Construction of a standardized training system for hospital infection prevention and control for new medical staff in internal medicine ICUs based on the Delphi method

Linfei Wu; Li Tang; Linli Zhuang; Wenyi Xie; Min Liu; Jianfang Li

doi:10.1371/journal.pone.0294606

. 2023 Nov 16;18(11):e0294606. doi: 10.1371/journal.pone.0294606

Construction of a standardized training system for hospital infection prevention and control for new medical staff in internal medicine ICUs based on the Delphi method

Linfei Wu ¹, Li Tang ^1,^*, Linli Zhuang ², Wenyi Xie ¹, Min Liu ³, Jianfang Li ¹

Editor: Arghya Das⁴

PMCID: PMC10653407 PMID: 37972142

Abstract

In China, studies have shown nosocomial infections contribute to increased mortality rates, prolonged hospital stays, and added financial burdens for patients. Previous studies have demonstrated that effective infection control training can enhance the quality of infection control practices, particularly in intensive care unit (ICU) settings. However, there is currently no universally accepted training mode or program that adequately addresses the specific needs of ICU medical staff regarding nosocomial infection control. The objective of this study was to develop a standardized training system for preventing and controlling hospital-acquired infections among new medical staff in the internal medicine ICU. Our methodology encompassed an extensive literature review, technical interviews focusing on key events, semi-structured in-depth interviews, and two rounds of Delphi expert correspondence. We employed intentional sampling to select 16 experts for the Delphi expert consultation. Indicators were chosen based on an average importance score of >3.5 and a coefficient of variation of <0.25. The weight of each indicator was determined using the analytic hierarchy process. The efficacy of the two rounds of questionnaires was also evaluated. Our findings revealed that the questionnaires achieved a 100% effective recovery rate, with expert authority coefficients of 0.96 and 0.90. The Kendall coordination coefficients for the first-, second-, and third-level indicators in the initial round of expert consultation questionnaires were 0.440, 0.204, and 0.386 (P < 0.001), respectively. In the second round of expert consultation questionnaires, the Kendall coordination coefficients for the first, second, and third-level indicators were 0.562, 0.467, and 0.556 (P < 0.001), respectively. The final training model consisted of four first-level indicators (hospital infection prevention and control training content, training methods/forms, assessment content, and evaluation indicators), 26 second-level indicators, and 44 third-level indicators. In conclusion, the proposed standardized training system for infection prevention and control among new medical staff in the internal medicine ICU is both scientifically sound and practical, which can contribute to improved patient safety, reduced healthcare costs, and enhanced overall quality of care in internal medicine ICUs. Moreover, it can serve as a framework for future training projects.

Introduction

The intensive care unit (ICU) is a specialized ward for critically ill patients and is particularly prone to hospital-acquired infections [1, 2]. Studies have revealed that the incidence of hospital infections in ICU patients ranges from 20% to 60% [3], which is five to ten times higher than that in general hospital departments [4]. ICU-acquired infections not only lead to extended hospital stays and increased financial burdens for patients but also result in higher mortality rates, making them a significant cause of death among ICU patients. Effective prevention measures have shown the potential to prevent more than 33% of nosocomial infections [5]. Consequently, the prevention and control of nosocomial infections in the ICU hold great importance in reducing the risk of infection among ICU patients.

The ICU primarily serves critically ill patients who require invasive diagnostic and treatment procedures, leading to a heightened risk of infection [6]. Despite the existence of standardized protocols for invasive procedures in the ICU, such as various types of intubation, adherence to these protocols is not always consistent among staff members. Previous studies have highlighted suboptimal rates of hand hygiene compliance among ICU medical staff, inadequate adherence to maximum sterile barrier precautions for central venous catheters, and the need for improved training, supervision, and feedback [7–9]. Consequently, experts have suggested that strengthening training in nosocomial infection knowledge is necessary to enhance in-hospital infection management [10].

A meta-analysis of 43 studies examining different training methods and their effects on nosocomial infection knowledge revealed that training programs for medical staff increased knowledge awareness by 41.80% [11]. The training targeted various personnel, including on-the-job medical staff, interns, new employees, and cleaning staff. The training methods employed included theoretical lectures, theoretical learning combined with demonstration operations, and comprehensive approaches. Liu Ying [12] proposed a multi-level, sub-specialty, and sub-form training concept for infection control personnel, demonstrating that the implementation of this diversified training model led to an increase in hand hygiene compliance from 86.38% to 92.27% and a decrease in infection rates from 2.04% to 0.63%. Wang Peng [13] discussed the effects of face-to-face teaching, online training, entrance training, and knowledge competitions on enhancing medical staff’s understanding of hospital infection-related knowledge. The findings revealed that while online learning was the most popular, its effectiveness was inferior to the other three methods. The possible reasons for this disparity may be attributed to the flexibility and convenience of online training, which lacks real-time supervision and may result in incomplete implementation. Consequently, the researchers suggested that a comprehensive training approach incorporating face-to-face lectures, online training, entrance training, and knowledge competitions should be considered. Additionally, research has explored other training methods, such as question teaching, case teaching, and feedback teaching, and role-playing. In summary, although these studies have been conducted in China, there remains a lack of a systematic and standardized training and evaluation system for hospital infection prevention and control. Specifically, there is a dearth of research on standardized training approaches for nosocomial infection prevention and control targeting newly recruited medical staff in the ICU.

Research has highlighted the significance of standardized training in nosocomial infection prevention and control as an effective approach to influence the knowledge, attitudes, and behaviors of individuals and groups [14, 15]. However, the existing training methods do not adequately address the specific requirements of ICU nosocomial infection prevention and control due to the unique characteristics of clinical work in the ICU and the diverse personnel involved. Furthermore, the current training approaches lack a standardized training model. Therefore, the objective of this study was to develop a standardized training system for hospital infection prevention and control targeting newly recruited medical staff in the internal medicine ICU. This system aims to improve the awareness of hospital infection prevention and control among medical staff and serve as a reference for establishing a comprehensive standardized training framework for hospital infection prevention and control.

Materials and methods

Study design

To carry out this study, we formed a research team comprising an associate professor, two advanced practice nurses, and two graduate students. Their responsibilities included conducting a thorough literature review, selecting experts, distributing and collecting letter questionnaires, and organizing and analyzing recommendations and data.

Initially, a qualitative literature search was conducted to compile a list of potential items for standardizing the training system of hospital infection prevention and control for newly recruited medical staff in the internal medicine ICU. After reviewing the abstracts of the retrieved literature, we identified eligible studies and extracted frequently recurring items relevant to this study. These recorded items were then discussed with the expert group, resulting in a pool of candidate items for constructing the standardized training system. To obtain expert opinions on the standardized training system, the Delphi method was employed, conducting consultations with experts specializing in hospital infection prevention and control for newly admitted medical staff in the internal medicine ICU between April and June 2022.

The Delphi research method involves anonymous feedback from experts who are unaware of each other’s identities and are unable to engage in direct discussions or exchanges of opinions during the research process. Multiple rounds of questionnaires are utilized to seek expert opinions [16], with no deliberations or exchanges of ideas [17]. Consensus is considered to have been reached when at least 70% of the experts agree on a particular opinion [18]. Therefore, this approach is deemed effective for this study.

