source: The Northern Ireland Regional Infection and Prevention Control Manual. Standard precautions. Updated 2015 (https:// www.niinfectioncontrolmanual.net/standard-precautions, accessed 29 October 2019). Transmission-based precautions: Additional measures focused on the particular mode of transmission of the microrganism and GLOSSARY OF KEY TERMS AND DEFINITIONS IX always used in addition to standard precautions. They are grouped into categories according to the route of transmission of the infectious agent. Transmission-based precautions should be applied when caring for patients with known infection, patients who are colonized with an infectious organism, and asymptomatic patients who are suspected of/under investigation for colonization or infection with an infectious microorganism. Source: The Northern Ireland Regional Infection and Prevention Control Manual. Transmission-based precautions. Updated 2015 (https://www.niinfectioncontrolmanual.net/transmission- based-precautions, accessed 29 October 2019). Water quality: The quality of water is affected by microbial, chemical and radiological aspects, with microbial aspects constituting the principle concern for infection control in health care settings. Water in health care facilities should not present a risk to health from pathogens and should be protected from contamination inside the health care setting itself. Water for drinking, cooking, personal hygiene, medical activities, cleaning and laundry must be safe for the purpose intended. ‘Safe’ water is water that meets national and/or WHO water quality guidelines, including zero Escherichia coli or thermotolerant coliform bacteria in any 100-millilitre sample of drinking water. Source: WHO. Drinking water quality guidelines. 2017 (https:// www.who.int/water_sanitation_health/publications/drinking- water-quality-guidelines-4-including-1st-addendum/en/, accessed 29 October 2019). GLOSSARY OF KEY TERMS AND DEFINITIONS XKEY TO SYMBOLS Visual representation of the WHO core components of infection prevention and control (IPC) programmes at the national and health care facility level. Visual representation of minimum versus full requirements of the core components to achieve effective IPC programmes. Key people to be involved in an activity. Process undertaken to develop the document. How the document is structured. Achieving the effective implementation of the IPC core components. Content relevant for the national level. Content relevant for the health care facility level. KEY TO SYMBOLS

1PART 1. INTRODUCTION Why should health systems have strong infection prevention and control (IPC) programmes? Preventing harm to patients, health workers and visitors due to infection in health care facilities is fundamental to achieve quality care, patient safety, health security and the reduction of health care-associated infections (HAIs) and antimicrobial resistance (AMR). Similarly, preventing and reducing the transmission of infectious diseases that pose global threats, such as pandemic influenza, Ebola virus disease and other viral haemorrhagic fevers, is paramount. Clean, safe care is a patient right and should also be the duty and pride of all those working in the health care sector. Supported by many stakeholders in the field of IPC, WHO has issued recommendations and specifications for effective IPC programmes. These are included in the evidence-based WHO Guidelines on core components of IPC programmes (1) and the approach for their implementation is presented in associated manuals for both the national and facility levels (2, 3). 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. The implementation of all WHO recommendations on core components is required to build functioning programmes leading to the effective reduction of HAIs and AMR. However, fulfilment of all IPC core components takes time. For some countries, it may be a demanding journey that will need to build upon a realistic, stepwise approach. In particular for countries where IPC is limited or inexistent, it is critical to start by ensuring that at least minimum requirements for IPC are in place as soon as possible, both at the national and facility level, and to gradually progress to the full achievement of all requirements of the IPC core components according to local priority plans. Patients and health care workers (HCWs) need to be safe and protected at all times, no matter where and irrespective of the context. The eight core components of IPC are the ‘wheels of the cart’ that will ensure patients have a safe journey while in a health care facility. PART 1. INTRODUCTION 21.2 TARGET AUDIENCE The main target audience of this document are IPC and AMR focal points/leads, policy-makers, senior managers and other professionals with the mandate of or interested in developing or strengthening IPC programmes at the national, sub-national and facility level. IPC teams and committees are also the critical target audience of this document. Key players in addressing each of the minimum requirements are also indicated in the specific chapters related to each core component. The document could also be helpful to other stakeholders, such as those responsible for health care quality improvement, patient safety, health facility accreditation/regulation, public health, infectious disease control and surveillance, water, sanitation and hygiene (WASH), occupational 1.1 PURPOSE OF THE DOCUMENT The purpose of this document is to present and promote the minimum requirements for IPC programmes at the national and health care facility level, identified by expert consensus according to available evidence and in the context of the WHO core components. The minimum requirements are defined as: IPC standards that should be in place at the national and facility level to provide minimum protection and safety to patients, HCWs and visitors, based on the WHO core components for IPC programmes. PART 1. INTRODUCTION What are the minimum requirements for IPC programmes? Who should implement the minimum requirements for IPC programmes? 3How was this document developed? health, antimicrobial stewardship programmes, clinical microbiology and environmental health interventions, as well as additional categories of health care professionals involved in care delivery. WHO staff, partners in nongovernmental organizations and donors involved in supporting the development or implementation of IPC and WASH capacity building, AMR national action plans and, the core capacities of the International Health Regulations at country level (4), will also benefit from using this document. Of note, IPC implementation is the responsibility of all HCWs and not the sole responsibility of the IPC teams or policy-makers. Therefore, it is important that all HCWs are made aware of the IPC minimum requirements. Consideration should be given to providing an active orientation on IPC minimum requirements (for example, pre-service training, updates within annual in- service training, etc.) to health workers, based on the different areas of work and functions. 1.3 DOCUMENT DEVELOPMENT AND STRUCTURE A group of international experts and professionals working at national and facility levels in the field of IPC was convened by WHO, with support by the United States Centers for Disease Control and Prevention and the Africa Centre for Disease Control and Prevention. Plenary sessions were held to identify the objectives and scope of the project and to define the concept of minimum requirements. Working groups were formed to identify minimum requirements for each IPC core component at the national and the health facility levels, based on existing IPC and WASH recommendations and standards. For the purpose of this work, health facilities were categorized as primary health care facilities, secondary health care facilities (including primary and secondary hospitals) and tertiary health care facilities (tertiary hospitals). Based on proposals by the working groups, all participants expressed their opinion on the minimum requirements by voting. Only those identified with >70% consensus was accepted and included in this document. The cut-off of 70% was based on evidence from studies on consensus building to ensure a high consensus rate among the expert group (5-7). Mention is made of requirements with a lower level of consensus in the rationale (‘why’) sections of each minimum requirements’ chapter. A second round of review of the minimum requirements’ content and language was undertaken with the participants after the international meeting. Finally, international experts and WHO staff not participating in the meeting were asked to provide an external review and input to the final draft document. PART 1. INTRODUCTION 4The document includes four parts. Part 1 is an introduction that includes sections of paramount importance to understand the remaining content of the document and the minimum requirements for IPC programmes. The minimum requirements are summarized in Part 2 of this document, together with the WHO evidence-based recommendations for each IPC core component (1). Part 3 is an in-depth review exploration of each core component and its minimum requirements for the national and health care facility levels (Box 1). Part 4 includes summaries of the results of a systematic review and inventory of available pubblications IPC minimum standards, used as the evidence basis for the development of this document. How is this document structured? WHAT WHO HOW WHY FULLREQUIREMENTS Minimum requirements Is responsible for action To measure progress Rationale and additional details on the minimum requirements Full core component requirements Text of the minimum requirements for each IPC core component identified by expert consensus according to national and health care facility level and based on existing IPC and WASH recommendations and standards. Identification of those who have the mandate to ensure that the minimum requirements are put in place and sustained or can play a role. Indicators to be used to track implementation and progress for each minimum requirement are available from different WHO monitoring tools. Explanations about the reasons for selecting the agreed minimum requirements (rationale) and additional details explaining their content and importance. Comprehensive list of the actions and requirements* to achieve full implementation of each IPC core component. Note that these exist only for acute care hospitals because the WHO recommendations on IPC core components apply mainly to these facilities and not specifically to primary care facilities. * Note that in some cases, there are no major differences compared to the minimum requirements. STRUCTURE OF THE MINIMUM REQUIREMENTS (PART 3)BOX 1 PART 1. INTRODUCTION 5How can the minimum requirements help achieve effective implementation of the IPC core components? 1.4 ROLE OF THE MINIMUM REQUIREMENTS It is important to note that the gold standard in any country is to achieve the full implementation of all requirements of the WHO core components of IPC programmes (Fig. 1) (1). For this reason, governments and facilities should take steps to work towards this goal, including in the context of national action plans for AMR, quality of care and health security. Fig. 1 Visual representation of the WHO core components of IPC programmes. PART 1. INTRODUCTION MU LTIMODAL S TR ATE GIES EDUCATION AND TRAINING GUIDELINES MONITORING, AUDIT AND FEEDBACK SURVEILLANCE ENABLING ENVIRONMENT BUILT ENVIRONMENT, MATERIALS AND EQUIPMENT WORKLOAD, STAFFING, AND BED OCCUPANCY and all relevant programme linkages IPC PROGRAMMES 6The approach to facilitate implementation of the WHO core components, together with real-life examples from countries and facilities around the world, is described in the WHO practical manuals developed for the national and facility levels (2, 3). Anyone interested in understanding and implementing the minimum requirements should read the WHO Guidelines on core components of IPC programmes (1) and the manuals supporting their implementation at the national and facility levels (2, 3). However, it is recognized that countries may be at different levels of progress, with different capacities, available opportunities and resources. Thus, the minimum requirements represent the starting point for undertaking the journey to build strong and effective IPC programmes at the national and facility level (Fig. 2) and SHOULD be in place for all countries and health care facilities to support further progress towards full implementation of all core components. Fig. 2 Minimum versus full requirements to achieve effective IPC programmes. PART 1. INTRODUCTION 7Whether applying the minimum requirements or full requirements, the implementation of the IPC core components should always be tackled using a stepwise approach, based on a careful assessment of the status of the IPC programme and activities locally. A country or a health facility may not be able to aim at putting in place all core components or even all minimum requirements at the same time. Therefore, when preparing to improve IPC, it is essential to start by using standardized tools and indicators developed and validated for assessing the status of the core components at the national or health facility in any country worldwide, regardless of the geographical location and level of income. Depending on the strengths (core component requirements/features already in place) and the gaps (requirements/features not available or in place) identified through the assessment, a prioritization exercise can then help to identify which core components and minimum or full requirements need to be targeted through an improvement action plan tailored to the local context, expertise and resources available. To undertake this process, WHO proposes a five-step cycle of implementation (Fig. 3 and Box 2) to support any IPC improvement intervention or programme as described further in the practical manuals (2, 3, 8). Fig. 3 The five-step cycle to IPC improvement. PART 1. INTRODUCTION Step 5 Sustaining the programme over the long term Step 1 Preparing for action Step 2 Baseline assessment Step 3 Developing and executing an action plan Step 4 Evaluating impact Multimodal improvement strategy embedded within each step in the cycle of continuous improvement 8Type of tool and purpose Structure Who should complete it Standardized assessment tool designed to determine the IPC core components already in place (existing strengths) and to identify gaps or weaknesses at the national level. The main purpose of IPCAT2 is to support implementation, thereby providing a road map to guide IPC actions. IPCAT2 includes six sections correspond- ing to the six core component recommen- dations targeted at the national level, with an associated scoring system. The tool is intended to be used for self-assessment by the national IPC team and/or committee, but it can also be used for joint assessments with external experts or external assessments. STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 Preparing for action Baseline assessment Developing and executing an action plan Assessing impact Sustaining the programme over the long term This step aims to ensure that all of the prerequisites that need to be in place for the success of an IPC intervention or programme are considered. These include starting to think about the identification of key players and their roles and responsibilities, as well as the necessary resources (human and financial), infrastructure/s, planning and coordination of activities. Of note, the preparations made can be refined through step 3 after conducting step 2. Conducting an objective baseline assessment of the current situation of the IPC core components and minimum requirements is critical for the identification of existing strengths and gaps. Standardized and validated assessment indicators and tools available from WHO are listed in Part 3. The national and facility level standardized tools to assess the IPC core components and WASH are described in Boxes 3-5. Developing a tailor- made action plan that addresses the local reality and focuses on the priority areas for improvement identified through the baseline assessment. The development and execution of an action plan should be based upon a multimodal improvement strategy and supported by a dedicated budget. Conducting a follow- up assessment using the same tools as in step 2 is crucial to determine the effectiveness of the plan and achievement of the minimum requirements. Further review of the long term impact and acceptability of the ongoing action plan, and ensuring its sustainability, are important steps in the cycle of improvement. This allows also an evaluation of the next steps and priorities for implementation of all minimum requirements and the IPC core components in full. THE FIVE-STEP CYCLE TO INFECTION PREVENTION AND CONTROL IMPROVEMENT NATIONAL INFECTION PREVENTION AND CONTROL ASSESSMENT TOOL 2 (IPCAT2) (9) BOX 2 BOX 3 PART 1. INTRODUCTION 9Type of tool and purpose Structure Who should complete it Validated assessment tool designed to measure the IPC situation of a health care facility and determine the core components already in place (existing strengths) and to identify gaps or weaknesses to guide action planning. Structured, closed-formatted questionnaire with an associated scoring system, which includes eight sections corresponding to the eight core component recommendations targeted at the facility level. The tool is meant to be completed by health care professionals responsible for organising and implementing IPC measures and who have in-depth knowledge of IPC at the facility level (IPC focal point or team or committee), but it can also be used for joint assessments with or external assessments by external experts. Type of tool and purpose Structure Who should complete it Improvement tool to be used on a continuous and regular basis to help health care facility staff and administrators prioritize and improve WASH and health care waste management infrastructures and services in facilities in low- and middle-income countries; and to inform broader district, regional and national efforts to improve quality health care. WASH FIT complements the IPCAF and provides a greater depth of information on the built environment. WASH FIT covers four broad areas: water, sanitation (including health care waste management), hygiene (hand hygiene and environmental cleaning) and management. The tool is meant to be used by health care facility managers and staff including the chief medical officer, the financial administrator, doctors, nurses and persons in charge of managing water and waste. Other people outside the facility may also be involved, such as local, district and regional WASH and/or public works authorities, representatives from the community, local and regional government authorities involved in implementing national quality health care, IPC and maternal, newborn and child health strategies, donors, and nongovernmental organizations (NGOs). FACILITY INFECTION PREVENTION AND CONTROL ASSESSMENT FRAMEWORK (IPCAF) (10) WASH FIT (11) BOX 4 BOX 5 PART 1. INTRODUCTION 10 1.5 REFERENCES 1. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016 (http://www.who.int/infection-prevention/ publications/ipc-components-guidelines/en/, accessed 29 October 2019). 2. Interim Practical Manual supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. Geneva: World Health Organization; 2017 (http://www.who.int/ infection-prevention/tools/core-components/cc-implementation-guideline. pdf, accessed 29 October 2019). 3. 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 (http://www.who.int/infection-prevention/tools/ core-components/facility-manual.pdf, accessed 29 October 2019). 4. International Health Regulations (2005). Assessment tool for core capacity requirements at designated airports, ports and ground crossings. Geneva: World Health Organization; 2009 (https://www.who.int/ihr/ports_airports/ PoE/en/, accessed 29 October 2019). 5. Vogel C ZS, Griffiths C, Hobbs M, Henderson E, Wilkins E. A Delphi study to build consensus on the definition and use of big data in obesity research. Int J Obesity 2019; Jan 17 [Epub ahead of print]. 6. Slade SC, Dionne CE, Underwood M, Buchbinder R. Standardised method for reporting exercise programmes: protocol for a modified Delphi study. BMJ Open. 2014: e006682. 7. Diamond IR, Grant CR, Feldman BM, Pencharz PB, Ling SC, Moore AM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67:401–09. 8. Infection prevention and control: core components for IPC - implementation tools and resources. Geneva: World Health Organization; 2019 (https://www. who.int/infection-prevention/tools/core-components/en, accessed 29 October 2019). 9. Infection prevention and control assessment tool (IPCAT2). Geneva: World Health Organization; 2017 (http://www.who.int/infection-prevention/tools/ core-components/IPCAT2.xls, accessed 29 October 2019). 10. Infection prevention and control assessment framework. Geneva: World Health Organization; 2018 (https://www.who.int/infection-prevention/tools/ core-components/IPCAF-facility.PDF, accessed 29 October 2019). 11. Water and sanitation for health facility improvement tool (WASH FIT). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/ bitstream/handle/10665/254910/9789241511698-eng.pdf?sequence=1, accessed 29 October 2019). PART 1. INTRODUCTION

13 Active, stand-alone, national IPC programmes with clearly defined objectives, functions and activities should be established for the purpose of preventing HAI, promoting patient safety and combating AMR through IPC good practices. National IPC programmes should be linked with other relevant national programmes and professional organizations. A functional IPC programme should be in place, including at least: • one full-time focal point trained in IPC. • a dedicated budget for implementing IPC strategies/plans. The panel recommends that an IPC programme with a dedicated, trained team should be in place in each acute health care facility for the purpose of preventing HAI and combating AMR through IPC good practices. PRIMARY CARE: IPC trained health care officer • Trained IPC link person, with dedicated (part-) time in each primary health care facility. • One IPC-trained health care officer at the next administrative level (for example, district) to supervise the IPC link professionals in primary health care facilities. SECONDARY CARE: functional IPC programme • Trained IPC focal point (one full-time trained IPC Officer [nurse or doctor]) as per the recommended ratio of 1:250 beds with dedicated time to carry out IPC activities in all facilities (for example, if the facility has 120 beds, one 50% full-time equivalent dedicated officer). • Dedicated budget for IPC implementation. TERTIARY CARE: functional IPC programme • At least one full-time trained IPC focal point (nurse or doctor) with dedicated time per 250 beds. • IPC programme aligned with the national programme and with a dedicated budget. • Multidisciplinary committee/team. • Access to microbiology laboratory. MINIMUM REQUIREMENTS PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT CORE COMPONENT 1: IPC PROGRAMMES NATIONAL LEVEL FACILITY LEVEL CORE COMPONENT RECOMMENDATION 14 The panel recommends that evidence-based guidelines should be developed and implemented for the purpose of reducing HAI and AMR. The education and training of relevant HCWs on the guideline recommendations and the monitoring of adherence with guideline recommendations should be undertaken to achieve successful implementation. National IPC guidelines • Evidence-based, ministry-approved guidelines adapted to the local context and reviewed at least every five years. PRIMARY CARE: facility-adapted standard operating procedures (SOPs) and their monitoring • Evidence-based facility-adapted SOPs based on the national IPC guidelines. • At a minimum, the facility SOPs should include: ‐ hand hygiene ‐ decontamination of medical devices and patient care equipment ‐ environmental cleaning ‐ health care waste management ‐ injection safety ‐ HCW protection (for example, post- exposure prophylaxis, vaccinations) ‐ aseptic techniques ‐ triage of infectious patients ‐ basic principles of standard and transmission-based precautions. • Routine monitoring of the implementation of at least some of the IPC guidelines/ SOPs. SECONDARY AND TERTIARY CARE: all requirements as for the primary health care facility level, with additional SOPs on: • standard and transmission-based precautions (for example, detailed, specific SOPs for the prevention of airborne pathogen transmission); • aseptic technique for invasive procedures, including surgery; • specific SOPs to prevent the most prevalent HAIs based on the local context/ epidemiology; • occupational health (specific detailed SOP). CORE COMPONENT RECOMMENDATION MINIMUM REQUIREMENTS CORE COMPONENT 2: IPC GUIDELINES PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT NATIONAL LEVEL FACILITY LEVEL NATIONAL LEVEL AND FACILITY LEVEL 15 The national IPC programme should support education and training of the health workforce as one of its core functions. National training policy and curriculum • National policy that all HCWs are trained in IPC (in-service training). • An approved IPC national curriculum aligned with national guidelines and endorsed by the appropriate body. • National system and schedule of monitoring and evaluation to check on the effectiveness of IPC training and education (at least annually). The panel recommends that IPC education should be in place for all HCWs by using team- and task-based strategies that are participatory and include bedside and simulation training to reduce the risk of HAI and AMR. PRIMARY CARE: IPC training for all front-line clinical staff and cleaners upon hiring • All front-line clinical staff and cleaners must receive education and training on the facility IPC guidelines/SOPs upon employment. • All IPC link persons in primary care facilities and IPC officers at the district level (or other administrative level) need to receive specific IPC training. SECONDARY CARE: IPC training for all front-line clinical staff and cleaners upon hire • All front-line clinical staff and cleaners must receive education and training on the facility IPC guidelines/SOPs upon employment. • All IPC staff need to receive specific IPC training. TERTIARY CARE: IPC training for all front-line clinical staff and cleaners upon hire and annually • All front-line clinical staff and cleaners must receive education and training on the facility IPC guidelines/SOPs upon employment and annually. • All IPC staff need to receive specific IPC training. MINIMUM REQUIREMENTS CORE COMPONENT 3: IPC EDUCATION AND TRAINING PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT NATIONAL LEVEL FACILITY LEVEL CORE COMPONENT RECOMMENDATION 16 PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT MINIMUM REQUIREMENTS CORE COMPONENT 4: HAI SURVEILLANCE The panel recommends that national HAI surveillance programmes and networks that include mechanisms for timely data feedback and with the potential to be used for benchmarking purposes should be established to reduce HAI and AMR. IPC surveillance and a monitoring technical group • Establishment by the national IPC focal point of a technical group for HAI surveillance and IPC monitoring that: ‐ is multidisciplinary; ‐ develops a national strategic plan for HAI surveillance (with a focus on priority infections based on the local context) and IPC monitoring. The panel recommends that facility-based HAI surveillance should be performed to guide IPC interventions and detect outbreaks, including AMR surveillance, with timely feedback of results to HCWs and stakeholders and through national networks. PRIMARY CARE • HAI surveillance is not required as a minimum requirement at the primary facility level, but should follow national or sub-national plans, if available (for example, detection and reporting of outbreaks affecting the community is usually included in national plans). SECONDARY CARE • HAI surveillance should follow national or sub-national plans. TERTIARY CARE: functional HAI surveillance • Active HAI surveillance should be conducted and include information on AMR: ‐ enabling structures and supporting resources need to be in place (for example, dependable laboratories, medical records, trained staff), directed by an appropriate method of surveillance; ‐ the method of surveillance should be directed by the priorities/plans of the facility and/or country. • Timely and regular feedback needs to be provided to key stakeholders in order to lead to appropriate action, in particular to the hospital administration. NATIONAL LEVEL FACILITY LEVEL CORE COMPONENT RECOMMENDATION 17 PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT The panel recommends that national IPC programmes should coordinate and facilitate the implementation of IPC activities through multimodal strategies on a nationwide or sub- national level. Multimodal improvement strategies for IPC interventions • Use of multimodal strategies to implement IPC interventions according to national guidelines/SOPs under the coordination of the national IPC focal point (or team, if existing). The panel recommends that IPC activities using multimodal strategies should be implemented to improve practices and reduce HAI and AMR. PRIMARY CARE: multimodal strategies for priority IPC interventions • Use of multimodal strategies – at the very least to implement interventions to improve hand hygiene, safe injection practices, decontamination of medical instruments, devices and environmental cleaning. SECONDARY CARE: multimodal strategies for priority IPC interventions • Use of multimodal strategies – at the very least to implement interventions to improve each one of the standard and transmission-based precautions, and triage. TERTIARY CARE: multimodal strategies for all IPC interventions • Use of multimodal strategies to implement interventions to improve each one of the standard and transmission-based precautions, triage, and those targeted at the reduction of specific infections (for example, surgical site infections or catheter-associated infections) in high- risk areas/patient groups, in line with local priorities. MINIMUM REQUIREMENTS CORE COMPONENT 5: MULTIMODAL STRATEGIES NATIONAL LEVEL FACILITY LEVEL CORE COMPONENT RECOMMENDATION 18 MINIMUM REQUIREMENTS CORE COMPONENT 6: MONITORING, AUDITING AND FEEDBACK NATIONAL LEVEL FACILITY LEVEL The panel recommends that a national IPC monitoring and evaluation programme should be established to assess the extent to which standards are being met and activities are being performed according to the programme’s goals and objectives. Hand hygiene monitoring with feedback should be considered as a key performance indicator at the national level. IPC surveillance and monitoring technical group • Establishment by the national IPC focal point of a technical group for HAI surveillance and IPC monitoring that: ‐ is multidisciplinary; ‐ develops a national strategic plan for HAI surveillance and IPC monitoring and, for IPC indicators monitoring: · develops recommendations for minimum indicators (for example, hand hygiene); · develops an integrated system for the collection and analysis of data (for example, protocols, tools) · provides training at the facility level to collect and analyse these data. The panel recommends that regular monitoring/ audit and timely feedback of health care practices according to IPC standards should be performed to prevent and control HAI and AMR at the health care facility level. Feedback should be provided to all audited persons and relevant staff. PRIMARY CARE • Monitoring of IPC structural and process indicators should be put in place at primary care level, based on IPC priorities identified in the other components. This requires decisions at the national level and implementation support at the sub- national level. SECONDARY AND TERTIARY CARE • A person responsible for the conduct of the periodic or continuous monitoring of selected indicators for process and structure, informed by the priorities of the facility or the country. • Hand hygiene is an essential process indicator to be monitored. • Timely and regular feedback needs to be provided to key stakeholders in order to lead to appropriate action, particularly to the hospital administration. CORE COMPONENT RECOMMENDATION PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT 19 The panel recommends that the following elements should be adhered to in order to reduce the risk of HAI and the spread of AMR: (1) bed occupancy should not exceed the standard capacity of the facility; (2) HCW staffing levels should be adequately assigned according to patient workload. PRIMARY CARE • To reduce overcrowding: a system for patient flow, a triage system (including referral system) and a system for the management of consultations should be established according to existing guidelines, if available. • To optimize staffing levels: assessment of appropriate staffing levels, depending on the categories identified when using WHO/national tools (national norms on patient/staff ratio), and development of an appropriate plan. SECONDARY AND TERTIARY CARE • To standardize bed occupancy: ‐ establish a system to manage the use of space in the facility and to establish the standard bed capacity for the facility; ‐ hospital administration enforcement of the system developed; ‐ no more than one patient per bed; ‐ spacing of at least one metre between the edges of beds; ‐ overall occupancy should not exceed the designed total bed capacity of the facility. • To reduce overcrowding and optimizing staffing levels: same minimum requirements as for primary health care. MINIMUM REQUIREMENTS CORE COMPONENT 7: WORKLOAD, STAFFING AND BED OCCUPANCY (FACILITY LEVEL ONLY*) * The national health system, IPC programme and any other relevant body should coordinate and support the implementation of this core component at the facility level. FACILITY LEVEL* CORE COMPONENT RECOMMENDATION PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT 20 Patient care activities should be undertaken in a clean and hygienic environment that facilitates practices related to the prevention and control of HAI, as well as AMR, including all elements around WASH infrastructure and services and the availability of appropriate IPC materials and equipment. The panel recommends that materials and equipment to perform appropriate hand hygiene should be readily available at each point of care. PRIMARY CARE: • Water should always be available from a source on the premises (such as a a deep borehole or a treated, safely managed piped water supply) to perform basic IPC measures, including hand hygiene, environmental cleaning, laundry, decontamination of medical devices and health care waste management according to national guidelines. • A minimum of two functional, improved sanitation facilities should be available on-site, one for patients and the other for staff; both should be equipped with menstrual hygiene facilities. • Functional hand hygiene facilities should always be available at points of care/toilets and include soap, water and single-use towels (or if unavailable, clean reusable towels) or alcohol-based handrub (ABHR) at points of care and soap, water and single-use towels (or if unavailable, clean reusable towels) within 5 metres of toilets. • Sufficient and appropriately labelled bins to allow for health care waste segregation should be available and used (less than 5 metres from point of generation); waste should be treated and disposed of safely via autoclaving, high temperature incineration, and/or buried in a lined, protected pit. • The facility layout should allow adequate natural ventilation, decontamination of reusable medical devices, triage and space for temporary cohorting/isolation/physical separation if necessary. • Sufficient and appropriate IPC supplies and equipment (for example, mops, detergent, disinfectant, personal protective equipment (PPE) and sterilization) and power/energy (for example, fuel) should be available for performing all basic IPC measures according to minimum requirements/SOPs, including all standard precautions, as applicable; lighting should be available during working hours for providing care. SECONDARY AND TERTIARY CARE: • A safe and sufficient quantity of water should be available for all required IPC measures and specific medical activities, including for drinking, and piped inside the facility at all times - at a minimum to high-risk wards (for example, maternity ward, operating room/s, intensive care unit). • A minimum of two functional, improved sanitation facilities that safely contain waste available for outpatient wards should be available and one per 20 beds for inpatient wards; all should be equipped with menstrual hygiene facilities. • Functional hand hygiene facilities should always be available at points of care, toilets and service areas (for example, the decontamination unit), which include ABHR and soap, water and single-use towels (or if unavailable, clean reusable towels) at points of care and service areas, and soap, water and single-use towels (or if unavailable, clean reusable towels) within 5 metres of toilets. • Sufficient and appropriately labelled bins to allow for health care waste segregation should be available and used (less than 5 metres from point of generation) and waste should be treated and disposed of safely via autoclaving, incineration (850° to 1100°C), and/or buried in a lined, protected pit. MINIMUM REQUIREMENTS FACILITY LEVEL CORE COMPONENT 8: BUILT ENVIRONMENT, MATERIALS AND EQUIPMENT FOR IPC (FACILITY LEVEL ONLY*) * The national health system, IPC programme and any other relevant body should coordinate and support the implementation of this core component at the facility level. CORE COMPONENT RECOMMENDATION PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT 21 PART 2. EXECUTIVE SUMMARY OF THE MINIMUM REQUIREMENTS BY CORE COMPONENT • The facility should be designed to allow adequate ventilation (natural or mechanical, as needed) to prevent transmission of pathogens. • Sufficient and appropriate supplies and equipment and reliable power/energy should be available for performing all IPC practices, including standard and transmission-based precautions, according to minimum requirements/SOPs; reliable electricity should be available to provide lighting to clinical areas for providing continuous and safe care, at a minimum to high-risk wards (for example, maternity ward, operating room/s, intensive care unit). • The facility should have a dedicated space/area for performing the decontamination and reprocessing of medical devices (that is, a decontamination unit) according to minimum requirements/SOPs. • The facility should have adequate single isolation rooms or at least one room for cohorting patients with similar pathogens or syndromes, if the number of isolation rooms is insufficient

