PHWR Public Health Weekly Report

Healthcare-associated infections (HAIs) are connected to medical procedures performed in healthcare institutions. They not only constitute a significant challenge to patient safety and health but also lead to various socioeconomic losses, such as increased healthcare costs and medical disputes [1,2]. Nevertheless, HAIs can be prevented and managed via active infection control activities in healthcare institutions, and policy support at the national level is a key factor in successful infection control [3]. Since its introduction in the 1990s, Korea’s HAI control system has steadily developed based on the Hospital Infection Control Guidelines in 1992, revision of the Medical Service Act in 2003, evaluation of healthcare institutions in 2004, introduction of a healthcare accreditation program in 2010, and establishment and operation of the Korean National Healthcare-associated Infections Surveillance System. The revision of the Medical Service Act in 2012 further highlights the significance of managing HAIs in healthcare institutions and emphasizes that infection control is not an option but an obligation for patient safety and medical safety. It is essential to alleviate the public’s anxiety attributable to the outbreak of infection epidemics in healthcare institutions, such as injection drug contamination-related neonatal cluster deaths in neonatal intensive care units and propofol-related sepsis. Accordingly, the Korean government established the “First Comprehensive Plan for Prevention of Healthcare-Related Infections (2018–2022)” in 2018 and the “Second Comprehensive Plan for Prevention and Control of Healthcare-Related Infections (2023–2027)” in 2023. These plans aim to provide national infection control policy direction and establish and implement measures to support infection control activities in healthcare institutions.

To evaluate the effectiveness of these national policies and plan for future improvements, accurately identifying the current status and problems of infection control in healthcare settings is necessary. Therefore, the Korea Disease Control and Prevention Agency (KDCA) established a healthcare institution infection control survey system based on Article 17 of the Prevention of Infectious Diseases Act—to provide basic data for establishing policies to support infection control in healthcare institutions—and administered the first hospital-level healthcare institution infection control survey on acute care hospitals and long-term care hospitals [4]. This article introduces the infection control survey operation system that the KDCA has been developing and operating since 2021 for hospital-level healthcare institutions.

1. Establishment of a Hospital-level Healthcare Institution Infection Control Survey System

The purpose of the hospital-level healthcare institution infection control survey is to periodically investigate the infection control status of hospital-level institutions using a standardized tool and to link the results with policies to support infection control in healthcare institutions, guiding healthcare institutions in establishing their own infection control systems. Therefore, a survey system using a survey tool for each type of healthcare institution was established to identify the infection control status without bias according to the specific characteristics of each type of healthcare institution. The survey was commissioned by the Korea Institute for Healthcare Accreditation. To ensure the smooth operation of the first survey, a general steering committee with infection control experts recommended by the KDCA, the Korean Society for Healthcare-associated Infection Control (KOSHIC), and the Korean Association of Infection Control Nurses (KAICN) was formed to advise and review the overall operation of the hospital-level healthcare institution infection control survey.

The survey system is based on a computer-assisted self-interviewing method. To minimize the limitations of self-interviewing and ensure the objectivity and reliability of the survey results, a professional investigators field survey was administered for randomly selected sample institutions to determine the consistency between the online and field survey responses (Figure 1).

Figure 1. Hospital-level healthcare-associated infection control assessment system

The online self-interviewing survey is a computerized system within the KDCA’s Integrated Disease and Health Management System (https://is.kdca.go.kr). It enables infection control officers at healthcare institutions to report whether they are meeting their infection control obligations, including the organization and workforce of the healthcare institution, and improved functionality during the operation period of the survey to increase accessibility and convenience for healthcare institutions (Figure 2). To help respondents understand the survey items, a separate survey guide and training videos on the survey items were provided. It was clarified in advance that the survey was not intended to evaluate the level of infection control at individual healthcare institutions but to identify the current status of infection control at healthcare institutions in the Republic of Korea (ROK).

Figure 2. Korea Disease Control and Prevention Agency integrated healthcare-associated infection control assessment system

For the site visits, approximately 10% of the healthcare institutions that completed the online survey were randomly selected to verify the survey responses’ reliability. To ensure the field survey’s professionalism and objectivity, a survey team of two infection control experts with a certain level of infection control experience was organized. Training was imparted to the field surveyors regarding the survey items and precautions required during the survey.