Participants

The Delphi method involves a varying number of experts, ranging from 5 to 20, 15 to 60, or even exceeding 1,000 [17]. The selection of experts is a crucial factor in the success of the Delphi method. Generally, it is necessary to choose experts who possess expertise in the field of study, possess relevant experience, and demonstrate a keen interest in research [19]. For this study, a total of 16 experts were selected using intentional sampling. In the first round, 16 questionnaires were distributed, and all were successfully completed and returned, resulting in a response rate of 100%. In the second round, a questionnaire survey was conducted among the 16 experts, with a 100% response rate achieved. The selected experts represented two provinces and cities, namely Sichuan and Fujian Province (China). The criteria for expert selection included the following: (1) possessing a bachelor’s degree or higher; (2) holding an intermediate title or higher; (3) being experts in hospital infection management and nursing with prior experience in hospital infection prevention and control; and (4) volunteering to participate in the study.

Data collection

In this study, we developed an interview outline by initially referring to the Knowledge, Belief, and Action Model (KAPB) through a literature review. This outline was further refined based on the research objectives and group discussions involving experienced medical staff engaged in clinical teaching and new ICU medical staff. The selection criteria for medical staff involved in clinical teaching included: (1) being nursing team leaders or doctors with clinical teaching responsibilities, (2) having a minimum of 10 years of experience in ICU work, and (3) expressing a willingness to share their insights and recommendations regarding hospital infection prevention and control competencies for clinical teaching and new medical staff. The selection criteria for new ICU medical personnel were: (1) being newly appointed doctors, nurses, or technicians in the medical ICU (MICU), (2) holding a professional qualification certificate, and (3) expressing a willingness to share their experiences and perspectives on ICU hospital infection prevention and control. In March 2022, we conducted semi-structured interviews with two nursing team leaders and three new nurses in the internal medicine ICU. Prior to the interviews, informed consent was obtained from all participants, and audio recordings were transcribed into written text within 48 h of the interviews.

The data collected was organized and analyzed using Nvivo 12.0 software, and an inductive content analysis approach was employed to identify elements of competency [20]. Ultimately, a preliminary model comprising four first-level indicators, twelve second-level indicators, and sixty-seven third-level indicators was constructed based on a combination of literature review findings and qualitative research. This model served as an evaluation index system for assessing competencies.

Expert consultation

Expert letter questionnaire

The expert letter questionnaire consisted of four sections: (1) Research introduction, which provided the background, purpose, and significance of the study, along with instructions for completing the questionnaire and details about the researcher’s identity; (2) Basic information of the experts, including age, gender, education, professional title, and professional field; (3) Construction of an expert consultation form, where the importance of indicators was assessed using the Likert five-point scoring method. The scale ranged from “very important” (5 points) to “not significant” (1 point). Experts were also given the opportunity to suggest additions, deletions, or modifications to the indicators; and (4) Experts were asked to provide their judgment basis and indicate their familiarity with the research content and indicators.

Implementation expert consultation

Initially, the letter questionnaires were distributed to experts via email or WeChat (Tencent, Shenzhen, China), following the acquisition of informed consent. Simultaneously, experts were requested to rate and provide revisions for each item. After the completion of the first round of questionnaire collection, the research team collated and analyzed the expert opinions. Indicators were adjusted based on a mean value > 3.5 and a coefficient of variation < 0.25. Following the revisions, the second round of expert consultation was conducted, and the results were thoroughly discussed and analyzed. This process ultimately led to the finalization of indicators for the preliminary model.

Ethics

This study adhered to the principles outlined in the Declaration of Helsinki and received approval from the Ethics Committee of West China Hospital, Sichuan University (Approval No. 2022 Annual Review (232); approved on March 9, 2022). Prior to the investigation, the purpose of the study was communicated to the experts, and their verbal consent was obtained. Participants were informed that they could withdraw from the survey at any point during the data collection process.

Quality management

To ensure the reliability of the study findings, the selection of experts was standardized using the inclusion criteria mentioned previously. A total of 16 experts from Sichuan and Fujian Provinces and cities were chosen. The research team summarized and analyzed the expert opinions. Kendall’s coordination coefficient and the chi-square value were employed during the data analysis process.

Analytic hierarchy process

The subjective judgments of the experts were subjected to quantitative scaling using the analytic hierarchy process [21]. The Saaty scale was determined based on the mean difference in importance assignments of evaluation indicators in the second round of expert consultation, and a hierarchical structure model was established. A judgment matrix was constructed, and single-level ranking and consistency checks were performed to determine the weight and composite weight of each index. A consistency ratio below 0.1 indicates a reasonable weight distribution for each indicator and good consistency [22].

Statistical analysis

Data analysis was conducted using the Statistical Package for the Social Sciences (SPSS, version 25.0; IBM, Armonk, US) software. Descriptive statistics such as mean and standard deviation were used to describe measurement data, while count data were described using frequency and percentage. The effectiveness of expert participation was measured by the questionnaire’s effective recovery rate, and the authority of the experts was expressed through the average value of the judgment coefficient and familiarity coefficient. The level of agreement among expert opinions was assessed using the Kendall coordination coefficient, which ranges between 0 (disagree) and 1 (completely agree). Statistical significance was determined at P<0.05. The weights of the indicators were calculated using the analytic hierarchy process.

Results

Basic information of experts

Following the selection criteria for experts, intentional sampling was employed in this study to select 16 specialists from Sichuan and Fujian Provinces and cities. All experts possessed experience in hospital infection management and training. The experts had a mean age of 42.87 ±5.78 years, with an average of 12.07 ±4.61 years of work experience. Table 1 presents the demographic characteristics of the experts.

Table 1. Demographic information of experts.

Categories	Project	Frequency (N)	Proportion (%)
Gander	Male	3	18.75
Gander	Female	13	81.25
Age (years)	30–39	5	31.25
	40–49	10	62.50
	≥50	1	6.25
Work years	3–9	3	18.75
	10–19	10	62.50
	20–29	3	18.75
	≥30	0	0
Title	Intermediate level	9	56.25
	Associate Senior level	4	25
	Senior level	3	18.75
Degree	Undergraduate	7	43.75
	Master	6	37.5
	Doctor	3	18.75
Research field	Infection Prevention and Control	7	43.75
Research field	Clinical research in intensive care unit	9	56.25
Department	Infection Prevention and Management	7	43.75
Department	ICU	9	56.25
Is it a postgraduate supervisors	Yes	3	18.75
Is it a postgraduate supervisors	No	13	81.25

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Study participation

The level of engagement among the experts was evaluated by assessing the response rate of the questionnaire. In the first round, all 16 questionnaires distributed were successfully recovered, resulting in a recovery rate of 100%. Likewise, in the second round, all 16 questionnaires distributed were retrieved, achieving a recovery rate of 100%.

Expert authority coefficient and opinion coordination degree

The expert authority coefficient measures the level of expertise and influence of each expert, while the opinion coordination degree quantifies the degree of agreement among experts. In the initial and subsequent rounds of expert consultation, the authority coefficients were determined to be 0.92 and 0.96, respectively, surpassing the threshold of an expert consultation authority coefficient > 0.7 [17]. The Kendall coordination coefficients for the first-, second-, and third-level indicators in the first round were 0.440, 0.204, and 0.386, respectively (Table 2). In the second round of expert consultation, the Kendall coordination coefficients for the first-, second-, and third-level indicators were 0.562, 0.467, and 0.556, respectively (Table 3). All Kendall tests yielded statistically significant results (all P<0.001).

Table 2. Results of expert suggestions’ coordination degree (first round).

Hierarchical indicator	Kendall’s W	X²	P
Primary indicator	0.440	36.912	<0.001
Secondary indicator	0.204	109.982	<0.001
Tertiary indicator	0.386	237.402	<0.001

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Table 3. Results of expert suggestions’ coordination degree (second round).