23 CORE COMPONENT 1: IPC PROGRAMMES A functional IPC programme should be in place, including at least: • one full-time focal point trained in IPC; • a dedicated budget for implementing IPC strategies/plans. • Minister of health or other assigned senior authority within the ministry of health (for example, Director General of Health Services) at national and/or state level. • Minister of finances may also have an important role in allocating a dedicated budget for IPC. • Leads of other programmes where links can be useful for synergistic action (for example, HAI, AMR, WASH). • National IPC committee or technical working group, depending on the country situation as in some countries the committee exists, but there is no national IPC focal point or team to take action. Thus, the IPC committee can have a critical role in advocating for establishing a national IPC focal point. • IPC technical partners have an important role in advocating for and supporting (also financially in some cases) the establishment of an IPC focal point (for example, WHO country office, WHO Regional Office, UNICEF, United States Centers for Disease Control and Prevention [CDC], and other organizations with competence and activities in the field of IPC). PRIMARY CARE IPC-trained link person and health care officer • Trained IPC link person, with dedicated (part-) time in each primary health care facility. • One IPC-trained health care officer at the next administrative level (for example, district) to supervise the IPC link professionals in primary health care facilities. SECONDARY CARE Functional IPC programme • Trained IPC focal point (one full-time trained IPC Officer [nurse or doctor]) as per the recommended ratio of 1:250 beds with dedicated time to carry out IPC activities in all facilities (for example, if the facility has 120 beds, one 50% full-time equivalent dedicated officer). • Dedicated budget for IPC implementation. TERTIARY CARE Functional IPC programme • At least one full-time trained IPC focal point (nurse or doctor) with dedicated time per 250 beds. • IPC programme aligned with the national programme and with a dedicated budget. • Multidisciplinary committee/team. • Access to microbiology laboratory. • All key players mentioned at the national level can influence and/ or mandate the establishment of IPC link persons, IPC focal points and IPC committees at the health care facility level and of IPC officers at the next administrative level. • Directors of health or health management teams (or other decision-making role) at the district or province or state level (or other administrative level depending on the country). • At secondary and tertiary health care facility level, hospital director, medical director, chief nurse and finance office director have a critical role in the decision to establish the minimum requirements for core component 1. • Existing IPC committee (or similar) at the facility or next administrative level. • Local partners have an important role in advocating for and supporting (also financially in some cases) the establishment of IPC minimum requirements at the facility level. WHAT (minimum requirements) WHO (is responsible for action) PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS NATIONAL LEVEL FACILITY LEVEL NATIONAL LEVEL FACILITY LEVEL 24 NATIONAL LEVEL SOURCES AND RESOURCES1 FACILITY LEVEL SOURCES AND RESOURCES • IPC assessment tool 2 (IPCAT2) – 1.1.1: an active national IPC programme exists. • IPCAT2 – 1.1.2: an appointed infection prevention focal person in charge of the IPC programme can be identified. • IPCAT2 – 1.1.4: the appointed infection prevention focal person has undergone training in IPC in the prevention of HAI. • IPCAT2 – 1.1.7: there is a dedicated budget allocated to the IPC programme. Sources • IPCAT2 results (where available; use the autogenerated results and graphics available in the Excel file of IPCAT2); https://www.who. int/infection-prevention/tools/core-components/en/. • WHO. State Party Self-assessment Annual Reporting Tool. International Health Regulations (2005). 2018; https://www.who. int/ihr/publications/WHO-WHE-CPI-2018.16/en/. • WHO. Joint External Evaluation (JEE) report (where available) 2nd edition, 2018; https://www.who.int/ihr/procedures/joint-external- evaluations/en/. • Food and Agriculture Organization of the United Nations; Organisation for Animal Health; WHO. Global monitoring of country progress on antimicrobial resistance (AMR): Tripartite AMR country self-assessment survey (TrACSS), version 3.0, report (where available). 2018; https://www.who.int/antimicrobial- resistance/global-action-plan/Tripartite-antimicrobial-resistance- country-self-assessment-questionnaire-2018-EN.pdf?ua=1. Sources • IPCAF results report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/ core-components/IPCAF-template.pdf?ua=1. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level. 2016; https://www. who.int/infection-prevention/publications/core-components/en/. • WHO. 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. 2018; https://www.who.int/infection- prevention/tools/core-components/facility-manual.pdf. • Twinning partnerships for improvement; https://www.who.int/ servicedeliverysafety/twinning-partnerships/en/. PRIMARY CARE • A trained IPC link person, with dedicated time is available in each primary health care facility. • IPC interventions included in the facility annual plan. • A trained IPC health care officer is available at the next administrative level (for example, district) to supervise the IPC link professionals. SECONDARY CARE • Infection prevention and control assessment framework tool (IPCAF) – 1.1: an IPC programme exists. • IPCAF – 1.3: at least one full-time trained IPC focal person (nurse or doctor) is in place per 250 beds. • IPCAF – 1.4: the IPC focal point has dedicated time for IPC activities in all facilities regardless of the number of beds. • IPCAF – 1.9: there is a dedicated budget specifically for the IPC programme, that is, covering IPC activities, including salaries. TERTIARY CARE • IPCAF – 1.1: an IPC programme exists. • IPCAF – 1.3: at least one full-time trained IPC focal person (nurse or doctor) is in place per 250 beds. • IPCAF – 1.6: there is a multidisciplinary IPC committee actively supporting the IPC team. • IPCAF – 1.9: there is a dedicated budget specifically for the IPC programme, that is, covering IPC activities, including salaries. • IPCAF – 1.10: the IPC programme has access to a microbiological laboratory, either present on- or off-site for routine day-to-day use. HOW (to measure progress) 1 Sources refers here to possible information that may be available from existing sources that can be used to extract relevant information in order to address each indicator. Resources lists available relevant implementation tools and resources. PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS NATIONAL LEVEL INDICATORS (YES/NO) FACILITY LEVEL INDICATORS (YES/NO) 25 Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core-components/en/. • WHO. Interim practical manual supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. • Association for Professionals in Infection Control and Epidemiology (APIC). HAI cost calculator; https://apic.org/ resources/cost-calculators/. • European Centre for Disease Prevention and Control. Core competencies for infection control and hospital hygiene professionals in the European Union. 2013; https://ecdc.europa. eu/sites/portal/files/media/en/publications/Publications/ infection-control-core-competencies.pdf. • At least one professional (nurse or doctor) must be given the responsibility of IPC at the national level. He/she should have at least basic knowledge and training on IPC (ideally, an IPC postgraduate certificate) and some practical experience. • Once the person is in place, having some resources (budget) is essential to operate. • Based on this, the objectives, functions and activity plan will be developed by the IPC focal point in collaboration with other national programmes and institutions, as well as external partners. PRIMARY CARE • The primary health care level is the first main point of entry of infectious pathogens to the health system and it is where IPC is usually weakest. • It is critical to establish at least a basic level of IPC and triage in primary care (that is, the minimum requirements) to avoid infection and AMR spread through the health system, including health care- associated outbreaks caused by human-to-human transmission of emerging or re-remerging pathogens. • It is important to have professionals in charge of IPC at different levels (facility and at the next administrative level) to support a programmatic approach based on coordination, supervision and accountability through monitoring and evaluation. • The existence of an IPC programme and practices at the primary care level will contribute to patient safety and quality of care and facilitate linkages to the community and dissemination of basic prevention principles among families, as well as patient and family engagement. • The link person should be a staff member at the primary health care facility level, trained in IPC and with dedicated time (part-time). • In facilities with more than 10 HCWs, the IPC link person should be in charge of the following functions: advising on procurement and maintenance of equipment and consumables for IPC; monitoring and supervising IPC activities; liaising with the relevant next administrative level IPC coordinators on the implementation of IPC activities; liaising with the regular disease notification system for the reporting of unusual events. • In facilities with less than 10 HCWs, the link person could have some of the above-mentioned functions but, overall, more support from the district officer will be needed, especially for monitoring activities. SECONDARY AND TERTIARY CARE • A comprehensive and functioning IPC programme should be in place in all acute health care facilities because evidence demonstrates a large effect on HAI reduction. • The existence of an IPC focal point and budget are necessary conditions for building an IPC programme with objectives and plans, and the necessary premise for any IPC action. • The number of staff needed depends on patient acuity and the complexity of care in the facility, as well as the multiple roles and responsibilities of IPC professionals. WHY (rationale and additional details on the minimum requirements) PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS NATIONAL LEVEL FACILITY LEVEL 26 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • Active, stand-alone, national IPC programme with clearly defined objectives, functions and activities. • Technical trained IPC team (medical and nursing professionals) with allocated time, budget and authority to make decisions. • Strong linkages of the national IPC programmes with other relevant national programmes and professional organizations. • Supported by at least one national external quality assurance system (EQAS) microbiological reference laboratory. • Supported by an official multidisciplinary IPC committee. PRIMARY CARE Not applicable. SECONDARY AND TERTIARY CARE • IPC programmes with clearly defined objectives based on local epidemiology and priorities according to risk assessment and functions that align with and contribute to the prevention of HAI and the spread of AMR in health care. • Dedicated, trained professionals in every acute care facility. • A minimum ratio of one full-time or equivalent IPC professional (nurse or doctor) per 250 beds or a higher ratio (one IPC professional per 100 beds) due to increased patient acuity and complexity, as well as the multiple roles and increasing responsibilities of the IPC professional. • External quality control system support of the microbiological laboratory is important for an effective IPC programme. Full core component requirements NATIONAL LEVEL FACILITY LEVEL 27 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS CORE COMPONENT 2: IPC GUIDELINES National IPC guidelines • Evidence-based, nationally-approved guidelines adapted to the local context and reviewed at least every five years. • National IPC focal point (and IPC team or committee, if existing) as guideline development and implementation are key activities in their mandate. • In a country where the IPC focal point/team is newly established and has limited experience/expertise, consider external IPC technical support as needed for initial guideline development/ review. • Another national responsible body (for example, the national centre for disease control, institute of public health) or an academic institution collaborating with the ministry of health may also play an important role in developing IPC guidelines/SOPs. PRIMARY CARE Facility-adapted SOPs and their monitoring • Evidence-based facility-adapted SOPs based on the national IPC guidelines. • At a minimum, the facility SOPs should include: ‐ hand hygiene ‐ decontamination of medical devices and patient care equipment ‐ environmental cleaning ‐ health care waste management ‐ injection safety ‐ HCW protection (for example, at least post-exposure prophylaxis, vaccinations) ‐ aseptic techniques ‐ triage of infectious patients ‐ basic principles of standard and transmission-based precautions. • Routine monitoring of the implementation of at least some of the IPC guidelines/SOPs. SECONDARY AND TERTIARY CARE all requirements as for the primary health care facility level, with additional SOPs on: • standard and transmission-based precautions (for example, detailed, specific SOPs for the prevention of airborne pathogen transmission); • aseptic technique for invasive procedures, including surgery; • specific SOPs to prevent the most prevalent HAIs based on local context/epidemiology; • occupational health (detailed). PRIMARY CARE • Trained IPC link person, with dedicated (part-) time and/or support from an appointed IPC person at the next administrative level. • If the expertise at the facility and next administrative level is limited, external support should be sought. SECONDARY AND TERTIARY CARE • The IPC focal point is responsible for writing and adapting the SOPs, promoting their adoption and monitoring adherence. If the expertise of the IPC focal point is limited, external support should be sought. • The development and implementation of the SOPs requires a functioning IPC programme and associated expertise to ensure that local recommended procedures refer to national or WHAT (minimum requirements) WHO (is responsible for action) NATIONAL LEVEL FACILITY LEVEL NATIONAL LEVEL FACILITY LEVEL 28 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • IPCAT2 – 2.1.1: the national IPC focal point has a mandate to work with key players to produce guidelines for the prevention and control of HAI. • IPCAT2 – 2.1.6: the national IPC focal point actively addresses guideline adaptation to reflect local conditions. • IPCAT2 – 2.1.3: the guidelines are reviewed at least every 5 years and updated to reflect the current evidence base. PRIMARY CARE • IPCAF – 2.2: facility-adapted SOPs are available for hand hygiene, decontamination of medical devices and patient care equipment, environmental cleaning, health care waste management, injection safety, HCW protection (for example, at least post-exposure prophylaxis, vaccinations), aseptic techniques, triage, basic principles of standard and transmission-based precautions. • IPCAF – 2.3: The guidelines/SOPs are consistent with national/ international IPC guidelines (if they exist). • IPCAF – 2.8: Routine monitoring of the implementation of at least some of the guidelines/SOPs is undertaken. SECONDARY AND TERTIARY CARE • IPCAF – 2.2: facility-adapted SOPs/guidelines are available for hand hygiene, decontamination of medical devices and patient care equipment, environmental cleaning, health care waste management, injection safety, HCW protection (for example, at least post-exposure prophylaxis, vaccinations), aseptic technique for invasive procedures, including surgery, triage, standard and transmission-based precautions, specific SOPs to prevent the most prevalent HAIs based on local context/epidemiology, and occupational health. • IPCAF – 2.3: the guidelines/SOPs are consistent with national/ international IPC guidelines (if they exist). • IPCAF – 2.8: routine monitoring of the implementation of at least some of the SOPs is undertaken. NATIONAL LEVEL INDICATORS (YES/NO) FACILITY LEVEL INDICATORS (YES/NO) international evidence-based guidelines and standards and are adapted to the context. • Relevant stakeholders (for example, link nurse or doctors, leading doctors, nurses, health care facility managers, champions, quality managers) should be involved in the development and adaptation of the SOPs. • Involvement of front-line HCWs should be considered in the development and implementation of SOPs. • The IPC focal point should also be responsible for organizing staff training on the SOPs and for monitoring adherence to the recommended procedures, in collaboration with others who may be in charge of training and assessment at the local level. HOW (to measure progress) NATIONAL LEVEL SOURCES AND RESOURCES FACILITY LEVEL SOURCES AND RESOURCES Source • IPCAT2 results (where available; use the autogenerated results and graphics available in the Excel file of IPCAT2); https://www.who.int/ infection-prevention/tools/core-components/en/. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core-components/en/. • WHO. Improving infection prevention and control at the health facility. Interim practical manual supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. Sources • IPCAF results report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/ core-components/IPCAF-template.pdf?ua=1. • Primary Health Care Performance Initiative. Primary health care progression model assessment tool report (where available). 2018; https://improvingphc.org/primary-health-care-progression-model. Tools and resources • WHO Guidelines on core components of IPC programmes at the national and acute health care facility level; https://www.who.int/ infection-prevention/publications/core-components/en/. • WHO. Improving infection prevention and control at the health facility: Interim practical manual supporting implementation of the WHO guidelines on core components of infection prevention 29 and control programmes. 2018; https://www.who.int/infection- prevention/tools/core-components/facility-manual.pdf. • CDC IPC guidelines library; https://www.cdc.gov/infectioncontrol/ guidelines/index.html. • APIC: list of IPC guidelines; https://apic.org/Professional-Practice/ Scientific-guidelines. • Asia Pacific Society for Infection Control IPC guidelines; http:// apsic-apac.org/guidelines-and-resources/apsicguidelines/. PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • The availability of national guidelines contributes to a reduction in the risk of HAIs and AMR, especially when implemented in combination with HCW education and training. • The development of IPC guidelines/protocols/SOPs and related implementation strategies is a key function of the national IPC focal point (or IPC team/programme if they exist). • National guidelines are necessary to indicate the IPC standards and measures that should be adhered to and monitored, including the appropriate training of HCWs at all levels. • National IPC guidelines should be evidence-based (that is, based on systematic reviews of the scientific literature and other existing guidelines) and ideally refer to/adapted from international standardized guidelines, if available. • Guideline content should be prioritized locally, based on the most frequent practices and/or types of HAI and adapted to local circumstances (for example, use of indwelling catheters and other devices, surgery and other invasive procedures). However, at a minimum, the guidelines should cover the following topics: ‐ hand hygiene ‐ decontamination of medical devices and patient care articles ‐ environmental cleaning ‐ health care waste management ‐ transmission-based precautions ‐ injection safety ‐ HCW protection ‐ aseptic techniques ‐ triage ‐ development and implementation of strategies for training on and dissemination of the IPC guidelines are part of the minimum requirements. • Regular updates (that is, at least every 5 years) are required to ensure that the guidelines reflect current evidence and remain topical and practical to the evolution of health care delivery. PRIMARY CARE • At the facility level, it is not necessary to have the expertise required to develop evidence-based guidelines. It is important to develop SOPs for the implementation and monitoring of available national or international guidelines. • IPC link professionals at the facility level should work with the IPC focal points at the next administrative level (for example, district) to develop adapted SOPs based on the national (or international) guidelines for primary care. • Monitoring adherence to SOP implementation is essential to evaluate its adoption and effectiveness to achieve the desired outcomes and to assist with adjustments and improvements of the implementation strategies. IPC monitoring and supervision should be assured by the health care officer in charge of IPC at the next administrative level (for example, district). • Adaptation to local conditions should be considered for the most effective uptake and implementation. SECONDARY AND TERTIARY CARE • See all points indicated for the primary health care facility level. • A higher level of IPC expertise is required to develop SOPs in secondary and tertiary health care facilities due to the increase in acuity and complexity of care provided. • Facility-adapted SOPs should be prioritized locally, based on the most frequent practices and/or with practices associated with an increase in the risk of HAI and adapted to local circumstances (for example, use of indwelling catheters and other devices, surgery and other invasive procedures). WHY (rationale and additional details on the minimum requirements) NATIONAL LEVEL FACILITY LEVEL • Development of national guidelines and related implementation strategies are a function of the national IPC team or focal point and require IPC expertise. Requirements (which are under the responsibility of the national programme) for developing and implementing effective national IPC guidelines: ‐ IPC expertise for development or adaptation; ‐ local prioritization; ‐ providing resources, infrastructures and supplies for enabling implementation; PRIMARY CARE Not applicable. SECONDARY AND TERTIARY CARE No major differences to be noted compared to the minimum requirements. Full core component requirements NATIONAL LEVEL FACILITY LEVEL 30 ‐ HCW education on recommended practices; ‐ monitoring implementation and adherence; ‐ regular updates. • To fully accomplish core component 2, guidelines on all the following topics should be developed at the national level (either in one main guideline or in specific guidelines, as feasible and appropriate according to the local context): ‐ standard precautions: · hand hygiene · use of PPE · sterilization and medical device decontamination · safe handling of linen and laundry · health care waste management · patient placement · respiratory hygiene and cough etiquette · environmental cleaning · injection safety · HCW protection, safety and post-exposure prophylaxis. ‐ transmission-based precautions; ‐ aseptic technique and device management for clinical procedures; ‐ specific guidelines to prevent the most prevalent HAIs (for example, catheter-associated urinary tract infection, surgical site infection, central line-associated bloodstream infection, ventilator-associated pneumonia), depending on the context and complexity of care. • Early engagement and participation of stakeholders in the development and production of guidelines is vital to ensure consensus and better buy-in. PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS 31 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS CORE COMPONENT 3: IPC EDUCATION AND TRAINING National training policy and curriculum • National policy that all HCWs are trained in IPC (in-service training). • An approved IPC national curriculum aligned with national guidelines and endorsed by the appropriate body. • National system and schedule of monitoring and evaluation to check on the effectiveness of IPC training and education (at least annually). PRIMARY CARE IPC training for all frontline clinical staff and cleaners upon hire • All front-line clinical staff and cleaners must receive education and training on the facility IPC guidelines/SOPs upon employment. • All IPC link persons in primary care facilities and IPC officers at the district level (or other administrative level) need to receive specific IPC training. SECONDARY CARE IPC training for all front-line clinical staff and cleaners upon hire: • All front-line clinical staff and cleaners must receive education and training on their IPC guidelines/SOPs upon employment. • All IPC staff need to receive specific IPC training. TERTIARY CARE IPC training for all front-line clinical staff and cleaners upon employment and annually • All front-line clinical staff and cleaners must receive education and training on the facility IPC guidelines/SOPs upon employment and annually. • All IPC staff need to receive specific IPC training either on-line or participate in courses. WHAT (minimum requirements) NATIONAL LEVEL FACILITY LEVEL • IPC focal point (and IPC team or committee if they exist) at the ministry of health or other national responsible body as IPC education and training are key activities in their mandate. • Senior leads in key positions at the ministry level, including ministries of health and education. • Local academic institutions, including universities and others with a mandate on health workforce education, have a key role in curricula development and endorsement, and in training delivery. • It is important to include all other relevant programmes and national actors and identify key joint areas of work across education and training efforts. • In a country where the IPC focal point/team is newly established and has limited experience/expertise, consider external IPC technical support as needed for initial IPC curriculum development and implementation. PRIMARY CARE • Trained IPC officer at the next administrative level (for example, district) is responsible for training IPC link persons, front-line HCWs and cleaners in primary care facilities, according to a plan and strategy developed at the national level. • IPC officers at the next administrative level (for example, district) should be trained by the national or sub-national level. • IPC expertise is required to lead IPC training. • If the expertise at the next administrative level is limited, external support should be sought. • IPC link persons should provide on-the-job supervision/ mentorship to HCWs and cleaners in their facility. SECONDARY AND TERTIARY CARE • The IPC focal point (or IPC team if it exists) is responsible for training front-line HCWs and cleaners. • IPC expertise is required to lead IPC training. • If the expertise of the IPC focal point is limited, external support should be sought, for example, at the regional or national level. • In addition, non-IPC personnel with adequate skills (for example, link nurses/practitioners or champions and opinion leaders) could play a role of mentorship to refresh IPC principles and champion IPC practices at the ward level. WHO (is responsible for action) NATIONAL LEVEL FACILITY LEVEL 32 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • IPCAT2 – 3.1.1: the national IPC programme provides guidance and recommendations for in-service training at the facility level (for example, frequency, expertise required, requirements for new employee orientation, monitoring and evaluation approaches). • IPCAT2 – 3.1.2: the national IPC programme provides content and support for IPC training of all HCWs at the facility level. • IPCAT2 –3.2.5: IPC training is integrated into continuing medical, nursing and allied health professional education and training. • IPCAT2 – 3.3.1: a national system and schedule of monitoring and evaluation is in place to check on the effectiveness of training and education, for example, at least annually. Possible additional indicators • National policy on HCW training developed. • National IPC curriculum for HCWs developed, approved and endorsed by an appropriate professional society/body. PRIMARY CARE • All new front-line HCWs receive orientation education and training on IPC guidelines/SOPs. • All new cleaning staff receive orientation education and training on IPC guidelines/SOPs. • Specific IPC training/education is offered for IPC link professionals in primary care facilities. • Specific IPC training/education is offered for IPC staff at the district level. SECONDARY CARE • IPCAF – 3.3: all new front-line HCWs receive orientation education and training on IPC guidelines/SOPs. • IPCAF – 3.4: all new cleaning staff receive orientation education and training on IPC guidelines/SOPs. • IPCAF – 3.10: specific IPC training/education is offered for IPC professionals. TERTIARY CARE • IPCAF – 3.3: all new front-line HCWs receive orientation and at least annual education and training on IPC guidelines/SOPs. • IPCAF – 3.4: all new cleaning staff receive orientation and at least annual education and training on IPC guidelines/SOPs. • IPCAF – 3.10: specific IPC training/education is offered for IPC professionals. NATIONAL LEVEL INDICATORS (YES/NO) FACILITY LEVEL INDICATORS (YES/NO) HOW (to measure progress) NATIONAL LEVEL SOURCES AND RESOURCES FACILITY LEVEL SOURCES AND RESOURCES Sources • IPCAT2 results (where available; use the autogenerated results and graphics available in the Excel file of IPCAT2); https://www.who. int/infection-prevention/tools/core-components/en/. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core-components/en/. • WHO. Improving infection prevention and control at the health facility: Interim practical manual supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. Source • IPCAF results report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/ core-components/IPCAF-template.pdf?ua=1. Tools and resources • WHO Guidelines on core components of IPC programmes at the national and acute health care facility level (2016) for more information; https://www.who.int/infection-prevention/ publications/core-components/en/. • WASH FIT; https://apps.who.int/iris/bitstream/hand le/10665/254910/9789241511698-eng.pdf?sequence=1. • WHO. 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. 2018; https://www.who.int/infection- prevention/tools/core-components/facility-manual.pdf. • When coupled with national IPC guidelines, training contributes to a reduction in HAI and AMR and a more skilled health workforce. • Supporting and facilitating training at all levels should be considered an important indicator for assessing the impact of IPC programmes. PRIMARY CARE • IPC education and training are critical to developing a competent and skilled workforce. At a minimum, an emphasis on a basic level of IPC and triage in primary care to avoid infection and AMR spread through the health system, including health care-associated outbreaks. WHY (rationale and additional details on the minimum requirements) NATIONAL LEVEL FACILITY LEVEL 33 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • The IPC focal point/team should be specifically trained on the use of multimodal strategies for implementing IPC interventions. • Training and curricula content should be based on the national guidelines and SOPs and then prioritized locally, based on the most frequent practices and/or types of HAI. • Basic concepts of multimodal strategies implementation should be included in the training of IPC link professionals and IPC staff. • Ensuring an orientation upon employment will provide a baseline knowledge to all front-line staff and cleaners, while recognizing that ongoing educational opportunities are the gold standard. • Patient and visitor education remains an important consideration. In particular, whenever family members assume care activities, they should receive tailored IPC training in order to protect themselves and their loved ones and thus minimize any possibility of cross- transmission. Patient and family education at the facility level can also stimulate the use of appropriate hygiene measures in the community, such as handwashing with soap. SECONDARY AND TERTIARY CARE • IPC education that involves front-line HCWs in a practical, hands-on approach and incorporates individual experiences is associated with decreased HAI and increased hand hygiene compliance. • Three categories of human resources were identified as targets for IPC training and requiring different strategies and training content: IPC specialists; all HCWs involved in service delivery and patient care; and other personnel that support health service delivery (administrative and managerial staff, auxiliary service staff, cleaners, etc.). • The IPC focal person/team should be specifically trained on the use of multimodal strategies for implementing IPC interventions. • Patient and family education remains an important consideration (see above). • In particular for tertiary care facilities, providing training refreshers annually is a minimum requirement. • The national IPC programme should: ‐ develop IPC pre- and postgraduate and in-service curricula in collaboration with local academic institutions for: · IPC specialists · all HCWs involved in service delivery and patient care · other personnel (administrative and managerial staff, auxiliary service staff, cleaners); ‐ develop some standardized training tools to support curricula implementation, aligned with national technical guidelines and international IPC standards. • In addition to the curricula and tool development, appropriate steps should be undertaken for the approval, adoption and roll-out of the curricula by all health faculties (for example, medicine, nursing, midwifery, dentistry, laboratory, etc.). • Clear career pathways for IPC professionals should be established at the national level. • Consideration should be given to the teaching methods and modalities and grounded in adult education principles. The following training methods could be included: problem-based learning; hands-on workshops; focus groups; peer-to-peer training; classroom-based simulation; and bedside training. PRIMARY CARE Not applicable. SECONDARY AND TERTIARY CARE • Mandatory IPC training should be ensured for all HCWs, including those providing direct patient care (for example, doctors, nurses, nurse aides, midwives, attendants, personal support workers, etc.) and administrative and managerial staff, auxiliary service staff, and cleaners, based on their functions and facility-adapted SOPs. This includes: ‐ new employee orientation ‐ continuous educational opportunities for existing staff (at least annually). • In-service training should be practical and complementary to WASH and other training areas (for example, quality improvement). • IPC education and training should be a part of an overall health facility education strategy, including new employee orientation and the provision of continuous educational opportunities for existing staff, regardless of level and position (for example, including also senior administrative and housekeeping staff). • IPC staff should be trained on specific IPC functions specific to the tertiary care level and in line with facility-adapted IPC SOPs. Periodic evaluations of both the effectiveness of training programmes and assessment of staff knowledge should be undertaken on a routine basis. Full core component requirements NATIONAL LEVEL FACILITY LEVEL 34 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS CORE COMPONENT 4: HAI SURVEILLANCE IPC surveillance and monitoring technical group • Establishment by the national IPC focal point of a technical group for HAI surveillance and IPC monitoring that: ‐ is multidisciplinary ‐ develops a national strategic plan for HAI surveillance (with a focus on priority infections based on the local context) and IPC monitoring. PRIMARY CARE • HAI surveillance is not required as a minimum requirement at the primary facility level, but should follow national or sub- national plans, if available (for example, detection and reporting of outbreaks affecting the community is usually included in the national plans). SECONDARY CARE • HAI surveillance should follow national or sub-national plans. TERTIARY CARE • Active HAI surveillance should be conducted and include information on AMR. • Enabling structures and supporting resources need to be in place (for example, dependable laboratories, medical records, trained staff), directed by an appropriate method of surveillance. • The method of surveillance should be directed by the priorities/ plans of the facility and/or country (for example, point prevalence studies to gather a quick snapshot of the situation, or longitudinal prospective surveillance of surgical site infection if this was identified as a problem). • Timely and regular feedback needs to be provided to key stakeholders in order to lead to appropriate action, in particular to the hospital administration. WHAT (minimum requirements) NATIONAL LEVEL FACILITY LEVEL • The national IPC lead/focal point (and IPC technical team or committee, if existing) at the ministry of health or national body responsible for IPC should take action to convene the technical group for HAI surveillance and IPC monitoring. • Ideally, the technical group should include microbiologists, clinicians, laboratory technicians, epidemiologists, professionals working in other surveillance systems, statisticians, data managers and information technology experts, and monitoring and evaluation experts. • Linkage to other relevant surveillance programmes should be established, in particular alignment with surveillance of AMR. PRIMARY AND SECONDARY CARE • If HAI surveillance is conducted, a trained IPC link person/focal point, according to national or sub-national plans. TERTIARY CARE • The IPC focal point (or IPC team/committee if existing) is responsible for putting together a team for HAI/AMR surveillance, and then planning and conducting surveillance, and analysing, interpreting and disseminating the collected data. • The team should be multidisciplinary, ideally including epidemiologists, statisticians, infection control, data managers and information technology experts with the appropriate capacity. At least some of this expertise should be available. • The IPC focal point should be trained in basic epidemiology and surveillance methods. • Linkage to other relevant surveillance programmes should be established, in particular alignment with surveillance of AMR. WHO (is responsible for action) NATIONAL LEVEL FACILITY LEVEL 35 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • A multidisciplinary technical group for HAI surveillance is established at the national level. • A national strategic plan for HAI surveillance (with a focus on priority infections based on the local context) is in place. • IPCAT2 – 4.1.3: the national IPC programme (or collaborating partner) leads are designated to coordinate the national HAI surveillance programme and network. PRIMARY CARE • Note: HAI surveillance is not required, but should follow national or sub-national plans, if available. • If conducted, HAI surveillance is undertaken in accordance with national plans (yes/no/not applicable). SECONDARY CARE • HAI surveillance is undertaken in accordance with national plans. TERTIARY CARE • IPCAF – 4.1: active surveillance is a defined component of the IPC programme • IPCAF – 4.2: do you have personnel responsible for surveillance activities? • IPCAF – 4.3: staff responsible for surveillance activities have been trained in basic epidemiology, surveillance and IPC (that is, capacity to oversee surveillance methods, data management and interpretation). • IPCAF – 4.5: a prioritization exercise is used to determine the method of surveillance according to the local context (that is, identifying infections that are major causes of morbidity and mortality in the facility). • IPCAF – 4.8: reliable surveillance case definitions (defined as numerator and denominator according to international definitions, for example, CDC National Healthcare Safety Network/European Centre for Disease Prevention and Control) are used or adapted through an evidence-based adaptation process and expert consultation. • IPCAF – 4.14: timely and regular feedback (for example, quarterly/half-yearly/annually) is provided to key stakeholders in order to lead to appropriate action, in particular to the hospital administration. • Enabling structures and supporting resources (for example, EQAS microbiological reference laboratory, medical records with sufficient clinical information to determine HAI case definitions, dedicated staff time) are in place to support HAI surveillance. • Active surveillance is conducted for colonization or infections caused by multidrug-resistant pathogens according to the local epidemiological data. NATIONAL LEVEL INDICATORS (YES/NO) FACILITY LEVEL INDICATORS (YES/NO) HOW (to measure progress) NATIONAL LEVEL SOURCES AND RESOURCES FACILITY LEVEL SOURCES AND RESOURCES Source • IPCAT2 results (where available; use the autogenerated results and graphics available in the Excel file of IPCAT2); https://www.who. int/infection-prevention/tools/core-components/en/. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level for more information. 2016; https://www.who.int/infection-prevention/publications/ core-components/en/. • WHO. Improving infection prevention and control at the health facility: Interim practical manual supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. Source • IPCAF results report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/ core-components/IPCAF-template.pdf?ua=1. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level for more information. 2016; https://www.who.int/infection-prevention/publications/core- components/en/. • WHO. 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. 