2. Operation of the Hospital-level Healthcare Institution Infection Control Survey

1) Subjects

The target of the healthcare institution infection control survey is healthcare institutions under Article 3 of the “Medical Service Act.” The first hospital-level healthcare institution infection control survey on infection control in hospital-level healthcare institutions was administered for all general hospitals, hospitals, and long-term care hospitals in the ROK, with surveys for general hospitals and hospitals in 2021 and surveys for long-term care hospitals in 2022.

2) Survey tool

The understanding and active participation of healthcare institutions in the survey are essential to ensure that the survey results accurately reflect the actual situation of healthcare institutions. Furthermore, a structured survey tool with key items for establishing infection control policies is required. The hospital-level healthcare institution infection control survey tool was developed by reflecting domestic regulations and guidelines as well as international survey tools. The developed survey tool was validated for reliability by collecting opinions from infection control experts recommended by the KOSHIC and KAICN and related organizations (Korean Convalescent Hospital Association) and administering a sample field survey. The survey was consisted of 110 items for acute-care hospitals in 2021 and 190 items for long-term care hospitals in 2022 (Table 1).

Table 1 Hospital-level healthcare-associated infection control assessment tools

Year	Variables	Category
2021	General hospitals	Infection control system, hand hygiene, injection practice, standard precautions and isolation guidelines, infection control of environment, insertion device, standard prevention of surgical site infections, disinfection and sterilization, installation for infection control
2022	Long-term care hospitals	Infection control operation system, infection control program, hand hygiene, injection practice, infection control related to insertion devices, isolation guidelines, disinfection and sterilization system, installation and environment for infection control

3) Survey method

The online survey was administered using a computer-assisted self-interviewing method whereby a representative of a healthcare institution accessed KDCA’s Integrated Disease and Health Management System, received permission to use the system, and responded directly to the survey items. The field survey was administered by a field survey team comprising pre-trained infection control experts. They randomly selected a sample of the subjects who completed the survey and conducted document verification, interviews, and on-site observation of the same items as the self-survey items.

4) Survey participation status

In the 2021 acute care hospitals infection control survey, 1,197 of 1,767 general hospital including tertiary hospitals and hospitals, participated in the online survey. The participation rate was 67.7%. The participation rate by healthcare institution type was 100.0% for tertiary hospitals, 92.2% for general hospitals, and 61.2% for hospitals. The field survey was administered at 125 of the healthcare institutions that completed the survey.

For the 2022 long-term care hospital infection control survey, 1,270 of 1,365 long-term care hospitals participated in the online survey. The participation rate was 93.0%. Regarding bed size, 93.7% of those with 100 or more beds and 88.5% of those with fewer than 100 beds participated. The field survey was administered at 140 of the healthcare institutions that completed the online self-interviewing survey (Table 2).

Table 2 Response proportion by type of healthcare facilities

Variables	Tertiary hospitals				General hospitals				Hospitals				Long-term care hospitals
	Target	Response	Rate		Target	Response	Rate		Target	Response	Rate		Target	Response	Rate
Total	45	45	100.0		319	294	92.2		1,403	858	61.2		1,365	1,270	93.0
More than 100 beds	45	45	100.0		319	294	92.2		493	348	70.6		1,200	1,124	93.7
Less than 100 beds	-	-	-		-	-	-		910	510	56.0		165	146	88.5

Unit: number, %..

To examine the online self-interviewing survey’s reliability, Gwet’s AC1 statistic was used to check for agreement. The infection control survey in the acute care hospital, the agreement between the online survey results and field survey results by domain was mostly moderate or better (Gwet’s AC1 above 0.40). The lowest agreement was between the survey and field survey results in the domain of isolation guidelines. In the long-term care hospital survey, the agreement was above 0.73 in all domains. However, the agreement was lower for a few items, such as establishing an infection control committee, establishing an infection control room, periodically revising infection control policies, establishing a rapid response team, and implementing an employee vaccination program (Table 3).

Table 3 Hospital-level medical infection control the concordance (Gwet’s AC1) between online survey responses and field survey results

Survey domain	Acute-care hospitals concordance (AC1)	Long-term care hospitals concordance (AC1)
Infection control system	0.63	0.79
Infection control program	-	0.73
Hand hygiene	0.67	0.86
Injection practice	0.84	0.92
Isolation Guidelines	0.52	0.84
Insertion device management	0.74	0.76
Standard prevention of surgical site infections	0.84	-
Disinfection and sterilization	0.63	0.78
Infection control of environment	0.68	-
Installation for infection control	0.63	-
Installation and environment for infection control	-	0.86

5) Survey results

In the acute care hospitals infection control survey, the rates of establishing infection control committees and infection control rooms, rates of staffing and training of infection control officers, and rates of conducting infection control program planning and evaluation were relatively higher in general hospitals, including tertiary hospitals, than in hospitals.