Hierarchical indicator	Kendall’s W	X²	P
Primary indicator	0.562	33.703	<0.001
Secondary indicator	0.467	119.023	<0.001
Tertiary indicator	0.556	349.986	<0.001

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Training model of hospital infection prevention and control for new ICU medical staff

The Delphi method was employed to conduct two rounds of consultation. In the first round, the research team incorporated feedback from experts, along with the exclusion criteria, and engaged in discussions to refine the feasibility evaluation of items. As a result, the training time for hospital infection prevention and control was determined, two indicators were merged, six indicators were removed, six indicators were added, and one indicator was modified. In the second round, two indicators were added, one indicator was removed, and two indicators were merged. Following these consultations, the training model was finalized, consisting of four first-level indicators, 26 second-level indicators, and 44 third-level indicators. The first-level indicators encompassed the training content, training format and duration, assessment content, and evaluation indicators for hospital infection prevention and control. The weights of the indicators were calculated using the analytic hierarchy process. In descending order, the weights were assigned to the following: “training content, training format and method, assessment content of the infectious disease knowledge system, and evaluation indicators for hospital infection prevention and control” (Table 4).

Table 4. Construction of standardized training model for hospital infection prevention and control for new medical staff in the internal medicine ICU.

Index level	Significance grade	Variable coefficient	Weight targets	Combination weight targets
1 Training content of hospital infection prevention and control	4.93 ±0.25	0.05	0.450	0.450
1.1 Laws and Regulations on Nosocomial Infection	4.56 ±0.63	0.14	0.036	0.016
1.1.1 “Law of the People’s Republic of China on the Prevention and Treatment of Infectious Diseases”	4.38 ±1.15	0.26	0.333	0.005
1.1.2 “Regulations on Emergency Response to Public Health Emergencies”	4.56 ±0.89	0.2	0.667	0.011
1.2 Nosocomial infection monitoring	4.56 ±0.63	0.14	0.037	0.017
1.2.1 Definition of nosocomial infection and reporting requirements	4.81 ±0.40	0.08	0.500	0.008
1.2.2 Judgment of common nosocomial infections	4.75 ±0.58	0.12	0.025	0.004
1.2.3 Nosocomial Infection Outbreak Definition and Reporting and Handling Process	4.75 ±0.58	0.12	0.025	0.004
1.3 Disinfection and sterilization	4.50 ±0.63	0.14	0.027	0.012
1.3.1 Basic principles of disinfection and sterilization	4.69 ±0.70	0.15	0.667	0.008
1.3.2 Item classification and selection principles for disinfection and sterilization	4.62 ±0.72	0.16	0.333	0.004
1.4 Hand hygiene	4.81 ±0.40	0.08	0.075	0.034
1.4.1 Definition of hand hygiene	4.81 ±0.54	0.11	0.198	0.007
1.4.2 Indications for hand hygiene	4.88 ±0.34	0.07	0.312	0.011
1.4.3 Methods and precautions for hand hygiene	4.94 ±0.25	0.05	0.490	0.017
1.5 Prevention and management of multidrug-resistant bacteria	4.94 ±0.25	0.05	0.130	0.059
1.5.1 Definition of multi-drug resistant bacteria	4.81 ±0.54	0.11	0.165	0.010
1.5.2 Key surveillance species of multidrug-resistant bacteria	4.81 ±0.4	0.08	0.165	0.010
1.5.3 Judgment criteria for multidrug-resistant bacteria	4.88 ±0.34	0.07	0.279	0.016
1.5.4 Prevention and control of multidrug-resistant bacteria	4.94 ±0.25	0.05	0.392	0.023
1.6 Classification management of medical waste	4.63 ±0.81	0.17	0.045	0.020
1.6.1 Definition and classification of medical waste	4.63 ±0.89	0.19	0.667	0.013
1.6.2 Requirements for Medical Waste Management	4.56 ±0.89	0.2	0.333	0.007
1.7 Occupational protection	4.88 ±0.34	0.07	0.107	0.048
1.7.1 Definition of Standard Precautions	4.81 ±0.4	0.08	0.185	0.009
1.7.2 Selection and use of protective equipment	4.94 ±0.25	0.05	0.433	0.021
1.7.3 Handling of occupational exposures	4.88 ±0.52	0.1	0.321	0.015
1.7.4 Safe injection	4.81 ±0.41	0.08	0.185	0.009
1.8 Ventilator-associated pneumonia prevention and control	4.81 ±0.41	0.08	0.289	0.076
1.8.1 Definition of Ventilator-Associated Pneumonia	4.63 ±0.62	0.13	0.297	0.018
1.8.2 Diagnosis of ventilator-associated pneumonia	4.5 ±0.63	0.14	0.164	0.010
1.8.3 Prevention and Control Strategies of Ventilator-Associated Pneumonia	4.81 ±0.41	0.08	0.539	0.033
1.9 Prevention and control of catheter-related bloodstream infection	4.4 ±0.72	0.16	0.057	0.026
1.9.1 Definition of catheter-related bloodstream infection	4.75 ±0.45	0.09	0.312	0.008
1.9.2 Diagnosis of catheter-related bloodstream infection	4.56 ±0.63	0.14	0.198	0.005
1.9.3 Prevention and control strategies for catheter-related bloodstream infections	4.81 ±0.4	0.08	0.491	0.013
1.10 Prevention and control of catheter-related urinary tract infections	4.44 ±0.73	0.16	0.051	0.023
1.10.1 Definition of catheter-related urinary tract infection	4.63 ±0.62	0.13	0.312	0.007
1.10.2 Diagnosis of catheter-related urinary tract infection	4.56 ±0.51	0.11	0.198	0.004
1.10.3 Prevention and control strategies for catheter-related urinary tract infections	4.75 ±0.44	0.09	0.491	0.011
1.11 Infectious disease knowledge	4.5±0.18	0.04	0.260	0.260
1.12 Aseptic technique (Operation)	4.81±0.85	0.17	0.154	0.017
1.13 Cleaning and Disinfection (Operation)	4.50 ±0.10	0.02	0.075	0.034
1.13.1 Disinfection of instruments and equipment	4.69 ±0.60	0.13	0.500	0.017
1.13.2 Terminal disinfection of bed units	4.69 ±0.60	0.13	0.500	0.017
1.14 Standard Prevention Related Skills (Operations)	4.88 ±0.09	0.02	0.109	0.049
1.14.1 hand hygiene	4.94 ±0.25	0.05	0.500	0.024
1.14.2 Correct putting on and taking off of gloves, masks, isolation gowns, protective clothing and other protective equipment	4.94 ±0.25	0.05	0.500	0.024
1.15 Specimen Collection (Operation)	4.75 ±0.11	0.02	0.057	0.026
1.15.1 Collection of blood samples	4.75 ±0.45	0.09	0.381	0.007
1.15.2 Sputum specimen collection	4.75 ±0.45	0.09	0.381	0.007
1.15.3 Urine specimen collection	4.69 ±0.6	0.13	0.381	0.007
1.15.4 Oropharyngeal/nasopharyngeal swab collection	4.75 ±0.45	0.09	0.191	0.004
2. Training methods/formats	4.50 ±0.73	0.16	0.260	0.260
2.1 Theory lecture + operation demonstration or video	4.75 ±0.11	0.02	0.667	0.173
2.2 Clinical case discussions or scenario presentations	4.69 ±0.15	0.03	0.333	0.087
3. Evaluation content	4.50 ±0.73	0.16	0.171	0.171
3.1 Theoretical knowledge examination	4.44 ±0.73	0.16	0.333	0.057
3.2 Operational skills examination	4.63 ±0.62	0.13	0.667	0.114
3.2.1 Hand hygiene	4.94 ±0.25	0.05	0.215	0.025
3.2.2 Putting on and taking off masks and gloves	4.94 ±0.25	0.05	0.215	0.025
3.2.3 Putting on and taking off the gown	4.81 ±0.41	0.08	0.154	0.017
3.2.4 Collection of blood samples	4.81 ±0.41	0.08	0.154	0.017
3.2.5 Sputum specimen collection	4.69 ±0.48	0.1	0.097	0.011
3.2.6 Urine specimen collection	4.69 ±0.48	0.1	0.097	0.011
3.2.7 Oropharyngeal/nasopharyngeal swab collection	4.44 ±0.73	0.16	0.068	0.008
4. Evaluation Indicators	4.43 ±0.64	0.14	0.120	0.120
4.1Qualification rate of knowledge of hospital infection prevention and control	4.64 ±0.62	0.13	0.114	0.014
4.2Hand hygiene compliance and correctness rate	4.88 ±0.34	0.07	0.203	0.024
4.3Qualified rate of aseptic operation	4.94 ±0.25	0.05	0.265	0.032
4.4Correct implementation rate of occupational protection	4.75 ±0.45	0.09	0.157	0.019
4.5Number of non-compliant operations	4.44 ±0.73	0.16	0.072	0.009
4.6 Incidence of occupational exposure	4.50 ±0.82	0.18	0.088	0.011
4.7 Course Training Satisfaction	4.31 ±0.79	0.18	0.044	0.005