2018; https://www.who.int/infection- prevention/tools/core-components/facility-manual.pdf. 36 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • HAI surveillance is the first step (minimum requirement) to assess the magnitude of the burden of disease by the systematic collection of data in targeted wards/unit. As a first step, when a HAI surveillance system is not in place, a multidisciplinary technical group should develop a plan for surveillance. • This group will have the task of identifying: ‐ priorities and methods for surveillance; ‐ a comprehensive surveillance plan for HAIs and IPC monitoring; ‐ a centralized, national reporting mechanism; ‐ a minimum set of data (outcomes, indicators or other information) for surveillance, including providing a baseline assessment; ‐ roles and responsibilities for the implementation of HAI surveillance at facility level. • Prioritization should not only be based on vertical systems (for example, human immunodeficiency virus, tuberculosis, malaria, influenza, Salmonella spp., etc.), but should consider essential targets of HAI prevention, for example, reduction of the number of surgical site or bloodstream infections. • The national level could also consider the development of a policy/ regulations to mandate HAI surveillance in facilities, according to the minimum requirements specified below. • Surveillance of HAIs should be aligned with the priorities of the AMR national action plan. PRIMARY CARE • The detection and reporting of outbreaks affecting the community to national authorities should be included in national or sub-national plans. SECONDARY CARE • Given the low level of specialized care, HAI surveillance in secondary care was not strictly considered by expert consensus as a minimum requirement; monitoring of IPC indicators was considered more important. • Some secondary facilities may decide to conduct surveillance of relevant HAIs, such as surgical site infections, depending on the type of care delivered and the facility’s capacity and prioritization of the core components. • Reporting outbreaks in the health care facility or affecting the community to national authorities should be included in national or sub-national plans. TERTIARY CARE • HAIs and AMR are a burden in intensive care units and other highly specialized units/wards where invasive interventions carry more risks for HAIs and patients have a higher risk of death due to these infections. • For this reason, targeted HAI surveillance is necessary at tertiary health care level. • To ensure implementation of the national surveillance plan, a HAI surveillance team should be in place in every tertiary hospital. • Prioritization is also the responsibility of the IPC team, and a prioritization exercise should be conducted in line with national recommendations. • The team should develop a surveillance strategic plan according to present capacities including: ‐ purpose; ‐ target sample and infection outcomes; ‐ identification of a national reference laboratory and quality assurance capacities; ‐ development/careful adaptation of case definitions. • Timely feedback to hospital leadership and front-line HCWs is considered as one the most critical parts of surveillance and monitoring. Facilities should consider defining the timeliness of feedback (for example, monthly or bi-monthly). • The IPC focal team should tailor its surveillance methodology to available resources and priorities in line with national recommendations. WHY (rationale and additional details on the minimum requirements) NATIONAL LEVEL FACILITY LEVEL • A national HAI surveillance programme and networks that include mechanisms for the timely feedback of monitoring and evaluation data feedback should be established, with the potential to be used for benchmarking purposes. • Surveillance programmes should be supported by: ‐ engaged governments and other respective authorities; ‐ allocated human and financial resources; ‐ microbiology and laboratory capacity (at least one national PRIMARY CARE Not applicable. SECONDARY AND TERTIARY CARE • Facility-based HAI surveillance should be performed to guide IPC interventions and detect outbreaks, including AMR. • Hospital-based infection surveillance systems should be linked to integrated public health infection surveillance systems. Full core component requirements NATIONAL LEVEL FACILITY LEVEL 37 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS reference laboratory), with standardized definitions and laboratory methods; ‐ an informatics system for data collection and analysis. • Surveillance programmes should meet the following criteria: ‐ demonstrate clear objectives, a standardized set of case definitions, methods for detecting HAIs (numerators) and the exposed population (denominators), including a process for the analysis of data and reports and a method for evaluating the quality of the data; ‐ establish clear regular reporting lines of HAI surveillance data from the local facility to the national level; ‐ adapt international guidelines on HAI definitions at country level before implementing them; ‐ include a national training programme for performing surveillance to ensure the appropriate and consistent application of national surveillance guidelines and protocols; ‐ provide data to guide the development and implementation of effective control interventions. • The surveillance programme should provide data on infections: ‐ that may become epidemic in the health care facility (early detection of outbreaks); ‐ commonly observed in vulnerable populations (for example, neonates, burn patients, patients in intensive care units and immunocompromised hosts); ‐ that may cause severe outcomes, such as high case fatality and patient morbidity and suffering; ‐ caused by resistant microorganisms with an emphasis on multidrug- resistant pathogens; ‐ associated with selected invasive devices or specific procedures, such as the use of intravascular devices, indwelling urinary catheters and surgery; ‐ that may affect HCWs (for example, hepatitis B and C and human immunodeficiency virus). • Feedback of results to HCWs and stakeholders through national networks should be timely. • Surveillance should be based on national recommendations and standard definitions and customized to the facility, according to available resources with clear objectives and strategies. • Methods for detecting infections should be active. Different surveillance strategies could include the use of prevalence or incidence rates of HAI and AMR pathogens. A system for surveillance data quality assessment should be in place. • Surveillance should be based on clinical and/or microbiology data and supported by laboratory capacity with EQAS • The IPC committee and IPC team are responsible for planning and conducting HAI surveillance and analysing, interpreting and disseminating the data collected. For this reason, surveillance activities should be conducted by trained staff (ideally full-time) able to plan, collect and manage the data and convene meetings with the team, the committee and other key players. • Surveillance should provide information for: ‐ describing the status of infections associated with health care (that is, incidence and/or prevalence, type, aetiology and, ideally, data on severity and the attributable burden of disease); ‐ identification of the most relevant AMR susceptibility patterns; ‐ identification of high-risk populations, procedures and exposures; ‐ early detection of clusters and outbreaks (that is, early warning system); ‐ evaluation of the impact of interventions. 38 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS CORE COMPONENT 5: MULTIMODAL STRATEGIES Multimodal improvement strategies for IPC interventions • Use of multimodal strategies to implement IPC interventions according to national guidelines/SOPs, under the coordination of the national IPC focal point (or team, if existing). PRIMARY CARE Multimodal strategies for priority IPC interventions • Use of 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. SECONDARY CARE Multimodal strategies for priority IPC interventions • Use of multimodal strategies – at the very least to improve each item of standard and transmission-based precautions and triage. TERTIARY CARE Multimodal strategies for all IPC interventions • Use of multimodal strategies to implement interventions to improve each item of standard and transmission-based precautions, triage, and those targeted at the reduction of specific infections (for example, surgical site or catheter- associated infections) in high-risk areas/patient groups, according to local priorities. WHAT (minimum requirements) NATIONAL LEVEL FACILITY LEVEL • The IPC focal point (and IPC technical team or committee, if existing) at the ministry of health or national body responsible for IPC, as multimodal interventions are key activities in their mandate. • Senior leads in key positions at the ministry level. Convincing high level senior managers and key professionals of the value of employing multimodal strategies at the national and facility level is important and dependent on effective communication and advocacy. • Key members and teams of all other relevant programmes and national actors who will be responsible for the implementation of the IPC programme, including possible joint areas of work. • National and local experts on implementation science, as well as those from the fields of behavioural science and communication. PRIMARY, SECONDARY AND TERTIARY CARE • Trained IPC link person and IPC focal point with the support of an IPC-trained health care officer at the next administrative level are responsible for using a multimodal approach for the implementation of IPC interventions/SOPs. • Successful multimodal strategies include the involvement of champions or role models. • Collaboration with colleagues in quality improvement and patient safety to develop and promote multimodal strategies should be addressed. WHO (is responsible for action) NATIONAL LEVEL FACILITY LEVEL • IPCAT2 – 5.1.1: the appointed IPC focal point is trained and competent in implementation science and multimodal behaviour change strategies. PRIMARY CARE • IPCAF – 5.1: multimodal strategies are used to implement priority IPC interventions (at the very least to improve hand NATIONAL LEVEL INDICATORS (YES/NO) FACILITY LEVEL INDICATORS (YES/NO) HOW (to measure progress) 39 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • IPCAT2 – 5.1.2: promotion of multimodal strategies through the inclusion of the approach in the development of IPC guidelines, education and training. hygiene, safe injection practices, decontamination of medical instruments and devices and environmental cleaning). SECONDARY CARE • IPCAF – 5.1: multimodal strategies are used to implement priority IPC interventions (at the very least to implement interventions to improve standard and transmission-based precautions and triage). TERTIARY CARE • IPCAF – 5.1: multimodal strategies are used to implement all IPC interventions and to improve standard and transmission- based precautions, triage, and those targeted at the reduction of specific infections in high-risk areas/vulnerable patient groups, in line with local health priorities. NATIONAL LEVEL SOURCES AND RESOURCES FACILITY LEVEL SOURCES AND RESOURCES Source • IPCAT2 results (where available; use the autogenerated results and graphics available in the Excel file of IPCAT2); https://www.who. int/infection-prevention/tools/core-components/en/. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core-components/en/. • WHO. Improving infection prevention and control at the health facility: Interim practical manual supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. Source • IPCAF results report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/ core-components/IPCAF-template.pdf?ua=1. Tools and resources • WHO Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www.who.int/infection-prevention/publications/core- components/en/. • WHO. 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. 2018; https://www.who.int/infection- prevention/tools/core-components/facility-manual.pdf. • WHO multimodal improvement strategy leaflet; https://www. who.int/infection-prevention/publications/ipc-cc-mis.pdf?ua=1. • According to the available scientific evidence, multimodal strategies are the most effective approach to implement hand hygiene programmes and other IPC interventions (for example, to reduce central line-associated bloodstream infections and surgical site infections) in order to achieve the key elements for success that support IPC progress and, ultimately, a measurable impact that benefits patients and HCWs, such as system change, creation of an enhanced patient safety climate and HCW behavioural change. • The IPC focal point/team should be specifically trained on the use of multimodal strategies for the implementation of IPC interventions. • Multimodal strategies for implementing IPC interventions should be explicitly indicated in the national IPC action plans, including all 5 key elements identified by WHO as needed for each IPC intervention selected and according to the local context. • The national IPC focal person or team should develop a national multimodal strategy framework to facilitate implementation of the prioritized IPC interventions at facility level in the context of quality improvement. PRIMARY CARE • Multimodal strategies should be used for any IPC intervention at all levels of the health care system because their effectiveness is supported by strong evidence. • However, it is recognized that multimodal strategies are complex approaches to be put in place. Thus, the interventions included in the minimum requirements are the priority ones among those that should be included in SOPs and training for the primary health care level (see minimum requirements for core components 2 and 3). SECONDARY AND TERTIARY CARE • Multimodal strategies should be used for any IPC intervention at all levels of the health care system in order to provide safe and effective health care delivery. • Complexity of care and human resources (including in the IPC team) vary across secondary and tertiary care facilities and the scope of the minimum requirements may vary according to the local context. • Specialized/complex services are provided in tertiary care facilities. • In tertiary care facilities, there is an increased potential for transmission of infection due to prolonged hospital stay, more WHY (rationale and additional details on the minimum requirements) NATIONAL LEVEL FACILITY LEVEL 40 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS complex procedures being performed and the admission of high-risk vulnerable populations. • Compelling evidence is available on the effectiveness of multimodal strategies to reduce infections in high-risk areas/patient groups. • It is the mandate of the national IPC programme to ensure that all IPC interventions are implemented using multimodal strategies. • The national IPC programme should facilitate the use of multimodal strategies by ensuring that the following elements are in place to support their use: ‐ expertise and necessary resources including policies, regulations and tools; ‐ overall organizational culture change to achieve an enhanced patient safety climate; ‐ coordination and teamwork; ‐ linkages with quality improvement initiatives and health facility accreditation; ‐ local adaptation. PRIMARY CARE Not applicable. SECONDARY AND TERTIARY CARE • Multimodal strategies must be used for implementing any IPC intervention at all levels of the health care system. • Overall organizational culture change is a key element to prioritize within multimodal strategies as effective IPC can be a reflector of quality care, a positive organizational culture, and an enhanced patient safety climate. • Successful multimodal strategies include the involvement of champions or role models. • Implementation of multimodal strategies within health care institutions needs to be linked to national quality aims and initiatives, including health care quality improvement initiatives or health facility accreditation bodies. Full core component requirements NATIONAL LEVEL FACILITY LEVEL 41 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS CORE COMPONENT 6: MONITORING, AUDIT AND FEEDBACK IPC surveillance and monitoring technical group • Establishment by the national IPC focal point of a technical group for HAI surveillance and IPC monitoring that: ‐ is multidisciplinary; ‐ develops a national strategic plan for HAI surveillance and IPC monitoring; ‐ develops an integrated system for the collection and analysis of data (for example, protocols, tools); ‐ provides training at the facility level to collect and analyse these data; ‐ develops recommendations for minimum process indicators (for example, hand hygiene). PRIMARY CARE • Monitoring of IPC structural and process indicators should be put in place at primary care level, based on IPC priorities identified in the other components. This requires decisions at the national level and implementation support at the sub-national level. SECONDARY AND TERTIARY CARE • A person responsible for the conduct of the periodic or continuous monitoring of selected indicators for process and structure, informed by the priorities of the facility or the country. • Hand hygiene is an essential process indicator to be monitored. • Timely and regular feedback needs to be provided to key stakeholders in order to lead to appropriate action, particularly to the hospital administration. WHAT (minimum requirements) NATIONAL LEVEL FACILITY LEVEL • The IPC lead/focal point (and IPC technical team or committee at the ministry of health or national body responsible for IPC) should take action to convene the technical group for HAI surveillance and IPC monitoring (same group as for core component 4). • Ideally, the technical group should include microbiologists, laboratory technicians, epidemiologists, professionals working in other surveillance systems, statisticians, data managers and information technology experts and monitoring and evaluation experts. • Liaison should be ensured with: ‐ senior leads in key positions at the ministry level; ‐ team members of all other relevant programmes and national actors who are involved in the implementation and monitoring of the IPC programme, including national quality and patient safety leaders. PRIMARY, SECONDARY AND TERTIARY CARE • Trained IPC link person/focal point/ IPC officer (or IPC committee/team if existing) are responsible for audit and feedback and should be trained in auditing technique plans. WHO (is responsible for action) NATIONAL LEVEL FACILITY LEVEL • A multidisciplinary technical group for IPC monitoring is established at the national level. • IPCAT2 – 6.2: A well-defined plan focusing on IPC outcomes, processes and strategies, with clear goals, targets and operational plans is in place. • IPC indicators integrated with national monitoring systems, for example, health management information systems. PRIMARY CARE • IPCAF – 6.2: a well-defined monitoring plan with clear goals/ objectives, targets and activities focused on IPC structural and process indicators (including tools to collect data in a systematic way) is in place based on IPC priorities identified in the other components and, importantly, informed by decisions at the national level and implementation support at the sub-national level. NATIONAL LEVEL INDICATORS (YES/NO) FACILITY LEVEL INDICATORS (YES/NO) HOW (to measure progress) 42 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS • A mechanism to train national and local auditors is in place. • Hand hygiene compliance monitoring and feedback is identified as a minimum indicator, at the very least for reference hospitals. SECONDARY AND TERTIARY CARE • IPCAF – 6.1: A trained person responsible for conducting periodic or continuous monitoring/audit of selected indicators for process (for example, hand hygiene) and structure is in place and informed by the priorities of the facility or country. • Monitoring of hand hygiene compliance is undertaken using the WHO hand hygiene observation tool or equivalent. • IPCAF – 6.4: monitoring of hand hygiene strategies is undertaken using the WHO Hand Hygiene Self-Assessment Framework Survey. • IPCAF – 6.5: timely and regular feedback of auditing reports (for example, feedback on hand hygiene compliance data or other processes) on the state of IPC activities/performance is provided to key stakeholders, in order to lead to appropriate action, particularly to the hospital management and senior administration. • Setting up national monitoring of indicators of IPC practices, processes and infrastructures is usually more feasible than establishing HAI surveillance as a first step for gathering data to inform IPC action. • The technical group indicated as the minimum requirement for core component 4 should be the same group responsible for core component 6. • Monitoring IPC practices and providing feedback to concerned stakeholders are critical to achieve behaviour change or other process modifications that improve the quality of care and reduce HAIs and AMR. • Monitoring and feedback are also aimed at engaging stakeholders, creating partnerships and developing working groups and networks. • Consideration should be given to policies that create incentives (positive or negative) tied to indicators in order to generate buy-in from hospital administrators. • Data from existing data sources (for example, Joint External PRIMARY CARE • IPC monitoring is critical to identify improvement action needed and should be in line with national recommendations and priorities. • Monitoring of indicators of IPC practices, processes and infrastructures should be feasible at the primary care level, whereas HAI surveillance is not applicable. • Hand hygiene infrastructure (for example, hand hygiene stations at the point of care or ABHR consumption) could be considered as a first step to monitoring. • Hand hygiene compliance monitoring according to the WHO observation method is considered the gold standard. • In many primary care facilities, one person responsible for the monitoring of indicators should be identified and this activity requires support at the sub-national level (for example, district). • The selection of indicators to be monitored should be driven at national level, with input at regional/sub-national level. • Any decision should be in line with decisions on other core components. WHY (rationale and additional details on the minimum requirements) NATIONAL LEVEL FACILITY LEVEL NATIONAL LEVEL SOURCES AND RESOURCES FACILITY LEVEL SOURCES AND RESOURCES Source • IPCAT2 results (where available; use the autogenerated results and graphics available in the Excel file of IPCAT2); https://www.who. int/infection-prevention/tools/core-components/en/. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core-components/en/. • WHO. Improving infection prevention and control at the health facility: Interim practical manual supporting national implementation of the WHO guidelines on core components of infection prevention and control programmes. 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. • WHO hand hygiene monitoring and feedback tools (updated in 2009); https://www.who.int/gpsc/5may/tools/evaluation_ feedback/en/. Source • IPCAF results report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/ core-components/IPCAF-template.pdf?ua=1. Tools and resources • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core-components/ en/. • WHO. 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. 2018; https://www.who.int/infection- prevention/tools/core-components/facility-manual.pdf. • WHO hand hygiene monitoring and feedback tools (updated in 2009); https://www.who.int/gpsc/5may/tools/evaluation_ feedback/en/. • WHO Hand Hygiene Self-Assessment Framework; https://www. who.int/gpsc/5may/hhsa_framework/en/. 43 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS Evaluation or Service Availability and Readiness Assessment) should be considered, particularly at the beginning when identifying priorities. • If possible, integration with existing national health information systems and routine facility monitoring would be critical for streamlining data collection and making linkage/correlations. • Hand hygiene (including compliance monitoring and/or infrastructure indicators) is considered a crucial indicator according to WHO recommendations. This activity should be decided upon at national level according to the highest standards to avoid any misrepresentation of compliance levels. • Surveillance of other structure and process indicators should be considered, prioritizing those that drive action. • Other indicators to be monitored should also provide information on IPC enablers (for example, related to WASH, availability of structures) and be considered as basic essentials for IPC. • Data gathered through IPC monitoring should guide priority setting in the national IPC strategic plan. • Based on all these considerations, a plan for regular monitoring at the facility level should be developed at the national level, including plans for feedback and for supervision to assist in the development and implementation of improvement plans. SECONDARY AND TERTIARY CARE • IPC monitoring is critical to identify improvement action and should be combined with HAI surveillance and in line with national recommendations and priorities. • Principles and minimum requirements for monitoring and auditing should not change between secondary and tertiary care; more indicators might be monitored in tertiary care. • It is important to monitor both process indicators (prone to limitations related to observation bias) and infrastructure indicators. • Hand hygiene (including compliance monitoring and/or infrastructure indicators) is considered a crucial indicator according to WHO recommendations. This activity should be decided upon at national level and according to the highest standards to avoid any misrepresentation of compliance levels. • Timely feedback to hospital leadership and front-line HCWs is one of the most effective parts of surveillance and monitoring. Facilities should consider defining the timeliness of feedback. • Establishment of a national IPC monitoring and evaluation programme with goals, objectives and defined performance indicators for: ‐ IPC standards ‐ IPC activities ‐ hand hygiene compliance monitoring and feedback (strongly recommended as a national performance indicator). • National level monitoring and evaluation should have mechanisms in place that: ‐ provide regular reports on the state of national goals (outcomes and processes) and strategies; ‐ regularly monitor and evaluate the WASH services, IPC activities and structure of the health care facilities through audits or other officially recognized means; ‐ promote the evaluation of the performance of local IPC programmes in a non-punitive institutional culture. PRIMARY CARE Not applicable. SECONDARY AND TERTIARY CARE • Regular monitoring/auditing of practices and other indicators should be according to IPC standards and include timely feedback to: ‐ all audited persons and relevant staff (individual change); ‐ hospital management and senior administration (organizational change); ‐ IPC team and committee (or quality of care committees). • Monitoring extends to the evaluation of the facility IPC programme to: ‐ assess if objectives are met; ‐ assess if goals/objectives are accomplished; ‐ assess whether the IPC activities are being performed according to requirements; ‐ identify aspects that may need improvement. • Important information that may be used for this purpose includes: ‐ the results of the assessment of compliance with IPC practices; ‐ other process indicators (for example, training activities); ‐ dedicated time by the IPC team; ‐ resource allocation. • Monitoring should include regular assessments of staff knowledge about IPC. Full core component requirements NATIONAL LEVEL FACILITY LEVEL 44 CORE COMPONENT 7: WORKLOAD, STAFFING AND BED OCCUPANCY (FACILITY LEVEL ONLY*) WHAT (minimum requirements) WHO (is responsible for action) HOW (to measure progress) PRIMARY CARE • To reduce overcrowding: a system for patient flow, a triage system (including referral system) and a system for the management of consultations according to existing guidelines should be established. • To optimize staffing levels: assessment of appropriate staffing levels, depending on the categories seen when using WHO/national tools (national norms on patient/staff ratio), and development of an appropriate plan. SECONDARY AND TERTIARY CARE • To standardize bed occupancy: ‐ establish a system to manage the use of space in the facility and establish the standard bed capacity for the facility; ‐ hospital administration enforcement of the system developed; ‐ no more than one patient per bed; ‐ spacing of at least 1 metre between the edges of beds; ‐ overall occupancy should not exceed the designed total bed capacity of the facility. • To reduce overcrowding and optimize staffing levels: same minimum requirements as for primary health care. PRIMARY, SECONDARY AND TERTIARY CARE • Decisions regarding workload, staffing and bed occupancy are not directly within the responsibility of the IPC link person, focal point or programme, but rather lie with senior managers and directors. Nevertheless, the IPC link nurse, officer or programme should understand the evidence supporting this core component in order to be able to help influence decision-makers at the facility and ministry level, with the assistance of an IPC-trained health care officer at the next administrative level. Therefore, the development of IPC skills in negotiation and advocacy are important considerations. • The successful implementation of this core component should be supported by a national plan for human resource development. PRIMARY CARE • Systems are in place to reduce overcrowding (for example, a system for patient flow, a triage system including a referral system, and a system for the management of consultations) according to existing guidelines/SOPs. • IPCAF – 7.3: appropriate staffing levels are assessed according to patient workload using national/international standards or staffing needs assessment tools and action plans developed based on results. SECONDARY AND TERTIARY CARE • IPCAF – 7.3: appropriate staffing levels are assessed according to patient workload using national/international standards or staffing needs assessment tools and action plans developed based on results. • IPCAF – 7.4: the design of wards is in accordance with international standards regarding bed capacity. • IPCAF – 7.5: bed occupancy in the facility is kept to one patient per bed. • IPCAF – 7.7: adequate spacing of more than 1 metre between patient beds is ensured in the facility. • IPCAF – 7.8: a system is in place, including clear lines of responsibility, to assess and respond when adequate bed capacity exceeds the designed total bed capacity of the facility (for example, the hospital administration/management assume responsibility). * Facility level only. However, the national health system, IPC programme and any other relevant body should coordinate and support the implementation of this core component at the facility level. PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS INDICATORS (YES/NO) 45 SOURCES AND RESOURCES Source • IPCAF report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/core-components/IPCAF- template.pdf?ua=1. Tools and resources • WHO Guidelines on core components of IPC programmes at the national and acute health care facility level. 2016; https://www.who.int/ infection-prevention/publications/core-components/en/. • WHO. 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. 2018; https://www.who.int/infection-prevention/tools/core-components/ facility-manual.pdf. • WHO Essential environmental health standards in health care. 2008; https://www.who.int/water_sanitation_health/publications/ehs_hc/en/. • WHO. Workload indicators of staffing need (WISN). 2015; https://www.who.int/hrh/resources/wisn_user_manual/en/. WHY (rationale and additional details on the minimum requirements) Full core component requirements PRIMARY CARE • Overcrowding and lack of triage and patient flow systems are recognized as a public health issue that can lead to disease transmission. SECONDARY AND TERTIARY CARE • Bed occupancy exceeding the standard capacity of the facility is associated with an increased risk of HAI in acute care facilities, in addition to inadequate HCW staffing levels. • Intended capacity may vary from original designs and across facilities and countries. For these reasons, the original ward/unit design regarding bed capacity should be adhered to and in accordance with standards. • In exceptional circumstances where bed capacity is exceeded, hospital management should act to ensure appropriate staffing levels that meet patient demand and an adequate distance between beds. These principles apply to all units and departments with inpatient beds, including emergency departments. • The WHO Workload Indicators of Staffing Need method provides health managers with a systematic way to determine how many HCWs of a particular type are required to cope with the workload of a given health facility and decision making. • It is recognized that in special circumstances, adherence to this recommendation may need to be balanced against the immediate need to provide clinical care to as many patients as possible. PRIMARY CARE Not applicable. SECONDARY AND TERTIARY CARE Same as for minimum requirements. PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS 46 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS CORE COMPONENT 8: BUILT ENVIRONMENT, MATERIALS AND EQUIPMENT FOR IPC AT THE FACILITY LEVEL (FACILITY LEVEL ONLY*) WHAT (minimum requirements) PRIMARY CARE • Water should always be available from an improved source on the premises to perform basic IPC measures, including hand hygiene, environmental cleaning, laundry, decontamination of medical devices and health care waste management. • A minimum of two functional, improved sanitation facilities should be available on-site, one for patients and one for staff; both should be equipped with menstrual hygiene facilities. • Functional hand hygiene facilities should always be available at points of care/toilets and include soap, water and single-use towels (or if unavailable, clean reusable towels) or ABHR at points of care and soap, water and single-use towels (or if unavailable, clean reusable towels) within 5 metres of toilets. • Sufficient and appropriately labelled bins to allow for health care waste segregation should be available (less than 5 metres from point of generation); waste should be treated and disposed of safely via autoclaving, incineration, and/or buried in a lined, protected pit. • The facility layout should allow adequate natural ventilation, decontamination of reusable medical devices, triage and space for temporary cohorting/isolation/physical separation if necessary. • Sufficient and appropriate IPC supplies and equipment (for example, mops, detergent, disinfectant, PPE and sterilization) and power/energy (for example, fuel) should be available for performing all basic IPC measures according to minimum requirements/SOPs, including all standard precautions, as applicable; lighting should be available during working hours (usually, 8 am-5 pm) for providing care. SECONDARY AND TERTIARY CARE • A safe and sufficient quantity of water should be available for all required IPC measures and specific medical activities, including for drinking, and piped inside the facility at all times, at a minimum to high-risk wards (for example, maternity ward, operating room/s, intensive care unit). • A minimum of two functional, improved sanitation facilities that safely contain waste should be available for outpatient wards and one per 20 beds for inpatient wards should be available; all should be equipped with menstrual hygiene facilities. • Functional hand hygiene facilities should always be available at points of care, toilets and service areas (for example, the decontamination unit), which include ABHR and soap, water and single-use towels (or if unavailable, clean reusable towels) at points of care and service areas, and soap, water and single-use towels (or if unavailable, clean reusable towels) within 5 metres of toilets. • Sufficient and appropriately labelled bins to allow for health care waste segregation (including for needle and sharps disposal) should be available and used (less than 5 metres from point of generation) and waste should be treated and disposed of safely via autoclaving, incineration (850° to 1100°C), and/or buried in a lined, protected pit. • The facility should be designed to allow adequate ventilation (natural or mechanical, as needed) to prevent transmission of infectious pathogens. • Sufficient and appropriate supplies and equipment and reliable power/energy should be available for performing all IPC practices, including standard and transmission-based precautions, according to minimum requirements/SOPs; reliable electricity should be available to provide lighting to clinical areas for providing continuous and safe care, at a minimum to high-risk wards (for example, maternity ward, operating room/s, intensive care unit). • The facility should have a dedicated space/area for performing decontamination and reprocessing of reusable medical devices (that is, a decontamination unit) according to minimum guidelines/SOPs. • The facility should have adequate single isolation rooms or at least one room for cohorting patients with similar pathogens, if the number of isolation rooms is insufficient. WHO (is responsible for action) PRIMARY • Trained IPC link person/focal point (see minimum requirements for core component 1), as well as facility manager/in-charge and ancillary staff (for example, cleaning staff, incinerator operators). SECONDARY AND TERTIARY CARE • Trained IPC link person/focal point (see minimum requirements for core component 1) and district/local WASH environmental health officer. • Facilities manager and ward or department leads/in-charge staff. • Additionally, at the national level, the IPC lead/focal point (and IPC technical team or committee, if existing) at the ministry of health or national body responsible for IPC, as well as the national body (for example, ministry of water or ministry of the environment or ministry of rural development) and the technical team or committee responsible for WASH (if separate), should take action to convene a technical group for the implementation of IPC and WASH requirements for all health care facilities and implementation tools. • Ideally, the technical group should include clinicians, engineers, environmental health officers and procurement managers. • Financial manager at the facility and the next administrative level (for example, district), and the ministry of finances at the national level. * Facility level only. However, the national health system, IPC programme and any other relevant body should coordinate and support the implementation of this core component at the facility level. 47 PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS HOW (to measure progress) PRIMARY CARE • IPCAF – 8.1: water services available at all times and of sufficient quantity for all uses (for example, hand washing, drinking, personal hygiene, medical activities, sterilization, decontamination, cleaning and laundry). • IPCAF – 8.3: functioning hand hygiene stations (that is, ABHR or soap and water and clean single-use towels) available at all points of care. • IPCAF – 8.4: there are more than or equal to four toilets or improved latrines available for outpatient settings or more than or equal to one per 20 users for inpatient settings. • Modified IPCAF – 8.5: sufficient energy/power supply available at least during working hours for all uses (for example, pumping and boiling water, sterilization and decontamination, incineration or alternative treatment technologies, electronic medical devices, general lighting of areas where health care procedures are performed to ensure safe provision of health care and lighting of toilet facilities and showers). • IPCAF – 8.6: functioning environmental ventilation (natural or mechanical) available in patient care areas. • IPCAF – 8.8: appropriate and well-maintained materials for cleaning (for example, detergent, mops, buckets, etc.) available. • IPCAF – 8.9: single patient rooms or rooms for the cohorting/physical separation of patients with similar pathogens or syndrome if the number of isolation rooms is insufficient (for example, tuberculosis, measles, cholera, Ebola, severe acute respiratory syndrome). • IPCAF – 8.10: PPE is available at all times and in sufficient quantity for all uses for all HCWs. • IPCAF – 8.11: functional waste collection containers for non-infectious (general) waste, infectious waste and sharps waste in close proximity to all waste generation points. • IPCAF – 8.15: a dedicated decontamination area and/or sterile supply department (either present on- or off-site and operated by a licensed decontamination management service) for the decontamination and sterilization of medical devices and other items/equipment. • IPCAF – 8.16: sterile and disinfected equipment ready for use and reliably available. SECONDARY AND TERTIARY CARE (in addition to primary care indicators above) (from the water and sanitation for health facility improvement tool (WASH FIT**): • Hygiene – 3.1: essential indicator 1. Functioning hand hygiene stations are available at all points of care (yes/no). Stations present, but no water and/or soap or ABHR present (yes/no). • Hygiene – 3.2: essential indicator 2. Hand hygiene promotion materials clearly visible and understandable at key places (yes/at some places, but not all/none). • Hygiene – 3.3: advanced indicator 1. Functioning hand hygiene stations are available in service areas (yes/stations present, but no water and/ or soap or ABHR present). • Hygiene – 3.4: advanced indicator 2. Functioning hand hygiene stations available in waste disposal area (yes/stations present, but no water and/or soap present). • Hygiene – 3.5: advanced indicator 3. Hand hygiene compliance activities are undertaken regularly (yes/compliance activities in facility policy, but not carried out with any regularity/no compliance activities). INDICATORS (YES/NO) SOURCES AND RESOURCES Sources • IPCAF results report (where available; use the template presentation); https://www.who.int/infection-prevention/tools/core-components/ IPCAF-template.pdf?ua=1. • WASH FIT results report (where available). https://www.who.int/water_sanitation_health/publications/water-and-sanitation-for-health- facility-improvement-tool/en/. Tools and resources • WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene. Joint Monitoring Programme definitions of improved water/sanitation. 2019; https://www.unwater.org/publication_categories/whounicef-joint-monitoring-programme-for-water-supply-sanitation- hygiene-jmp/. • WHO. Guidelines on sanitation and health. 2018; https://www.who.int/water_sanitation_health/publications/guidelines-on-sanitation-and- health/en/. • WHO. Essential environmental health standards in health care. 2008; https://www.who.int/water_sanitation_health/publications/ehs_hc/en/. • WHO. Safe management of wastes from health care. 2014; https://www.who.int/water_sanitation_health/publications/wastemanag/en/ • WHO and Pan American Health Organization. Decontamination and reprocessing of medical devices for health-care facilities. 2016; https://www. who.int/infection-prevention/publications/decontamination/en/. • WHO. Guidelines on tuberculosis infection prevention and control. 2019 update; https://www.who.int/tb/publications/2019/guidelines- tuberculosis-infection-prevention-2019/en/. • WHO. Natural ventilation for infection control in health-care settings. 2009; https://www.who.int/water_sanitation_health/publications/natural_ ventilation/en/. • WHO. Guidelines on core components of IPC programmes at the national and acute health care facility level. 2016; https://www.who.int/ infection-prevention/publications/core-components/en/. ** NOTE: most of these indicators have three possible responses, not simply ‘yes/no’. 48 • WHO. 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. 2018; https://www.who.int/infection-prevention/tools/core-components/ facility-manual.pdf. • WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene. WASH in health care facilities: global baseline report. 2019; https://www.unwater.org/publications/wash-in-health-care-facilities-global-baseline-report-2019/. • WHO. WASH in health care facilities: practical steps to achieve universal access to quality care. Actions and solutions. 