survey of environmental cleaning in thai hospitals 1251 Our multivariable regression analyses revealed that the


presence of a hospital epidemiologist was associated with the presence of an ECD checklist (OR, 2.37; 95% CI, 1.25–4.51; P= .01) and the existence of ECD auditing (OR, 3.19; 95% CI, 1.66–6.12; P=.001) (Table 2). Good- to-excellent hospital administration support for the infection control program was associated with greater adherence to implemented ECD protocols (OR, 5.36; 95% CI, 2.64–10.89; P<.001) and to ECD checklists (OR, 3.71; 95% CI, 1.49–9.23; P=.005).


discussion


A few key findings emerged from our national survey. First, while most Thai hospitals reported having ECD protocols and ECD auditing, adherence to ECD protocols and adherence to ECD checklists remained suboptimal. Second, we identified the significant roles of the hospital epidemiologist and strong administration support for an infection control program to enhance the adoption of ECD practices in this middle-income country. To our knowledge, this is the first national survey to investigate the policies and practices related to ECD in a country in the Asia Pacific region. Our findings help identify areas for improvement and can help inform appropriate strategies to improve ECD practices in this region. Previous national surveys from the United States, Japan, and


table 1. Hospital Characteristics, Policy, Practice, and Barriers to Implementing Environmental Cleaning/Disinfection (ECD) Policies


Characteristics


Type of ownership Private


Government owned Military


Total number of acute-care hospital beds (including ICU)


Affiliated with medical school Facility has infectious diseases specialist(s)


Overall support of infection control program is good/excellent


Facility has hospital epidemiologist Total FTEs for all infection preventionists


Lead infection preventionist certified in infection control


How does your facility obtain environmental services? Internal employees


Contract service with an external company Both internal employees and contract services Facility implements ECD protocol Facility has ECD checklist


Facility has a mechanism to audit ECD practices


Thailand identified several factors associated with the adoption of numerous HAI preventive practices.8–10 These factors include strong safety culture in the organization, participation in an HAI preventive effort, and good-to-excellent support from hospital leadership.8–10 Similarly, in this study, good- to-excellent hospital administration support for the infection control program was associated with greater adherence to ECD protocols and to ECD checklists. Additionally, having a hospital epidemiologist was associated with presence of an ECD checklist as well as regular ECD auditing. This association may be explained in part by the curriculum created by the Thai government to provide formal training for postgraduate physicians in infection prevention to become hospital epide- miologists. This finding highlights an opportunity for other countries in Asia to provide formal training in hospital epidemiology through national and regional societies (eg, Asia Pacific Society of Infection Control) as part of strategic infection prevention plans to improve national and regional ECD practices. This study has some limitations. First, because the response


rate was less than 100%, our results are susceptible to non- response bias. Although we achieved a very high response rate, our findings may not be generalizable to all hospitals. Second, because we relied on self-reported data from the lead infection preventionist at each facility to determine the frequency of the various practices being used, there is a potential for respondent bias. Third, ECDpractice compliance rates were reported by the lead infection preventionist and may not reflect actual com- pliance. Finally, we did not have access to (and thus could not


Method used to audit ECD practicesa ATP or bioluminescent testing Flourescent marking


Microbiological monitoring Visual inspection for cleanliness


Barrier for effectively implementing ECD protocolb Staffing concerns Time constraints


Lack of resources or funding Facility culture


Inadequate education provided to staff


Uncertainty regarding which cleaning and disinfecting products to use


No. (%)a


44 (20.8) 148 (69.8) 20 (9.4)


545.9±468.5 111 (52.4)


Facility has environmental health and safety/services 130 (61.3) Involved in HAI collaborative


108 (50.9) 105 (49.5)


135 (63.7) 83 (39.2) 196 (92.5)


3.5±3.4


65 (20.7) 40 (18.9) 105 (49.5) 192 (90.6) 117 (55.2) 92 (43.4)


9 (9.8)


13 (14.1) 52 (57.1) 60 (65.9)


168 (79.3) 124 (58.5) 128 (60.4) 139 (65.6) 160 (75.5) 121 (57.1)


NOTE. HAI, healthcare-associated infection; ICU, intensive care unit;


FTEs, full-time equivalents; ATP, adenosine triphosphate. aUnless otherwise indicated. bRespondents can respond with >1 answer. The sum of all methods used to audit ECD practices is >100%.


adjust for) patient-level or hospital case-mix data. As such, our regression estimates could be biased because of unmeasured confounding, and our results can only be interpreted as pro- viding evidence for associations rather than causal mechanisms. In conclusion, we identified key strategies that Thai hospitals


engaged in ECD practices should focus on. Garnering strong leadership support for infection prevention efforts and having a hospital epidemiologist on staff to champion the resources and buy-in necessary for a successful infection control program may help improve future ECD practices in Thailand.


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