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Discussion

The standardized training system proposed for hospital infection prevention and control among newly recruited medical staff in the internal medicine ICU is both scientifically grounded and practical. It was developed based on the KAPB model, incorporating findings from literature research, interviews, the Delphi method, and other sources. The model consists of first-level indicators, including hospital infection prevention and control training content, training format and duration, assessment content, and evaluation indicators. It further encompasses 26 second-level indicators and 44 third-level indicators. Overall, this research system is scientifically robust and comprehensive, addressing the essential knowledge and skills required by new medical staff to effectively prevent and control nosocomial infections in the ICU. Among the 16 experts involved in the study, seven were renowned nationwide experts in hospital infection management, nine had expertise in intensive care. All of the selected experts possess extensive experience in ICU infection prevention and actively contribute to teaching and research in the field of ICU or nosocomial infection prevention and control. This underscores the reliability of the parameters chosen for the proposed model.

The index system developed in this study is comprised of four primary indicators, 26 secondary indicators, and 44 tertiary indicators. The weights of these indicators, listed in descending order, include: “training content, training form and method, assessment content of the infectious disease knowledge system, and evaluation indicators for hospital infection prevention and control.” Of these, “Nosocomial infection prevention and control training content” bears the most significant weight, highlighting its importance in enabling new medical personnel to effectively prevent and control hospital infections in the ICU. This suggests a crucial need for mastery of the knowledge and skills related to hospital infection. In line with the theoretical framework of “knowing, trusting, and doing,” proper knowledge training serves as the bedrock. Swift assimilation of theoretical knowledge bolsters infection prevention and control practices.

Within the secondary indicators, “patient management of multidrug-resistant bacteria” in “training content of hospital infection prevention and control” and “aseptic operation qualification rate” in “evaluation indicators” bore the highest weights. This suggests that managing multidrug resistance bacteria and implementing aseptic operations are vital components of infection prevention in the ICU, aligning with findings from other studies [23]. Common infections in the ICU, including ventilator-associated pneumonia, catheter-related bloodstream infections, and urinary tract infections [24], are intimately linked to invasive procedures. Consequently, this study incorporated pertinent infection prevention and control knowledge in theoretical training and emphasized aseptic techniques in skills operation training. This aims to fortify medical personnel’s awareness of infection prevention and control and enhance their skills in aseptic technique to curb the spread of cross-infection in the ICU, ensure patient safety, and minimize ICU stay duration. Among the tertiary indicators, “hand hygiene,” “prevention and control of multidrug-resistant bacteria,” and “correct donning and doffing of protective equipment” were given the highest weight. Firstly, physical contacts and hand hygiene play pivotal roles in indirect transmission, as most hospital-acquired infections spread via this mode. Despite hand hygiene being deemed as the most fundamental, effective, and important measure for nosocomial infection prevention and control, medical staff compliance remains suboptimal. This underscores the significance of reinforcing hand hygiene training. Secondly, multidrug-resistant bacterial infection poses a global threat to patient safety and healthcare quality, and targeted training for new medical staff can mitigate problems associated with multidrug-resistant bacteria [25, 26]. Lastly, correctly wearing and removing protective equipment is an essential step in infection prevention [27] and a vital skill for emergency rescue [28]. In summary, it is advised to prioritize protective skills during training for new medical personnel to effectively disrupt the transmission pathways of infectious diseases and reduce occupational exposure incidents [29].

The shortage of clinical medical staff, coupled with high workloads and strenuous tasks, impedes the swift completion of high-quality hospital infection prevention and control training. Taking into account the constrained training timeframe and the practicality of implementation, in conjunction with the basic requisites for hospital infection prevention and control in the ICU, this study revisited and refined the training curriculum. This was achieved through two rounds of expert consultation, with an augmented focus on the core knowledge and pivotal skills required for hospital infection prevention and control. This enhancement aids medical personnel in rapidly acquiring key knowledge and skills, thus, reducing learning duration. It facilitates the swift integration of knowledge into practice, thereby advancing the awareness and capacity of new ICU staff in the prevention and control of nosocomial infections.

Nonetheless, this study is not without limitations. The consulted experts hail solely from two provinces in China, and the initially constructed training system is still predominantly within the theoretical framework. Future steps involve undertaking clinical applications and broadening the research scope to verify its scientific validity and efficacy, particularly in medical settings experiencing a scarcity of medical personnel.

Conclusion

Drawing upon the KAPB model, this study engineered a standardized training system for hospital infection prevention and control. This system targets new medical personnel within the internal medicine ICU and was developed via literature research, qualitative interviews, expert consultations, and the AHP. The method of construction is rigorous, and the training content is both targeted and comprehensive, encompassing various facets of ICU hospital infection management. This includes pertinent theoretical knowledge and practical operational training aimed at enhancing the overall competency of new ICU medical staff in preventing and controlling hospital infections. In addition, it can strengthen patient safety and reduce healthcare-associated infections.

Supporting information

S1 Data

(ZIP)

Click here for additional data file.^{(72.2KB, zip)}

Acknowledgments

Thank you to all the experts who participated in this study during their busy schedules.

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

1.Initials of the authors who received each award:Wu Linfei 2.Grant numbers awarded to each author:HXHL21063 3.The full name of each funder:West China Nursing Discipline Development Special Fund Project, Sichuan University(NO.HXHL21063) 4.URL of each funder website:N/A 5.Did the sponsors or funders play any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript?:The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0294606.r001

Decision Letter 0

Faizan Iqbal

29 May 2023

PONE-D-23-09513Construction of a standardized training system for hospital infection prevention and control for new medical staff in internal medicine ICUs based on the Delphi methodPLOS ONE

Dear Dr. Tang,

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Here are few suggestions/comments, incorporating specific examples from the article to support and substantiate each suggestion

Abstract:

• Instead of stating "positive results were obtained," provide the specific percentage or statistical measure to indicate the level of effectiveness or success achieved. For instance, you can mention that "the standardized training system resulted in a 40% reduction in healthcare-associated infections among medical staff in internal medicine ICUs."

• Include information about the significance and implications of the study findings. For example, highlight how the development of a standardized training system can contribute to improved patient safety, reduced healthcare costs, and enhanced overall quality of care in internal medicine ICUs.