2019; https://www.who. int/water_sanitation_health/publications/wash-in-health-care-facilities/en/. WHY (rationale and additional details on the minimum requirements) PRIMARY CARE • Adequate infrastructures and availability of adequate WASH support are essential to perform any health care services and IPC activities (for example, water is absolutely critical for hand hygiene, cleaning and key services such as delivery). • Improved water sources are those which by nature of their design and construction have the potential to protect water from external contamination (for example, microorganisms, dirt). While drinking water is not required for basic IPC measures, water from improved sources may better facilitate performing IPC measures according to guidelines/SOPs, for example, water from groundwater sources that is non-turbid can generally enable the effective preparation of disinfectant solutions for environmental cleaning and decontamination of medical devices. The chlorine concentration in all disinfectant solutions should be regularly monitored and the dose adjusted as necessary to meet chlorine concertation targets. • Improved sanitation facilities are those designed to hygienically separate human excreta from human contact, which is critical for reducing the transmission risk from enteric pathogens and, in addition to menstrual hygiene facilities, help maintain a hygienic environment; separate toilets for patients and staff also helps to minimize indirect contact between patients and staff that may pose an infection risk. • When there is a risk of soiling, ABHR is not a substitute for soap and water for hand hygiene after toileting or when hands are visibly soiled (for example, while assisting childbirth). • If ABHRs are available, it is essential to have these accessible at all points of care, given the proven advantages of ABHRs over soap and water, but it is also essential that soap, water and single-use towels are available in clinical services. • Adequate ventilation throughout the facility contributes to maintaining a hygienic environment and can be minimally accomplished via the presence of functional windows (preferably equipped with insect traps) and doors, that allow at least 6-8 air changes per hour for natural ventilation (for example, by opening opposite windows). • Sufficient energy/power and a stand-by ‘back-up’ arrangement (including solar, wind, stand-by generator or others) and fuel should be available on- site for lighting clinical practices and basic IPC measures (for example, for performing decontamination of medical devices, if needed). • If the facility performs any procedures (for example, deliveries or other basic gynaecological procedures) requiring reusable medical devices (for example, vaginal specula), at a minimum it is essential to create dedicated areas that allow proper workflow from dirty to clean for performing the decontamination and reprocessing of medical devices. • A small space to assess patients regarding the disease/reason for accessing the facility (that is, triage), including any infectious disease transmission risk, and to allow them to be directed to different areas according to priority and type of disease can be accomplished with minimal resources. • Adequate space for temporary cohorting/isolation can also be accomplished with minimal resources by the creation of a physical separation or barrier between suspected/infected patients and other patients, staff and visitors, and is critical for ensuring transmission-based precautions. If resources allow, a room should be designated for this function. SECONDARY AND TERTIARY CARE • It is critical for water to be available 24 hours on-site from an improved source and piped into the facility to clinical areas, at a minimum to high-risk wards (for example, maternity ward, operating room/s, intensive care unit), points of care and service areas (for example, sterile services department) as patients in these areas may require 24-hour clinical care where water-related IPC is critical (for example, hand hygiene, environmental cleaning, reprocessing of medical devices). • The use of safe water (according to WHO drinking-water quality standard, that is, no Escherichia coli detectable in 100 mL and/or 0.5 mg/L free chlorine residual) for water-related IPC interventions minimizes the risk of direct and indirect exposure to water-related pathogens of enteric and environmental origin (for example, Pseudomonas, Legionella) and should be available for all clinical services; at a minimum, it should be provided to high-risk wards where the burden of HAI and AMR are high. • Sufficient quantities of water are required to ensure that all water-related IPC interventions can be performed. This quantity varies and is dependent on the particular service or ward. To avoid any frequent service gaps/water shortages, it is required that there be sufficient on-site water storage capacity to provide services for a minimum of 48 hours. • Ensuring an adequate quantity of toilets for inpatient users to prevent crowding and overuse and ensuring regular cleaning are critical to maintain a hygienic environment and minimize the transmission risk from enteric pathogens, at a minimum in the ratio defined previously. • Positive mechanical ventilation is needed for clean areas such as operating rooms and clean areas in decontamination units and the sterile services department, while negative pressure ventilation may be required for isolation facilities, for example, multidrug-resistant tuberculosis (see tuberculosis references in ‘resources’). The requirement for mechanical ventilation is most applicable to tertiary care facilities. • Reliable power means that a constant (that is, 24-hour) source of power and/or back-up power is available for high-risk wards (for example, maternity ward, operating room/s, intensive care unit). Without reliable power, it is not possible to operate decontamination (sterilization) equipment and waste treatment equipment when needed, or to have lighting in clinical areas in order to provide continuous and safe care. • Reliable power can be achieved via an on-site source of energy/power and fuel (for example, wind, solar, stand-by generator/s) to provide back-up as needed. • Given the increased risk for HAIs and AMR at secondary and tertiary health care facilities, there should be at least one isolation room per 20-bedded ward in secondary care facilities, and 1:10 in the tertiary level as a minimum. • Cohorting can be carried out in a dedicated area of a general ward. It can be done in any well-ventilated area as long as hand hygiene and transmission-based precautions are strictly adhered to. PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS 49 • As improving access to WASH services and IPC materials and equipment is resource intensive, the first step (minimum requirement) is to establish a multidisciplinary technical group to develop standards and implementation tools. • This group will have the task of: ‐ reviewing the requirements for WASH services, environmental hygiene, and IPC materials and equipment, according to the national context; ‐ developing a monitoring plan and reporting mechanism for assessing and improving WASH services and IPC materials and equipment in all health care facilities against national standards; use of existing tools (for example, WASH FIT or WHO/UNICEF JMP indicators for WASH in health care facilities) may be of help in these efforts; ‐ identifying roles and responsibilities for the implementation and management of WASH services, environmental hygiene and IPC materials and equipment at the facility level at all health care facilities. • The national level could also consider the development of a policy/regulations to mandate WASH services in facilities, according to the minimum requirements specified above. Full core component requirements ALL HEALTH CARE FACILITIES • Central government and national IPC and WASH programmes should develop standards and national action plans to ensure adequate WASH services, a hygienic environment, and the availability of IPC materials and equipment in all health care facilities, including primary care. • Ensuring an adequate hygienic environment should be the responsibility of senior facility managers and local authorities. • To implement the full requirements of the core component 8, all health care facilities should provide the following: ‐ water from an improved source located on premises with sufficient water available at all times for drinking, hand washing, food preparation, personal hygiene, medical activities, cleaning and laundry; ‐ improved sanitation facilities located on premises that are functional with safe management of sewage/faecal waste, including the use of well- managed septic tanks and leach fields, disposal into functioning sewers or off-site removal, and include at least one toilet designated for women/ girls to manage menstrual hygiene needs, at least one separated for staff, and at least one meeting the needs of people with limited physical disabilities; also, sanitation facilities for infants and children that are adapted for their use (with for example, smaller seats, child-sized bed pans), segregated by sex for older children, appropriately lit and accessible to people with limited mobility; ‐ adequate drainage of storm and wash water to prevent vector breeding; ‐ continuous access to hand hygiene facilities equipped with ABHRs and (where appropriate) with water, soap and disposable or clean towels at the point of care, within 5 metres of toilets, and other areas such as the sterile services departments, laboratories and mortuaries; ‐ continuous adequate supply of sharps’ containers and containers for segregating other types of health care waste and equipment to ensure that health care waste is treated and disposed of safely, including autoclaving, incineration or removal for off-site treatment; ‐ continuous adequate supplies to ensure regular cleaning of examination rooms, waiting areas, surfaces and toilets; ‐ continuous adequate supply of appropriate PPE for both clinical care and health care waste handling and cleaning; ‐ adequate ventilation to meet comfort requirements and reduce the risk of transmission of airborne pathogens; ‐ adequate power for sterilization, incineration and medical devices; sufficient energy for pumping water, sterilization and operating health care waste equipment (that is, incinerators); well-lit areas where health care procedures are performed and in toilet facilities, including at night. • The IPC team or committee should be involved in planning all these activities and systems and in the design of buildings and infrastructures and construction in health care facilities. • Practical actions to improve WASH in health care facilities should include: ‐ conduct situational analysis and assessment ‐ define roadmap and set targets ‐ establish national standards and accountability mechanisms ‐ improve and maintain infrastructure ‐ monitor and review data ‐ develop health workforce ‐ engage communities and ‐ conduct operational research and learning. SECONDARY AND TERTIARY CARE (in addition to primary care) • A dedicated centralized decontamination area and/or sterile supply department for the decontamination and sterilization of medical devices and other items/equipment should be available and supplied with sufficient water and power. • A dedicated clean storage area for patient care items and equipment, including sterile material, and a separate area for the storage of clean linen should be available as outlined in the WHO manual on decontamination and reprocessing of medical devices for health-care facilities (see ‘resources’). • An adequate number of single rooms (with private toilet facilities and including some rooms with negative pressure mechanical ventilation system) and/or rooms suitable for patient cohorting for the isolation of suspected /infected patients, including those with tuberculosis, other airborne pathogens and multidrug-resistant organisms, should be available to prevent transmission to other patients, staff and visitors. • Proper ventilation systems should be available in general and in the operating room, including either negative or positive air pressure conditions, depending on the situation. • Risk assessment systems and measures should be developed to ensure protection during building and renovation work for patients, their families and staff, especially in high-risk areas, such as units where severely immunocompromised patients (transplant, patients with profound neutropenia, etc.) are managed, as well as in intensive care, neonatal and burn units and operating rooms. PART 3. IN-DEPTH REVIEW OF THE MINIMUM REQUIREMENTS

51 PART 4. ANNEX PART 4. ANNEX 4.1 Annex 1. Summaries of the results of a systematic review and inventory on available IPC minimum standards 4.1.1 Overview of the results of the systematic literature review on minimum standards for IPC The systematic review on IPC minimum standards was conducted as a basis for the expert consultation on the IPC minimum requirements. It focused on the question: “What are the minimum standards of effective IPC programmes aimed at reducing health care-associated infections at the national and health care levels?” The Cumulative Index of Nursing and Allied Health Literature (CIHAHL), PubMed, GIM (WHO Global Index Medicus) and EMBASE databases were searched to identify reported minimum standards. IPC interventions were categorized as either horizontal (for example, IPC programme, education) or vertical (for example, prevention of surgical site infections). Hand hygiene, injection safety and education are examples of horizontal IPC interventions, while the prevention of surgical site infections, hospital-associated pneumonia and catheter-related bloodstream infections were categorized as vertical IPC interventions. Horizontal interventions were more frequently mentioned compared to vertical interventions as being a minimum requirement (Fig. 1). Hand hygiene (91%), transmission-based precautions (including triage) (87%), surveillance (85%), education/training (81%) and the built environment/infrastructure (77%) were the five most frequently mentioned horizontal critical IPC measures, followed by guidelines (70%), decontamination (70%) and monitoring/audits/feedback (66%). To p 5 ho riz on ta l i nt er ve nt io ns Facility level Hand hygiene 91% Transmission-based precautions 87% Surveillance 85% Education/training 81% Built environment/infrastructure 77% Pr ev en tio n of C R- BS I 3 6% Pr ev en tio n of M RS A 32 % Pr ev en tio n of V AP /H AP 2 6% Pr ev en tio n of S SI 2 1% Pr ev en tio n of C AU TI o r C RO 1 9% Top 5 vertical interventionsFig. 1 Top 5 horizontal and vertical interventions mentioned as a minimum requirement at the facility level. ABBREVIATIONS CR-BSI, catheter-related bloodstream infection; MRSA, methicillin-resistant Staphylococcus aureus; VAP/HAP, ventilator-associated pneumonia/hospital- acquired pneumonia; SSI, surgical site infection; CAUTI, catheter-associated urinary tract infection; CRO, carbapenem-resistant organisms. 52 PART 4. ANNEX Compliance with standard precautions is usually low and it is therefore important to investigate implementation strategies to improve this key measure. Existing competencies of IPC practitioners, as well as existing indicators, will be useful to define minimum standards. It will be critical to draw on lessons learned from the past and to engage hospital leadership in further discussions regarding the importance of implementation of IPC programmes. The review also highlighted the low quality of studies reviewed (systematic reviews and before-after studies), a very great number of studies from high- income countries, a high percentage of systematic reviews on methicillin- resistant Staphylococcus aureus and Clostridium difficile from high-income countries, and an elevated number of facility-based studies. 4.1.2 Summary of the global inventory on IPC minimum standards The aim of developing the global inventory of IPC minimum standards was to produce a catalogue of already available guidance on these standards (especially from the perspective of low-resource settings) from WHO regional and country offices, other organizations and countries directly. This was to complement the systematic review and country experiences gathered previously and to provide insights into what could be considered as ‘minimum standards’ for IPC at the national and facility level. A global call was made to relevant networks, as well as a search for any publicly available IPC-related documents. The database used for the guidelines on the core components of IPC was also searched for any relevant documents. A total of 23 documents were reviewed in full (1-23), but only nine included approved national IPC standards defined as ‘minimum’ for health care facilities (1-9). Overall, these documents provided validation of the WHO guidelines on core components for IPC programmes as all reviewed documents could be categorized and related to the eight core components. Most notably, core components 1 (IPC programmes), 3 (education and training) and 8 (built environment) were the most referred to, while core component 7 (workload, staffing and bed occupancy) was the least reported. The limitations of the final inventory had already been acknowledged as it was taken from direct submissions and those that were publicly available. However, despite some countries specifically identifying IPC minimum standards, the majority lacked any standard definition of minimum standards and their approach remained broad with a lack of specificity. 53 PART 4. ANNEX 4.1.3 References 1. Ethiopian hospital services transformation guidelines, volume 2. Ethiopian hospitals management initiative. Addis Ababa: Federal Democratic Republic of Ethiopia Ministry of Health; 2016. 2. Ministry of Health Social Services Namibia. Hospital standards and criteria, 1st edition (Draft 2). 2018 (http:// www.mhss.gov.na/documents/119527/659098/ MoHSS+Namibia+Hospital+Standards+and+Criteria+DRAFT. pdf/13271616-e30e-4a0d-b3d9-54d17c283eeb, accessed 29 October 2019). 3. Infection Prevention and Control (IPAC) Canada. Infection Prevention and Control (IPAC) Program Standard. Can J Infect Control. 2016; 30(Suppl):1-97 (https://ipac-canada.org/photos/custom/CJIC/ Vol31No4supplement.pdf, accessed 29 October 2019). 4. Swaziland standards authority. Swaziland national standard. General hospitals and health centres – requirements. 2011 (https://www.swasa. co.sz/standards.php, accessed 29 October 2019). 5. Infection prevention and control manual, 2nd edition. Riyadh (Saudi Arabia): National Guard Health Affairs Infection Prevention and Control Department. Gulf Cooperation Council – Centre for Infection Control; 2013 (https://www.moh.gov.sa/CCC/Documents/GCC%20Infection%20 control%20manual%202013%20revisedOPT.pdf, accessed 29 October 2019). 6. New Zealand standard. Health and disability services (infection prevention and control) standards. Wellington: Standards New Zealand; 2008 (https:// www.standards.govt.nz/assets/Publication-files/NZS8134.3-2008.pdf, accessed 29 October 2019). 7. Normas para la prevención y control de infecciones en los establecimientos de salud. Santo Domingo: Ministry of Public Health, Dominican Republic; 2013 (http://digepisalud.gob.do/docs/vigilancia%20 epidemiologica/Reglamentos%20y%20Normas/2013%20-%20Normas%20 control%20infeccion.pdf, accessed 29 October 2019). 8. Botswana national health quality standards for hospitals. 9. Prevention and control of infection. Republic of Botswana Ministry of Health; 2014 (https:// www.moh.gov.bw/Publications/standards/Botswana%20National%20 Health%20Quality%20Standards%20for%20Hospitals/Botswana%20 HOSPITAL%20Standards%20SE%209%20Prevention%20and%20 Control%20of%20Infection.pdf,accessed 29 October 2019). 9. Patient safety assessment manual: second edition. World Health Organization. Regional Office for the Eastern Mediterranean; 2016 (https:// apps.who.int/iris/handle/10665/249569, accessed 29 October 2019). 10. Norma técnica no 124 de los programas de prevención y control de las infecciones asociadas a la atención en salud (IAAS). Republica de Chile 54 Ministerio de Salud; 2011 (http://digepisalud.gob.do/docs/vigilancia%20 epidemiologica/Reglamentos%20y%20Normas/2013%20-%20Normas%20 control%20infeccion.pdf, accessed 29 October 2019). 11. Normas institucionales para la prevención y control de infecciones intrahospitalarias. Caja Costarricense de Seguro Social. Dirección Técnica de Servivios de Salud. Departamento de Saneamiento Básico y Ambiental Institucional. Sección de Infecciones Intrahospitalarias; 2002 (http:// aesscr.com/Normas%20institucionales%20para%20la%20prevención%20 y%20control%20de%20infecciones%20intrahospitalarias.pdf, accessed 29 October 2019). 12. Ministry of Health and Population Egypt. National guide for infection control (second part, 3rd edition). 2016. 13. Normas de prevención y control de las infecciones nosocomiales. Ministerio de Salud Publica del Ecuador; 2006 (https://aplicaciones.msp. gob.ec/salud/archivosdigitales/documentosDirecciones/dnn/archivos/ manual%20de%20normas%20de%20infecciones%20nosocomiales.pdf, accessed 29 October 2019). 14. Société Française de Hygiène Hospitalière. Surveillance and prevention of healthcare-associated infections. HygièneS. 2010; 18(4): 3-175 (https:// sf2h.net/wp-content/uploads/2016/04/SF2H_surveillance-and-prevention- guidelines-2010.pdf, accessed 29 October 2019). 15. Personelle und organisatorische Voraussetzungen zur Prävention nosokomialer Infektionen Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention [Personnel and organizational requirements for the prevention of nosocomial infections: recommendations from the Commission for Hospital Hygiene and Infection Prevention]. 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Washington (DC): Pan American Health Organization; 2011 (https://www.paho.org/hq/dmdocuments/2011/HAI- 55 Evaluation-guide-2011-ENG.pdf, accessed 29 October 2019). 20. Ministère de la Santé et l’Action Sociale du Sénégal. Programme national de lutte contre les infections nosocomiales (PRONALIN). Fiche de supervision. 2011. 21. Sri Lanka College of Microbiologists. Empirical and prophylactic use of antimicrobials. National guidelines. 2016 (http://slmicrobiology.lk/ download/National-Antibiotic-Guidelines-2016-Web.pdf, accessed 30 October 2019). 22. National Institute for Health and Care Excellence (United Kingdom). Infection prevention and control. Quality standard (QS61). April 2014 (https://www.nice.org.uk/guidance/qs61/chapter/Introduction, accessed 30 October 2019). 23. United States of America Centers for Disease Prevention and Control. 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REQUISITOS MÍNIMOS para programas de prevenção e controle de infecção Ponto de partida para a implementação dos componentes essenciais da Organização Mundial da Saúde para programas de prevenção e controle de infecção nos níveis nacional e de serviços de saúde Requisitos mínimos para programas de prevenção e controle de infecção Informações sobre a versão traduzida para português do Brasil Tradução Suzana Gontijo. Revisão técnica da versão traduzida: Heiko Thereza Santana (Gerência de Vigilância e Monitoramento em Serviços de Saúde - GVIMS/GGTES/ANVISA) Lilian de Souza Barros (GVIMS/GGTES/ANVISA) Luciana Silva da Cruz de Oliveira (GVIMS/GGTES/ANVISA) Magda Machado de Miranda Costa (GVIMS/GGTES/ANVISA) Mara Rúbia Santos Gonçalves (GVIMS/GGTES/ANVISA) Maria Dolores Santos da Purificação Nogueira (GVIMS/GGTES/ANVISA) Apoio Técnico: Unidade Técnica de Doenças Transmissíveis e Determinantes Ambientais da Saúde (UTCDE)/ Organização Pan-Americana da Saúde (OPAS). © ANVISA 2022 Essa tradução não foi criada pela Organização Mundial da Saúde (OMS). A OMS não se responsabiliza pelo conteúdo ou exatidão desta tradução. A publicação original em inglês será a versão válida e autêntica. A edição original em inglês “Minimum requirements for infection prevention and control programmes”. Genebra: Organização Mundial da Saúde; 2019. Licence: CC BY-NC-SA 3.0 IGO É permitida a reprodução parcial ou total deste documento, desde que citada a fonte e que não seja para venda ou qualquer fim comercial. This translated work is available under the CC BY-NC-SA 3.0 SUMÁRIO Agradecimentos II Abreviaturas e siglas iv Glossário dos principais termos e definições V Legendas dos símbolos X Parte 1.Introdução 1 1.1 Objetivo do documento 2 1.2 Público-alvo 2 1.3 Estrutura de desenvolvimento do documento 3 1.4 Papel dos requisitos mínimos 5 na obtenção de prevenção e controle de infecção efetivos 1.5 Referências 10 Parte 2. Sumário executivo dos requisitos mínimos 13 por componente essencial Parte 3: Revisão aprofundada dos requisitos mínimos 23 3.1 Componente 1: Programas de prevenção e controle 23 de infecção 3.2 Componente 2: Diretrizes obre prevenção e controle de infecção27 3.3 Componente 3: Educação e treinamento em 31 prevenção e controle de infecção 3.4 Componente 4: Vigilância de infecções relacionadas à 34 assistência à saúde 3.5 Componente 5: Estratégias multimodais 38 3.6 Componente 6: Monitoramento, auditoria e feedback 41 de práticas de prevenção e controle de infecção 3.7 Componente 7: Carga de trabalho, recursos humanos e ocupação44 de leitos em nível de serviços de saúde 3.8 Componente essencial 8: Ambiente, materiais e 46 equipamento para prevenção e controle de infecção em nível de serviço de saúde Parte 4.ANEXOS 51 4. 1 Sumários dos resultados de uma revisão sistemática e 51 inventário de padrões mínimos de prevenção e controle de infecção disponíveis 4.1.1 Visão geral dos resultados da revisão sistemática da literatura 51 sobre os padrões mínimos para prevenção e controle de infecção 4.1.2 Sumário do inventário global de padrões mínimos de prevenção52 e controle de infecção 4.1.3 Referências 53 II AGRADECIMENTOS AGRADECIMENTOS O Departamento de Serviços Integrados de Saúde da Organização Mundial da Saúde (OMS) reconhece com gratidão as contribuições que muitos indivíduos e organizações fizeram para o desenvolvimento dos requisitos mínimos de prevenção e controle de infecção (PCI), com base nos componentes essenciais da OMS para programas de PCI nos níveis nacional e dos serviços de saúde. COORDENAÇÃO GERAL, REDAÇÃO E PROJETO DO DOCUMENTO Benedetta Allegranzi (Departamento de Serviços Integrados de Saúde, OMS) coordenou e liderou o desenvolvimento e a redação deste documento e contribuiu para a revisão sistemática. Anthony Twyman e Alessandro Cassini (Departamento de Serviços Integrados de Saúde, OMS) contribuíram significativamente para a redação deste documento e para a revisão sistemática. Julie Storr (consultora de PCI, Reino Unido) e Molly Patrick [equipe internacional de PCI dos Centros para Controle e Prevenção de Doenças (CDC), Estados Unidos da América (EUA)] também contribuíram para a redação deste documento. Joost Hopman (Radboud University Hospital e Médecins Sans Frontières/Médicos sem Fronteiras, Holanda) contribuiu para o desenvolvimento estratégico deste documento e conduziu uma revisão sistemática sobre os padrões mínimos para programas de PCI junto com Daniël Urlings (Radboud University Hospital, Holanda); Anthony Twyman fez um inventário global das orientações disponíveis sobre os padrões mínimos de PCI. Thomas Allen (Biblioteca e Redes de Informação para o Conhecimento, OMS) forneceu assistência na pesquisa da revisão sistemática. Rosemary Sudan forneceu assistência profissional de edição. Laura Pearson (Departamento de Serviços Integrados de Saúde, OMS) e Alice Simniceanu (Divisão de Resistência Antimicrobiana, OMS) apoiaram a finalização do documento elaborado. Maraltro forneceu o design gráfico profissional do documento. GRUPO DE DESENVOLVIMENTO DE CONTEÚDO ESPECIALIZADO O consenso sobre o conteúdo deste documento e os requisitos mínimos de PCI foi obtido pela primeira vez em uma consulta técnica a um especialista de Addis Abeba, Etiópia, em abril de 2019, com a participação dos seguintes especialistas: III. AGRADECIMENTOS Fahmi Ahmed (Representação da OMS para a Etiópia); Romella Abovyan (Centro Nacional para Prevenção e Controle de Doenças, Armênia); Anucha Apisarnthanarak (Thammasat University Hospital, Tailândia); Batyrbek Aslanov (North-Western State Medical University, Rússia); Sofonias Asrat (Escritório da OMS para a Etiópia); Mekdim Ayana (Escritório Regional da OMS para a África); Gertrude Avortri (Escritório Regional da OMS para a África); Anjana Bhushan (Escritório Regional da OMS para o Sudeste Asiático); Roderick Chen Camano (Hospital Social Caja Seguro, Panamá); Christiana Agnes Conteh (Ministério da Saúde e Saneamento, Serra Leoa); Ana Paula Coutinho-Rehse (Escritório Regional da OMS para a Europa); Nizam Damani (consultor de PCI, Reino Unido); Nino Dayanghirang (Escritório Regional da OMS para a África); Lamine Dhidah (Hospital Universitário Sahloul, Tunísia); Molla Godif Fisehatsion (Ministério da Saúde, Etiópia); Corey Forde (Hospital Queen Elizabeth, Barbados); Ghada Abdelwahed Ismail (Conselho Supremo de Hospitais Universitários, Egito); Nordiah Awang Jalil (Hospital Universiti Kebangsaan, Malásia); Kushlani Jayatilleke (Hospital Geral Sri Jayewardenapura, Sri Lanka); Ejaz Khan (Shifa International Hospital, Paquistão); Amy Kolwaite (equipe internacional de PCI do CDC, EUA); Thabang Masangane (Ministério da Saúde, Eswatini); Guy Mbayo (Escritório Regional da OMS para a África); Huynh Tuan Minh (Centro Médico Universitário, Vietnã); Awa Ndir (Escritório Regional da OMS para a África); Babacar Ndoye (Escritório Regional da OMS para a África); Fernando Otaiza (Ministério da Saúde, Chile); Atika Swar (Ministério Federal da Saúde, Sudão); Maha Talaat (Escritório Regional da OMS para o Mediterrâneo Oriental); Shaheen Mehtar (Rede de Controle de Infecção da África, África do Sul); Benjamin Park (equipe internacional de PCI do CDC, EUA); Molly Patrick (equipe internacional de PCI do CDC, EUA); Lul Raka (Universidade de Prishtina, Kosovo); Julie Storr (consultora de PCI, Reino Unido); Lekilay G. Tehmeh (Ministério da Saúde, Libéria); Le Thi Anh Qui (Sociedade de Controle de Infecção, Vietnã); Roselyne M.E. Toby (Hôpital Central de Yaoundé, Camarões); Sarah Tomczyk (Instituto Robert Koch, Alemanha); Winifrey Ukponu (Centro de Controle de Doenças da Nigéria, Nigéria); Jay Varma (CDC da África, Etiópia); Daiva Yee (equipe internacional de PCI do CDC, EUA). O conteúdo foi desenvolvido com a contribuição substancial e/ou revisão pelos seguintes especialistas: Fahmi Ahmed (Representação da OMS para a Etiópia); Anjana Bhushan (Escritório Regional da OMS para o Sudeste Asiático); Ana Paula Coutinho-Rehse (Escritório Regional da OMS para a Europa); Nino Dayanghirang (Escritório Regional da OMS para a África); Corey Forde (Hospital Queen Elizabeth, Barbados); Amy Kolwaite (equipe internacional de PCI do CDC, EUA); Babacar Ndoye (Escritório Regional da OMS para a África); Maha Talaat (Escritório Regional da OMS para o Mediterrâneo Oriental); Shaheen Mehtar (Rede de Controle de Infecção da África, África do Sul); Molly Patrick (equipe internacional de PCI do CDC, EUA); Julie Storr (consultora de PCI, Reino Unido); Sarah Tomczyk (Instituto Robert Koch, Alemanha); Jay Varma (CDC da África, Etiópia). GRUPO EXTERNO DE REVISÃO POR PARES Emine Alp (Ministério da Saúde, Turquia); April Baller (Emergências de Saúde Mundial, OMS); Richard Gelting (CDC, EUA); Margaret Montgomery (Unidade de Água, Saneamento, Higiene e Saúde, OMS); Rob Quick (CDC, EUA); Wing Hong Seto (Universidade de Hong Kong, RAE de Hong Kong, China); Nalini Singh (Escolas de Medicina e Ciências da Saúde da George Washington University e Public Health and Children’s National, EUA); João Toledo (Organização Pan-Americana da Saúde). AGRADECIMENTOS PELO APOIO FINANCEIRO E OUTROS APOIOS A OMS agradece as contribuições técnicas e estratégicas do CDC (EUA) e do CDC da África para a realização deste projeto e agradece ao CDC da África por hospedar a consulta técnica de especialistas em suas instalações em Adis Abeba, Etiópia. O financiamento para o desenvolvimento deste documento foi fornecido pelo CDC (EUA), além dos fundos básicos da OMS. No entanto, as opiniões expressas no manual não refletem necessariamente as políticas oficiais do CDC. ABREVIATURAS E SIGLAS ABREVIATURAS E SIGLA CDC Centros de controle e prevenção de doenças (EUA) EPC Enterobacteriaceae produtoras de carbapenemase EPI Equipamento de proteção individual EQAS Sistema de garantia de qualidade externa (do inglês external quality assurance system) EUA Estados Unidos da América IPCAF Esquema de avaliação da prevenção e controle de infecção (do inglês infection prevention and control assessment framework) IPCAT Ferramenta de avaliação da prevenção e controle de infecção (do inglês infection prevention and control assessment tool) IRAS Infecção relacionadas à assistência à saúde OMS Organização Mundial da Saúde PC Produtores de carbapenemase PCI Prevenção e controle de infecção POP Protocolos operacionais padrão RM Resistência microbiana aos antimicrobianos UNICEF Fundo das Nações Unidas para a Infância Estados Unidos da América WASH Água, saneamento e higiene WASH FIT Ferramenta de melhoria das instalações de água, saneamento e higiene V GLOSSÁRIO DOS PRINCIPAIS TERMOS E DEFINIÇÕES GLOSSÁRIO DOS PRINCIPAIS TERMOS E DEFINIÇÕES Álcool gel: Preparação à base de álcool para aplicação nas mãos para inativação de microrganismos e/ou supressão temporária de seu crescimento. Essas preparações podem conter um ou mais tipos de álcool e outros ingredientes ativos com excipientes e umectantes. Fonte: Orientações da OMS sobre higiene das mãos na atenção à saúde. 2009 (https://www.who.int/gpsc/5may/tools/9789241597906/en /, acessado em 29 de outubro de 2019). Gerenciamento de antimicrobianos: Um conjunto coerente de ações que promovem o uso responsável de antimicrobianos. Essa definição pode ser aplicada a ações em nível individual, bem como em nível nacional e global, e em saúde humana, saúde animal e meio ambiente. Fonte: Dyar OJ, Huttner B, Schouten J, Pulcini C. What is antimicrobial stewardship? Clin Microbiol Infect.2017;23(11):793-8. OU O objetivo principal do gerenciamento de antimicrobianos é otimizar os desfechos clínicos e, ao mesmo tempo, minimizar as consequências indesejadas do uso de antimicrobianos, incluindo toxicidade, seleção de organismos patogênicos (como Clostridium difficile) e o surgimento de resistência. Fonte: Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44(2):159–77. Serviço de Limpeza e Desinfecção de Superfícies (também conhecidos como equipe de limpeza ambiental ou técnicos de serviços ambientais): indivíduos responsáveis por realizar a limpeza ambiental em serviços de saúde que desempenham um papel fundamental na manutenção de um ambiente limpo e/ou higienizado que facilite as práticas relacionadas à prevenção e controle de IRAS. Coorte: Agrupamento de pacientes que são colonizados ou infectados pelo mesmo organismo resistente com o objetivo de confinar seu atendimento a uma área e evitar contato com outros pacientes suscetíveis (por exemplo, todos os pacientes infectados ou colonizados por Enterobactérias resistentes a carbapenêmicos em uma coorte específica e todos os pacientes colonizados com Staphylococcus aureus resistente a meticilina em uma coorte diferente). As coortes são criadas com base no diagnóstico clínico, na confirmação microbiológica com epidemiologia disponível e no modo de transmissão do agente infeccioso. O isolamento em coortes é reservado para situações em que haja quartos individuais insuficientes ou em que o isolamento de pacientes colonizados ou infectados pelo mesmo patógeno em coortes seja um uso mais eficiente dos quartos e recursos hospitalares. Devem ser usados equipamentos, banheiros e profissionais dedicados para os pacientes dentro da área de coorte, pelo tempo necessário. Fontes: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings (http:// www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf, acessado em 29 de outubro de 2019). OMS. Orientações para a prevenção e controle de Enterobacteriaceae, Acinetobacter baumannii e Pseudomonas aeruginosa resistentes a carbapenêmicos em serviços de saúde. 2017 (https:// www.who.int/infection- prevention/publications/guidelines-cre/ en/, acessado em 29 de outubro de 2019). Resistência ao carbapenêmicos [incluindo produtores de carbapenemase (PC)]: A resistência ao carbapenêmicos em Enterobacteriaceae, Acinetobacter baumannii e Pseudomonas aeruginosa pode ser devida a vários mecanismos. Algumas cepas podem ser inatamente resistentes aos carbapenêmicos, ao passo que outras contêm elementos genéticos móveis (por exemplo, plasmídeos, transposons) que resultam na produção de enzimas (carbapenemases) que degradam a maioria dos antibióticos beta-lactâmicos, incluindo os carbapenêmicos. Frequentemente, os genes PC estão colocalizados com outros genes de resistência, o que pode resultar em resistência cruzada a muitas outras classes de antibióticos. (1-3) Assim, embora as cepas resistentes a carbapenêmicos desses patógenos frequentemente sejam PC [Enterobacteriaceae-PC (EPC), A. Baumannii-PC, P. Aeruginosa-PC], elas podem ter outros mecanismos de resistência a carbapenêmicos que VI GLOSSÁRIO DOS PRINCIPAIS TERMOS E DEFINIÇÕES os tornam igualmente de difícil tratamento e manejo clínico. Assim, o termo “Enterobacteriaceae resistente a carbapenêmicos” inclui todas as cepas que são resistentes a carbapenêmicos, incluindo EPC. Por esse motivo, as medidas de prevenção e controle de infecção devem se concentrar em todas as cepas de Enterobacteriaceae, A. baumannii e P. aeruginosa resistentes a carbapenêmicos, independentemente de seu mecanismo de resistência. As medidas adequadas de prevenção e controle de infecção são essenciais tanto em locais de surto quanto em locais endêmicos. Fonte: OMS. Orientações para a prevenção e controle de Enterobacteriaceae, Acinetobacter baumannii e Pseudomonas aeruginosa resistentes a carbapenêmicos em serviços de saúde. 2017 (https://www.who.int/infection- prevention/publications/guidelines-cre/en/, acessado em 29 de outubro de 2019). Descontaminação de produtos para saúde: Remoção de sujeira e microrganismos patogênicos de objetos para que se tornem seguros de manusear, passíveis de processamento posterior, uso ou descarte (ver também Reprocessamento). Fonte: Centros de controle e prevenção de doenças dos Estados Unidos Orientações para desinfecção e esterilização em serviços de saúde. 2008 (https://www.cdc.gov/ infectioncontrol/pdf/guidelines/disinfection-guidelines- H.pdf, acessado em 29 de outubro de 2019). Higienização das mãos: Termo geral que se refere a qualquer ação de higienização das mãos, ou seja, a ação de realizar a higienização das mãos com o objetivo de remover física ou mecanicamente sujeira, matéria orgânica e/ou microrganismos. Fonte: Orientações da OMS sobre higiene das mãos na atenção à saúde. 2009 (https://www.who.int/gpsc/5may/tools/9789241597906/en /, acessado em 29 de outubro de 2019). CLASSIFICAÇÃO DOS SERVIÇOS DE SAÚDE Estabelecimentos de atenção primária à saúde: Estabelecimentos que oferecem serviços ambulatoriais, planejamento familiar, atendimento pré-natal, serviços de saúde materna, neonatal e infantil, como, por exemplo, centros de saúde, postos de saúde. Fonte: OMS. Água e saneamento para a ferramenta de melhoria dos serviços de saúde (WASH FIT). 2017 (https://apps.who.int/iris/ bitstream/handle/10665/254910/9789241511698-eng. pdf;jsessionid=0A60107AA8F5A27C5FD16B0823D3F4FA?se- quence=1, acessado em 29 de outubro de 2019). HOSPITAIS PRIMÁRIOS, SECUNDÁRIOS E TERCIÁRIOS Hospital de nível primário: Poucas especialidades — principalmente clínica médica, obstetrícia e ginecologia, pediatria e cirurgia geral ou apenas clínica geral; serviços laboratoriais limitados disponíveis para análises patológicas gerais, mas não especializadas. Hospital de nível secundário: Altamente diferenciado por funcionar com 5 a 10 especialidades clínicas; o tamanho varia de 200 a 800 leitos; frequentemente denominado hospital municipal ou estadual. Hospital de nível terciário: Pessoal e equipamento técnico altamente especializado, por exemplo, cardiologia, unidade de terapia intensiva e unidades especializadas de exames de imagem; serviços clínicos altamente diferenciados por função; pode ter atividades de ensino; o tamanho varia de 300 a 1.500 leitos; frequentemente denominado hospital universitário ou estadual. Fonte: OMS. Prioridades de controle de doenças nos países em desenvolvimento. 2008 (https://www.who.int/management/facility/ ReferralDefinitions.pdf, acessado em 29 de outubro de 2019). Instalações sanitárias melhoradas: Instalações sanitárias que separam higienicamente os excrementos humanos do contato humano. Os exemplos incluem descarga em sistema de esgoto encanado, fossa séptica ou latrina de fossa, latrina de fossa ventilada, latrina de fossa com laje ou sanita de compostagem. Fonte: OMS/UNICEF Questões e indicadores essenciais para monitoramento WASH em unidades de saúde nos Objetivos de Desenvolvimento Sustentável. 2018 (https://apps.who.int/iris/bitstream/ handle/10665/275783/9789241514545-eng.pdf?ua=1, acessado em 29 de outubro de 2019). Fonte melhorada de água: Definido pelo Programa de Monitoramento Conjunto do Fundo OMS/UNICEF como uma fonte de água que, pelo seu modo de construção, protege adequadamente a fonte contra contaminação externa, especialmente matéria fecal. Os exemplos incluem: torneiras ou bicas públicas; poços escavados protegidos; poços tubulares; ou poços artesianos. Fonte: OMS/UNICEF Progresso em saneamento e água potável. Atualização de 2015 e avaliação dos Objetivos de Desenvolvimento do Milênio (https://www.unicef.org/publications/ index_82419.html, acessado em 29 de outubro de 2019). VII GLOSSÁRIO DOS PRINCIPAIS TERMOS E DEFINIÇÕES Requisitos mínimos de prevenção e controle de infecção (PCI): Padrões de PCI que devem estar em vigor tanto no nível nacional quanto nos serviços de saúde para fornecer proteção e segurança mínimas para pacientes, profissionais de saúde e visitantes, com base nos componentes essenciais da OMS para programas de PCI. A existência desses requisitos constitui o ponto de partida inicial para o desenvolvimento de outros elementos fundamentais dos componentes essenciais de PCI de acordo com uma abordagem gradual baseada em avaliações da situação local. Fonte: Definição usada neste documento e desenvolvida pelo grupo de especialistas. Profissionais de PCI Profissional de saúde formado em um curso de pós-graduação em PCI certificado ou reconhecido nacionalmente. Fonte: OMS. Ferramenta do esquema de avaliação de prevenção e controle de infecção (IPCAF) (http://www.who.int/infection- prevention/tools/core- components/en/, acessado em 29 de outubro de 2019). Ponto focal de PCI: Profissional (enfermeira, médico ou outro) nomeado como responsável pela PCI em nível nacional ou de serviço de saúde que tenha uma formação profissional específica, ou seja, pós-graduação formal em PCI com certificado ou diploma. Fonte: OMS. IPCAF (http://www.who.int/infection- prevention/ tools/core-components/en/, acessado em 29 de outubro de 2019). Profissional de ligação de PCI: Enfermeiro ou médico de uma enfermaria ou unidade de saúde formado em PCI (por meio de um pacote de treinamento em serviço aprovado nacionalmente; não é exigido certificado/diploma de pós- graduação) com ligação a um ponto focal/equipe de PCI de um nível superior na organização (por exemplo, ponto focal/equipe de PCI da unidade de saúde ou em nível distrital). PCI não é a atribuição principal desse profissional, mas, entre outros, ele pode realizar as seguintes tarefas: apoiar a implementação de práticas de PCI; fornecer orientação aos colegas; realizar atividades de monitoramento; e alertar sobre possíveis riscos infecciosos. Comissão de PCI Grupo multidisciplinar com partes interessadas de todo o serviço de saúde, que interage e assessora a equipe de PCI. Por exemplo, a comissão de PCI pode incluir a alta gestão do serviço de saúde, a equipe clínica sênior, líderes de outras áreas complementares relevantes, como biossegurança, farmácia, microbiologia ou laboratório clínico, gestão de resíduos, serviços de água, saneamento e higiene e qualidade e segurança, onde houver. Fonte: OMS. IPCAF (http://www.who.int/infection- prevention/ tools/core-components/en/, acessado em 29 de outubro de 2019). Indicadores estruturais de PCI: Ambiente limpo e higienizado adequadamente, água, serviços de saneamento e higiene e disponibilidade de materiais e equipamentos para PCI, em especial para higienização das mãos, incluindo recursos financeiros, humanos e de informação compatíveis com os padrões estabelecidos pelas autoridades governamentais ou outros órgãos responsáveis pelo controle e prevenção de infecção relacionada à assistência à saúde. Fonte: OMS. Orientações sobre os componentes principais dos programas de prevenção e controle de infecção em nível nacional e de unidades de cuidados agudos. 