In the long-term care hospital survey, the status of infection control room installation and staffing were relatively higher in nursing hospitals with more than 100 beds compared to those with less than 100 beds. Some infection control activities, such as infectious disease epidemic preparedness training and infection control facilities and equipment, were found to be insufficient.

The main results of the hospital-level infection control survey were published on the KDCA website in accordance with Article 15 of the Enforcement Rules of the “Infectious Disease Control and Prevention Act.” To promote infection control in hospital-level healthcare institutions, the expansion of the healthcare-related infection surveillance system and establishment of a regular inspection system are being promoted as key issues in the “Second Comprehensive Plan for Prevention and Control of Healthcare-Related Infections (2023–2027).”

3. Improvement Measures for the Hospital-level Healthcare Institution Infection Control Survey System

The infection control survey was conducted to identify the overall infection control status of hospital-level healthcare institutions and provide policy support for healthcare-related infection control. To ensure reliable survey results in the future, it is planned to establish a field survey system comprising infection control experts by selecting a representative sample. By supplementing and further developing standardized survey items suitable for field surveys, including in special departments with a high risk of infection (operating rooms, intensive care units, dialysis units, endoscopy units, etc.), the foundation for infection control will be confirmed and reflected in the second acute care hospital infection control survey system.

Based on Article 17 of the Infectious Disease Control and Prevention Act and Article 15 of the Enforcement Rules of the same Act as the legal basis for enforcing the duty to survey HAIs, the KDCA administered an online self-interviewing survey of all hospital-level healthcare institutions to comprehensively identify the infection control status of healthcare institutions in the ROK.

To verify the survey results’ reliability, a field survey was administered for randomly selected sample institutions that participated in the online self-interviewing survey. A survey system was established to verify the self-survey responses’ reliability. The method of filling out the survey by self-diagnosing the infection control status of the healthcare institution may cause errors depending on the level of respondents’ understanding of the survey items. Additionally, some healthcare institutions with poor infection control may not even participate in the survey. The response rate of the self-interviewing survey was not high—approximately 50.2%, 51.0%, and 62.2%, respectively, not only in the ROK but also in foreign countries, such as Germany, Austria, and Ghana [5,-7]. Thus, the possibility of selection bias could not be excluded. To minimize the limitations of the self-interviewing survey, a separate survey guide and training videos on the survey items were provided. Consequently, the results of the online self-interviewing survey and field survey showed more than moderate agreement. However, in some cases, the agreement was lower, depending on the respondents’ understanding of the items. As numerous items were developed to provide a comprehensive picture of infection control in hospital-level healthcare institutions, some items may not have been sufficiently understood by healthcare institutions. Therefore, it will be necessary to improve the survey items by considering policy requirements and field conditions of healthcare institutions, minimize problems that may occur when inexperienced officers lacking an understanding of infection control in healthcare institutions respond to the self-interviewing survey, and have a third party review the survey method to derive objective and reliable survey results.

A healthcare institution infection control survey is essential for establishing and evaluating HAI prevention and control policies. The survey results will be used as basic data for developing evidence-based infection control policies.

The KDCA established the first hospital-level healthcare institution infection control survey system in the ROK and successfully administered the first survey. By performing an in-depth analysis of some of the limitations identified during the operation process and seeking ways to improve them, the KDCA will establish a healthcare institution infection control survey system and regularize the survey. This will facilitate the preparation of reliable basic data for the establishment of national policies for enhancing infection control in healthcare institutions and for activities to improve infection control in private healthcare institutions.

Ethics Statement: Not applicable.

Funding Source: None.

Acknowledgments: None.

Conflict of Interest: The authors have no conflicts of interest to declare.

Author Contributions: Conceptualization: SKP, JSS, NYK. Data curation: NYK, JSS. Formal analysis: NYK, JSS. Investigation: ISH, KYS, HWJ. Methodology: SKP, JSS, NYK. Project administration: SKP, JSS, NYK. Supervision: SKP. Validation: SKP, JSS. Writing – original draft: NYK, JSS. Writing – review & editing: SKP, JSS.