Introduction/Background:

• Provide more context and background information on the current challenges or gaps in existing training systems for medical staff in internal medicine ICUs. For instance, discuss the prevalence of healthcare-associated infections and their impact on patient outcomes, emphasizing the need for effective infection prevention and control measures.

• Incorporate a brief review of relevant literature or previous studies that highlight the need for a standardized training system. For example, cite studies that have identified deficiencies in current training practices or have shown the positive impact of comprehensive training programs on infection control outcomes.

Methods:

• Provide a clear explanation of the selection criteria for the expert panel. Specify the desired qualifications or expertise sought in the experts who participated in the Delphi method. For example, state that experts were selected based on their experience in infection prevention and control, knowledge of internal medicine ICU practices, and familiarity with the Delphi method.

• Describe the measures taken to ensure the reliability and validity of the expert opinions collected through the Delphi method. For example, discuss how potential biases or conflicts of interest were addressed, such as ensuring anonymity and independence of the experts.

• Include a description of how consensus was determined in the Delphi process. Specify the criteria used to determine when expert opinions reached convergence or stability. For example, mention that consensus was considered achieved when at least 70% of experts agreed on a particular item or recommendation.

Results:

• Supplement the tables with brief explanatory text to help readers interpret and understand the key findings. For example, provide a concise summary of the main results, such as the percentage of experts agreeing on each item or the most commonly recommended training components.

• When discussing the expert authority coefficient and opinion coordination degree, explain these measures and their significance in assessing the level of agreement or consensus among the expert opinions. For example, state that the expert authority coefficient measures the level of expertise and influence of each expert, while the opinion coordination degree quantifies the degree of agreement among experts.

Discussion:

• Expand on the implications and potential applications of the study findings. For instance, discuss how the developed standardized training system can be implemented in real-world settings, highlighting its potential impact on reducing healthcare-associated infections and improving patient safety.

• Compare the developed system with existing training systems or guidelines in other similar healthcare settings. Discuss how the developed system differs or improves upon current practices. For example, highlight its adaptability to different ICU settings and its focus on evidence-based practices in infection prevention and control.

• Discuss limitations or potential challenges of the developed training system. Address factors such as feasibility, scalability, and sustainability, as well as potential barriers to implementation. Provide suggestions or strategies for addressing these limitations, such as incorporating ongoing evaluation and feedback mechanisms or considering tailored adaptations for different healthcare contexts.

Conclusion:

• Provide a concise and impactful summary of the study findings and their implications. Emphasize the significance of the developed standardized training system in improving infection prevention and control in internal medicine ICUs, emphasizing its potential to enhance patient safety and reduce healthcare-associated infections.

• Highlight the broader relevance and applicability of the research beyond the specific study setting. Discuss the potential for adaptation or adoption of the developed system in other healthcare institutions or settings, both nationally and internationally. For example, mention that the standardized training system could be implemented in various internal medicine ICUs across different countries, leading to standardized practices and improved infection prevention and control outcomes.

References:

• Ensure that all references cited in the text are included in the reference list, and vice versa. Cross-reference the in-text citations with the corresponding entries in the reference list to ensure accuracy and completeness. For example, in the introduction section, the study references previous research on the importance of infection prevention and control in healthcare settings. It is important to verify that these references are correctly listed in the reference list and that there are no missing citations.

General Feedback:

• Pay attention to the overall flow and organization of the article. Ensure that the sections logically progress from one to another and that the content within each section is well-structured. For instance, in the methods section, there could be a more systematic and clear presentation of the steps involved in the Delphi method. This would enhance the overall organization and readability of the section.

• Review the article for grammatical and syntactical errors to improve clarity and readability. For example, in the results section, there are instances of inconsistent tense usage, such as switching between past and present tense within the same paragraph. These inconsistencies should be corrected to maintain consistency throughout the manuscript.

• Check for compliance with the STROBE guidelines for observational studies. Ensure that the study design, data collection, and analysis methods align with the recommended reporting standards. For example, in the methods section, it would be beneficial to provide more details on the participant recruitment process and any eligibility criteria used. This information is essential for readers to understand the study population and potential biases.

By addressing these feedback and suggestions, the article can be strengthened in terms of scientific rigor, clarity, and overall quality.

Reviewer #2: The article used appropriate methods in proposing a standardised training system of infection prevention and control for new medical staff in the internal medicine ICU in two provinces in China. It is an important addition to literature on improving the prevention of nosocomial infections through appropriate and affection training. However, some clarification and suggested revisions are required to improve the quality of the manuscript. Below are some of the comments:

1. In the abstract, a statement/sentence on the subject matter in China will be appropriate in providing the study context.

2. "The Kendall coordination coefficients of the first-, second-, and third-level indicators were 0.440, 0.204, and 0.386 (P <0.001), 0.562, 0.467 and 0.556(P <0.001)." Authors should clarify which of the reported coefficients are from the first round of survey and which are from the second.

3. The study setting is in China, however no background information on nosocomial infection in the country was provided in the introduction. It is essential to provide such information in the introductions for context.

4. "Upon comparing the features of the ICU and other wards, we found that patients in the ICU had more invasive treatments and were more prone to infections than patients from other wards." Provide more details on how this comparison was done.

5. "After reading the retrieved literature abstracts, we screened for eligible studies and extracted frequently appearing items of interest for this present study." Define what the "items of interest" are in the study design.

6. As highlighted in the introduction, doctors and nurses from different regions and countries have different ideas regarding the content, type and mode of hospital infection prevention and control training. The results would have been greatly improved and more generalizable if participants were selected from different provinces and cities across the country.

7. The text under participants needs some clarification. The authors indicated that 16 expert were purposively sampled for two rounds of questionnaires. They later indicate that the "subject" finally selected 16 experts. Who is/are the "subjects" here and are these 16 experts different from the ones who answered the questionnaires? If yes, how were they engaged in the study?

8. In the selection criteria for the experts, the authors indicated “bachelor's degree or above” and “intermediate certificate or above”. If they are both academic certificates, having both in your selection criteria means the participant must have both in order to be selected to participate in the study.

9. How many hospitals from each province where participants selected from?

10. "We conducted semi-structured interviews with 2 nursing team leaders and 3 new nurses in the internal medicine ICU in March 2022." Why were the semi-structured interviews conducted with only 5 nurses? Where they all from the same hospital? Were the doctors and technicians not engaged for interviews?

11. The “delphi consulting and feedback cycle” and the “expert letter questionnaire” could be merged into one section.

12. The authors need to provide details on how the familiarity and judgement coefficients were calculated.

13. "In the first round, according to the exclusion criteria and expert opinions, combined with the discussion of the research group, the research team added the feasibility evaluation of the items and gave the training time for the training content of hospital infection, following which 2 indicators were merged, 6 indicators were deleted, 6 indicators were added, and 1 indicator was modified." What are these “exclusion criteria” and how where they determined?

14. "In the second round, the research group changed 2 indicators, eliminated 1 indicator, and merged 1 indicator. " Do the author mean 2 indicators were merged?

15. "Of the 16 experts, 7 specialized in nosocomial infection management, 3 were well-known experts in the field of hospital infection management nationwide, 9 specialized in intensive care, 6 were ICU head nurses, and 3 specialized in hospital infection management.” Do some of the experts have multiple specializations? Are the 3 well-known experts in the field of hospital infection management nationwide the same as the 3 specialized in hospital infection management?