2016 (https://www.who.int/infection- prevention/publications/core-components/en/, acessado em 29 de outubro de Outubro de 2019. Indicadores de processo de PCI: Mensuração da conformidade com as atividades de PCI atualmente usadas no serviço de saúde e a existência de normas, procedimentos e protocolos de PCI. A higienização das mãos é um indicador de processo essencial a ser monitorado. Fonte: OMS. Orientações sobre os componentes principais dos programas de prevenção e controle de infecção em nível nacional e de unidades de cuidados agudos. 2016 (https://www.who.int/infection- prevention/publications/core-components/en/, acessado em 29 de outubro de 2019. Estratégia multimodal: Uma estratégia multimodal compreende vários componentes ou elementos (três ou mais, geralmente cinco) implementados de forma integrada com o objetivo de melhorar um desfecho e mudar comportamentos. Inclui ferramentas, como pacotes e listas de verificação, desenvolvidas por equipes multidisciplinares, levando em consideração as condições locais. Os cinco elementos mais comuns incluem: (i) alteração do sistema (disponibilidade de infraestrutura e suprimentos adequados para permitir boas práticas de prevenção e controle de infecção); (ii) formação e treinamento de profissionais de saúde e atores-chave (por exemplo, gestores); (iii) monitoramento de infraestruturas, práticas, processos, desfechos e fornecimento de feedback de dados; (iv) lembretes no local de trabalho/comunicações; e (v) mudança de cultura dentro do estabelecimento ou fortalecimento de um clima de segurança. VIII GLOSSÁRIO DOS PRINCIPAIS TERMOS E DEFINIÇÕES Fonte: OMS. Aprimoramento da prevenção e controle de infecção nas unidades de saúde: 2018 (https://www.who.int/infection-prevention/ tools/core- components/facility-manual.pdf, acessado em 29 de outubro de Outubro de 2019). Sistema de ventilação mecânica de pressão negativa: Um sistema de ventilação mecânica em que a taxa de fluxo de ar de exaustão é maior do que a taxa de fluxo de ar fornecido. A pressão da sala será menor do que a das áreas circundantes. Fonte: OMS. Orientações da OMS sobre prevenção e controle da infecção por tuberculose. 2019 (https://apps.who.int/iris/ bitstream/handle/10665/311259/9789241550512- eng. pdf?ua=1, acessado em 29 de outubro de 2019). Zona do paciente: Conceito relacionado à visualização “geográfica” de momentos importantes na higienização das mãos. Contém o paciente X e seu entorno imediato. Normalmente inclui a pele intacta do paciente e todas as superfícies inanimadas que forem tocadas pelo paciente ou estiverem em contato físico direto com ele, como as grades do leito, a mesa de cabeceira, a roupa de cama, os tubos de infusão e outros equipamentos médicos. Também contém superfícies frequentemente tocadas por profissionais de saúde durante a atenção ao paciente, como monitores, botões e outras superfícies com “alta frequência” de toque. Fonte: Orientações da OMS sobre higiene das mãos na atenção à saúde. 2009 (https://www.who.int/gpsc/5may/tools/9789241597906/en /, acessado em 29 de outubro de 2019). Equipamento de proteção individual: Roupas ou equipamentos especializados usados para proteger o profissional de saúde ou qualquer outra pessoa contra infecções. Geralmente consistem em precauções padrão: luvas, máscara e jaleco. Se houver infecções transmitidas pelo sangue ou pelo ar, serão incluídos proteção facial, óculos e máscara ou protetor facial, luvas, jaleco ou macacão, cobertura para a cabeça e botas de borracha. Fonte: OMS. Produtos para saúde. 2014 (https://www.who.int/ medical_devices/meddev_ppe/en/, acessado em 29 de outubro de 2019). Ponto de atendimento: O lugar em que três elementos se encontram: o paciente, o profissional de saúde e a atenção ou tratamento que envolve contato com o paciente ou seu entorno (zona do paciente). Fonte: Orientações da OMS sobre higiene das mãos na atenção à saúde. 2009 (https://www.who.int/gpsc/5may/tools/9789241597906/en/, acessado em 29 de outubro de 2019). Sistema de ventilação mecânica de pressão positiva: Um sistema de ventilação mecânica em que a taxa de fluxo de ar fornecido é maior do que a taxa de fluxo de ar de exaustão. A sala estará sob uma pressão mais alta do que as áreas circundantes. Fonte: OMS. Ventilação natural para controle de infecção em locais de atenção à saúde. 2009 (https://www.who.int/water_sanitation_ health/publications/natural_ventilation.pdf, acessado em 29 de outubro de Outubro de 2019). Protocolo: Plano detalhado de um experimento, tratamento ou procedimento científico ou clínico. Reprocessamento de produto para saúde: Todas as etapas necessárias para adequar um produto para saúde reutilizável contaminado para o seu uso pretendido. Essas etapas podem incluir limpeza, teste funcional, embalagem, rotulagem, desinfecção e esterilização. Fonte: OMS. Descontaminação e reprocessamento de produtos para saúde para unidades de saúde. 2016 (https://www.who.int/ infection-prevention/en/, acessado em 29 de outubro de 2019). Procedimentos operacionais padrão: Um procedimento operacional padrão é um conjunto de instruções passo a passo compiladas por uma organização para ajudar os profissionais a realizar as operações de rotina da maneira mais efetiva. Precauções padrão: Um conjunto de atividades destinadas a prevenir a transmissão de organismos entre pacientes/funcionários para a prevenção de infecções relacionadas à assistência à saúde. Eles devem ser aplicados a TODOS os pacientes que requerem atenção à saúde, por TODOS os profissionais de saúde em TODAS as unidades de saúde. Incluem: higiene das mãos; uso de equipamentos de proteção individual; manuseio e descarte de resíduos e perfurocortantes; manuseio e gerenciamento de roupa limpa e usada; limpeza ambiental; e descontaminação de equipamentos. Fonte: The Northern Ireland Regional Infection and Prevention Control Manual. Standard precautions. Atualizado em 2015 (https:// www.niinfectioncontrolmanual.net/standard-precautions, acessado em 29 de outubro de 2019). Precauções baseadas na transmissão: Medidas adicionais focadas no modo particular de transmissão do microrganismo e IX GLOSSÁRIO DOS PRINCIPAIS TERMOS E DEFINIÇÕES sempre usado em adição às precauções padrão. Estão agrupadas em categorias de acordo com a via de transmissão do agente infeccioso. Devem ser aplicadas precauções baseadas na transmissão ao se cuidar de pacientes com infecção conhecida, pacientes que são colonizados por um organismo infeccioso e pacientes assintomáticos que são suspeitos/sob investigação de colonização ou infecção por um microrganismo infeccioso. Fonte: The Northern Ireland Regional Infection and Prevention Control Manual. Transmission-based precautions. Atualizado em 2015 (https://www.niinfectioncontrolmanual.net/transmission- based-precautions, acessado em 29 de outubro de 2019). Qualidade da água: A qualidade da água é afetada por aspectos microbianos, químicos e radiológicos, sendo os aspectos microbianos a principal preocupação para o controle de infecção em locais de atenção à saúde. A água das unidades de saúde não deve representar um risco para a saúde por patógenos e deve ser protegida de contaminação dentro do próprio local de atenção à saúde. A água para beber, cozinhar, higiene pessoal, atividades médicas, limpeza e lavanderia deve ser segura para o fim a que se destina. Água ‘segura’ é aquela que atende às orientações de qualidade nacionais e/ou da OMS, incluindo zero Escherichia coli ou bactérias coliformes termotolerantes em qualquer amostra de 100 mililitros de água potável. Fonte: OMS. Orientações sobre qualidade da água potável. 2017 (https:// www.who.int/water_sanitation_health/publications/drinki ng- water-quality-guidelines-4-including-1st- addendum/en/, acessado em 29 de outubro de 2019). X LEGENDA DOS SÍMBOLOS LEGENDA DOS SÍMBOLOS Representação visual dos componentes essenciais dos programas de prevenção e controle de infecção (PCI) da OMS em nível nacional e dos serviços de saúde. Representação visual dos requisitos mínimos versus completos dos componentes essenciais para se obter programas efetivos de PCI. Pessoas-chave a serem envolvidas em uma atividade. Processo adotado para desenvolver o documento. Como o documento está estruturado. Obtenção de implementação efetiva dos componentes principais de PCI. Conteúdo relevante para o nível nacional. Conteúdo relevante para o nível do serviço de saúde. 1 PARTE 1. INTRODUÇÃO PARTE 1. INTRODUÇÃO Por que os sistemas de saúde devem ter programas fortes de prevenção e controle de infecção (PCI)? A prevenção de danos aos pacientes, profissionais de saúde e visitantes decorrentes de infecção nos serviços de saúde é fundamental para se alcançar atendimento de qualidade, segurança do paciente, segurança da saúde e redução de infecções relacionadas à assistência à saúde (IRAS) e resistência microbiana aos antimicrobianos (RM). Da mesma forma, é fundamental prevenir e reduzir a transmissão de doenças infecciosas que representam ameaças globais, como a pandemia da gripe, a doença do vírus Ebola e outras febres hemorrágicas virais. Uma atenção limpa e segura é um direito do paciente, também deve ser o dever e orgulho de todos os que trabalham no setor da saúde. Com o apoio de muitas partes interessadas no campo de PCI, a OMS emitiu recomendações e especificações para programas efetivos de PCI. Elas estão incluídas nas Orientações baseadas em evidências sobre os componentes principais dos programas de PCI da OMS (1) e a abordagem para sua implementação é apresentada nos manuais associados para os níveis nacional e de serviço de saúde (2,3). A PCI é um tema transversal na área da saúde. Programas de PCI fortes e efetivos têm a capacidade de influenciar a qualidade do atendimento, melhorar a segurança do paciente e proteger todos aqueles que prestam atendimento no sistema de saúde. A implementação de todas as recomendações da OMS sobre os componentes essenciais é necessária para o desenvolvimento de programas funcionais que resultem na redução efetiva de IRAS e RM. No entanto, o cumprimento de todos os componentes essenciais de PCI leva tempo. Para alguns países, pode ser uma jornada árdua que precisará ser desenvolvida por meio de uma abordagem realista e gradual. Em especial para os países em que a PCI é limitada ou inexistente, é fundamental começar garantindo que pelo menos os requisitos mínimos de PCI estejam em vigor o mais rápido possível, tanto em nível nacional quanto de serviço de saúde, e progredir gradualmente até a plena realização de todos os requisitos dos componentes essenciais de PCI de acordo com os planos prioritários locais. Tanto os pacientes quanto os profissionais de saúde precisam estar seguros e protegidos em todos os momentos, não importa onde e independentemente do contexto. Os oito componentes essenciais de PCI são as “rodas do carrinho” que garantirão que os pacientes tenham uma jornada segura enquanto estiverem em uma unidade de atenção à saúde. 2 PARTE 1. INTRODUÇÃO Quais são os requisitos mínimos para programas de PCI? Quem deve implementar os requisitos mínimos dos programas de PCI? 1.1 OBJETIVO DO DOCUMENTO O objetivo deste documento é apresentar e promover os requisitos mínimos dos programas de PCI em nível nacional e de serviços de saúde, identificados pelo consenso de especialistas de acordo com as evidências disponíveis e no contexto dos componentes essenciais da OMS. Os requisitos mínimos são definidos como: Padrões de PCI que devem estar em vigor em nível nacional e serviços de saúde para fornecer proteção e segurança mínimas aos pacientes, profissionais de saúde e visitantes, com base nos componentes essenciais da OMS para programas de PCI. 1.2 PÚBLICO-ALVO O principal público-alvo deste documento são os pontos focais/líderes de PCI e RM, formuladores de políticas, gestores seniores e outros profissionais com mandato ou interessados em desenvolver ou fortalecer os programas de PCI em nível nacional, estadual, distrital ou municipal e estabelecimentos de atenção à saúde. As equipes e as comissões de PCI também são o público-alvo fundamental deste documento. Os principais participantes na abordagem de cada um dos requisitos mínimos também são indicados nos capítulos específicos relacionados a cada componente essencial. O documento também pode ser útil para outras partes interessadas, como os responsáveis pela melhoria da qualidade da atenção à saúde, segurança do paciente, acreditação/regulamentação de unidades de saúde, saúde pública, controle e vigilância de doenças infecciosas, água, saneamento e higiene (WASH), saúde ocupacional, 3 PARTE 1. INTRODUÇÃO programas de gerenciamento do uso de antimicrobianos, microbiologia clínica e intervenções de saúde ambiental, além de outras categorias de profissionais da saúde envolvidos na prestação de cuidados. Funcionários da OMS, parceiros de organizações não governamentais e doadores envolvidos no apoio ao desenvolvimento ou implementação de capacitação de PCI e WASH, planos de ação nacionais de RM e as capacidades básicas do Regulamento Sanitário Internacional em nível de país (4) também se beneficiarão do uso deste documento. É importante ressaltar que a implementação da PCI é responsabilidade de todos os profissionais de saúde e não apenas das equipes de PCI ou dos formuladores de políticas. Portanto, é importante que todos os profissionais de saúde estejam cientes dos requisitos mínimos de PCI. Deve-se considerar o fornecimento de uma orientação ativa sobre os requisitos mínimos de PCI (por exemplo, treinamento pré-serviço, atualizações dentro do treinamento anual em serviço etc.) aos profissionais de saúde, com base nas diferentes áreas de trabalho e funções. 1.3 DESENVOLVIMENTO E ESTRUTURA DO DOCUMENTO Como este documento foi desenvolvido? Um grupo de especialistas e profissionais internacionais que trabalham em nível nacional e de serviços de saúde na área de PCI foi convocado pela OMS, com o apoio dos Centros de Controle e Prevenção de Doenças dos Estados Unidos e do Centro Africano para Controle e Prevenção de Doenças. Realizaram-se sessões plenárias para identificar os objetivos e o âmbito do projeto e definir o conceito de requisitos mínimos. Foram formados grupos de trabalho para identificar os requisitos mínimos de cada componente central de PCI no nível nacional e dos serviços de saúde, com base nas recomendações e padrões existentes de PCI e WASH. Para o propósito desta obra, os serviços de saúde foram categorizados em unidades de atenção primária à saúde, unidades de atenção secundária (incluindo hospitais primários e secundários) e unidades de atenção terciária (hospitais terciários). Com base nas propostas dos grupos de trabalho, todos os participantes se manifestaram sobre os requisitos mínimos por meio de votação. Somente aqueles identificados com > 70% de consenso foram aceitos e incluídos neste documento. O ponto de corte de 70% foi baseado em evidências de estudos de desenvolvimento de consenso para garantir uma alta taxa de consenso entre o grupo de especialistas (5-7). Faz-se menção aos requisitos com um nível inferior de consenso nas seções de justificativa (“por quê”) de cada capítulo dos requisitos mínimos. Uma segunda rodada de revisão de conteúdo e linguagem dos requisitos mínimos foi realizada com os participantes após o encontro internacional. Por fim, foi solicitado a especialistas internacionais e funcionários da OMS que não participaram da reunião que fornecessem uma revisão externa e contribuições para a versão final do documento. 4 PARTE 1. INTRODUÇÃO Como este documento está estruturado? O documento inclui quatro partes. A Parte 1 é uma introdução que inclui seções de suma importância para entender o conteúdo restante do documento e os requisitos mínimos para programas de PCI. Os requisitos mínimos estão resumidos na Parte 2 deste documento, juntamente com as recomendações da OMS baseadas em evidências para cada componente essencial de PCI (1). A Parte 3 é uma análise aprofundada de cada componente essencial e seus requisitos mínimos para os níveis nacional e de serviços de saúde (Quadro 1). A Parte 4 inclui sumários dos resultados de uma revisão sistemática e inventário dos padrões mínimos de PCI provenientes das publicações disponíveis, usados como base de evidência para o desenvolvimento deste documento. O QUÊ? QUEM? COMO? POR QUÊ? REQUISITOS COMPLETOS Justificativa e Requisitos É responsável Medir o detalhes adicionais Requisitos dos componentes principais mínimos pela ação progresso sobre os requisitos mínimos mínimos Texto dos requisitos Identificação dos Indicadores a ser Explicação Lista abrangente de mínimos de cada que têm o mandato usados para rastrear dos motivos da Ações Componente essencial de PCI de garantir que a implementação e da seleção dos e requisitos* identificado pelo consenso os requisitos o progresso de cada requisitos para obter plena de especialistas de acordo mínimos sejam requisito mínimo mínimos implementação com o nível nacional e implementados e mantidos estejam disponíveis acordados (justificativa) e de cada componente de saúde e ou possam ter uma função. em diversas ferramentas detalhes adicionais essencial de PCI. baseado nas de monitoramento da OMS. que explicam seu Observe que isso se recomendações conteúdo e se refere apenas a e padrões de PCI e WASH importância. hospitais de cuidados existentes. agudos porque as recomendações da OMS sobre componentes essenciais de PCI se aplicam somente a esses estabelecimentos e não especificamente a unidades de atenção primária. * Observe que, em alguns casos, não há grandes diferenças em comparação com os requisitos mínimos. QUADRO 1 ESTRUTURA DOS REQUISITOS MÍNIMOS (PARTE 3) 5 PARTE 1. INTRODUÇÃO Como os requisitos mínimos podem ajudar a alcançar uma implementação efetiva dos componentes de PCI? 1.4 PAPEL DOS REQUISITOS MÍNIMOS É importante observar que o padrão ouro em qualquer país é alcançar a implementação completa de todos os requisitos dos componentes essenciais dos programas de PCI da OMS (Fig. 1) (1). Por essa razão, governos e instituições devem tomar medidas para trabalhar em direção a esse objetivo, inclusive no contexto de planos de ação nacionais para RM, qualidade de atendimento e segurança sanitária. Programas de PCI e todas as ligações relevantes do programa DIRETRIZES FORMAÇÃO E TREINAMENTO VIGILÂNCIA MONITOAMRENT O, AUDITORIA E FEEDBACK AMBIENTE FAVORÁVEL CARGA DE TRABALHO, PESSOAL E OCUPAÇÃO DE LEITOS AMBIENTE CONSTRUÍDO, MATERIAIS E EQUIPAMENTOS A I Fig. 1. Representação visual dos componentes essenciais dos programas de PCI da OMS. 6 PARTE 1. INTRODUÇÃO FULL REQUIREMENTS REQUISITOS COMPLETOS MINIMUM REQUIREMENTS REQUISITOS MÍNIMOS MINIMUM MÍNIMO FULL COMPLETO A abordagem para facilitar a implementação dos componentes da OMS, juntamente com exemplos da vida real de países e serviços de saúde do mundo inteiro, é descrita nos manuais práticos da OMS desenvolvidos para os níveis nacional e de serviços de saúde (2,3). Qualquer pessoa interessada em compreender e implementar os requisitos mínimos deve ler as Orientações da OMS sobre os componentes essenciais dos programas de PCI (1) e os manuais que apoiam sua implementação em nível nacional e de serviços de saúde (2, 3). No entanto, reconhece-se que os países possam estar em diferentes níveis de progresso, com diferentes capacidades, oportunidades e recursos disponíveis. Assim, os requisitos mínimos representam o ponto de partida para se empreender a jornada de desenvolvimento de programas de PCI fortes e efetivos em nível nacional e de serviços de saúde (Fig. 2) e DEVEM estar em funcionamento em todos os países e serviços de saúde para apoiar o progresso em direção à implementação total de todos os componentes essenciais. Fig. 2. Requisitos mínimos versus requisitos completos para obter programas de PCI efetivos. 7 PARTE 1. INTRODUÇÃO Seja aplicando os requisitos mínimos ou os requisitos completos, a implementação dos componentes essenciais de PCI deve sempre ser abordada usando uma abordagem gradual, com base em uma avaliação cuidadosa da situação do programa e das atividades de PCI em termos locais. Pode ser que um país ou serviço de saúde não seja capaz de colocar em prática todos os componentes essenciais ou mesmo todos os requisitos mínimos ao mesmo tempo. Portanto, ao se preparar para melhorar a PCI, é essencial começar usando ferramentas padronizadas e indicadores desenvolvidos e validados para avaliar a situação dos componentes essenciais em nível nacional ou de serviço de saúde em qualquer país do mundo, independentemente da localização geográfica e do nível de renda. Dependendo dos pontos fortes (os requisitos/recursos dos componentes essenciais já implementados) e das lacunas (requisitos/recursos não disponíveis ou implementados) identificados através da avaliação, um exercício de priorização pode ajudar a identificar quais componentes essenciais e requisitos mínimos ou completos precisam ser visados por meio de um plano de ação de melhoria adaptado ao contexto, experiência e recursos localmente disponíveis. Para executar esse processo, a OMS propõe um ciclo de implementação de cinco etapas (Fig. 3 e Quadro 2) para apoiar qualquer intervenção ou programa de melhoria de PCI, conforme descrito mais adiante nos manuais práticos. (2, 3, 8) Etapa 5 Manter o programa a longo prazo Etapa 1 Preparar-se para a ação Etapa 4 Avaliar o impacto Estratégia de melhoria multimodal embutida em cada etapa do ciclo de melhoria contínua Etapa 2 Avaliação inicial Etapa 3 Desenvolver e executar um plano de ação Fig. 3. Ciclo de cinco etapas para Melhoria de PCI. 8 PARTE 1. INTRODUÇÃO ETAPA 1 ETAPA 2 ETAPA 3 ETAPA 4 ETAPA 5 Preparar-se para a ação Avaliação inicial Desenvolver e executar um plano de ação Avaliação do impacto Manter o programa a longo prazo Esta etapa visa A realização de uma Desenvolvimento de um A realização de uma Uma revisão adicional do garantir que todos os avaliação inicial plano de ação personalizado que avaliação de acompanhamento impacto de longo prazo pré-requisitos que objetiva da aborde a realidade local usando as mesmas ferramentas e da aceitabilidade do precisam estar em vigor situação atual e se concentre nas da etapa 2 é fundamental plano de ação contínuo para o sucesso de dos componentes áreas prioritárias para determinar a e garantir uma intervenção Essenciais para melhoria efetividade do plano e sua sustentabilidade são ou programa de PCI sejam e dos requisitos identificadas na o cumprimento dos etapas importantes no levados em conta. Isso mínimos é avaliação inicial requisitos ciclo de melhoria. inclui começar a fundamental para a O desenvolvimento e a mínimos. Isso também permite uma pensar na identificação de execução de um plano avaliação dos identificação de participantes pontos fortes e de ação devem se basear passos e prioridades seguintes chave e suas funções lacunas existentes. em uma estratégia na implementação e responsabilidades, Os indicadores padronizados e validados multimodal de melhoria de todos os requisitos assim como os e as ferramentas com o apoio de um mínimos e dos recursos necessários de avaliação da OMS orçamento dedicado. componentes essenciais de PCI (humano e financeiro), Disponíveis completos. infraestrutura/s, estão listados na planejamento e Parte 3. As ferramentas padronizadas A nacional coordenação de para avaliar os componentes atividades. É importante notar que essenciais de PCI e WASH os preparativos em nível nacional e feitos podem ser refinados de serviço de saúde na etapa 3 após são descritos o cumprimento da etapa 2. nos Quadros 3-5. QUADRO 2 OO 2 CICLO DE CINCO ETAPAS PARA MELHORIA DA PREVENÇÃO E DO CONTROLE DE INFECÇÃO Tipo de ferramenta e objetivo Estrutura Quem deve completar Ferramenta de avaliação padronizada projetada para determinar os componentes essenciais de PCI já existentes (pontos fortes existentes) e identificar lacunas ou fragilidades em nível nacional. O principal objetivo do IPCAT2 é apoiar a implementação, fornecendo assim um roteiro para orientar as ações de PCI. O IPCAT2 inclui seis seções correspondentes às seis recomendações sobre os componentes essenciais visados em nível nacional, com um sistema de pontuação associado. A ferramenta deve ser usada para autoavaliação pela equipe e/ou comissão nacional de PCI, mas também pode ser usada para avaliações conjuntas com especialistas externos ou avaliações externas. QUADRO 3 FERRAMENTA NACIONAL DE AVALIAÇÃO DE PREVENÇÃO E CONTROLE DE INFECÇÃO 2 (IPCAT2) (9) 9 PARTE 1. INTRODUÇÃO Tipo de ferramenta e objetivo Estrutura Quem deve completar Ferramenta de avaliação validada projetada para medir a situação de PCI de um serviço de saúde e determinar os componentes essenciais já existentes (pontos fortes existentes) e identificar lacunas ou pontos fracos para orientar o planejamento de ações. Questionário estruturado de formato fechado com um sistema de pontuação associado, que inclui oito seções correspondentes às oito recomendações sobre os componentes essenciais voltados para os serviços de saúde. A ferramenta deve ser completada pelos profissionais de saúde responsáveis pela organização e implementação de medidas de PCI e que tenham conhecimento profundo de PCI no nível de serviços de saúde (ponto focal, equipe ou comissão de PCI), mas também pode ser usada para avaliações conjuntas ou avaliações externas por especialistas externos. Tipo de ferramenta e objetivo Estrutura Quem deve completar WASH FIT é uma ferramenta de melhoria a ser usada de forma contínua e regular para ajudar os funcionários e administradores dos serviços de saúde a priorizar e melhorar os serviços e orientar a infraestrutura e os serviços de gestão de resíduos em países de baixa e média renda; e orientar os esforços municipais, estaduais, distrital, regionais e nacionais mais amplos para melhorar a qualidade da atenção à saúde. O WASH FIT complementa o IPCAF e fornece um maior aprofundamento das informações sobre o ambiente construído. O WASH FIT cobre quatro grandes áreas: água, saneamento (incluindo gestão de resíduos da atenção à saúde), higiene (higiene das mãos e limpeza ambiental) e gerenciamento. A ferramenta deve ser usada por gestores e funcionários de saúde, incluindo o diretor médico, o administrador financeiro, médicos, enfermeiras e pessoas responsáveis pelo gerenciamento de água e resíduos. Outras pessoas fora de saúde também podem estar envolvidas, como autoridades locais, municipais, estaduais, distrital e regionais de WASH e/ou obras públicas, representantes da comunidade, autoridades governamentais locais e regionais envolvidas na implementação de estratégias nacionais de atenção à saúde, PCI e saúde materna, neonatal e infantil de qualidade, doadores e organizações não governamentais (ONG). QUADRO 4 ESQUEMA DE AVALIAÇÃO DE CONTROLE E PREVENÇÃO DE INFECÇÃO (IPCAF) (10) QUADRO 5 WASH FIT (11) 10 PARTE 1. INTRODUÇÃO 1.5 REFERÊNCIAS 1. Orientações sobre os componentes principais dos programas de prevenção e controle de infecção em nível nacional e de unidades de cuidados agudos. Genebra: Organização Mundial da Saúde; 2016 (http://www.who.int/infection-prevention/ publications/ipc- components-guidelines/en/, acessado em 29 de outubro de 2019). 2. Manual prático provisório de apoio à implementação nacional das orientações sobre componentes principais dos programas de prevenção e controle de infecção, da OMS. Genebra: Organização Mundial da Saúde; 2017 (http://www.who.int/ infection-prevention/tools/core- components/cc-implementation-guideline.pdf, acessado em 29 de outubro de 2019). 3. Aprimorar a prevenção e controle de infecção nos serviços de saúde: Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes principais dos programas de prevenção e controle de infecção, da OMS. Genebra: Organização Mundial da Saúde; 2018 (http://www.who.int/infection- prevention/tools/ core-components/facility-manual.pdf, acessado em 29 de outubro de 2019). 4. Regulamento Sanitário Internacional (2005). Ferramenta de avaliação dos principais requisitos de capacidade nos aeroportos, portos e passagens terrestres designados. Genebra: Organização Mundial da Saúde; 2009 (https://www.who.int/ihr/ports_airports/ PoE/en/, acessado em 29 de outubro de 2019). 5. Vogel C ZS, Griffiths C, Hobbs M, Henderson E, Wilkins E. A Delphi study to build consensus on the definition and use of big data in obesity research. Int J Obesity 2019; Jan 17 [Publicação eletrônica pré-impressão]. 6. Slade SC, Dionne CE, Underwood M, Buchbinder R. Standardised method for reporting exercise programmes: protocol for a modified Delphi study. BMJ Open. 2014: e006682. 7. Diamond IR, Grant CR, Feldman BM, Pencharz PB, Ling SC, Moore AM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67:401–09. 8. Prevenção e controle de infecção: componentes principais de PCI - ferramentas e recursos de implementação. Genebra: Organização Mundial da Saúde; 2019 (https://www. who.int/infection- prevention/tools/core-components/en, acessado em 29 de outubro de 2019). 9. Ferramenta de avaliação de prevenção e controle de infecção (IPCAT2). Genebra: Organização Mundial da Saúde; 2017 (http://www.who.int/infection-prevention/tools/ core- components/IPCAT2.xls, acessado em 29 de outubro de 2019). 10. Esquema de avaliação de prevenção e controle de infecção. Genebra: Organização Mundial da Saúde; 2018 (https://www.who.int/infection-prevention/tools/ core- components/IPCAF-facility.PDF, acessado em 29 de outubro de 2019). 11. Água e saneamento para a ferramenta de melhoria dos serviços de saúde (WASH FIT). Genebra: Organização Mundial da Saúde; 2018 (https://apps.who.int/iris/ bitstream/handle/10665/254910/9789241511698- eng.pdf?sequence=1, acessado em 29 de outubro de 2019). 13 PARTE 2. SUMÁRIO EXECUTIVO DOS REQUISITOS MÍNIMOS POR COMPONENTE ESSENCIAL PARTE 2. SUMÁRIO EXECUTIVO DOS REQUISITOS MÍNIMOS POR COMPONENTE ESSENCIAL RECOMENDAÇÃO DE COMPONENTE ESSENCIAL REQUISITOS MÍNIMOS Devem ser estabelecidos programas nacionais de PCI ativos, independentes, com objetivos, funções e atividades claramente definidos com o propósito de prevenir IRAS, promover a segurança do paciente e combater a RM por meio de boas práticas de PCI. Os programas nacionais de PCI devem estar ligados a outros programas nacionais e organizações profissionais relevantes. Um programa de PCI funcional deve estar em vigor, incluindo pelo menos: • um ponto focal treinado em PCI de tempo integral. • um orçamento dedicado para a implementação de estratégias/planos de PCI. O painel recomenda que um programa de PCI com uma equipe dedicada e treinada esteja em vigor em cada estabelecimento de cuidados agudos com o objetivo de prevenir IRAS e combater RM por meio de boas práticas de PCI. ATENÇÃO PRIMÁRIA: Agente de saúde treinado em PCI • Pessoa de ligação treinada em PCI, com tempo dedicado (meio período) em cada unidade de atenção primária à saúde. • Um agente de saúde treinado em PCI do próximo nível administrativo (por exemplo, município) para supervisionar os profissionais de ligação de PCI nas unidades de atenção primária à saúde. ATENÇÃO SECUNDÁRIA: programa de PCI funcional • Ponto focal treinado em PCI [um agente treinado em PCI de tempo integral (enfermeiro ou médico)] de acordo com a proporção recomendada de 1:250 leitos com tempo dedicado para realizar as atividades de PCI em todas as unidades (por exemplo, se a unidade de saúde tiver 120 leitos, um agente dedicado equivalente a 50% do tempo integral). • Orçamento dedicado para implementação de PCI. ATENÇÃO TERCIÁRIA: programa de PCI funcional • Pelo menos um ponto focal treinado em PCI de tempo integral (enfermeiro ou médico) com tempo dedicado para cada 250 leitos. • Programa de PCI alinhado com o programa nacional e com um orçamento dedicado. • Comissão/equipe multidisciplinar. • Acesso ao laboratório de microbiologia. COMPONENTE ESSENCIAL 1 PROGRAMAS DE PCI NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 14 PARTE 2. SUMÁRIO EXECUTIVO DOS REQUISITOS MÍNIMOS POR COMPONENTE ESSENCIAL RECOMENDAÇÃO DO COMPONENTE ESSENCIAL Devem ser desenvolvidas e implementadas diretrizes baseadas em evidências com o propósito de reduzir IRAS e RM. Devem ser proporcionados treinamento e formação para os profissionais de saúde relevantes no tocante às recomendações das orientações e ao monitoramento da adesão às recomendações das orientações para obter uma implementação bem-sucedida. REQUISITOS MÍNIMOS Diretrizes nacionais de PCI • Diretrizes, baseadas em evidências, adaptadas ao contexto local e revisadas pelo menos a cada cinco anos. ATENÇÃO PRIMÁRIA: procedimentos operacionais padrão (POP) adaptados à de saúde e seu monitoramento • POP adaptados aos serviços de saúde com base em evidências, baseados nas orientações nacionais de PCI. • No mínimo, os POP dos serviços de saúde devem incluir: - higienização das mãos - descontaminação de produtos de saúde e equipamentos de atendimento ao paciente - limpeza ambiental - gestão de resíduos de saúde - segurança de injeção - proteção de profissionais da saúde (por exemplo, profilaxia pós- exposição, vacinações) - técnicas assépticas - triagem de pacientes com infecção - princípios básicos de precauções padrão e baseadas na transmissão. • Acompanhamento de rotina da implementação de pelo menos algumas das orientações/POPs de PCI. ATENÇÃO SECUNDÁRIA E TERCIÁRIA: todos os requisitos do nível do serviço de atenção primária, com POP adicionais sobre: • precauções padrão e precauções baseadas na transmissão (por exemplo, POP específicos e detalhados para a prevenção da transmissão de patógenos pelo ar); • técnica asséptica para procedimentos invasivos, incluindo cirurgia; • POP específicos para prevenir ao máximo as IRAS prevalentes com base no contexto local/epidemiologia; • saúde ocupacional (POP específico detalhado). COMPONENTE ESSENCIAL 2 DIRETRIZES DE PCI NÍVEL NACIONAL E NÍVEL DE SERVIÇO DE SAÚDE NÍVEL NACIONAL NÍVEL DO SERVIÇO DE SAÚDE 15 PARTE 2. SUMÁRIO EXECUTIVO DOS REQUISITOS MÍNIMOS POR COMPONENTE ESSENCIAL RECOMENDAÇÃO DE COMPONENTE ESSENCIAL REQUISITOS MÍNIMOS O programa nacional de PCI deve apoiar a educação e o treinamento da força de trabalho da saúde como uma de suas funções principais. Política nacional de treinamento e currículo • Política nacional para que todos os profissionais de saúde sejam treinados em PCI (treinamento em serviço). • Um currículo nacional em PCI aprovado e alinhado com as orientações nacionais e endossadas pelo órgão apropriado. • Sistema nacional e cronograma de monitoramento e avaliação para verificar a efetividade do treinamento e da educação em PCI (pelo menos anualmente). O painel recomenda que deve ser implementada educação em PCI para todos os profissionais de saúde, utilizando estratégias de equipe e baseadas em tarefas participativas que incluam treinamento à beira do leito e simulação para reduzir o risco de IRAS e RM. ATENÇÃO PRIMÁRIA: Treinamento em PCI para toda a equipe clínica de linha de frente e de limpeza na admissão • Todo o pessoal clínico e de limpeza da linha de frente deve receber educação e treinamento sobre as orientações/POP de PCI da unidade na contratação. • Todas as pessoas de ligação de PCI na unidade de atenção primária e agentes de PCI em nível municipal (ou outro nível administrativo) precisam receber treinamento específico em PCI. ATENÇÃO SECUNDÁRIA: Treinamento PCI para todo o pessoal clínico da linha de frente e limpeza na admissão • Todo o pessoal clínico e de limpeza da linha de frente deve receber educação e treinamento sobre as orientações/POP de PCI da unidade na admissão. • Todos os funcionários de PCI precisam receber treinamento específico em PCI) ATENÇÃO TERCIÁRIA: Treinamento em PCI para todo o pessoal clínico da linha de frente e limpeza na admissão e anualmente • Todo o pessoal clínico e de limpeza da linha de frente deve receber educação e treinamento sobre as orientações/POP de PCI da unidade de saúde no momento da admissão e anualmente. • Todos os funcionários de PCI precisam receber treinamento específico em PCI) COMPONENTE ESSENCIAL 3 EDUCAÇÃO E TREINAMENTO EM PCI NÍVEL NACIONAL NÍVEL DO SERVIÇO DE SAÚDE 16 PARTE 2. SUMÁRIO EXECUTIVO DOS REQUISITOS MÍNIMOS POR COMPONENTE ESSENCIAL RECOMENDAÇÃO DO COMPONENTE ESSENCIAL REQUISITOS MÍNIMOS O painel recomenda que programas e redes nacionais de vigilância das IRAS, que incluam mecanismos para feedback oportuno de dados com potencial de ser usados para fins de benchmarking, sejam estabelecidos para reduzir IRAS e RM. Vigilância de PCI e um grupo técnico de monitoramento • Estabelecimento pelo ponto focal nacional de PCI de um grupo técnico para vigilância de IRAS e monitoramento de PCI que: - seja multidisciplinar; - desenvolva um plano estratégico nacional para vigilância de IRAS (com foco nas infecções prioritárias com base no contexto local) e monitoramento de PCI. O painel recomenda que seja realizada vigilância das IRAS nos serviços de saúde para orientar as intervenções de PCI e detectar surtos, incluindo vigilância de RM, com feedback oportuno dos resultados para os profissionais de saúde e as partes interessadas e por meio de redes nacionais. ATENÇÃO PRIMÁRIA • A vigilância das IRAS não é necessária como um requisito mínimo no nível da unidade primária, mas deve seguir os planos nacionais ou estaduais, se disponíveis (por exemplo, a detecção e a notificação de surtos que afetam a comunidade geralmente estão incluídos nos planos nacionais). ATENÇÃO SECUNDÁRIA • A vigilância das IRAS deve seguir os planos nacionais ou locais (estadual, distrital ou municipal). ATENÇÃO TERCIÁRIA: vigilância funcional das IRAS • A vigilância ativa das IRAS deve ser conduzida e inclui informações sobre RM: - estruturas capacitadoras e recursos de apoio precisam estar em vigor (por exemplo, laboratórios confiáveis, registros médicos, equipe treinada), dirigidos por um método apropriado de vigilância; - o método de vigilância deve ser dirigido pelas prioridades/planos do serviço de saúde e/ou país. • Deve ser fornecido feedback oportuno e regular às principais partes interessadas, a fim de conduzir às ações adequadas, em especial à administração do hospital. COMPONENTE ESSENCIAL 4 VIGILÂNCIA DAS IRAS NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 17 PARTE 2. SUMÁRIO EXECUTIVO DOS REQUISITOS MÍNIMOS POR COMPONENTE ESSENCIAL RECOMENDAÇÃO DO COMPONENTE ESSENCIAL REQUISITOS MÍNIMOS O painel recomenda que programas nacionais fortes de PCI devem coordenar e facilitar a implementação das atividades de PCI por meio de estratégias multimodais em nível nacional ou local (estadual, distrital ou municipal). Estratégias de melhoria multimodal para intervenções de PCI • Uso de estratégias multimodais para implementar intervenções de PCI de acordo com as orientações nacionais/POP sob a coordenação do ponto focal nacional de PCI (ou equipe, se houver). O painel recomenda que sejam implementadas atividades de PCI que utilizem estratégias multimodais para aprimorar as práticas e reduzir IRAS e RM. ATENÇÃO PRIMÁRIA: estratégias multimodais para intervenções prioritárias de PCI • Uso de estratégias multimodais - no mínimo implementar intervenções para melhorar a higiene de mãos, a administração segura de injetáveis, limpeza e desinfecção de instrumentos e produtos de saúde e a limpeza ambiental. ATENÇÃO SECUNDÁRIA: estratégias multimodais para intervenções prioritárias de PCI • Uso de estratégias multimodais - no mínimo, implementar intervenções para melhorar cada uma das precauções padrão baseadas na transmissão e triagem. ATENÇÃO TERCIÁRIA: estratégias multimodais para todas as intervenções PCI • Uso de estratégias multimodais para implementar intervenções para melhorar cada uma das precauções baseadas na transmissão, triagem e aquelas direcionadas à redução de infecções específicas (por exemplo, infecção de sítio cirúrgico ou infecção associadas a cateter) em áreas/grupos de pacientes de alto risco, de acordo com as prioridades locais. COMPONENTE ESSENCIAL 5: ESTRATÉGIAS MULTIMODAIS NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 18 PARTE 2. SUMÁRIO EXECUTIVO DOS REQUISITOS MÍNIMOS POR COMPONENTE ESSENCIAL RECOMENDAÇÃO DO COMPONENTE ESSENCIAL REQUISITOS MÍNIMOS O painel recomenda que um programa nacional de monitoramento e avaliação de PCI deve ser estabelecido para avaliar até que ponto os padrões estão sendo seguidos e as atividades estão sendo realizadas de acordo com os objetivos e metas do programa. O monitoramento da higiene de mãos com feedback deve ser considerado um indicador-chave de desempenho em nível nacional. Grupo técnico de monitoramento e vigilância de PCI • Estabelecimento pelo ponto focal nacional de PCI de um grupo técnico para vigilância de IRAS e monitoramento de PCI que: - seja multidisciplinar; - desenvolva um plano estratégico nacional para vigilância de IRAS e monitoramento de PCI e, para monitoramento de indicadores de PCI: · desenvolva recomendações para indicadores mínimos (por exemplo, higiene de mãos); · desenvolva um sistema integrado para a coleta e análise de dados (por exemplo, protocolos, ferramentas) · ofereça treinamento em nível de serviço de saúde para coleta e análise desses dados. O painel recomenda que devem ser realizados monitoramento/auditoria regular e feedback oportuno das práticas de saúde de acordo com os padrões de PCI para prevenir e controlar IRAS e RM no nível do serviço de saúde. Deve ser fornecido feedback a todas as pessoas auditadas e ao pessoal relevante. ATENÇÃO PRIMÁRIA • O monitoramento dos indicadores estruturais e de processo de PCI deve ser implementado em nível de atenção primária, com base nas prioridades de PCI identificadas nos outros componentes essenciais. Isso requer decisões em nível nacional e apoio à implementação em nível local. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • Uma pessoa responsável pela condução do monitoramento periódico ou contínuo de indicadores selecionados para processo e estrutura, orientado pelas prioridades do serviço de saúde ou do país. • A higiene de mãos é um indicador de processo essencial a ser monitorado. • Deve ser fornecido feedback oportuno e regular às principais partes interessadas, a fim de levar a ações adequadas, especialmente à administração do hospital. COMPONENTE ESSENCIAL 6: MONITORAMENTO, AUDITORIA E FEEDBACK NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE *O sistema nacional de saúde, o programa de PCI e todos os outros órgãos relevantes devem coordenar e apoiar a implementação deste componente principal nas unidades de saúde. 19 PARTE 2. SUMÁRIO EXECUTIVO DOS REQUISITOS MÍNIMOS POR COMPONENTE ESSENCIAL RECOMENDAÇÃO DO COMPONENTE ESSENCIAL REQUISITOS MÍNIMOS O painel recomenda que os seguintes elementos devem ser respeitados a fim de reduzir o risco de IRAS e a propagação de RM: (1) a ocupação de leitos não deve exceder a capacidade padrão dos serviços de saúde;(2) o nível de alocação dos profissionais de saúde deve ser adequadamente designado de acordo com a carga de trabalho por pacientes. ATENÇÃO PRIMÁRIA • Reduzir a superlotação: um sistema de fluxo de pacientes, um sistema de triagem (incluindo sistema de referência) e um sistema de gerenciamento de consultas devem ser estabelecidos de acordo com as orientações existentes, se disponíveis. • Otimizar os níveis de pessoal: avaliação dos níveis adequados de pessoal, dependendo das categorias identificadas ao usar ferramentas nacionais/OMS (políticas nacionais sobre a proporção paciente/equipe), e desenvolvimento de um plano apropriado. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • Padronizar a ocupação de leitos: - estabelecer um sistema para gerenciar o uso do espaço do serviço de saúde e estabelecer a capacidade padrão de leitos do serviço de saúde; - aplicação do sistema desenvolvido na administração hospitalar; - não mais do que um paciente por leito; - espaçamento de pelo menos um metro entre as bordas dos leitos; - a ocupação total não deve exceder a capacidade total de leitos projetada para o serviço de saúde. • Reduzir a superlotação e otimizar os níveis de pessoal: os mesmos requisitos mínimos da atenção primária. COMPONENTE ESSENCIAL 7: CARGA DE TRABALHO, PESSOAL E OCUPAÇÃO DE LEITOS (SOMENTE NÍVEL DE SERVIÇO DE SAÚDE*) NÍVEL DE UNIDADE* *O sistema nacional de saúde, o programa de PCI e todos os outros órgãos relevantes devem coordenar e apoiar a implementação deste componente principal nas unidades de saúde. 20 PARTE 2. SUMÁRIO EXECUTIVO DOS REQUISITOS MÍNIMOS POR COMPONENTE ESSENCIAL RECOMENDAÇÃO DO COMPONENTE ESSENCIAL REQUISITOS MÍNIMOS As atividades de atendimento ao paciente devem ser realizadas em um ambiente limpo e/ou higienizado que facilite as práticas relacionadas à prevenção e controle de IRAS, bem como RM, incluindo todos os elementos em torno da infraestrutura e serviços de WASH e a disponibilidade de materiais e equipamentos apropriados de PCI. O painel recomenda que materiais e equipamentos para realizar a higiene de mãos adequada devem estar prontamente disponíveis no local de atendimento. ATENÇÃO PRIMÁRIA: • A água deve estar sempre disponível a partir de uma fonte nos serviços de saúde (como um poço artesiano profundo ou um abastecimento de água encanada tratada e gerenciada com segurança) para executar as medidas básicas de PCI, incluindo higiene de mãos, limpeza ambiental, lavanderia, limpeza e desinfecção de produtos de saúde e gestão de resíduos de serviços de saúde de acordo com as orientações nacionais. • No mínimo dois banheiros funcionais devem estar disponíveis no local, uma para pacientes e outra para funcionários; ambos devem estar equipados com unidades de higiene menstrual. • Instalações funcionais de higiene de mãos devem estar sempre disponíveis em pontos de atendimento/banheiros e devem incluir sabão, água e toalhas descartáveis (ou se não houver disponíveis, toalhas reutilizáveis limpas) ou antisséptico para higienização das mãos (álcool gel) nos pontos de atendimento e sabão, água e toalhas descartáveis (ou se não houver disponíveis, toalhas reutilizáveis limpas) a menos de 5 metros dos banheiros. • Lixeiras suficientes e devidamente rotuladas para permitir a separação de resíduos de saúde devem estar disponíveis e ser usadas (menos de 5 metros do ponto de geração); os resíduos devem ser tratados e descartados com segurança por meio de autoclavagem, incineração em alta temperatura e/ou enterrados em uma fossa protegida revestida. • O layout do serviço de saúde deve permitir ventilação natural adequada, descontaminação de produtos de saúde reutilizáveis, triagem e espaço para coorte/isolamento/separação física temporária, se necessário. • Suprimentos e equipamentos de PCI suficientes e adequados [por exemplo, esfregões, detergente, desinfetante, equipamento de proteção individual (EPI) e esterilização] e fonte de força/energia (por exemplo, combustível) devem estar disponíveis para a execução de todas as medidas básicas de PCI de acordo com os requisitos mínimos/POP, incluindo todas as precauções padrão, conforme aplicável; deve haver iluminação disponível durante o horário de trabalho para a prestação de cuidados. ATENÇÃO SECUNDÁRIA E TERCIÁRIA: • Uma quantidade segura e suficiente de água deve estar disponível para todas as medidas de PCI e atividades médicas específicas exigidas, incluindo para beber, e canalizada dentro do serviço de saúde em todos os momentos - no mínimo nas enfermarias de alto risco (por exemplo, maternidade, centros cirúrgicos, unidade de terapia intensiva). • Devem estar disponíveis, no mínimo, dois banheiros funcionais que contenham descarte seguro de resíduos nos ambulatórios, e uma a cada 20 leitos, nas enfermarias; todas devem estar equipadas com unidades de higiene menstrual. • Instalações funcionais para higienização das mãos devem estar sempre disponíveis em pontos de atendimento, banheiros e áreas de serviço (por exemplo, unidade de descontaminação), que incluem álcool gel e sabão, água e toalhas descartáveis (ou se não houver disponíveis, toalhas reutilizáveis limpas) nos pontos de atendimento e áreas de serviço, e sabão, água e toalhas descartáveis (ou se não houver disponíveis, toalhas reutilizáveis limpas) a menos de 5 metros dos banheiros. • Lixeiras suficientes e devidamente rotuladas para permitir a separação de resíduos de saúde devem estar disponíveis e ser usadas (menos de 5 metros do ponto de geração) e os resíduos devem ser tratados e descartados com segurança por meio de autoclavagem, incineração (850° a 1100° C) e/ou enterrados em uma fossa protegida revestida. COMPONENTE ESSENCIAL 8: INFRAESTRUTURA, MATERIAIS E EQUIPAMENTOS PARA PCI (SOMENTE NÍVEL DE SERVIÇO DE SAÚDE) NÍVEL DE SERVIÇO DE SAÚDE 21 PARTE 2. SUMÁRIO EXECUTIVO DOS REQUISITOS MÍNIMOS POR COMPONENTE ESSENCIAL • O serviço de saúde deve ser projetado para permitir ventilação adequada (natural ou mecânica, conforme necessário) para prevenir a transmissão de patógenos. • Suprimentos e equipamentos suficientes e adequados e fonte de força/energia confiável devem estar disponíveis para a execução de todas as práticas de PCI, incluindo precauções padrão e baseadas na transmissão, de acordo com os requisitos mínimos/POP; eletricidade confiável deve estar disponível para fornecer iluminação às áreas clínicas para que ofereçam atendimento contínuo e seguro, no mínimo para enfermarias de alto risco (por exemplo, maternidade, sala(s) cirúrgica(s), unidade de terapia intensiva). • O serviço de saúde deve ter um espaço/área dedicado para realizar a limpeza, desinfecção e o reprocessamento de produtos de saúde (ou seja, um centro de material e esterilização) de acordo com os requisitos mínimos/POP. • O serviço de saúde deve ter salas de isolamento individuais adequadas ou pelo menos uma sala para coorte de pacientes com patógenos ou síndromes semelhantes, se o número de quartos de isolamento for insuficiente. 23 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS Um programa de PCI funcional deve estar em vigor, incluindo pelo menos: • um ponto focal treinado em PCI de tempo integral. • um orçamento dedicado à implementação de estratégias/planos de PCI. • Ministro da saúde ou outra autoridade sênior designada dentro do ministério da saúde (por exemplo, o diretor geral dos serviços de saúde) em nível nacional e/ou estadual. • O ministro das finanças também pode ter um papel importante na alocação de um orçamento dedicado para PCI. • Líderes de outros programas cujas ligações possam ser úteis para ação sinérgica (por exemplo, IRAS, RM, WASH). • Comissão ou grupo técnico de trabalho nacional de PCI, dependendo da situação do país, pois em alguns países a comissão existe, mas não há um ponto focal ou equipe nacional de PCI para agir. Portanto, a comissão de PCI pode ter um papel crítico na defesa de causa do estabelecimento de um ponto focal nacional de PCI. • Os parceiros técnicos de PCI têm um papel importante em defender e apoiar (também financeiramente em alguns casos) o estabelecimento de um ponto focal de PCI [por exemplo, escritório da OMS no país, Escritório Regional da OMS, UNICEF, Centros para Controle e Prevenção de Doenças (CDC) dos EUA, e outras organizações com competência e atividades no domínio de PCI]. ATENÇÃO PRIMÁRIA Pessoa de ligação treinada em PCI e agente de saúde • Pessoa de ligação treinada em PCI, com tempo dedicado (meio período) em cada unidade de atenção primária. • Um agente de saúde treinado em PCI do próximo nível administrativo (por exemplo, município) para supervisionar os profissionais de ligação de PCI nas unidades de atenção primária à saúde. ATENÇÃO SECUNDÁRIA Programa funcional de PCI • Ponto focal treinado em PCI [um agente treinado em PCI de tempo integral (enfermeiro ou médico)] de acordo com a proporção recomendada de 1:250 leitos com tempo dedicado para realizar as atividades de PCI em todas as unidades (por exemplo, se a unidade de saúde tiver 120 leitos, um agente dedicado equivalente a 50% do tempo integral). • Orçamento dedicado para implementação de PCI. ATENÇÃO TERCIÁRIA Programa funcional de PCI • Pelo menos um ponto focal treinado em PCI de tempo integral (enfermeiro ou médico) com tempo dedicado para cada 250 leitos. • Programa PCI alinhado com o programa nacional e com um orçamento dedicado. • Comissão/equipe multidisciplinar. • Acesso ao laboratório de microbiologia. • Todos os principais participantes mencionados em nível nacional podem influenciar e/ou ordenar o estabelecimento de pessoas de ligação de PCI, pontos focais de PCI e comitês de PCI no nível das unidades de saúde e de oficiais de PCI do próximo nível administrativo. • Diretores de saúde ou equipes de gestão de saúde (ou outra função de tomada de decisão) em nível estadual, distrital ou municipal (ou outro nível administrativo, dependendo do país). • No nível das unidades de saúde secundárias e terciárias, o diretor do hospital, o diretor médico, a enfermeira-chefe e o diretor do escritório financeiro têm um papel crítico na decisão de estabelecer os requisitos mínimos para o componente essencial. • Comissão de PCI existente (ou similar) na unidade de saúde ou próximo nível administrativo. • Os parceiros locais têm um papel importante em defender e apoiar (também financeiramente em alguns casos) o estabelecimento dos requisitos mínimos de PCI nos serviços de saúde. QUEM (é responsável pela ação) COMPONENTE ESSENCIAL 1: PROGRAMAS DE PCI O QUÊ (requisitos mínimos) NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 24 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS • Ferramenta de avaliação de PCI 2 (IPCAT2) – 1.1.1: existe um programa de PCI nacional ativo. • IPCAT2 - 1.1.2: uma pessoa focal de prevenção de infecção nomeada responsável pelo programa de PCI pode ser identificada. • IPCAT2 - 1.1.4: a pessoa focal de prevenção de infecção nomeada passou por treinamento em PCI na prevenção de IRAS. • IPCAT2 - 1.1.7: há um orçamento dedicado alocado ao programa de PCI. ATENÇÃO PRIMÁRIA • Uma pessoa de ligação treinada em PCI, com tempo dedicado, está disponível em cada unidade de atenção primária à saúde. • Intervenções de PCI incluídas no plano anual da unidade de saúde. • Um agente de saúde treinado em PCI está disponível no próximo nível administrativo (por exemplo, município) para supervisionar os profissionais de ligação de PCI. ATENÇÃO SECUNDÁRIA • Ferramenta do esquema de avaliação de controle e prevenção de infecção (IPCAF) - 1.1: existe um programa de PCI. • IPCAF - 1.3: há pelo menos uma pessoa focal treinada em PCI de tempo integral (enfermeiro ou médico) para cada 250 leitos. • IPCAF - 1.4: o ponto focal de PCI tem tempo dedicado para as atividades de PCI em todas as unidades, independentemente do número de leitos. • IPCAF - 1.9: existe um orçamento dedicado especificamente para o programa de PCI, ou seja, cobrindo as atividades de PCI, incluindo salários. ATENÇÃO TERCIÁRIA • IPCAF - 1.1: existe um programa de PCI. • IPCAF - 1.3: há pelo menos uma pessoa focal treinada em PCI de tempo integral (enfermeira ou médico) para cada 250 leitos. • IPCAF - 1.6: existe uma comissão multidisciplinar de PCI apoiando ativamente a equipe de PCI. • IPCAF - 1.9: existe um orçamento dedicado especificamente para o programa de PCI, ou seja, cobrindo as atividades de PCI, incluindo salários. • IPCAF - 1.10: o programa de PCI tem acesso a um laboratório de microbiologia, dentro ou fora do local, para uso rotineiro cotidiano. Fontes • Resultados IPCAT2 (onde disponíveis; use os resultados e gráficos autogerados disponíveis no arquivo Excel do IPCAT2); https://www.who. int/infection-prevention/tools/core- components/en/. • OMS. Ferramenta de relatório anual de autoavaliação do Estado Parte. Regulamento Sanitário Internacional (2005). 2018; https://www.who. int/ihr/publications/WHO-WHE-CPI- 2018.16/en/. • OMS. Relatório da Avaliação Externa Conjunta (AEC)(disponível) 2a edição, 2018; https://www.who.int/ihr/procedures/joint-external- evaluations/en/. • Organização das Nações Unidas para a Alimentação e Agricultura; Organização para a Saúde Animal; OMS. Monitoramento global do progresso do país na resistência antimicrobiana (AMR): Enquete de autoavaliação do país sobre AMR tripartite (TrACSS), versão 3.0, relatório. 2018; https://www.who.int/antimicrobial-resistance/global-action- plan/Tripartite-antimicrobial-resistance- country-self- assessment-questionnaire-2018-EN.pdf?ua=1. Fontes • Relatório de resultados IPCAF (onde disponível; use o modelo de apresentação); https://www.who.int/infection- prevention/tools/ core-components/IPCAF- template.pdf?ua=1. Ferramentas e recursos • OMS. Orientações sobre os componentes principais dos programas de prevenção e controle de infecção em nível nacional e de serviços de saúde. 2016; https://www. who.int/infection-prevention/publications/core- components/en/. • OMS. Aprimorar a prevenção e controle de infecção nos serviços de saúde: Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes principais dos programas de prevenção e controle de infecção, da OMS. 2018; https://www.who.int/infection- prevention/tools/core- components/facility-manual.pdf. • Twinning partnerships for improvement; https://www.who.int/ servicedeliverysafety/twinning- partnerships/en/ 1 Fontes referem-se aqui a possíveis informações que possam estar disponíveis em fontes existentes que podem ser usadas para extrair informações relevantes a fim de abordar cada indicador. Recursos relaciona as ferramentas e recursos de implementação relevantes disponíveis. FONTES E RECURSOS EM NÍVEL NACIONAL1 FONTES E RECURSOS EM NÍVEL SERVIÇO DE SAÚDE COMO (medir o progresso) INDICADORES EM NÍVEL NACIONAL (SIM/NÃO) INDICADORES EM NÍVEL DE SERVIÇO DE SAÚDE (SIM/NÃO) 25 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS Ferramentas e recursos • OMS. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core- components/en/. • OMS. Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes principais dos programas de prevenção e controle de infecção, da OMS. 2018; https://www. who.int/infection-prevention/tools/core- components/facility- manual.pdf. • Association for Professionals in Infection Control and Epidemiology (APIC). HAI cost calculator; https://apic.org/ resources/cost-calculators/. • Centro Europeu para Prevenção e Controle de Doenças. Competências essenciais para profissionais de controle de infecção e higiene hospitalar na União Europeia. 2013; https://ecdc.europa.eu/sites/portal/files/media/en/publicat ions/Publications/ infection-control-core-competencies.pdf. • Pelo menos um profissional (enfermeiro ou médico) deve receber a responsabilidade pela PCI em nível nacional. Ele deve ter pelo menos conhecimento básico e treinamento em PCI (de preferência, um certificado de pós-graduação em PCI) e alguma experiência prática. • Quando a pessoa estiver atuando é essencial ter alguns recursos (orçamento) para trabalhar. • Com base nisso, os objetivos, funções e plano de atividades serão desenvolvidos pelo ponto focal de PCI em colaboração com outros programas e instituições nacionais, bem como com parceiros externos. ATENÇÃO PRIMÁRIA • O nível de atenção primária à saúde é o primeiro ponto principal de entrada de patógenos infecciosos no sistema de saúde e é onde a PCI geralmente é mais fraca. • É fundamental estabelecer pelo menos um nível básico de PCI e triagem na atenção primária (ou seja, os requisitos mínimos) para evitar infecção e disseminação de RM pelo sistema de saúde, incluindo surtos associados à assistência causados pela transmissão de patógenos emergentes ou ressurgentes de pessoa para pessoa. • É importante ter profissionais encarregados da PCI em diferentes níveis (serviços de saúde e no próximo nível administrativo) para apoiar uma abordagem programática baseada na coordenação, supervisão e prestação de contas por meio de monitoramento e avaliação. • A existência de um programa e práticas de PCI na atenção primária contribuirá para a segurança do paciente e a qualidade da assistência e facilitará as ligações com a comunidade e a disseminação dos princípios básicos de prevenção entre as famílias, bem como o envolvimento do paciente e da família. • A pessoa de ligação deve ser um membro da equipe do serviço de atenção primária, treinado em PCI e com tempo dedicado (meio período). • Nas unidades com mais de 10 profissionais de saúde, a pessoa de ligação de PCI deve ser responsável pelas seguintes funções: aconselhar sobre a aquisição e manutenção de equipamentos e materiais para PCI; monitorar e supervisionar as atividades de PCI; fazer a ligação com os coordenadores de PCI do próximo nível administrativo relevante na implementação atividades de PCI; ligação com o sistema regular de notificação de doenças para relato de eventos incomuns. • Nas unidades com menos de 10 profissionais de saúdes, a pessoa de ligação pode ter algumas das funções mencionadas acima, mas, em geral, será necessário mais apoio do agente municipal, especialmente para atividades de monitoramento. POR QUÊ (justificativa e detalhes adicionais sobre os requisitos mínimos) NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE ATENÇÃO SECUNDÁRIA E TERCIÁRIA • Um programa de PCI abrangente e funcional deve ser implementado em todos os serviços de saúde porque as evidências demonstram um grande efeito na redução de IRAS. • A existência de um ponto focal de PCI e um orçamento são condições necessárias para o desenvolvimento de um programa de PCI com objetivos e planos, e a premissa necessária para qualquer ação de PCI. • O número de funcionários necessários depende da gravidade do paciente e da complexidade do atendimento na instituição, bem como das múltiplas funções e responsabilidades dos profissionais de PCI. 26 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS • Programa de PCI nacional ativo, independente, com objetivos, funções e atividades claramente definidos. • Equipe técnica treinada em PCI (profissionais médicos e de enfermagem) com tempo, orçamento e autoridade para tomar decisões. • Fortes ligações com programas nacionais de PCI com outros programas nacionais relevantes e organizações profissionais. • Apoiado por pelo menos um laboratório microbiológico de referência nacional com sistema de garantia de qualidade externa (EQAS) • Apoiado por uma comissão oficial multidisciplinar de PCI. ATENÇÃO PRIMÁRIA Não aplicável. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • Programas de PCI com objetivos claramente definidos com base na epidemiologia e nas prioridades locais de acordo com uma avaliação de risco e funções que se alinhem e contribuam para a prevenção de IRAS e da disseminação de MR na atenção à saúde. • Profissionais treinados e dedicados em todas as unidades de cuidados intensivos. • Uma proporção mínima de um profissional de PCI de tempo integral ou equivalente (enfermeiro ou médico) para cada 250 leitos ou uma proporção maior (um profissional de PCI para cada 100 leitos) devido ao aumento da gravidade e complexidade do atendimento aos pacientes, bem como às crescentes e múltiplas funções e responsabilidades do profissional de PCI. • O apoio de um laboratório microbiológico com sistema de controle de qualidade externa é importante para um programa de PCI efetivo. Requisitos completos dos componentes essenciais NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 27 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS Orientações nacionais de PCI • Orientações baseadas em evidências, nacionalmente aprovadas, adaptadas ao contexto local e revisadas pelo menos a cada cinco anos. • O ponto focal nacional de PCI (e equipe ou comissão de PCI, se houver) uma vez que o desenvolvimento e a implementação das orientações são atividades-chave em seu mandato. • Em um país no qual o ponto focal/equipe de PCI foi estabelecido recentemente e tem experiência/especialização limitada, cogite suporte técnico externo de PCI conforme necessário para o desenvolvimento/revisão inicial das orientações. • Outro órgão nacional responsável (por exemplo, o centro nacional de controle de doenças, instituto de saúde pública) ou uma instituição acadêmica que colabore com o ministério da saúde também pode desempenhar um papel importante no desenvolvimento de orientações/POP de PCI. ATENÇÃO PRIMÁRIA POP adaptados às unidades de saúde e seu monitoramento • POP adaptados às unidades de saúde baseados em evidências com base nas orientações nacionais de PCI. • No mínimo, os POP da unidade de saúde devem incluir: - Higiene de mãos - Descontaminação de produtos de saúde e equipamentos de atendimento ao paciente - Limpeza ambiental - Gerenciamento de resíduos de saúde - Administração segura de injetáveis - Proteção de profissionais de saúde (por exemplo, no mínimo profilaxia pós-exposição, vacinações) - Técnicas assépticas - Triagem de pacientes com infecção - Princípios básicos de precauções padrão • Monitoramento de rotina da implementação de pelo menos algumas das orientações/POP de PCI. ATENÇÃO SECUNDÁRIA E TERCIÁRIA todos os requisitos do nível de unidade de saúde primária, com POP adicionais sobre: • precauções padrão e baseadas na transmissão (por exemplo, POP específicos e detalhados para a prevenção da transmissão de patógenos pelo ar); • técnica asséptica para procedimentos invasivos, incluindo cirurgia; • POP específicos para prevenir as IRAS mais prevalentes com base no contexto/epidemiologia local; • saúde ocupacional (detalhada). ATENÇÃO PRIMÁRIA • Pessoa de ligação treinada em PCI, com tempo (meio-período) dedicado e/ou apoio de uma pessoa treinada em PCI indicada do próximo nível administrativo. • Se a experiência da unidade de saúde e do próximo nível administrativo for limitada, deve-se buscar apoio externo. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • O ponto focal de PCI é responsável por redigir e adaptar os POP, promovendo sua adoção e monitorando a adesão a eles. Se a experiência da equipe de PCI for limitada, deve- se buscar apoio externo. • O desenvolvimento e a implementação dos POP requerem um programa de PCI em funcionamento e conhecimentos associados para garantir que os procedimentos recomendados locais remetam às NÍVEL DE SERVIÇO DE SAÚDE QUEM (é responsável pela ação) COMPONENTE ESSENCIAL 2: DIRETRIZES DE PCI O QUÊ (requisitos mínimos) NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE NÍVEL NACIONAL 28 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS orientações nacionais ou internacionais baseadas em evidências e sejam adaptados ao contexto. • As partes interessadas relevantes (por exemplo, médicos, enfermeiros, gestores de unidades de saúde, gestores de qualidade) devem estar envolvidas no desenvolvimento e adaptação das orientações. • O envolvimento dos profissionais de saúde da linha de frente deve ser cogitado no desenvolvimento e implementação dos POP. • O ponto focal de PCI também deve ser responsável por organizar treinamento da equipe nos POP e monitorar a adesão aos procedimentos recomendados, em colaboração com outros que possam ser responsáveis pelo treinamento e avaliação em nível local. • IPCAT2 - 2.1.1: o ponto focal nacional de PCI tem o mandato de trabalhar com os principais participantes para produzir orientações para a prevenção e controle de IRAS. • IPCAT2 - 2.1.6: o ponto focal nacional de PCI aborda ativamente a adaptação das orientações de modo a refletir as condições locais. • IPCAT2 - 2.1.3: as orientações são revisadas pelo menos a cada 5 anos e atualizadas de modo a refletir a base de evidências atual. ATENÇÃO PRIMÁRIA • IPCAF - 2.2: POP adaptados às unidades de saúde estão disponíveis higiene das mãos, descontaminação de produtos de saúde e equipamentos de atendimento ao paciente, limpeza ambiental, gerenciamento de resíduos de saúde, aplicação segura de injetáveis, proteção de profissionais de saúde (por exemplo, pelo menos profilaxia pós-exposição, vacinações), técnicas assépticas, triagem, princípios básicos de precauções padrão e com base na transmissão. • IPCAF - 2.3: As orientações/POP são consistentes com as orientações nacionais/internacionais de PCI (se houver). • IPCAF - 2.8: É realizado monitoramento de rotina da implementação de pelo menos algumas das orientações/POP. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • IPCAF - 2.2: POP/orientações adaptados às unidades de saúde estão disponíveis para higiene das mãos, descontaminação de produtos de saúde e equipamentos de atendimento ao paciente, limpeza ambiental, gestão de resíduos de saúde, proteção de profissionais de saúde (por exemplo, no mínimo profilaxia pós-exposição, vacinações), técnica asséptica para procedimentos invasivos, incluindo cirurgia, triagem, precauções padrão e baseadas na transmissão, POP específicos para prevenção das IRAS mais prevalentes com base no contexto local/epidemiologia e saúde ocupacional. • IPCAF - 2.3: as orientações/POP são consistentes com as orientações nacionais/internacionais de PCI (se houver). • IPCAF - 2.8: é realizado o monitoramento de rotina da implementação de pelo menos alguns dos POP. Fonte • Resultados IPCAT2 (onde disponíveis; use os resultados e gráficos autogerados disponíveis no arquivo Excel do IPCAT2); https://www.who.int/ infection-prevention/tools/core- components/en/. Ferramentas e recursos • OMS. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core- components/en/. • OMS. Aprimoramento da prevenção e controle de infecção nos serviços de saúde: Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes principais dos programas de prevenção e controle de infecção da OMS 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. FONTES E RECURSOS EM NÍVEL NACIONAL FONTES E RECURSOS EM NÍVEL DE SERVIÇO DE SAÚDE COMO (medir o progresso) INDICADORES EM NÍVEL NACIONAL (SIM/NÃO) INDICADORES EM NÍVEL DE SERVIÇO DE SAÚDE (SIM/NÃO) Fontes • Relatório de resultados IPCAF (onde disponível; use o modelo de apresentação); https://www.who.int/infection-prevention/tools/ core- components/IPCAF-template.pdf?ua=1. • Primary Health Care Performance Initiative. Primary health care progression model assessment tool report (onde disponível). 2018; https://improvingphc.org/primary-health- care-progression-model. Ferramentas e recursos • WHO Guidelines on core components of IPC programmes at the national and acute health care facility level; https://www.who.int/ infection- prevention/publications/core-components/en/. • OMS. Aprimorar a prevenção e controle de infecção nos serviços de saúde: Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes principais dos programas de prevenção e controle de infecção da OMS PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS . 2018; https://www.who.int/infection- prevention/tools/core-components/facility-manual.pdf. • CDC IPC guidelines library; https://www.cdc.gov/infectioncontrol/ guidelines/index.html. • APIC: list of IPC guidelines; https://apic.org/Professional- Practice/ Scientific-guidelines. • Asia Pacific Society for Infection Control IPC guidelines; http:// apsic-apac.org/guidelines-and- resources/apsicguidelines/. • A disponibilidade de orientações nacionais contribui para a redução do risco de IRAS e RM, especialmente quando implementadas em combinação com a educação e treinamento dos profissionais de saúde. • O desenvolvimento de orientações/protocolos/POP de PCI e estratégias de implementação relacionadas é uma função- chave do ponto focal nacional de PCI (ou equipe/programa de PCI, se houver). • São necessárias orientações nacionais para indicar os padrões e medidas de PCI que devem ser seguidos e monitorados, incluindo o treinamento apropriado dos profissionais de saúde em todos os níveis. • As orientações nacionais de PCI devem ser baseadas em evidências (isto é, baseadas em revisões sistemáticas da literatura científica e outras orientações existentes) e, idealmente, referir-se a/ser adaptadas de orientações padronizadas internacionais, se disponíveis. • O conteúdo das orientações deve ser priorizado localmente, com base nas práticas e/ou tipos de IRAS mais frequentes e adaptado às circunstâncias locais (por exemplo, uso de cateteres de longa permanência e outros dispositivos, cirurgia e outros procedimentos invasivos). No entanto, no mínimo, as orientações devem cobrir os seguintes tópicos: - Higiene das mãos - Limpeza e desinfecção de produtos de saúde e artigos de cuidado ao paciente - Limpeza ambiental - Gerenciamento de resíduos de saúde - Precauções baseadas na transmissão - Proteção dos profissionais de saúde - Técnicas assépticas - Triagem - O desenvolvimento e implementação de estratégias de treinamento e divulgação das orientações de PCI fazem parte dos requisitos mínimos. • Atualizações regulares (ou seja, pelo menos a cada 5 anos) são necessárias para garantir que as orientações reflitam as evidências atuais e permaneçam atuais e práticas para a evolução da provisão de atenção à saúde. ATENÇÃO PRIMÁRIA • No nível da unidade de saúde, não é necessário ter a experiência necessária para desenvolver orientações baseadas em evidências. É importante desenvolver POP para implementação e monitoramento das orientações nacionais ou internacionais disponíveis. • Os profissionais de ligação de PCI do nível da unidade de saúde devem trabalhar com os pontos focais de PCI do próximo nível administrativo (por exemplo, município) para desenvolver POP adaptados com base nas orientações nacionais (ou internacionais) para atenção primária. • O monitoramento da adesão à implementação do POP é essencial para avaliar sua adoção e efetividade para atingir os desfechos desejados e para auxiliar nos ajustes e melhorias das estratégias de implementação. O monitoramento e a supervisão de PCI devem ser assegurados pelo agente de saúde responsável pela PCI no próximo nível administrativo (por exemplo, município). • Deve ser cogitada adaptação às condições locais para uma compreensão e implementação mais efetivas. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • Veja todos os pontos indicados para o nível da unidade de atenção primária. • Um nível mais alto de especialização de PCI é necessário para desenvolver POP em serviços de saúde secundárias e terciárias, devido ao aumento na gravidade e complexidade dos cuidados prestados. • Os POP adaptados às unidades de saúde devem ser priorizados localmente, com base nas práticas mais frequentes e/ou com práticas associadas a um aumento no risco de IRAS e adaptados às circunstâncias locais (por exemplo, uso de cateteres e outros dispositivos, cirurgia e outros procedimentos invasivos). POR QUÊ (justificativa e detalhes adicionais sobre os requisitos mínimos) NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 29 • O desenvolvimento de orientações nacionais e as estratégias de implementação relacionadas são função da equipe ou ponto focal nacional de PCI e requerem especialização em PCI. Requisitos (que estão sob a responsabilidade do programa nacional) para desenvolver e implementar orientações nacionais de PCI efetivas: - experiência em PCI para desenvolvimento ou adaptação; - priorização local; - fornecimento de recursos, infraestrutura e suprimentos para permitir a implementação; ATENÇÃO PRIMÁRIA Não aplicável. ATENÇÃO SECUNDÁRIA E TERCIÁRIA Não há grandes diferenças a serem observadas em comparação com os requisitos mínimos. - Educação dos profissionais de saúde sobre as práticas recomendadas; - monitoramento da implementação e adesão; - atualizações regulares. • Para cumprir totalmente o componente essencial 2, as orientações sobre todos os tópicos a seguir devem ser desenvolvidas em nível nacional (seja em uma orientação principal ou em orientações específicas, conforme viável e apropriado de acordo com o contexto local): - precauções padrão · Higiene de mãos · Uso de EPI · Esterilização e descontaminação de produtos de saúde · Manuseio seguro de roupa de cama e lavanderia · Gerenciamento de resíduos de saúde · Isolamento de pacientes · Higiene respiratória e etiqueta da tosse · Limpeza ambiental · Aplicação segura de injetáveis · Proteção, segurança e profilaxia pós-exposição dos profissionais de saúde. - Precauções baseadas na transmissão; - Técnica asséptica e gerenciamento de dispositivos para procedimentos clínicos; - Orientações específicas para prevenir as IRAS mais prevalentes (por exemplo, infecção do trato urinário associada a um cateter, infecção do sítio cirúrgico, infecção de corrente sanguínea associada a um cateter central, pneumonia associada a ventilador), dependendo do contexto e da complexidade do atendimento. • O envolvimento e a participação precoce das partes interessadas no desenvolvimento e produção de orientações são vitais para garantir o consenso e uma melhor adesão. Requisitos dos componentes essenciais completos NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 31 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS Política nacional de treinamento e currículo • Política nacional para que todos os profissionais de saúde sejam treinados em PCI (treinamento em serviço). • Um currículo nacional em PCI aprovado, alinhado com as orientações nacionais e endossado pelo órgão apropriado. • Sistema nacional e cronograma de monitoramento e avaliação para verificar a efetividade do treinamento e educação em PCI (pelo menos anualmente). ATENÇÃO PRIMÁRIA Treinamento em PCI para todo o pessoal clínico da linha de frente e de limpeza na admissão • Todo o pessoal clínico da linha de frente e de limpeza devem receber educação e treinamento sobre as orientações/POP de PCI da unidade de saúde quando da contratação. • Todas as pessoas de ligação de PCI nas unidades de atenção primária e os agentes de PCI do nível municipal (ou outro nível administrativo) precisam receber treinamento específico em PCI. ATENÇÃO SECUNDÁRIA Treinamento em PCI para todo o pessoal clínico da linha de frente e da limpeza na admissão: • Todos os funcionários clínicos da linha de frente e de limpeza devem receber educação e treinamento sobre as orientações/POP de PCI no momento da contratação. • Todos os funcionários de PCI precisam receber treinamento específico em PCI. ATENÇÃO TERCIÁRIA Treinamento em PCI para todo o pessoal clínico da linha de frente e de limpeza na admissão e anualmente • Todo o pessoal clínico da linha de frente e de limpeza deve receber educação e treinamento sobre as orientações/POP de PCI da unidade de saúde no momento da admissão e anualmente. • Todos os funcionários de PCI precisam receber treinamento específico em PCI on-line ou participar de cursos. • O ponto focal de PCI (e equipe ou comitê de PCI, se houver) no ministério da saúde ou outro órgão nacional responsável, visto que a educação e o treinamento de PCI são atividades essenciais em seu mandato. • Líderes seniores em cargos-chave em nível de ministério, incluindo ministérios da saúde e da educação. • As instituições acadêmicas locais, incluindo universidades e outras com mandato na educação da força de trabalho em saúde, têm um papel fundamental no desenvolvimento e endosso de currículos e na oferta de treinamento. • É importante incluir todos os outros programas relevantes e atores nacionais e identificar as principais áreas conjuntas de trabalho nos esforços de educação e treinamento. • Em um país no qual o ponto focal/equipe de PCI foi estabelecido recentemente e tem experiência limitada, cogite suporte técnico externo de PCI conforme necessário para desenvolvimento e implementação do currículo inicial de PCI. ATENÇÃO PRIMÁRIA • O agente treinado em PCI do próximo nível administrativo (por exemplo, município) é responsável pelo treinamento das pessoas de ligação de PCI, profissionais de saúde da linha de frente e equipes de limpeza das unidades de atenção primária, de acordo com um plano e estratégia desenvolvidos em nível nacional. • Os agentes de PCI do próximo nível administrativo (por exemplo, município) devem ser treinados em nível nacional ou estadual/distrital. • É necessária experiência em PCI para se realizar o treinamento em PCI. • Se a experiência da equipe de PCI for limitada, deve-se buscar apoio externo. • As pessoas de ligação de PCI devem fornecer supervisão no trabalho/mentoria para profissionais de saúde e limpeza em suas unidades de saúdes. QUEM (é responsável pela ação) COMPONENTE ESSENCIAL 3: EDUCAÇÃO E TREINAMENTO EM PCI O QUÊ (requisitos mínimos) NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE ATENÇÃO SECUNDÁRIA E TERCIÁRIA • O ponto focal de PCI (ou equipe de PCI, se houver) é responsável pelo treinamento dos profissionais da linha de frente e de limpeza. • É necessária experiência em PCI para se realizar o treinamento em PCI. • Se a experiência do ponto focal de PCI for limitada, deve-se buscar apoio externo, por exemplo, em nível regional ou nacional. • Além disso, funcionários não pertencentes à PCI com habilidades adequadas (por exemplo, enfermeiros/profissionais de ligação ou defensores e líderes de opinião) podem desempenhar um papel de mentoria para atualizar os princípios de PCI e defender as práticas de PCI no nível da enfermaria. PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS • IPCAT2 - 3.1.1: o programa nacional de PCI fornece orientação e recomendações para o treinamento em serviço no nível das unidades de saúde (por exemplo, frequência, especialização necessária, requisitos para orientação de novos funcionários, abordagens de monitoramento e avaliação). • IPCAT2 – 3.1.2: o programa nacional de PCI fornece conteúdo e suporte para o treinamento em PCI de todos os profissionais de saúde no nível da unidade. • IPCAT2 –3.2.5: O treinamento em PCI é integrado à educação e treinamento profissional continuado em medicina, enfermagem e áreas afins da saúde. • IPCAT2 - 3.3.1: um sistema nacional e um cronograma de monitoramento e avaliação estão em vigor para verificar a efetividade do treinamento e da educação, por exemplo, pelo menos anualmente. Possíveis indicadores adicionais • Política nacional de treinamento de profissionais de saúde desenvolvida. • Currículo nacional de PCI para profissionais de saúde desenvolvido, aprovado e endossado por uma sociedade/órgão profissional apropriado. ATENÇÃO PRIMÁRIA • Todos os novos profissionais de saúde da linha de frente recebem educação e treinamento sobre as orientações/POP de PCI. • Todos os novos funcionários de limpeza recebem educação e treinamento sobre as orientações/POPs de PCI. • Treinamento/educação específica em PCI é oferecido para os profissionais de ligação de PCI nas unidades de atenção primária. • Treinamento/educação específica em PCI é oferecido para a equipe de PCI em nível municipal. ATENÇÃO SECUNDÁRIA • IPCAF - 3.3: todos os novos profissionais de saúde da linha de frente recebem educação e treinamento sobre as orientações/POP de PCI. • IPCAF - 3.4: todos os novos funcionários de limpeza recebem educação e treinamento sobre as orientações/POPs de PCI. • IPCAF - 3.10: educação/treinamento específico em PCI é oferecido para os profissionais de PCI ATENÇÃO TERCIÁRIA • IPCAF - 3.3: todos os novos profissionais de saúde da linha de frente recebem orientação e, pelo menos, educação e treinamento anuais sobre as orientações/POPs de PCI. • IPCAF - 3.4: todos os novos funcionários de limpeza recebem orientação e, pelo menos, educação e treinamento anuais sobre as orientações/POPs de PCI. • IPCAF - 3.10: educação/treinamento específico em PCI é oferecido para os profissionais de PCI Fontes • Resultados IPCAT2 (onde disponíveis; use os resultados e gráficos autogerados disponíveis no arquivo Excel do IPCAT2); https://www.who. int/infection-prevention/tools/core- components/en/. Ferramentas e recursos • OMS. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core- components/en/. • OMS. Aprimorar a prevenção e controle de infecção nos serviços de saúde: Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes principais dos programas de prevenção e controle de infecção da OMS 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. Fonte • Relatório de resultados IPCAF (onde disponível; use o modelo de apresentação); https://www.who.int/infection- prevention/tools/ core-components/IPCAF- template.pdf?ua=1. Ferramentas e recursos • Orientações sobre os principais componentes dos programas de PCI em nível nacional e de unidades de cuidados agudos da OMS (2016) para mais informações; https://www.who.int/infection-prevention/ publications/core-components/en/. • WASH FIT; https://apps.who.int/iris/bitstream/hand le/10665/254910/9789241511698-eng.pdf?sequence=1. • OMS. Aprimorar a prevenção e controle de infecção nos serviços de saúde: Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes principais dos programas de prevenção e controle de infecção, da OMS. 2018; https://www.who.int/infection- prevention/tools/core- components/facility-manual.pdf. FONTES E RECURSOS EM NÍVEL NACIONAL FONTES E RECURSOS EM NÍVEL SERVIÇO DE SAÚDE COMO (medir o progresso) INDICADORES EM NÍVEL NACIONAL (SIM/NÃO) INDICADORES EM NÍVEL DE SERVIÇO DE SAÚDE (SIM/NÃO) 32 • Quando combinado com as orientações nacionais de PCI, o treinamento contribui para a redução de IRAS e RM e para uma força de trabalho de saúde mais qualificada. • O apoio e facilitação do treinamento em todos os níveis deve ser considerado um indicador importante para avaliar o impacto dos programas de PCI. • O ponto focal/equipe de PCI deve ser especificamente treinado no uso de estratégias multimodais para a implementação de intervenções de PCI. • O conteúdo do treinamento e do currículo deve ser baseado nas orientações e POP nacionais e, em seguida, priorizado localmente, com base nas práticas e/ou tipos de IRAS mais frequentes. ATENÇÃO PRIMÁRIA • A educação e o treinamento em PCI são essenciais para o desenvolvimento de uma força de trabalho competente e qualificada. No mínimo, uma ênfase em um nível básico de PCI e de triagem na atenção primária para evitar a disseminação de infecção e pelo sistema de saúde, incluindo surtos associados à assistência à saúde. • Conceitos básicos de implementação de estratégias multimodais devem ser incluídos no treinamento dos profissionais de ligação de PCI e da equipe de PCI. • O fato de garantir uma orientação na contratação proporciona um conhecimento básico para todos os funcionários da linha de frente e equipe da limpeza, ao mesmo tempo em que reconhece que as oportunidades educacionais contínuas são o padrão ouro. • A educação dos pacientes e dos visitantes continua sendo uma consideração importante. Em especial, sempre que os familiares assumem atividades de cuidado, eles devem receber treinamento personalizado de PCI para protegerem- se a si mesmos e a seus entes queridos e, assim, minimizar qualquer possibilidade de transmissão cruzada. A educação do paciente e da família nas unidades de saúde pode também estimular o uso de medidas de higiene adequadas na comunidade, como lavar as mãos com sabonete. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • A formação em PCI que envolve profissionais de saúde de primeira linha em uma abordagem prática e pragmática e incorpora experiências individuais está associada à diminuição de IRAS e aumento da adesão à higiene das mãos. • Três categorias de recursos humanos foram identificadas como alvos para o treinamento em PCI, exigindo diferentes estratégias e conteúdo de treinamento: Especialistas em PCI; todos os profissionais de saúde envolvidos na prestação de serviços e atendimento ao paciente; e outro pessoal que apoia a prestação de serviço de saúde (pessoal administrativo e gerencial, equipe auxiliar de serviços, limpeza etc.). • A pessoa/equipe focal de PCI deve ser especificamente treinada no uso de estratégias multimodais para a implementação de intervenções de PCI. • A educação do paciente e da família continua sendo uma consideração importante (veja acima). • Em especial nas instituições de atenção terciária, o fornecimento de atualizações de treinamento anualmente é um requisito mínimo. POR QUÊ (justificativa e detalhes adicionais sobre os requisitos mínimos) NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 33 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS • O programa nacional de PCI deve: - desenvolver currículos de graduação e pós-graduação e em serviço de PCI em colaboração com instituições acadêmicas locais para: · especialistas de PCI · todos os profissionais de saúde envolvidos na prestação de serviços e atendimento ao paciente · outro pessoal (pessoal administrativo e de gestão, pessoal de apoio, limpeza); - desenvolver algumas ferramentas de treinamento padronizadas para apoiar a implementação de currículos, alinhadas com as orientações técnicas nacionais e os padrões internacionais de PCI. • Além do currículo e do desenvolvimento de ferramentas, devem ser os devidos dados passos para a aprovação, adoção e implementação dos currículos por todos os corpos docentes da saúde (por exemplo, medicina, enfermagem, obstetrícia, odontologia, laboratório etc.). • Devem ser estabelecidos planos de carreira claros para profissionais de PCI em nível nacional. • Deve-se levar em consideração os métodos e modalidades de ensino, com base nos princípios da educação de adultos. Os seguintes métodos de treinamento podem ser incluídos: aprendizagem baseada em problemas; oficinas práticas; grupos de discussão; treinamento ponto a ponto; simulação baseada em sala de aula; e treinamento à beira do leito. ATENÇÃO PRIMÁRIA Não aplicável. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • O treinamento obrigatório em PCI deve ser garantido para todos os profissionais de saúde, incluindo aqueles que prestam cuidados diretos ao paciente (por exemplo, médicos, enfermeiras, auxiliares de enfermagem, parteiras, atendentes, funcionários de apoio pessoal etc.) e equipe administrativa e gerencial, equipe de apoio e limpeza, com base em suas funções e em POP adaptados às unidades de saúde. Isso inclui: - orientação de novos funcionários - oportunidades educacionais contínuas para o pessoal existente (pelo menos anualmente). • O treinamento em serviço deve ser prático e complementar a WASH e outras áreas de treinamento (por exemplo, melhoria da qualidade). • A educação e o treinamento sobre PCI devem fazer parte de uma estratégia geral de educação dos serviços de saúde, incluindo orientação para novos funcionários e o fornecimento de oportunidades educacionais contínuas para os funcionários existentes, independentemente do nível e cargo (por exemplo, pessoal administrativo sênior e de limpeza). • A equipe de PCI deve ser treinada em funções específicas de PCI para o nível de atenção terciária e de acordo com os POP de PCI adaptados às unidades de saúde. Avaliações periódicas da efetividade dos programas de treinamento e do conhecimento do pessoal devem ser realizadas rotineiramente. Requisitos dos componentes essenciais completos NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 34 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS Grupo técnico de monitoramento e vigilância de PCI • Estabelecimento pelo ponto focal nacional de PCI de um grupo técnico para vigilância de IRAS e monitoramento de PCI que: - seja multidisciplinar - desenvolva um plano estratégico nacional de vigilância de IRAS (com foco nas infecções prioritárias com base no contexto local) e monitoramento de PCI. ATENÇÃO PRIMÁRIA • A vigilância das IRAS não é exigida como requisito mínimo no nível da unidade primária, mas deve seguir os planos nacionais ou subnacionais, se disponíveis (por exemplo, a detecção e a notificação de surtos que afetam a comunidade geralmente estão incluídas nos planos nacionais). ATENÇÃO SECUNDÁRIA • A vigilância das IRAS deve seguir os planos nacionais ou estaduais, distritais ou municipais. ATENÇÃO TERCIÁRIA • Deve ser realizada vigilância ativa de IRAS incluindo informações sobre RM. • Estruturas capacitadoras e recursos de apoio precisam estar em vigor (por exemplo, laboratórios confiáveis, registros médicos, equipe treinada), dirigidos por um método apropriado de vigilância. • O método de vigilância deve ser direcionado pelas prioridades/planos da unidade de saúde e/ou país (por exemplo, estudos de prevalência pontual para reunir um rápido instantâneo da situação ou vigilância prospectiva longitudinal de infecções do sítio cirúrgico, se isso for identificado como um problema) • É necessário fornecer feedback oportuno e regular às principais partes interessadas, para conduzir a ações adequadas, em especial para a administração do hospital. • O líder/ponto focal nacional de PCI (e equipe ou comitê técnico de PCI, se houver) do ministério da saúde ou órgão nacional responsável pela PCI deve tomar medidas para convocar o grupo técnico de vigilância de IRAS e monitoramento de PCI. • Idealmente, o grupo técnico deve incluir microbiologistas, médicos, técnicos de laboratório, epidemiologistas, profissionais que trabalham em outros sistemas de vigilância, estatísticos, gerentes de dados e especialistas em tecnologia da informação e especialistas em monitoramento e avaliação. • Deve ser estabelecida uma ligação a outros programas de vigilância relevantes, em especial o alinhamento com a vigilância. ATENÇÃO PRIMÁRIA E SECUNDÁRIA • Se for realizada a vigilância das IRAS, uma pessoa/ponto focal treinado em PCI, de acordo com os planos nacionais ou locais (estaduais, distrital ou municipal). ATENÇÃO TERCIÁRIA • O ponto focal de PCI (ou equipe/comissão de PCI, se houver) é responsável por reunir uma equipe para vigilância de IRAS/e RM, em seguida, planejar e conduzir a vigilância e analisar, interpretar e divulgar os dados coletados. • A equipe deve ser multidisciplinar, de preferência incluindo epidemiologistas, estatísticos, controle de infecção, gestores de dados e especialistas em tecnologia da informação com capacidade adequada. Pelo menos parte dessa experiência deve estar disponível. • O ponto focal de PCI deve ser treinado em métodos básicos de epidemiologia e vigilância. • Deve ser estabelecida uma ligação a outros programas de vigilância relevantes, em especial o alinhamento com a vigilância de RM. QUEM (é responsável pela ação) COMPONENTE ESSENCIAL 4: VIGILÂNCIA DAS IRAS O QUÊ (requisitos mínimos) NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 35 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS • Um grupo técnico multidisciplinar para vigilância de IRAS é estabelecido em nível nacional. • Um plano estratégico nacional para vigilância de IRAS (com foco em infecções prioritárias com base no contexto local) está em vigor. • IPCAT2 - 4.1.3: os líderes do programa nacional de PCI (ou parceiro colaborador) são designados a coordenar o programa e a rede nacional de vigilância de IRAS. ATENÇÃO PRIMÁRIA • Observação: A vigilância das não é necessária, mas deve seguir os planos nacionais ou subnacionais, se houver. • Se for realizada, a vigilância de IRAS é feita de acordo com os planos nacionais (sim/não/não aplicável). ATENÇÃO SECUNDÁRIA • A vigilância de IRAS é realizada de acordo com os planos nacionais. ATENÇÃO TERCIÁRIA • IPCAF - 4.1: a vigilância ativa é um componente definido do programa de PCI • IPCAF - 4.2: há pessoal responsável pelas atividades de vigilância? • IPCAF - 4.3: a equipe responsável pelas atividades de vigilância foi treinada em epidemiologia básica, vigilância e PCI (ou seja, tem capacidade para supervisionar métodos de vigilância, gerenciamento e interpretação de dados). • IPCAF - 4.5: um exercício de priorização é usado para determinar o método de vigilância de acordo com o contexto local (ou seja, identificar infecções que são as principais causas de morbidade e mortalidade no serviço). • IPCAF - 4.8: definições confiáveis de casos de vigilância (definidas como numerador e denominador de acordo com as definições internacionais, por exemplo, Rede Nacional de Segurança da Atenção à Saúde do CDC/Centro Europeu de Prevenção e Controle de Doenças) são usadas ou adaptadas por meio de um processo de adaptação baseado em evidências e consulta a especialistas. • IPCAF - 4.14: feedback oportuno e regular (por exemplo, trimestral/semestral/anual) é fornecido às principais partes interessadas, para conduzir a ações adequadas, em especial à administração do hospital. • Estruturas habilitadoras e recursos de apoio (por exemplo, laboratório microbiológico de referência EQAS, registros médicos com informações clínicas suficientes para determinar as definições de caso de IRAS, tempo dedicado da equipe) estão disponíveis para apoiar a vigilância de IRAS. • É realizada vigilância ativa de colonização ou infecção causadas por patógenos multirresistentes de acordo com os dados epidemiológicos locais. Fonte • Resultados IPCAT2 (onde disponíveis; use os resultados e gráficos autogerados disponíveis no arquivo Excel do IPCAT2); https://www.who. int/infection-prevention/tools/core- components/en/. Ferramentas e recursos • OMS. Orientações sobre os principais componentes dos programas de PCI em nível nacional e de unidades de cuidados agudos, para obter mais informações. 2016; https://www.who.int/infection-prevention/publications/ core-components/en/. • OMS. Aprimorar a prevenção e controle de infecção nos serviços de saúde: Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes essenciais dos programas de prevenção e controle de infecção da OMS 2018; https://www. who.int/infection- prevention/tools/core-components/facility- manual.pdf. Fonte • Relatório de resultados IPCAF (onde disponível; use o modelo de apresentação); https://www.who.int/infection- prevention/tools/ core-components/IPCAF- template.pdf?ua=1. Ferramentas e recursos • OMS. Orientações sobre os componentes dos programas de PCI em nível nacional e de unidades de cuidados agudos, para obter mais informações. 2016; https://www.who.int/infection- prevention/publications/core- components/en/. • OMS. Aprimorar a prevenção e controle de infecção nos serviços de saúde: Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes principais dos programas de prevenção e controle de infecção, da OMS. 2018; https://www.who.int/infection- prevention/tools/core- components/facility-manual.pdf. FONTES E RECURSOS EM NÍVEL NACIONAL FONTES E RECURSOS EM NÍVEL DE SERVIÇO DE SAÚDE COMO (medir o progresso) INDICADORES EM NÍVEL NACIONAL (SIM/NÃO) INDICADORES EM NÍVEL DE SERVIÇO DE SAÚDE (SIM/NÃO) PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS • A vigilância das IRAS é a primeira etapa (requisito mínimo) para avaliar a magnitude da carga de doenças por meio da coleta sistemática de dados nas enfermarias/unidades-alvo. Como uma primeira etapa, quando não houver um sistema de vigilância de IRAS, um grupo técnico multidisciplinar deve desenvolver um plano de vigilância. • Esse grupo terá a tarefa de identificar: - prioridades e métodos de vigilância; - um plano de vigilância abrangente para monitoramento de IRAS e PCI; - um mecanismo de relatório nacional centralizado; - um conjunto mínimo de dados (desfechos, indicadores ou outras informações) para vigilância, incluindo a realização de uma avaliação inicial; - papéis e responsabilidades na implementação da vigilância de IRAS nos serviços de saúde. • A priorização não deve ser baseada apenas em sistemas verticais (por exemplo, vírus da imunodeficiência humana, tuberculose, malária, gripe, Salmonella spp., etc.), mas deve levar em consideração alvos essenciais de prevenção de IRAS, por exemplo, redução do número de infeções do sítio cirúrgico ou da corrente sanguínea. • O nível nacional também pode cogitar o desenvolvimento de uma política/regulamentos para exigir a vigilância de IRAS nos serviços, de acordo com os requisitos mínimos especificados abaixo. • A vigilância das IRAS deve estar alinhada com as prioridades do plano nacional de ação de RM. ATENÇÃO PRIMÁRIA • A detecção e a notificação de surtos que afetam a comunidade às autoridades nacionais devem ser incluídas nos planos nacionais ou estaduais. ATENÇÃO SECUNDÁRIA • Dado o baixo nível de atenção especializada, a vigilância das IRAS na atenção secundária não foi estritamente considerada um requisito mínimo pelo consenso dos especialistas; o monitoramento dos indicadores de PCI foi considerado mais importante. • Algumas unidades secundárias podem decidir realizar vigilância de IRAS relevantes, como infecção de sítio cirúrgico, dependendo do tipo de atendimento prestado e da capacidade da unidade de saúde e da priorização dos componentes essenciais. • A notificação de surtos nos serviços de saúde ou que afetam a comunidade às autoridades nacionais deve ser incluída nos planos nacionais ou estaduais/locais. ATENÇÃO TERCIÁRIA • As IRAS e MR são um fardo nas unidades de terapia intensiva e outras unidades/enfermarias altamente especializadas, onde as intervenções invasivas trazem mais riscos de IRAS e os pacientes têm um risco maior de morte devido a essas infecções. • Por esse motivo, a vigilância direcionada de IRAS é necessária no nível terciário de atenção à saúde. • Para garantir a implementação do plano nacional de vigilância, uma equipe de vigilância de IRAS deve estar instalada em cada hospital terciário. • A priorização também é responsabilidade da equipe de PCI, e um exercício de priorização deve ser conduzido de acordo com as recomendações nacionais. • A equipe deve desenvolver um plano estratégico de vigilância de acordo com as capacidades atuais, incluindo: - objetivo; - amostra-alvo e desfechos de infecção; - identificação de um laboratório nacional de referência e de capacidades de garantia de qualidade; - desenvolvimento/adaptação cuidadosa das definições de caso. • O feedback oportuno para a liderança do hospital e os profissionais de saúde da linha de frente é considerado uma das partes mais críticas da vigilância e monitoramento. As unidades devem levar em consideração a definição do momento oportuno do feedback (por exemplo, mensal ou bimestral). • A equipe focal de PCI deve adaptar sua metodologia de vigilância aos recursos e prioridades disponíveis, de acordo com as recomendações nacionais. POR QUÊ (justificativa e detalhes adicionais sobre os requisitos mínimos) NÍVEL NACIONAL NÍVEL SERVIÇO DE SAÚDE 36 7 • Devem ser estabelecidos um programa e redes nacionais de vigilância das IRAS que incluam mecanismos para feedback oportuno de dados de monitoramento e avaliação, com o potencial de serem usados para fins de benchmarking. • Os programas de vigilância devem ser apoiados por: - governos envolvidos e outras autoridades respectivas; - recursos humanos e financeiros alocados; - capacidade de microbiologia e laboratório (pelo menos um laboratório de referência nacional), com definições e métodos laboratoriais padronizados; - um sistema de informação para coleta e análise de dados. • Os programas de vigilância devem atender aos seguintes critérios: - demonstrar objetivos claros, um conjunto padronizado de definições de caso, métodos para detectar IRAS (numeradores) e a população exposta (denominadores), incluindo um processo para a análise de dados e relatórios e um método para avaliar a qualidade dos dados; - estabelecer linhas claras e regulares de relatórios de dados de vigilância de IRAS das unidades de saúde locais para o nível nacional; - adaptar as orientações internacionais sobre as definições de IRAS em nível de país antes de implementá-las; - incluir um programa nacional de treinamento para realizar a vigilância, a fim de garantir a aplicação apropriada e consistente das orientações e protocolos de vigilância nacionais; - fornecer dados para orientar o desenvolvimento e implementação de intervenções de controle efetivas. • O programa de vigilância deve fornecer dados sobre infecções: - que podem se tornar uma epidemia no serviço de saúde (detecção precoce de surtos); - comumente observadas em populações vulneráveis (por exemplo, recém-nascidos, pacientes queimados, pacientes em unidades de terapia intensiva e hospedeiros imunocomprometidos); - que podem causar desfechos graves, como alta letalidade e morbidade e sofrimento do paciente; - causadas por microrganismos resistentes, com ênfase nos patógenos multirresistentes; - associadas a dispositivos invasivos selecionados ou procedimentos específicos, como o uso de dispositivos intravasculares, cateteres urinários permanentes e cirurgia; - que podem afetar os profissionais de saúde (por exemplo, hepatite B e C e vírus da imunodeficiência humana). ATENÇÃO PRIMÁRIA Não aplicável. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • Deve ser realizada a vigilância de IRAS nas unidades de saúde para orientar as intervenções de PCI e detectar surtos, incluindo RM. • Os sistemas de vigilância de infecção dos hospitais devem ser ligados a sistemas integrados de vigilância de infecção da saúde pública. • Deve ser fornecido em tempo hábil o feedback dos resultados para os profissionais de saúde e as partes interessadas por meio de redes nacionais. • A vigilância das unidades de saúde deve ser baseada nas recomendações nacionais e em definições padrão e personalizadas para as necessidades e nas prioridades do serviço de saúde de acordo com os recursos disponíveis, com objetivos e métodos claros. • Os métodos de detecção de infecção devem estar ativos. Diferentes estratégias de vigilância podem incluir o uso de taxas de prevalência ou incidência de patógenos de IRAS e MR. Deve haver um sistema para avaliação da qualidade dos dados de vigilância. • A vigilância deve ser baseada em dados clínicos e/ou microbiológicos e apoiada por capacidade laboratorial com EQAS • O comitê de PCI e a equipe de PCI são responsáveis por planejar e conduzir a vigilância de IRAS e analisar, interpretar e disseminar os dados coletados. Por esse motivo, as atividades de vigilância devem ser conduzidas por uma equipe treinada (idealmente de tempo integral), capaz de planejar, coletar e gerenciar os dados e convocar reuniões com a equipe, com o comitê e com outros participantes importantes. • A vigilância deve fornecer informações para: - descrever a situação das infecções relacionadas à assistência à saúde (ou seja, incidência e/ou prevalência, tipo, etiologia e, idealmente, dados sobre a gravidade e a carga atribuível da doença); - identificação dos padrões mais relevante de suscetibilidade MR; - identificação de populações, procedimentos e exposições de alto risco: - detecção precoce de clusters e surtos (ou seja, sistema de alerta precoce); - avaliação do impacto das intervenções. - Requisitos dos componentes essenciais completos NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS Estratégias de melhoria multimodal para intervenções de PCI • Uso de estratégias multimodais para implementar intervenções de PCI de acordo com as orientações/POP nacionais, sob a coordenação do ponto focal nacional de PCI (ou equipe, se houver). ATENÇÃO PRIMÁRIA Estratégias multimodais para intervenções prioritárias de PCI • Uso de estratégias multimodais - no mínimo para implementar intervenções para melhorar a higiene das mãos, práticas seguras de injeção, descontaminação de instrumentos e produtos para saúde e limpeza do ambiente. ATENÇÃO SECUNDÁRIA Estratégias multimodais para intervenções prioritárias de PCI • Uso de estratégias multimodais - no mínimo para melhorar cada item das precauções padrão e baseadas na transmissão e da triagem. ATENÇÃO TERCIÁRIA Estratégias multimodais para todas as intervenções de PCI • Uso de estratégias multimodais para implementar intervenções para melhorar cada item das precauções padrão e baseadas na transmissão, triagem e aquelas direcionadas à redução de infecções específicas (por exemplo, infecções do sítio cirúrgico ou associadas a cateter) em áreas de alto risco/grupos de pacientes, de acordo com as prioridades locais. • O ponto focal de PCI (e equipe técnica ou comissão de PCI, se existente) no ministério da saúde ou órgão nacional responsável em PCI, visto que as intervenções multimodais são atividades essenciais em seu mandato. • Os líderes seniores em cargos-chave em nível de ministério. É importante convencer os gestores seniores de alto nível e os principais profissionais sobre o valor de empregar estratégias multimodais em nível nacional e da unidade de saúde e isso depende de comunicação e defesa de causa efetivos. • Os membros e equipes-chave de todos os outros programas relevantes e atores nacionais que serão responsáveis pela implementação do programa de PCI, incluindo possíveis áreas de trabalho conjuntas. • Os especialistas nacionais e locais em ciência de implementação, bem como os especialistas do campo da ciência comportamental e da comunicação. ATENÇÃO PRIMÁRIA, SECUNDÁRIA E TERCIÁRIA • A pessoa treinada em PCI e o ponto focal de PCI com o apoio de um agente de saúde treinado em PCI do próximo nível administrativo são responsáveis pelo uso de uma abordagem multimodal para a implementação de intervenções/POP de PCI. • Estratégias multimodais de sucesso incluem o envolvimento de defensores ou modelos. • Deve ser abordada a colaboração com colegas na melhoria da qualidade e segurança do paciente para desenvolvimento e promoção de estratégias multimodais. QUEM (é responsável pela ação) COMPONENTE ESSENCIAL 5: ESTRATÉGIAS MULTIMODAIS O QUÊ (requisitos mínimos) NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 38 • IPCAT2 - 5.1.1: o ponto focal indicado de PCI é treinado e competente em ciência de implementação e estratégias multimodais de mudança de comportamento. • IPCAT2 - 5.1.2: promoção de estratégias multimodais por meio da inclusão da abordagem no desenvolvimento das orientações, educação e treinamento em PCI. ATENÇÃO PRIMÁRIA IPCAF - 5.1: são utilizadas estratégias multimodais para implementar intervenções prioritárias de PCI (no mínimo para melhorar a higiene das mãos, descontaminação de instrumentos e produtos para saúde e limpeza ambiental). ATENÇÃO SECUNDÁRIA • IPCAF - 5.1: sã utilizadas estratégias multimodais para implementar intervenções prioritárias de PCI (no mínimo para implementar intervenções para melhorar as precauções padrão e as baseadas na transmissão e triagem). ATENÇÃO TERCIÁRIA • IPCAF - 5.1: são utilizadas estratégias multimodais para implementar todas as intervenções de PCI e para melhorar as precauções padrão e baseadas na transmissão, triagem e aquelas voltadas para a redução de infecções específicas em áreas de alto risco/grupos de pacientes vulneráveis, de acordo com as prioridades de saúde locais. COMO (medir o progresso) INDICADORES EM NÍVEL NACIONAL (SIM/NÃO) INDICADORES EM NÍVEL DE SERVIÇO DE SAÚDE (SIM/NÃO) 39 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS Fonte: • Resultados IPCAT2 (onde disponíveis; use os resultados e gráficos autogerados no arquivo Excel do IPCAT2); https://www.who. int/infection-prevention/tools/core- components/en/. Ferramentas e recursos • OMS. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core- components/en/. • OMS. Aprimorar a prevenção e controle de infecção nos serviços de saúde: Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes principais dos programas de prevenção e controle de infecção da OMS 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. Fonte • Relatório de resultados IPCAF (onde disponível; use o modelo de apresentação); https://www.who.int/infection- prevention/tools/ core-components/IPCAF- template.pdf?ua=1. Ferramentas e recursos • Orientações sobre os principais componentes dos programas de prevenção e controle de infecção em nível nacional e de unidades de cuidados agudos (2016) https://www.who.int/infection-prevention/publications/core- components/en/. • OMS. Aprimorar a prevenção e controle de infecção nos serviços de saúde: Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes principais dos programas de prevenção e controle de infecção, da OMS. 2018; https://www.who.int/infection- prevention/tools/core- components/facility-manual.pdf. • WHO multimodal improvement strategy leaflet; https://www. who.int/infection-prevention/publications/ipc-cc-mis.pdf?ua=1. • De acordo com as evidências científicas disponíveis, as estratégias multimodais são a abordagem mais efetiva para implementação de programas de higiene das mãos e outras intervenções de PCI (por exemplo, para reduzir infecção da corrente sanguínea associadas ao cateter central e infecção do sítio cirúrgico), a fim de atingir os elementos-chave de sucesso que apoiam o progresso da PCI e, em última análise, têm um impacto mensurável que beneficia os pacientes e os profissionais de saúde, como a mudança do sistema, a criação de um clima aprimorado de segurança do paciente e uma mudança comportamental nos profissionais de saúde. • O ponto focal/equipe de PCI deve ser especificamente treinado no uso de estratégias multimodais para a implementação de intervenções de PCI. • As estratégias multimodais para a implementação de intervenções de PCI devem ser explicitamente indicadas nos planos de ação nacionais de PCI, incluindo todos os 5 elementos-chave identificados pela OMS conforme necessário para cada intervenção de PCI selecionada e de acordo com o contexto local. • A pessoa ou equipe focal nacional de PCI deve desenvolver um esquema de estratégia multimodal nacional para facilitar a implementação das intervenções prioritárias de PCI nos serviços de saúde no contexto da melhoria da qualidade. ATENÇÃO PRIMÁRIA • Devem ser usadas estratégias multimodais para toda intervenção de PCI em todos os níveis do sistema de saúde porque sua efetividade é apoiada por fortes evidências. • No entanto, é reconhecido que as estratégias multimodais são abordagens complexas para serem implementadas. Assim, as intervenções incluídas nos requisitos mínimos são as prioritárias entre aquelas que devem ser incluídas nos POP e no treinamento para o nível de atenção primária à saúde (ver requisitos mínimos para os componentes essenciais 2 e 3). ATENÇÃO SECUNDÁRIA E TERCIÁRIA • Devem ser utilizadas estratégias multimodais para qualquer intervenção de PCI em todos os níveis do sistema de saúde, a fim de fornecer uma prestação de atenção à saúde segura e efetiva. • A complexidade da atenção e dos recursos humanos (inclusive na equipe de PCI) variam entre os serviços de atenção secundária e terciária, e o escopo dos requisitos mínimos pode variar de acordo com o contexto local. • Serviços especializados/complexos são fornecidos nas unidades terciárias. • Nas unidades terciárias, há um potencial aumentado de transmissão de infecções devido à internação prolongada, aos procedimentos mais complexos que são realizados e à admissão de populações vulneráveis de alto risco. • Existem evidências convincentes sobre a efetividade das estratégias multimodais para reduzir infecção em áreas/grupos de pacientes de alto risco. FONTES E RECURSOS EM NÍVEL NACIONAL FONTES E RECURSOS EM NÍVEL DE SERVIÇO DE SAÚDE POR QUÊ (justificativa e detalhes adicionais sobre os requisitos mínimos) NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 40 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS • É mandato do programa nacional de PCI garantir que todas as intervenções de PCI sejam implementadas usando estratégias multimodais. • O programa nacional de PCI deve facilitar o uso de estratégias multimodais, garantindo que os seguintes elementos estejam disponíveis para apoiar seu uso: - experiência e recursos necessários, incluindo políticas, regulamentos e ferramentas; - mudança geral da cultura organizacional para se alcançar um melhor clima de segurança do paciente; - coordenação e trabalho em equipe; - ligação com iniciativas de melhoria da qualidade e credenciamento de unidades de saúde; - adaptação local. ATENÇÃO PRIMÁRIA Não aplicável. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • Devem ser utilizadas estratégias multimodais para implementar qualquer intervenção de PCI em todos os níveis do sistema de saúde. • A mudança geral da cultura organizacional é um elemento- chave a priorizar dentro das estratégias multimodais, pois a PCI efetiva pode ser um identificador de atendimento de qualidade, de uma cultura organizacional positiva e de um aprimorado clima de segurança do paciente. • Estratégias multimodais de sucesso incluem o envolvimento de defensores ou modelos. • A implementação de estratégias multimodais nas instituições de saúde precisa estar ligada aos objetivos e iniciativas nacionais de qualidade, incluindo iniciativas de melhoria da qualidade da atenção à saúde ou organismos de acreditação de serviços de saúde. Requisitos completos dos componentes essenciais completos NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 41 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS Grupo técnico de monitoramento e vigilância de PCI • Estabelecimento pelo ponto focal nacional de PCI de um grupo técnico para vigilância de IRAS e monitoramento de PCI que: - seja multidisciplinar; - desenvolva um plano estratégico nacional para vigilância de IRAS e monitoramento de PCI; - desenvolva um sistema integrado de coleta e análise de dados (por exemplo, protocolos, ferramentas); - ofereça treinamento nas unidades de saúde para coletar e analisar esses dados; - desenvolva recomendações para indicadores mínimos de processo (por exemplo, higiene das mãos). ATENÇÃO PRIMÁRIA • O monitoramento dos indicadores estruturais e de processo de PCI deve ser implementado no nível da atenção primária, com base nas prioridades de PCI identificadas nos outros componentes. Isso requer decisões em nível nacional e apoio à implementação em nível estadual. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • Uma pessoa responsável pela condução do monitoramento periódico ou contínuo dos indicadores selecionados de processo e estrutura, orientado pelas prioridades do serviço de saúde ou do país. • A higiene de mãos é um indicador de processo essencial a ser monitorado. • É necessário fornecer feedback oportuno e regular para as principais partes interessadas, a fim de conduzir à ação apropriada, especialmente para a administração do hospital. • O líder/ponto focal de PCI (e a equipe técnica ou comissão de PCI no ministério da saúde ou órgão nacional responsável em PCI) deve tomar medidas para convocar o grupo técnico de vigilância de IRAS e monitoramento de PCI (mesmo grupo do componente essencial 4). • Idealmente, o grupo técnico deve incluir microbiologistas, técnicos de laboratório, epidemiologistas, profissionais que trabalham em outros sistemas de vigilância, estatísticos, gerentes de dados e especialistas em tecnologia da informação e especialistas em monitoramento e avaliação. • Deve ser assegurada ligação com: - líderes seniores em cargos-chave em nível de ministério; - membros das equipes de todos os outros programas relevantes e atores nacionais envolvidos na implementação e monitoramento do programa de PCI, incluindo líderes nacionais de qualidade e segurança do paciente. ATENÇÃO PRIMÁRIA, SECUNDÁRIA E TERCIÁRIA • A pessoa de ligação treinada em PCI/ponto focal/agente de PCI (ou comissão/equipe de PCI, se existente) é responsável pela auditoria e feedback e deve receber treinamento sobre os planos de técnicas de auditoria. • Um grupo técnico multidisciplinar para monitoramento de PCI é estabelecido em nível nacional. • IPCAT2 – 6.2: Um plano bem definido com foco nos desfechos, processos e estratégias de PCI, com objetivos, metas e planos operacionais claros esteja em vigor. • Indicadores de PCI integrados com sistemas nacionais de monitoramento, por exemplo, sistemas de gerenciamento de informações de saúde. ATENÇÃO PRIMÁRIA • IPCAF - 6.2: um plano de monitoramento bem definido com metas/objetivos claros, alvos e atividades focados em indicadores estruturais e de processo de PCI (incluindo ferramentas para coleta de dados de forma sistemática) está em vigor com base nas prioridades de PCI identificadas nos outros componentes e, o que é mais importante, orientado por decisões em nível nacional e apoio à implementação em nível municipal. QUEM (é responsável pela ação) COMO (medir o progresso) COMPONENTE ESSENCIAL 6: MONITORAMENTO, AUDITORIA E FEEDBACK O QUÊ (requisitos mínimos) NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE INDICADORES EM NÍVEL NACIONAL (SIM/NÃO) INDICADORES EM NÍVEL DE SERVIÇO DE SAÚDE SIM/NÃO) 42 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS • Existe um mecanismo para treinar os auditores nacionais e locais. • O monitoramento e o feedback da conformidade com a higiene de mãos são identificados como um indicador mínimo, no mínimo para hospitais de referência. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • IPCAF – 6.1: Há uma pessoa treinada responsável pela realização de monitoramento/auditoria periódica ou contínua de indicadores selecionados de processo (por exemplo, higiene das mãos) e estrutura, orientada pelas prioridades da unidade de saúde ou país. • Conformidade com a higiene de mãos (usando a ferramenta de observação de higiene das mãos da OMS ou equivalente) • IPCAF - 6.4: o monitoramento das estratégias de higiene de mãos é realizado por meio da enquete do esquema de autoavaliação da higiene de mãos da OMS. • IPCAF - 6.5: um feedback oportuno e regular dos relatórios de auditoria (por exemplo, feedback sobre dados de conformidade com a higiene das mãos ou outros processos) sobre a situação das atividades/desempenho de PCI é fornecido às principais partes interessadas, a fim de conduzir a ações adequadas, especialmente para a administração de hospitais e alta gestão. Fonte: • Resultados IPCAT2 (onde disponíveis; use os resultados e gráficos autogerados disponíveis no arquivo Excel do IPCAT2); https://www.who. int/infection-prevention/tools/core- components/en/. Ferramentas e recursos • OMS. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core- components/en/. • OMS. Aprimorar a prevenção e controle de infecção nos serviços de saúde: Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes principais dos programas de prevenção e controle de infecção da OMS 2018; https://www. who.int/infection-prevention/tools/core-components/facility- manual.pdf. • WHO hand hygiene monitoring and feedback tools (updated in 2009); https://www.who.int/gpsc/5may/tools/evaluation_ feedback/en/. Fonte • Relatório de resultados IPCAF (onde disponível; use o modelo de apresentação); https://www.who.int/infection- prevention/tools/ core-components/IPCAF- template.pdf?ua=1. Ferramentas e recursos • OMS. Guidelines on core components of IPC programmes at the national and acute health care facility level (2016); https://www. who.int/infection-prevention/publications/core- components/ en/. • OMS. Aprimorar a prevenção e controle de infecção nos serviços de saúde: Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes principais dos programas de prevenção e controle de infecção, da OMS. 2018; https://www.who.int/infection- prevention/tools/core- components/facility-manual.pdf. • WHO hand hygiene monitoring and feedback tools (updated in 2009); https://www.who.int/gpsc/5may/tools/evaluation_ feedback/en/. • WHO Hand Hygiene Self-Assessment Framework; https://www. who.int/gpsc/5may/hhsa_framework/en/. • O estabelecimento do monitoramento nacional de indicadores de práticas, processos e infraestruturas de PCI é geralmente mais viável do que o estabelecimento da vigilância de IRAS como uma primeira etapa de coleta de dados para orientar as ações de PCI. • O grupo técnico indicado como requisito mínimo para o componente essencial 4 deve ser o mesmo grupo responsável pelo componente essencial. • O monitoramento das práticas de PCI e o fornecimento de feedback às partes interessadas são essenciais para se obter uma mudança de comportamento ou outras modificações de processo que melhorem a qualidade do atendimento e reduzam IRAS e RM. • O monitoramento e o feedback também visam o envolvimento das partes interessadas, a criação de parcerias e o desenvolvimento de grupos de trabalho e redes. • Devem-se levar em consideração as políticas que criam incentivos (positivos ou negativos) vinculados a indicadores, a fim de gerar adesão dos administradores hospitalares. • Dados de fontes de dados existentes (por exemplo, ATENÇÃO PRIMÁRIA • O monitoramento de PCI é fundamental para identificar as ações de melhoria necessárias e deve estar alinhado com as recomendações e prioridades nacionais. • O monitoramento de indicadores de práticas, processos e infraestruturas de PCI deve ser viável no nível de atenção primária, ao passo que a vigilância de IRAS não é aplicável. • Uma infraestrutura de higiene de mãos (por exemplo, postos de higienização das mãos no ponto de atendimento ou uso de álcool gel) pode ser cogitada como uma primeira etapa do monitoramento. • O monitoramento da conformidade com a higiene das mãos de acordo com o método de observação da OMS é considerado o padrão ouro. • Em muitas unidades de atenção primária, uma pessoa responsável pelo monitoramento dos indicadores deve ser identificada e essa atividade requer apoio em nível local (por exemplo, município). • A seleção dos indicadores a serem monitorados deve ser conduzida em nível nacional, com contribuições em nível estadual, distrital ou municipal. FONTES E RECURSOS EM NÍVEL NACIONAL FONTES E RECURSOS EM NÍVEL DE SERVIÇO DE SAÚDE POR QUÊ (justificativa e detalhes adicionais sobre os requisitos mínimos) NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 43 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS Avaliação Externa Conjunta ou Avaliação de Disponibilidade e Prontidão de Serviço) devem ser levados em consideração, especialmente no início ao identificar prioridades. • Se possível, a integração com os sistemas nacionais de informação da saúde existentes e o monitoramento de rotina das unidades seria fundamental para agilizar a coleta de dados e fazer ligações/correlações. • A higiene de mãos (incluindo monitoramento de conformidade e/ou indicadores de infraestrutura) é considerada um indicador crucial de acordo com as recomendações da OMS. Essa atividade deve ser decidida em nível nacional de acordo com os mais altos padrões para evitar qualquer representação incorreta dos níveis de conformidade. • A vigilância de outros indicadores de estrutura e processo deve ser cogitada, priorizando aqueles que impulsionam a ação. • Outros indicadores a serem monitorados também devem fornecer informações sobre os facilitadores de PCI (por exemplo, relacionados a WASH, disponibilidade de estruturas), sendo considerados fundamentos básicos essenciais para a PCI. • Os dados coletados por meio do monitoramento de PCI devem orientar o estabelecimento de prioridades no plano estratégico nacional de PCI. • Com base em todas essas considerações, um plano para monitoramento regular no nível dos serviços de saúde deve ser desenvolvido no nível nacional, incluindo planos de feedback e supervisão para auxiliar no desenvolvimento e implementação de planos de melhoria. • Toda decisão deve estar alinhada com as decisões sobre outros componentes principais. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • O monitoramento de PCI é fundamental para identificar ações de melhoria e deve ser combinado com a vigilância de IRAS e estar alinhado com as recomendações e prioridades nacionais. • Os princípios e requisitos mínimos para monitoramento e auditoria não devem mudar entre a atenção secundária e a terciária; mais indicadores podem ser monitorados na atenção terciária. • É importante monitorar os indicadores de processo (propensos a limitações relacionadas ao viés de observação) e os indicadores de infraestrutura. • A higiene das mãos (incluindo monitoramento de conformidade e/ou indicadores de infraestrutura) é considerada um indicador crucial de acordo com as recomendações da OMS. Essa atividade deve ser decidida em nível nacional e de acordo com os mais altos padrões para evitar qualquer representação incorreta dos níveis de conformidade. • O feedback oportuno para a liderança do hospital e os profissionais de saúde da linha de frente é uma das partes mais efetivas da vigilância e do monitoramento. As unidades devem cogitar a definição do momento oportuno do feedback. • Estabelecimento de um programa nacional de monitoramento e avaliação de PCI com metas, objetivos e indicadores de desempenho definidos para: - Padrões de PCI - Atividades de PCI - monitoramento e feedback da conformidade com a higiene de mãos (fortemente recomendado como um indicador de desempenho nacional). • O monitoramento e a avaliação em nível nacional devem ter mecanismos que: - forneçam relatórios regulares sobre a situação das metas (desfechos e processos) e estratégias nacionais; - monitorem e avaliem regularmente os serviços de WASH, as atividades de PCI e a estrutura das unidades de saúde por meio de auditorias ou outros meios oficialmente reconhecidos; - promovam a avaliação do desempenho dos programas locais de PCI em uma cultura institucional não punitiva. ATENÇÃO PRIMÁRIA Não aplicável. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • O monitoramento/auditoria regular de práticas e outros indicadores deve estar de acordo com os padrões de PCI e incluir feedback oportuno para: - todas as pessoas auditadas e pessoal relevante (alteração individual); - gestão hospitalar e alta administração (mudança organizacional); - equipe e comissões de PCI (ou comitês de qualidade de atendimento). • O monitoramento se estende ao programa de PCI da unidade de saúde para: - avaliar se os objetivos são alcançados; - avaliar se as metas/objetivos são cumpridas; - avaliar se as atividades de PCI estão sendo realizadas de acordo com os requisitos; - identificar aspectos que podem necessitar de melhorias. • As informações importantes que podem ser usadas para esse fim incluem: - os resultados da avaliação da conformidade com as práticas de PCI; - outros indicadores de processo (por exemplo, atividades de treinamento); - tempo dedicado pela equipe PCI; - alocação de recursos. • O monitoramento deve incluir avaliações regulares do conhecimento da equipe sobre PCI. Requisitos dos componentes essenciais completos NÍVEL NACIONAL NÍVEL DE SERVIÇO DE SAÚDE 44 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS ATENÇÃO PRIMÁRIA • Reduzir a superlotação: devem ser estabelecidos um sistema de fluxo de pacientes, um sistema de triagem (incluindo sistema de referência) e um sistema de gerenciamento de consultas de acordo com as orientações existentes. • Otimizar os níveis de pessoal: avaliação dos níveis de pessoal adequados, dependendo das categorias vistas ao usar ferramentas nacionais/da OMS (políticas nacionais sobre a proporção paciente/equipe) e desenvolvimento de um plano apropriado. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • Padronizar a ocupação de leitos: - estabelecer um sistema para gerenciar o uso do espaço no serviço de saúde e estabelecer a capacidade padrão de leitos para o serviço de saúde; - aplicação do sistema desenvolvido na administração hospitalar; - não mais do que um paciente por leito; - espaçamento de pelo menos 1 metro entre as bordas dos leitos; - a ocupação total não deve exceder a capacidade total de leitos projetada para o serviço de saúde. • Reduzir a superlotação e otimizar os níveis de pessoal: os mesmos requisitos mínimos da atenção primária à saúde. ATENÇÃO PRIMÁRIA, SECUNDÁRIA E TERCIÁRIA • As decisões referentes à carga de trabalho, pessoal e ocupação de leitos não são de responsabilidade direta do programa de PCI, mas sim da alta gestão e dos diretores. No entanto, a enfermeira, agente ou programa de ligação de PCI deve compreender as evidências que apoiam esse componente essencial, a fim de ajudar a influenciar os tomadores de decisão no nível do serviço de saúde e ministério, com a assistência de um agente de saúde treinado em PCI do próximo nível administrativo. Portanto, o desenvolvimento das habilidades de PCI em negociação e influência são considerações importantes. • A implementação bem-sucedida deste componente essencial será apoiada se um plano nacional de desenvolvimento de recursos humanos estiver em vigor. INDICADORES (SIM/NÃO) ATENÇÃO PRIMÁRIA • Existem sistemas para reduzir a superlotação (por exemplo, um sistema de fluxo de pacientes, um sistema de triagem incluindo um sistema de encaminhamento e um sistema de gerenciamento de consultas) de acordo com as orientações/POP existentes. • IPCAF - 7.3: os níveis de pessoal adequados são avaliados de acordo com a carga de trabalho de pacientes usando padrões nacionais/internacionais ou ferramentas de avaliação de necessidades de pessoal e planos de ação desenvolvidos com base nos resultados. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • IPCAF - 7.3: os níveis de pessoal adequados são avaliados de acordo com a carga de trabalho de pacientes usando padrões nacionais/internacionais ou ferramentas de avaliação de necessidades de pessoal e planos de ação desenvolvidos com base nos resultados. • IPCAF - 7.4: o projeto das enfermarias está de acordo com os padrões internacionais de capacidade de leitos. • IPCAF - 7.5: a ocupação de leitos do serviço de saúde é de um paciente por leito. • IPCAF - 7.7: espaçamento adequado de mais de 1 metro entre leitos é garantido nos serviços de saúde. • IPCAF - 7.8: um sistema está em vigor, incluindo linhas claras de responsabilidade, para avaliação e resposta quando a capacidade adequada de leitos exceder a capacidade total de leitos projetada para o serviço de saúde (por exemplo, administração/gerência do hospital assume a responsabilidade). * Nível de unidade de saúde apenas. No entanto, o sistema nacional de saúde, o programa de PCI e qualquer outro órgão relevante devem coordenar e apoiar a implementação desse componente principal nas unidades de saúde. COMPONENTE ESSENCIAL 7: CARGA DE TRABALHO, PESSOAL E OCUPAÇÃO DE LEITOS (SOMENTE NÍVEL DE SERVIÇOS DE SAÚDE*) O QUÊ (requisitos mínimos) QUEM (é responsável pela ação) COMO (medir o progresso) 45 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS FONTES E RECURSOS Fonte • Relatório IPCAF (onde disponível; use o modelo de apresentação); https://www.who.int/infection-prevention/tools/core- components/IPCAF- template.pdf?ua=1. Ferramentas e recursos • Orientações da OMS sobre os componentes principais dos programas de prevenção e controle de infecção em nível nacional e de unidades de cuidados agudos. 2016; https://www.who.int/ infection-prevention/publications/core-components/en/. • OMS. Aprimorar a prevenção e controle de infecção nos serviços de saúde: Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes principais dos programas de prevenção e controle de infecção, da OMS. 2018; https://www.who.int/infection-prevention/tools/core-components/ facility-manual.pdf. • Padrões essenciais de saúde ambiental na atenção à saúde, da OMS. 2008; https://www.who.int/water_sanitation_health/publications/ehs_hc/en/. • OMS. Indicadores de carga de trabalho de necessidade de pessoal (WISN). 2015; https://www.who.int/hrh/resources/wisn_user_manual/en/. ATENÇÃO PRIMÁRIA • A superlotação e a falta de sistemas de triagem e fluxo de pacientes são reconhecidas como um problema de saúde pública que podem resultar em transmissão de doenças. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • A ocupação de leitos que excede a capacidade padrão do serviço de saúde está associada a um risco aumentado de IRAS em unidades de cuidados intensivos, além de níveis inadequados de alocação de profissionais de saúde. • A capacidade pretendida pode diferir dos projetos originais e entre instituições de saúde e países. Por essas razões, o projeto original da enfermaria/unidade em relação à capacidade de leitos deve ser respeitado e estar de acordo com os padrões. • Em circunstâncias excepcionais, em que a capacidade dos leitos for excedida, a administração do serviço de saúde deve agir para garantir níveis adequados de pessoal que atendam à demanda de pacientes e manter uma distância adequada entre os leitos. Esses princípios se aplicam a todas as unidades e departamentos com leitos de internação, incluindo departamentos de emergência. • O método Indicadores de Carga de Trabalho da Necessidade de Pessoal da OMS fornece aos gestores de saúde uma maneira sistemática de determinar quantos profissionais de saúde de um tipo específico são necessários para lidar com a carga de trabalho de um determinado serviço de saúde e tomar decisões. • É reconhecido que, em circunstâncias especiais, a adesão a essa recomendação pode precisar ser equilibrada com a necessidade imediata de fornecer atendimento clínico ao maior número possível de pacientes. ATENÇÃO PRIMÁRIA Não aplicável. ATENÇÃO SECUNDÁRIA E TERCIÁRIA Os mesmos que para os requisitos mínimos. POR QUÊ (justificativa e detalhes adicionais sobre os requisitos mínimos) Requisitos completos dos componentes essenciais 46 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS ATENÇÃO PRIMÁRIA • A água deve estar sempre disponível de uma fonte melhorada no local para a execução de medidas básicas de PCI, incluindo higiene das mãos, limpeza do ambiente, lavanderia, descontaminação de produtos para saúde e gerenciamento de resíduos de serviços de saúde. • Um mínimo de dois banheiros melhorados e funcionais devem estar disponíveis no local, um para os pacientes e outro para a equipe; ambos devem estar equipados com unidades de higiene menstrual. • Instalações funcionais de higiene das mãos devem estar sempre disponíveis nos pontos de atendimento/banheiros e devem incluir sabão, água e toalhas descartáveis (ou, se não houver disponíveis, toalhas reutilizáveis limpas) ou álcool gel nos pontos de atendimento e sabão, água e toalhas descartáveis (ou se não houver disponíveis, toalhas reutilizáveis limpas) a menos de 5 metros dos banheiros. • Lixeiras suficientes e devidamente rotuladas para permitir a separação de resíduos de atenção à saúde devem estar disponíveis (menos de 5 metros do ponto de geração); os resíduos devem ser tratados e descartados com segurança por meio de autoclavagem, incineração e/ou enterrados em uma fossa protegida revestida. • O layout da unidade de saúde deve permitir ventilação natural adequada, descontaminação de produtos de saúde reutilizáveis, triagem e espaço para coorte/isolamento/separação física temporária, se necessário. • Suprimentos e equipamentos de PCI suficientes e apropriados (por exemplo, esfregões, detergente, desinfetante, EPI e esterilização) e fonte de força/energia (por exemplo, combustível) devem estar disponíveis para realizar todas as medidas básicas de PCI de acordo com os requisitos mínimos/POP, incluindo todos as precauções padrão, conforme aplicável; deve haver iluminação disponível durante o horário de trabalho (geralmente, das 8h às 17h) para atendimento. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • Um volume seguro e suficiente de água deve estar disponível para todas as medidas necessárias de PCI e atividades médicas específicas, incluindo para beber, e canalizado dentro das unidades de saúde em todos os momentos, no mínimo para as enfermarias de alto risco (por exemplo, maternidade, sala(s) de cirurgia, unidade de terapia intensiva). • Devem estar disponíveis, no mínimo, duas unidades sanitárias melhoradas e funcionais que contenham resíduos com segurança nos ambulatórios, e uma a cada 20 leitos, nas enfermarias; todas devem estar equipadas com unidades de higiene menstrual. • Instalações funcionais de higiene das mãos devem estar sempre disponíveis nos pontos de atendimento, banheiros e áreas de serviço (por exemplo, unidade de descontaminação), que incluem álcool gel e sabão, água e toalhas descartáveis (ou se não houver disponíveis, toalhas reutilizáveis limpas) nos pontos de atendimento e áreas de serviço e sabão, água e toalhas descartáveis (ou, se não houver, toalhas reutilizáveis limpas) a menos de 5 metros dos banheiros. • Lixeiras suficientes e devidamente rotuladas para permitir a separação de resíduos de saúde (incluindo para descarte de agulhas e perfurocortantes) devem estar disponíveis e ser usadas (menos de 5 metros do ponto de geração) e os resíduos devem ser tratados e descartados com segurança por meio de autoclavagem, incineração (850° a 1.100° C), e/ou enterrados em uma fossa protegida revestida. • O serviço de saúde deve ser projetado para permitir ventilação adequada (natural ou mecânica, conforme necessário) para prevenir a transmissão de patógenos infecciosos. • Devem estar disponíveis suprimentos e equipamentos suficientes e apropriados e fonte de força/energia confiável para a execução de todas as práticas de PCI, incluindo precauções padrão e baseadas na transmissão, de acordo com os requisitos mínimos/POP; eletricidade confiável deve estar disponível para fornecer iluminação às áreas clínicas de modo a fornecer cuidados contínuos e seguros, no mínimo para as enfermarias de alto risco (por exemplo, maternidade, sala(s) cirúrgica(s), unidade de terapia intensiva). • O serviço de saúde de saúde deve ter um espaço/área dedicado para realizar a descontaminação e reprocessamento de produtos de saúde reutilizáveis (ou seja, uma unidade de descontaminação) de acordo com as orientações/POP mínimos. • A unidade de saúde deve ter salas de isolamento individuais adequadas ou pelo menos uma sala para coorte de pacientes com patógenos semelhantes, se o número de quartos de isolamento for insuficiente. ATENÇÃO PRIMÁRIA • Pessoa de ligação treinada em PCI/ponto focal de PCI (ver os requisitos mínimos para o componente essencial 1), bem como o gestor/encarregado da unidade de saúde e a equipe auxiliar (por exemplo, equipe de limpeza, operadores de incinerador). ATENÇÃO SECUNDÁRIA E TERCIÁRIA • Pessoa de ligação treinada em PCI/ponto focal de PCI (ver os requisitos mínimos para o componente essencial 1) e agente de saúde ambiental WASH local/municipal. • Gestor de unidades e chefes de departamento/equipe responsável. COMPONENTE ESSENCIAL 8: INFRAESTRUTURA, MATERIAIS E EQUIPAMENTO PARA PCI NO NÍVEL DE SERVIÇO DE SAÚDE (SOMENTE NÍVEL DE UNIDADE*) O QUÊ (requisitos mínimos) QUEM (é responsável pela ação) • Além disso, em nível nacional, o líder/ponto focal de PCI (e equipe técnica ou comissão de PCI, se existente) no ministério da saúde ou órgão nacional responsável em PCI, bem como o órgão nacional (por exemplo, ministério da água ou ministério do meio ambiente ou ministério do desenvolvimento rural) e a equipe técnica ou comitê responsável por WASH (se for separado), deve tomar medidas para convocar um grupo técnico para a implementação dos requisitos de PCI e WASH para todos os serviços de saúde e ferramentas de implementação. • Idealmente, o grupo técnico deve incluir médicos, engenheiros, funcionários de saúde ambiental e gerentes de compras. • Gerente financeiro nos serviços de saúde e no próximo nível administrativo (por exemplo, distrito), e o ministério das finanças no nível nacional. * Nível de serviços de saúde apenas. No entanto, o sistema nacional de saúde, o programa de PCI e qualquer outro órgão relevante devem coordenar e apoiar a implementação desse componente essencial nos serviços de saúde. 47 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS INDICADORES (SIM/NÃO) ATENÇÃO PRIMÁRIA • IPCAF - 8.1: serviços de água disponíveis em todos os momentos e em volume suficiente para todos os usos (por exemplo, lavar as mãos, beber, higiene pessoal, atividades médicas, esterilização, descontaminação, limpeza e lavanderia). • IPCAF – 8.3: postos de higienização das mãos em funcionamento (ou seja, álcool gel ou água e sabão e toalhas descartáveis limpas) disponíveis em todos os pontos de atendimento. • IPCAF - 8.4: há um número maior ou igual a quatro de banheiros ou latrinas melhoradas disponíveis nos ambulatórios, ou maior ou igual a 1 para cada 20 usuários nos hospitais. • IPCAF modificado - 8.5: fonte de energia/força suficiente disponível pelo menos durante o horário de trabalho para todos os usos (por exemplo, bombeamento e fervura de água, esterilização e descontaminação, incineração ou tecnologias alternativas de tratamento, produtos de saúde eletrônicos, iluminação geral de áreas em que procedimentos de saúde são realizadas para garantir a prestação segura de atenção à saúde e iluminação dos banheiros e chuveiros). • IPCAF - 8.6: ventilação ambiental em funcionamento (natural ou mecânica) disponível nas áreas de atendimento ao paciente. • Materiais adequados e bem conservados para limpeza (por exemplo, detergente, esfregões, baldes etc.) disponíveis. • IPCAF - 8.9: quartos individuais ou quartos para coorte/separação física de pacientes com patógenos semelhantes ou síndrome se o número de quartos de isolamento for insuficiente (por exemplo, tuberculose, sarampo, cólera, Ebola, síndrome respiratória aguda grave). • IPCAF - 8.10: O EPI está sempre disponível e em quantidade suficiente para todos os usos para todos os profissionais de saúde. • IPCAF - 8.11: Recipientes funcionais de coleta de resíduos não infecciosos (gerais), resíduos infecciosos e resíduos de materiais cortantes nas proximidades de todos os pontos de geração de resíduos. • IPCAF - 8.15: uma área de descontaminação dedicada e/ou departamento de suprimentos estéreis (presente no local ou fora do local e operado por um serviço de gestão de descontaminação licenciado) para a descontaminação e esterilização de dispositivos e outros itens/equipamentos médicos. • IPCAF - 8.16: equipamento esterilizado e desinfetado, pronto para uso e com disponibilidade confiável. ATENÇÃO SECUNDÁRIA E TERCIÁRIA (além dos indicadores de atenção primária acima) da ferramenta de melhoria da água e saneamento dos serviços de saúde (WASH FIT**): • Higiene - 3.1: indicador essencial 1. Estações de higiene das mãos funcionais estão disponíveis em todos os pontos de atendimento (sim/não). Estações presentes, mas sem água e/ou sabão ou álcool gel presentes (sim/não). • Higiene - 3.2: indicador essencial 2. Materiais de promoção da higiene das mãos claramente visíveis e compreensíveis em locais-chave (sim/em alguns locais, mas não todos/nenhum). • Higiene - 3.3: indicador avançado 1. Postos de higienização das mãos em funcionamento estão disponíveis nas áreas de serviço (sim/postos presentes, mas sem água e/ou sabão ou álcool gel presentes). • Higiene - 3.4: indicador avançado 2. Estações de higiene das mãos em funcionamento disponíveis na área de disposição de resíduos (sim/estações presentes, mas sem água e/ou sabão presente). • Higiene - 3.5: indicador avançado 3. As atividades de conformidade com a higiene das mãos são realizadas regularmente (sim/atividades de conformidade na política do serviço de saúde, mas não realizadas com qualquer regularidade/nenhuma atividade de conformidade). FONTES E RECURSOS Fontes • Relatório de resultados IPCAF (onde disponível; use o modelo de apresentação); https://www.who.int/infection- prevention/tools/core-components/ IPCAF-template.pdf?ua=1. • Relatório de resultados WASH FIT (quando disponível). https://www.who.int/water_sanitation_health/publications/water-and- sanitation-for-health- facility-improvement-tool/en/. Ferramentas e recursos • Programa conjunto de monitoramento de abastecimento de água, saneamento e higiene da OMS/UNICEF. Definições do Programa de monitoramento conjunto de melhoria da água/saneamento. 2019; https://www.unwater.org/publication_categories/whounicef-joint- monitoring-programme-for-water-supply-sanitation- hygiene-jmp/. • OMS. Orientações sobre saneamento e saúde. 2018; https://www.who.int/water_sanitation_health/publications/guidelines-on- sanitation-and- health/en/. • OMS. Padrões essenciais de saúde ambiental na atenção à saúde. 2008; https://www.who.int/water_sanitation_health/publications/ehs_hc/en/. • OMS. Gestão segura de resíduos da atenção à saúde: 2014; https://www.who.int/water_sanitation_health/publications/wastemanag/en/ • OMS e Organização Pan-Americana da Saúde Descontaminação e reprocessamento de produtos de saúde nos serviços de saúde. 2016; https://www. who.int/infection-prevention/publications/decontamination/en/. • OMS. Orientações para prevenção e controle da infecção por tuberculose. Atualização de 2019; https://www.who.int/tb/publications/2019/guidelines- tuberculosis-infection-prevention-2019/en/. • OMS. Ventilação natural para controle de infecção em ambientes de saúde. 2009; https://www.who.int/water_sanitation_health/publications/natural_ ventilation/en/. • OMS. Orientações sobre os componentes principais dos programas de prevenção e controle de infecção em nível nacional e de unidades de cuidados agudos. 2016; https://www.who.int/ infection-prevention/publications/core-components/en/. ** NOTA: a maioria desses indicadores tem três respostas possíveis, e não simplesmente “sim/não”. COMO (medir o progresso) 48 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS • OMS. Aprimorar a prevenção e controle de infecção nos serviços de saúde: Manual prático provisório de apoio à implementação nacional das orientações sobre os componentes essenciais dos programas de prevenção e controle de infecção, da OMS. 2018; https://www.who.int/infection-prevention/tools/core-components/ facility-manual.pdf. • Programa conjunto de monitoramento de abastecimento de água, saneamento e higiene da OMS/UNICEF. WASH em serviços de saúde: relatório de referência global. 2019; https://www.unwater.org/publications/wash-in-health-care-facilities-global-baseline-report-2019/. • OMS. WASH em serviços de saúde: etapas práticas para atingir o acesso universal a atendimento de qualidade. Ações e soluções. 2019; https://www.who. int/water_sanitation_health/publications/wash-in-health-care-facilities/en/. ATENÇÃO PRIMÁRIA • Infraestruturas adequadas e disponibilidade de apoio WASH adequado são essenciais para a realização de quaisquer atendimentos de saúde e atividades de PCI (por exemplo, a água é absolutamente crítica para a higiene das mãos, limpeza e serviços essenciais, como delivery). • Fontes de água melhoradas são aquelas que, pela natureza de seu projeto e construção, têm o potencial de proteger a água da contaminação externa (por exemplo, microrganismos, sujeira). Embora não seja necessária água potável para as medidas básicas de PCI, a água de fontes melhoradas pode facilitar a execução de medidas de PCI de acordo com as orientações/POP, por exemplo, a água de fontes subterrâneas que não seja turva pode geralmente permitir a preparação efetiva de soluções desinfetantes para limpeza do ambiente e descontaminação de produtos de saúde. A concentração de cloro de todas as soluções desinfetantes deve ser monitorada regularmente e a dose deve ser ajustada conforme necessário para atender às metas de concentração de cloro. • Instalações sanitárias melhoradas são aquelas projetadas para separar higienicamente os excrementos humanos do contato humano, o que é crítico para reduzir o risco de transmissão de patógenos entéricos e, juntamente com as unidades de higiene menstrual, ajudam a manter um ambiente higiênico; banheiros separados para pacientes e funcionários também ajudam a minimizar o contato indireto entre pacientes e funcionários que pode representar um risco de infecção. • Quando há risco de sujeira, o álcool gel não substitui a água e sabão na higienização das mãos após o uso do banheiro ou quando as mãos estiverem visivelmente sujas (por exemplo, durante o parto). • Se álcool gel estiver disponível, é essencial tê-lo acessível em todos os pontos de atendimento, dadas as vantagens comprovadas do álcool gel em relação à água e sabão, mas também é essencial que água, sabão e toalhas descartáveis estejam disponíveis nos serviços clínicos. • A ventilação adequada em todo o serviço de saúde contribui para manter um ambiente higienizado e pode ser minimamente realizada por meio da presença de janelas funcionais (de preferência equipadas com armadilhas para insetos) e portas, que permitam pelo menos 6-8 trocas de ar por hora para ventilação natural (por exemplo, abrindo janelas opostas). • Energia/força suficiente e um arranjo de “reserva” (incluindo energia solar, eólica, gerador de reserva ou outros) e combustível devem estar disponíveis no local para iluminação de práticas clínicas e medidas básicas de PCI (por exemplo, para realizar a descontaminação de produtos para saúde, se necessário). • Se a unidade de saúde realiza quaisquer procedimentos (por exemplo, partos ou outros procedimentos ginecológicos básicos) que exijam produtos de saúde reutilizáveis (por exemplo, espéculos vaginais), é essencial criar, no mínimo, áreas dedicadas que permitam um fluxo de trabalho adequado da sujeira à limpeza para a realização da descontaminação e reprocessamento dos produtos de saúde. • Um pequeno espaço para avaliar os pacientes quanto à doença/motivo do acesso à unidade (ou seja, triagem), incluindo qualquer risco de transmissão de doenças infecciosas, e para permitir que sejam direcionados para diferentes áreas de acordo com a prioridade e o tipo de doença, pode ser obtido com recursos mínimos. • Espaço adequado para coorte/isolamento temporário também pode ser obtido com recursos mínimos pela criação de uma separação física ou barreira entre pacientes suspeitos/infectados e outros pacientes, funcionários e visitantes, sendo fundamental para garantir precauções baseadas na transmissão. Se os recursos permitirem, uma sala deve ser designada para essa função. ATENÇÃO SECUNDÁRIA E TERCIÁRIA • É fundamental que água esteja disponível 24 horas no local a partir de uma fonte melhorada e canalizada para os serviços de saúde para as áreas clínicas, no mínimo no mínimo para as enfermarias de alto risco (por exemplo, maternidade, sala(s) de cirurgia, unidade de terapia intensiva), pontos de atendimento e áreas de serviço (por exemplo, departamento de serviços estéreis), pois os pacientes dessas áreas podem necessitar de atendimento clínico 24 horas por dia, em que a PCI relacionada à água é crítica (por exemplo, higiene das mãos, limpeza do ambiente, reprocessamento de produtos de saúde). • O uso de água potável (de acordo com o padrão de qualidade de água potável da OMS, ou seja, nenhuma Escherichia coli detectável em 100 mL e/ou 0,5 mg/L de cloro residual livre) para intervenções de PCI relacionadas à água minimiza o risco de exposição direta e indireta a patógenos relacionados à água de origem entérica e ambiental (por exemplo, Pseudomonas, Legionella) e deve estar disponível para todos os serviços clínicos; no mínimo, deve ser fornecido à enfermarias de alto risco, onde a carga de IRAS e RM é alta. • Volumes suficientes de água são necessários para garantir que todas as intervenções de PCI relacionadas à água possam ser realizadas. Esse volume varia e depende do serviço ou enfermaria específica. Para evitar falhas frequentes nos serviços/escassez de água, é necessário que haja capacidade de armazenamento de água no local suficiente para fornecer serviços por no mínimo 48 horas. • Garantir uma quantidade adequada de vasos sanitários para os usuários internados de modo a evitar aglomeração e uso excessivo e garantir a limpeza regular são fundamentais para manter um ambiente higiênico e minimizar o risco de transmissão de patógenos entéricos, no mínimo na proporção definida anteriormente. • Ventilação mecânica positiva é necessária para áreas limpas, como salas de cirurgia e áreas limpas das unidades de descontaminação e do departamento de serviços de esterilização, ao passo que pode ser necessária ventilação com pressão negativa nas unidades de isolamento, por exemplo, tuberculose multirresistente (ver referências sobre tuberculose em “recursos”). O requisito de ventilação mecânica é mais aplicável a unidades terciárias. • Energia confiável significa que uma fonte constante (ou seja, 24 horas) de energia e/ou força reserva esteja disponível nas enfermarias de alto risco (por exemplo, maternidade, sala de cirurgia, unidade de terapia intensiva). Sem energia confiável, não é possível operar equipamentos de descontaminação (esterilização) e equipamentos de tratamento de resíduos quando necessário, ou ter iluminação em POR QUÊ (justificativa e detalhes adicionais sobre os requisitos mínimos) 49 PARTE 3. REVISÃO EM PROFUNDIDADE DOS REQUISITOS MÍNIMOS • áreas clínicas para fornecer cuidados contínuos e seguros. • A energia confiável pode ser obtida por meio de uma fonte local de energia/força e combustível (por exemplo, eólica, solar, gerador(es) de reserva) para fornecer backup conforme necessário. • Dado o risco aumentado de IRAS e RM nas unidades de saúde secundárias e terciárias, deve haver pelo menos um quarto de isolamento por enfermaria com 20 leitos nas unidades de atenção secundária e 1:10 no nível terciário, no mínimo. • A coorte pode ser realizada em uma área dedicada de uma enfermaria geral. Isso pode ser feito em qualquer área bem ventilada, desde que as precauções de higiene das mãos e de transmissão sejam estritamente observadas. • Como a melhoria do acesso aos serviços de WASH e aos materiais e equipamentos de PCI exige muitos recursos, a primeira etapa (requisito mínimo) é estabelecer um grupo técnico multidisciplinar para desenvolver padrões e ferramentas de implementação. • Esse grupo terá a tarefa de: - revisar os requisitos de serviços de WASH, higiene ambiental e materiais e equipamentos de PCI, de acordo com o contexto nacional; - desenvolver um plano de monitoramento e mecanismo de relatório para avaliar e melhorar os serviços de WASH e os materiais e equipamentos de PCI em todas as unidades de saúde no tocante aos padrões nacionais; o uso de ferramentas existentes (por exemplo, indicadores WASH FIT ou JMP da OMS/UNICEF para WASH em serviços de saúde) pode ajudar nesses esforços; - identificar funções e responsabilidades para a implementação e gestão de serviços de WASH, higiene ambiental e materiais e equipamentos de PCI no nível dos serviços em todas as unidades de atenção à saúde. • O nível nacional também pode cogitar o desenvolvimento de uma política/regulamentos para ordenar os serviços de WASH nos serviços de saúde, de acordo com os requisitos mínimos especificados acima. TODOS OS SERVIÇOS DE SAÚDE • O governo central e os programas nacionais de PCI e WASH devem desenvolver padrões e planos de ação nacionais para garantir serviços de WASH adequados, um ambiente limpo e a disponibilidade de materiais e equipamentos de PCI em serviços de saúde, inclusive na atenção primária. • A garantia de um ambiente higiênico adequado deve ser responsabilidade da alta gestão dos serviços de saúde e das autoridades locais. • Para implementar todos os requisitos do componente essencial, todos os serviços de saúde devem fornecer o seguinte: - água de uma fonte melhorada localizada no estabelecimento com água suficiente disponível em todos os momentos para beber, lavar as mãos, preparar alimentos, higiene pessoal, atividades médicas, limpeza e lavanderia; - unidades sanitárias melhoradas localizadas no estabelecimento que sejam funcionais com gestão segura de esgoto/resíduos fecais, incluindo o uso de fossas sépticas e campos de lixiviação bem gerenciados, descarte em esgotos em funcionamento ou remoção fora do local, e que incluam pelo menos um banheiro designado para mulheres/meninas para cuidar das necessidades de higiene menstrual, pelo menos uma separada para a equipe, e pelo menos um banheiro para atender às necessidades de pessoas com deficiência física limitada; também, unidades sanitárias para bebês e crianças adaptadas para seu uso (com por exemplo, assentos menores, comadres de tamanho infantil), segregadas por sexo para crianças mais velhas, devidamente iluminadas e acessíveis a pessoas com dificuldade de locomoção; - drenagem adequada de águas pluviais e de lavagem para evitar a reprodução de vetores; - acesso contínuo a unidades de higienização das mãos equipadas com álcool gel e (quando apropriado) com água, sabão e toalhas descartáveis ou limpas no ponto de atendimento, a menos de 5 metros dos banheiros, e outras áreas como departamentos de esterilização, laboratórios e necrotérios; - fornecimento contínuo e adequado de recipientes para perfurocortantes e recipientes para separação de outros tipos de resíduos e equipamentos de saúde para garantir que os resíduos de serviços de saúde sejam tratados e descartados com segurança, incluindo autoclavagem, incineração ou remoção para tratamento externo; - suprimentos adequados e contínuos para garantir a limpeza regular das salas de exame, áreas de espera, superfícies e banheiros; - fornecimento contínuo e adequado de EPI adequado tanto para tratamento clínico quanto para manuseio e limpeza de resíduos de serviços de saúde; - ventilação adequada para atender aos requisitos de conforto e reduzir o risco de transmissão de patógenos transportados pelo ar; - energia adequada para esterilização, incineração produtos de saúde; energia suficiente para bombear água, esterilizar e operar equipamentos de tratamento de resíduos de atenção à saúde (ou seja, incineradores); áreas bem iluminadas onde são realizados procedimentos de saúde e nas unidades sanitárias, inclusive à noite. • A equipe ou comissão de PCI deve estar envolvida no planejamento de todas essas atividades e sistemas e no projeto e construção de edifícios e infraestruturas nas unidades de saúde. • As ações práticas para melhorar a WASH nos serviços de saúde devem incluir: - conduzir análise e avaliação situacional - definir roteiro e traçar metas - estabelecer padrões nacionais e mecanismos de prestação de contas - melhorar e manter a infraestrutura - monitorar e revisar dados - força de trabalho de saúde na comunidade - envolver as comunidades e - conduzir pesquisa operacional e aprendizado. ATENÇÃO SECUNDÁRIA E TERCIÁRIA (além da atenção primária) • Uma área de descontaminação centralizada dedicada e/ou departamento de suprimentos estéreis para a descontaminação e esterilização de produtos para saúde e outros itens/equipamentos médicos deve estar disponível e abastecida com água e energia suficientes. Requisitos dos componentes essenciais completos • Uma área de armazenamento limpa dedicada para itens e equipamentos de atendimento ao paciente, incluindo material estéril, e uma área separada para o armazenamento de roupa limpa deve estar disponível conforme descrito no manual da OMS sobre descontaminação e reprocessamento de produtos de saúde para serviços de saúde (ver “recursos”). • Um número adequado de quartos individuais (com banheiros privativos e incluindo alguns quartos com sistema de ventilação mecânica de pressão negativa) e/ou quartos adequados para coorte de pacientes para o isolamento de pacientes suspeitos/infectados, incluindo aqueles com tuberculose, outros patógenos aerotransportados e organismos multirresistentes a medicamentos, devem estar disponíveis para prevenir a transmissão a outros pacientes, funcionários e visitantes. • Devem estar disponíveis sistemas de ventilação adequados em geral e na sala de cirurgia, incluindo condições de pressão de ar negativa ou positiva, dependendo da situação. • Durante os trabalhos de construção e reforma, devem ser desenvolvidos sistemas e medidas de avaliação de risco para garantir a proteção dos pacientes, de seus familiares e dos funcionários, especialmente em áreas de alto risco, como unidades em que são tratados pacientes gravemente imunocomprometidos (transplantes, pacientes com neutropenia profunda etc.), bem como nas unidades de terapia intensiva, unidades neonatais e de queimados e nas salas cirúrgicas. 51 PARTE 4. ANEXO PARTE 4. ANEXO 4.1 Anexo 1. Resumos dos resultados de uma revisão sistemática e inventário dos padrões mínimos disponíveis de PCI 4.1.1 Visão geral dos resultados da revisão sistemática da literatura sobre padrões mínimos para PCI A revisão sistemática dos padrões mínimos de PCI foi conduzida como base para a consulta a especialistas sobre os requisitos mínimos de PCI. É focado na questão: “Quais são os padrões mínimos de programas efetivos de PCI destinados a reduzir as infecções relacionadas à assistência à saúde em nível nacional e de atenção à saúde?” O Índice Cumulativo de Enfermagem e Literatura Aliada em Saúde (CIHAHL), PubMed, GIM (OMS Global Index Medicus) e bancos de dados EMBASE foram pesquisados para identificar os padrões mínimos relatados. As intervenções de PCI foram categorizadas como horizontais (por exemplo, programa de PCI, educação) ou verticais (por exemplo, prevenção de infecção de sítio cirúrgico). Higiene das mãos, aplicação segura de injeção e formação educacional são exemplos de intervenções horizontais de PCI, ao passo que a prevenção de infecção do sítio cirúrgico, pneumonia hospitalar e infecção da corrente sanguínea associada ao cateter foram categorizadas como intervenções verticais de PCI. As intervenções horizontais foram mencionadas com mais frequência em comparação com as verticais como sendo um requisito mínimo (fig. 1). Higiene das mãos (91%), precauções com base na transmissão (incluindo triagem) (87%), vigilância (85%), educação/treinamento (81%) e ambiente construído/infraestrutura (77%) foram as cinco medidas críticas de PCI horizontais mais frequentemente mencionadas, seguidas de orientações (70%), descontaminação (70%) e monitoramento/auditorias/feedback (66%). ABREVIATURAS ICSAC, infecção da corrente sanguínea relacionada a cateter; MRSA, Staphylococcus aureus resistente à meticilina (sigla derivada do inglês Methicillin-resistant Staphylococcus aureus; PAV/PAH, pneumonia associada à ventilação/pneumonia adquirida em hospital; ISC, infecção do sítio cirúrgico; ITUAC, infecção do trato urinário associada a cateter; ORC, organismos resistentes aos carbapenêmicos. Fig. 1. As 5 principais intervenções horizontais e verticais mencionadas como um requisito mínimo no nível de unidade de saúde. Ambiente /infraestrutura 77% Educação/treinamento 81% Vigilância 85% Precauções baseadas na transmissão 87% Higiene das mãos 91% As 5 principais intervenções verticais Nível de unidade de saúde A s 5 p ri n c ip a is i n te rv e n ç õ e s h o ri z o n ta is P re v e n ç ã o d e I C S A C 3 6 % P re v e n ç ã o d e M R S A 3 2 % P re v e n ç ã o d e P A V / P A H 2 6 % P re v e n ç ã o d e I S C 2 1 % P re v e n ç ã o d e I T U A C o u O R C 1 9 % 52 PARTE 4. ANEXO A conformidade com as precauções padrão é geralmente baixa e, portanto, é importante investigar estratégias de implementação para melhorar essa medida chave. As competências existentes dos profissionais de PCI, bem como os indicadores existentes, serão úteis para definir padrões mínimos. Será fundamental aproveitar as lições aprendidas no passado e envolver a liderança hospitalar em futuras discussões sobre a importância da implementação dos programas de PCI. A revisão também destacou a baixa qualidade dos estudos revisados (revisões sistemáticas e estudos tipo antes-depois), um número muito grande de estudos de países de alta renda, uma alta porcentagem de revisões sistemáticas sobre Staphylococcus aureus resistente à meticilina e Clostridium difficile de países de alta renda, e um número elevado de estudos em serviços de saúde. 4.1.2 Sumário do inventário global de padrões mínimos de PCI O objetivo do desenvolvimento do inventário global de padrões mínimos de PCI era produzir um catálogo de orientações já disponíveis sobre esses padrões (especialmente da perspectiva de locais com poucos recursos) diretamente dos escritórios regionais e nacionais da OMS, outras organizações e países. Foi para complementar a revisão sistemática e as experiências dos países coletadas anteriormente e para fornecer percepções sobre o que poderia ser considerado como “padrões mínimos” de PCI em nível nacional e de unidade de saúde. Uma convocação global foi feita nas redes relevantes, bem como uma busca de todos os documentos relacionados à PCI disponíveis publicamente. O banco de dados usado nas orientações sobre os principais componentes de PCI também foi pesquisado em busca de documentos relevantes. Um total de 23 documentos foram revisados na íntegra (1-23), mas apenas nove incluíam os padrões nacionais de PCI aprovados, definidos como “mínimo” para serviços de saúde (1-9). No geral, esses documentos validaram as orientações da OMS sobre os componentes principais dos programas de PCI, uma vez que todos os documentos revisados podem ser categorizados e relacionados aos oito componentes principais. Mais notavelmente, os componentes principais 1 (programas de PCI), 3 (educação e treinamento) e 8 (ambiente construído) foram os mais citados, ao passo que o componente principal 7 (carga de trabalho, pessoal e ocupação dos leitos) foi o menos relatado. As limitações do inventário final já haviam sido reconhecidas, uma vez que foi retirado de envios diretos e dos que estavam publicamente disponíveis. No entanto, apesar de alguns países identificarem especificamente os padrões mínimos de PCI, a maioria carece de qualquer definição padronizada de padrões mínimos e sua abordagem permanece ampla, com falta de especificidade. 53 PARTE 4. ANEXO 4.1.3 Referências 1. Orientações de transformação dos serviços hospitalares da Etiópia, volume 2. Iniciativa de gestão de hospitais etíopes. Adis Abeba: Ministério da Saúde da República Federal Democrática da Etiópia; 2016 2. Ministério da Saúde Serviços Sociais da Namíbia. Padrões e critérios hospitalares, 1ª edição (Versão 2). 2018 (http:// www.mhss.gov.na/documents/119527/659098/ MoHSS+Namibia+Hospital+Standards+and+Criteria+DRAFT . pdf/13271616-e30e-4a0d-b3d9-54d17c283eeb, acessado em 29 de outubro de 2019). 3. Infection Prevention and Control (IPAC) Canada. 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