16. The structure of the discussion could be improved to make the content flow better for easy comprehension. For instance, the initial part of the third paragraph of the discussion section “In China, there is a shortage of medical resources, and medical staff usually have intensive working hours and cannot complete all training before entering clinical practice. Thus, the short-cycle centralized training method of the proposed model is more in line with the Chinese ICU hospital settings, which helps to quickly combine knowledge and practice and improve the ability and quality of ICU medical staff to manage hospital infection” could be move to the last section of the same paragraph to improve the flow

17. "Among the three-level indicators, "hand hygiene, prevention and control of multidrug-resistant bacteria, and correct wearing and taking off of protective equipment" had the highest weight." Each of the indicators in this sentence should be in quotation marks to be identified as different indicators "Among the three-level indicators..." should be written as "Among the level three indicators..."

18. There a few punctuation and sentence structures errors. For instance, the last sentence under data collection needs to be qualified. Also avoid sub-headings in the discussion

19. "Based on the KAPB model, this study constructed a standardized training system for hospital infection prevention and control for new medical staff in the internal medicine ICU through literature research, qualitative interviews, expert interviews and AHP." The AHP has not been defined and not presented in the methods

20. The authors should also discuss the limitations of the study

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Reviewer #1: Yes: Adepoju Victor Abiola

Reviewer #2: No

**********

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PLoS One. 2023 Nov 16;18(11):e0294606. doi: 10.1371/journal.pone.0294606.r002

Author response to Decision Letter 0

25 Aug 2023

Point-by-point response to the reviewers’ comments

Thanks for the reviewers’ comments and consideration for further review for our manuscript. Those comments were all valuable and very helpful for revising and improving our paper. To ensure our manuscript satisfactorily addresses reviewers’ comments, we have improved the main text's clarity in the revised version.

Please let us know if you have any further suggestions. We look forward to hearing from you soon.

Reviewer #1 (Comments to the Authors (Required)):

Comment 1: Instead of stating "positive results were obtained," provide the specific percentage or statistical measure to indicate the level of effectiveness or success achieved. For instance, you can mention that "the standardized training system resulted in a 40% reduction in healthcare-associated infections among medical staff in internal medicine ICUs."

Response: Thank you for your suggestion. We have provided specific data in the manuscript to support the current research status

Comment 2: Include information about the significance and implications of the study findings. For example, highlight how the development of a standardized training system can contribute to improved patient safety, reduced healthcare costs, and enhanced overall quality of care in internal medicine ICUs.

Response: Thank you for your suggestion. We have added explanations on relevant issues in the manuscript.

In conclusion, the proposed standardized training system for infection prevention and control among new medical staff in the internal medicine ICU is both scientifically sound and practical. Can contribute to improved patient safety, reduced healthcare costs, and enhanced overall quality of care in internal medicine ICUs.

Please refer to lines 43 to 46 on page 3 for details.

Comment 3: Provide more context and background information on the current challenges or gaps in existing training systems for medical staff in internal medicine ICUs. For instance, discuss the prevalence of healthcare-associated infections and their impact on patient outcomes, emphasizing the need for effective infection prevention and control measures.

Response: We have discussed the prevalence of healthcare-associated infections and their impact on patient outcomes, emphasized the need for effective infection prevention and control measures.

Please see details at pages 3，lines 50 to 58.

Comment 4: Incorporate a brief review of relevant literature or previous studies that highlight the need for a standardized training system. For example, cite studies that have identified deficiencies in current training practices or have shown the positive impact of comprehensive training programs on infection control outcomes.

Response: As you suggested, we have reviewed and summarized the relevant literature，For details, please refer to pages 4-5 , lines 67 to 87 of the revised manuscript.

Comment 5: Provide a clear explanation of the selection criteria for the expert panel. Specify the desired qualifications or expertise sought in the experts who participated in the Delphi method. For example, state that experts were selected based on their experience in infection prevention and control, knowledge of internal medicine ICU practices, and familiarity with the Delphi method.

Response: We have added an explanation on the criteria for selecting experts. The previous manuscript also provided relevant explanations.

Please refer to lines 121 to 123 and 128 to 131 on page 7 for details.

Comment 6: Describe the measures taken to ensure the reliability and validity of the expert opinions collected through the Delphi method. For example, discuss how potential biases or conflicts of interest were addressed, such as ensuring anonymity and independence of the experts.

Response: This has been described in previous manuscripts. The letter questionnaires were distributed to experts via email or WeChat (Tencent, Shenzhen, Chiana), they are unaware of each other’s identities and are unable to engage in direct discussions or exchanges of opinions during the research process.

For details, please refer to page 6, lines 113 to 115, and page 9, lines 164 to 165.

Comment 7: Include a description of how consensus was determined in the Delphi process. Specify the criteria used to determine when expert opinions reached convergence or stability. For example, mention that consensus was considered achieved when at least 70% of experts agreed on a particular item or recommendation.

Response: Thank you very much for your valuable feedback. We have added this comment to the manuscript.: ' Consensus is considered to have been reached when at least 70% of the experts agree on a particular opinion'.

For details, please see page 6, lines 116 to 117.

Comment 8: Supplement the tables with brief explanatory text to help readers interpret and understand the key findings. For example, provide a concise summary of the main results, such as the percentage of experts agreeing on each item or the most commonly recommended training components.

Response: Thank you for your suggestion. The manuscript already provides a detailed explanation of all tables.

Comment 9: When discussing the expert authority coefficient and opinion coordination degree, explain these measures and their significance in assessing the level of agreement or consensus among the expert opinions. For example, state that the expert authority coefficient measures the level of expertise and influence of each expert, while the opinion coordination degree quantifies the degree of agreement among experts.

Response: Your suggestion is very important, and we have added an explanation of the significance of expert authority coefficient and opinion coordination in evaluating the degree of consensus or agreement among experts. For details, please see page 13, lines 214 to 215.

Comment 10: Expand on the implications and potential applications of the study findings. For instance, discuss how the developed standardized training system can be implemented in real-world settings, highlighting its potential impact on reducing healthcare-associated infections and improving patient safety.

Response: Thank you for your suggestion. We have added 'Significance of this study' in the discussion section.

For details, please see page 25 to 26, lines 306 to 317.

Comment 11: Compare the developed system with existing training systems or guidelines in other similar healthcare settings. Discuss how the developed system differs or improves upon current practices. For example, highlight its adaptability to different ICU settings and its focus on evidence-based practices in infection prevention and control.

Response: Our study is different from other studies in that, taking into account the constrained training timeframe, this study focus on the core knowledge and pivotal skills required for hospital infection prevention and control. This enhancement aids medical personnel in rapidly acquiring key knowledge and skills, thus, reducing learning duration. It facilitates the swift integration of knowledge into practice, thereby advancing the awareness and capacity of new ICU staff in the prevention and control of nosocomial infections.

For details, please see page 26, lines 309 to 317.

Comment 12: Discuss limitations or potential challenges of the developed training system. Address factors such as feasibility, scalability, and sustainability, as well as potential barriers to implementation. Provide suggestions or strategies for addressing these limitations, such as incorporating ongoing evaluation and feedback mechanisms or considering tailored adaptations for different healthcare contexts.

Response: Due to the fact that the training system in this study has not yet been applied in clinical practice, some potential challenges remain unknown. However, in terms of theoretical research, this study does have limitations，the consulted experts hail solely from two provinces in China. Therefore, future study involve conducting clinical applications and broadening the research scope.

Comment 13: Provide a concise and impactful summary of the study findings and their implications. Emphasize the significance of the developed standardized training system in improving infection prevention and control in internal medicine ICUs, emphasizing its potential to enhance patient safety and reduce healthcare-associated infections.

Response: Thank you for your suggestion. We have provided a detailed description in the discussion section.

Drawing upon the KAPB model, this study engineered a standardized training system for hospital infection prevention and control. This system targets new medical personnel within the internal medicine ICU and was developed via literature research, qualitative interviews, expert consultations, and the AHP. The method of construction is rigorous, and the training content is both targeted and comprehensive, encompassing various facets of ICU hospital infection management. This includes pertinent theoretical knowledge and practical operational training aimed at enhancing the overall competency of new ICU medical staff in preventing and controlling hospital infections. And strengthening patient safety and reducing healthcare-associated infections.

For details, please see page 26 , lines 319 to 327.

Comment 14: Highlight the broader relevance and applicability of the research beyond the specific study setting. Discuss the potential for adaptation or adoption of the developed system in other healthcare institutions or settings, both nationally and internationally. For example, mention that the standardized training system could be implemented in various internal medicine ICUs across different countries, leading to standardized practices and improved infection prevention and control outcomes.

Response: Thank you for your suggestion. We have added relevant explanations in the manuscript.

Future steps involve undertaking clinical applications and broadening the research scope to verify its scientific validity and efficacy, particularly in medical settings experiencing a scarcity of medical personnel.

For details, please see page 27 , lines 330 to 333.

Comment 15: Ensure that all references cited in the text are included in the reference list, and vice versa. Cross-reference the in-text citations with the corresponding entries in the reference list to ensure accuracy and completeness. For example, in the introduction section, the study references previous research on the importance of infection prevention and control in healthcare settings. It is important to verify that these references are correctly listed in the reference list and that there are no missing citations.

Response: Thank you for your reminder. We have ensured that all references cited in the text are included in the reference list.

Comment 16: Pay attention to the overall flow and organization of the article. Ensure that the sections logically progress from one to another and that the content within each section is well-structured. For instance, in the methods section, there could be a more systematic and clear presentation of the steps involved in the Delphi method. This would enhance the overall organization and readability of the section.

Response: Thank you for your suggestion. We have made relevant adjustments to the Delphi process and structure in the method section according to your suggestion.

For details, please see page 8 to 9, lines 152 to 170.

Comment 17: Review the article for grammatical and syntactical errors to improve clarity and readability. For example, in the results section, there are instances of inconsistent tense usage, such as switching between past and present tense within the same paragraph. These inconsistencies should be corrected to maintain consistency throughout the manuscript.

Response: Thank you for your suggestion. We have revised the language expression and grammar of the entire text.

Comment 18: Check for compliance with the STROBE guidelines for observational studies. Ensure that the study design, data collection, and analysis methods align with the recommended reporting standards. For example, in the methods section, it would be beneficial to provide more details on the participant recruitment process and any eligibility criteria used. This information is essential for readers to understand the study population and potential biases.

Response: Thank you for your suggestion. We have detailed the criteria for selecting experts and including semi-structured interviewees in the manuscript.

For details, please refer to page 7, lines 128 to 131, and page 7 to 8, lines 136 to 143.

Reviewer 2

Comment 1: In the abstract, a statement/sentence on the subject matter in China will be appropriate in providing the study context.

Response: Thank you for your suggestion. We have added relevant explanations in the manuscript.

In China , studies have shown nosocomial infections contribute to increased mortality rates, prolonged hospital stays, and added financial burdens for patients.

For details, please see page 2, lines 23 to 24.

Comment 2: "The Kendall coordination coefficients of the first-, second-, and third-level indicators were 0.440, 0.204, and 0.386 (P <0.001), 0.562, 0.467 and 0.556(P <0.001)." Authors should clarify which of the reported coefficients are from the first round of survey and which are from the second.

Response: In order to make the expression of the manuscript clearer, we have made modifications according to your requirements.

The Kendall coordination coefficients for the first-, second-, and third-level indicators in the initial round of expert consultation questionnaires were 0.440, 0.204, and 0.386 (P < 0.001), respectively. In the second round of expert consultation questionnaires, the Kendall coordination coefficients for the first, second, and third-level indicators were 0.562, 0.467, and 0.556 (P < 0.001), respectively.

For details, please see page 2 to 3, lines 37 to 40.

Comment 3: The study setting is in China, however no background information on nosocomial infection in the country was provided in the introduction. It is essential to provide such information in the introductions for context.

Response: This is a very important suggestion for us. And we have added relevant background on nosocomial infection in China in the introductions for context.

For details, please see page 3, lines 50 to 53.

Comment 4: "Upon comparing the features of the ICU and other wards, we found that patients in the ICU had more invasive treatments and were more prone to infections than patients from other wards." Provide more details on how this comparison was done.

Response: We are so sorry that there may be some issues with our language description. To this end, we have revised the description of this sentence and provided relevant references.

The ICU primarily serves critically ill patients who require invasive diagnostic and treatment procedures, leading to a heightened risk of infection [6]

For details, please see page 4, lines 59 to 60.

Comment 5: "After reading the retrieved literature abstracts, we screened for eligible studies and extracted frequently appearing items of interest for this present study." Define what the "items of interest" are in the study design.

Response: After inspection, we found that this is a problem caused by our incorrect wording, and we have corrected it.

After reviewing the abstracts of the retrieved literature, we identified eligible studies and extracted frequently recurring items relevant to this study.

For details, please see page 6, lines 106 to 107.

Comment 6: As highlighted in the introduction, doctors and nurses from different regions and countries have different ideas regarding the content, type and mode of hospital infection prevention and control training. The results would have been greatly improved and more generalizable if participants were selected from different provinces and cities across the country.

Response: As you said: The results would have been greatly improved and more generalizable if participants were selected from different provinces and cities across the country. This is the limitation of this study, and we will expand our research in the next step.

Comment 7: The text under participants needs some clarification. The authors indicated that 16 expert were purposively sampled for two rounds of questionnaires. They later indicate that the "subject" finally selected 16 experts. Who is/are the "subjects" here and are these 16 experts different from the ones who answered the questionnaires? If yes, how were they engaged in the study?

Response: This may be a textual description error, and these 6 experts are the experts who participated in the expert consultation and answered the questionnaire. We have made modifications to the language description of the manuscript.

Comment 8: In the selection criteria for the experts, the authors indicated “bachelor's degree or above” and “intermediate certificate or above”. If they are both academic certificates, having both in your selection criteria means the participant must have both in order to be selected to participate in the study.

Response: This is an expression mistake. We have revised “intermediate certificate or above” to " holding an intermediate title or higher ".

The criteria for expert selection included the following: (1) possessing a bachelor’s degree or higher; (2) holding an intermediate title or higher; (3) being experts in hospital infection management and nursing with prior experience in hospital infection prevention and control; and (4) volunteering to participate in the study.

For details, please see page 7, lines 128 to 131.

Comment 9: How many hospitals from each province where participants selected from?

Response: Considering factors such as the authority, professionalism, and convenience of experts, this study selected two hospitals from Sichuan Province and one hospital from Fujian.

Comment 10: "We conducted semi-structured interviews with 2 nursing team leaders and 3 new nurses in the internal medicine ICU in March 2022." Why were the semi-structured interviews conducted with only 5 nurses? Where they all from the same hospital? Were the doctors and technicians not engaged for interviews?

Response: 5 semi-structured interviewees all come from the same hospital and meet the inclusion criteria for this study.

Comment 11: The “delphi consulting and feedback cycle” and the “expert letter questionnaire” could be merged into one section.

Response: Thank you very much for your suggestion. We have merged the two parts according to your suggestion.

Comment 12: The authors need to provide details on how the familiarity and judgement coefficients were calculated.

Response: For specific calculation methods, please refer to the Data Availability statement.

Comment 13:"In the first round, according to the exclusion criteria and expert opinions, combined with the discussion of the research group, the research team added the feasibility evaluation of the items and gave the training time for the training content of hospital infection, following which 2 indicators were merged, 6 indicators were deleted, 6 indicators were added, and 1 indicator was modified." What are these “exclusion criteria” and how where they determined?

Response: In the section on "Implementing Expert Consultation" in the manuscript, we have described the criteria for selecting indicators.

Indicators were adjusted based on a mean value > 3.5 and a coefficient of variation < 0.25.

For details, please see page 9, lines 167 to 168.

Comment 14: "In the second round, the research group changed 2 indicators, eliminated 1 indicator, and merged 1 indicator. " Do the author mean 2 indicators were merged?

Response: Yes, as you said, we merged two indicators in the second round.

In the second round, two indicators were added, one indicator was removed, and two indicators were merged.

For details, please see page 14 to 15, lines 231 to 232.

Comment 15: "Of the 16 experts, 7 specialized in nosocomial infection management, 3 were well-known experts in the field of hospital infection management nationwide, 9 specialized in intensive care, 6 were ICU head nurses, and 3 specialized in hospital infection management.” Do some of the experts have multiple specializations? Are the 3 well-known experts in the field of hospital infection management nationwide the same as the 3 specialized in hospital infection management?

Response: To avoid unnecessary misunderstandings, we have simplified the description of the selected experts.

Among the 16 experts involved in the study, seven were renowned nationwide experts in hospital infection management, nine had expertise in intensive care.

For details, please see page 23, lines 258 to 260.

Comment 16: The structure of the discussion could be improved to make the content flow better for easy comprehension. For instance, the initial part of the third paragraph of the discussion section “In China, there is a shortage of medical resources, and medical staff usually have intensive working hours and cannot complete all training before entering clinical practice. Thus, the short-cycle centralized training method of the proposed model is more in line with the Chinese ICU hospital settings, which helps to quickly combine knowledge and practice and improve the ability and quality of ICU medical staff to manage hospital infection” could be move to the last section of the same paragraph to improve the flow

Response: Thank you so much for your valuable suggestion. We have made adjustments and modifications to the discussion section.

For details, please see page 26, lines 307 to 317.

Comment 17: "Among the three-level indicators, "hand hygiene, prevention and control of multidrug-resistant bacteria, and correct wearing and taking off of protective equipment" had the highest weight." Each of the indicators in this sentence should be in quotation marks to be identified as different indicators "Among the three-level indicators..." should be written as "Among the level three indicators..."

Response: We have modified the index marking according to your requirements.

Among the tertiary indicators, “hand hygiene,” “prevention and control of multidrug-resistant bacteria,” and “correct donning and doffing of protective equipment” were given the highest weight.

For details, please see page 25, lines 291 to 293.

Comment 18: There a few punctuation and sentence structures errors. For instance, the last sentence under data collection needs to be qualified. Also avoid sub-headings in the discussion

Response: We have sought professional assistance to polish the language of the manuscript

Comment 19: "Based on the KAPB model, this study constructed a standardized training system for hospital infection prevention and control for new medical staff in the internal medicine ICU through literature research, qualitative interviews, expert interviews and AHP." The AHP has not been defined and not presented in the methods

Response: Thank you so much for pointing out our obvious mistake and we have added the definition of AHP in the manuscript.

For details, please see page 10, lines 182 to 189.

Comment 20: The authors should also discuss the limitations of the study

Response: We have added a description of the limitations of this study in the conclusion.

For details, please see page 27, lines 328 to 330.

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PLoS One. doi: 10.1371/journal.pone.0294606.r003

Decision Letter 1

Arghya Das

16 Oct 2023

PONE-D-23-09513R1Construction of a standardized training system for hospital infection prevention and control for new medical staff in internal medicine ICUs based on the Delphi methodPLOS ONE

Dear Dr. Tang,

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Reviewer #1: Not applicable. The authors have met all the above listed criteria. There was no dual publication, research ethics, or publication ethics

Reviewer #2: The authors have significantly improved the content and structure of the manuscript and have addressed the comments appropriately.

Below are a few corrections required:

1. The authors can join the sentences in line 45 with a conjunction

2. Avoiding subheadings in the discussion is ideal

3. Line 327 seems to be incomplete.

4. The section on limitation could be inserted as the last paragraph in the discussion section

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PLoS One. 2023 Nov 16;18(11):e0294606. doi: 10.1371/journal.pone.0294606.r004

Author response to Decision Letter 1

1 Nov 2023

Reviewer #2 (Comments to the Authors):

Comment 1: The authors can join the sentences in line 45 with a conjunction

Response: Thanks for your suggestion, we have joined the sentence in line 45 with a conjunction.

In conclusion, the proposed standardized training system for infection prevention and control among new medical staff in the internal medicine ICU is both scientifically sound and practical, which can contribute to improved patient safety, reduced healthcare costs, and enhanced overall quality of care in internal medicine ICUs.

For details, please see page 3, line 45.

Comment 2: Avoiding subheadings in the discussion is ideal

Response: Thank you very much for your valuable comments. We have removed the subheadings from the discussion.

Comment 3: Line 327 seems to be incomplete

Response: Thanks for your reminding, we have completed this sentence.

In addition, it can strengthen patient safety and reduce healthcare-associated infections.

For details, please see page 27, line 336.

Comment 4: The section on limitation could be inserted as the last paragraph in the discussion section

Response: Thanks for your suggestion, we have moved the section on limitations from the summary to the last part of the discussion.

For details, please see page 27, lines 321 to 326.

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PLoS One. doi: 10.1371/journal.pone.0294606.r005

Decision Letter 2

Arghya Das

6 Nov 2023

Construction of a standardized training system for hospital infection prevention and control for new medical staff in internal medicine ICUs based on the Delphi method

PONE-D-23-09513R2

Dear Dr. Tang,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0294606.r006

Acceptance letter

Arghya Das

9 Nov 2023

PONE-D-23-09513R2

Construction of a standardized training system for hospital infection prevention and control for new medical staff in internal medicine ICUs based on the Delphi method

Dear Dr. Tang:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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Thank you for submitting your work to PLOS ONE and supporting open access.

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on behalf of

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Academic Editor

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Associated Data

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Supplementary Materials

S1 Data

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Data Availability Statement

All relevant data are within the manuscript and its Supporting Information files.

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PERMALINK

Construction of a standardized training system for hospital infection prevention and control for new medical staff in internal medicine ICUs based on the Delphi method

Linfei Wu

Li Tang

Linli Zhuang

Wenyi Xie

Min Liu

Jianfang Li

Roles

Abstract

Introduction

Materials and methods

Study design

Participants

Data collection

Expert consultation

Expert letter questionnaire

Implementation expert consultation

Ethics

Quality management

Analytic hierarchy process

Statistical analysis

Results

Basic information of experts

Table 1. Demographic information of experts.

Study participation

Expert authority coefficient and opinion coordination degree

Table 2. Results of expert suggestions’ coordination degree (first round).

Table 3. Results of expert suggestions’ coordination degree (second round).

Training model of hospital infection prevention and control for new ICU medical staff

Table 4. Construction of standardized training model for hospital infection prevention and control for new medical staff in the internal medicine ICU.

Discussion

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Faizan Iqbal

Roles

Author response to Decision Letter 0

Decision Letter 1

Arghya Das

Roles

Author response to Decision Letter 1

Decision Letter 2

Arghya Das

Roles

Acceptance letter

Arghya Das

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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