Table 5.

Themes, codes and representative quotes obtained from interviews, HAI Network’s BSI Surveillance evaluation, India, 2022

Themes	Codes	Quotes
Developed a resource-appropriate case definition	Simple easy to implement case-definition Applicable to Indian hospitals Sensitive case definition	“The team developed a simple case definition, clear SOP, which helped us train sites well” #ProgramCoordinator “I’m pretty confident that in a given unit, more than 80–90% of the BSIs were being captured, pre-COVID-19.” #TechnicalTeam01 “Modified case definition is sensitive in capturing true CLABSIs: “when you do these focussed QI projects, their CLABSI rates go down significantly, which tells us there’s probably not a huge definitional gap where we are finding BSI and classifying them as CLABSI when they are really secondary BSI” #TechnicalTeam02
Established a representative network-based surveillance to detect trends and investigate outbreaks	Implementing a surveillance program across different states Representative of different patient populations within ICUs Representation of public and private hospitals Geographically representative Outbreaks detected	“(we have been successful in helping) how to implement a surveillance and prevention program that can be implemented consistently across a network of 39 + hospitals in a relatively well-resourced setting, it’s a huge success.” #TechnicalTeam01 “Good representation of patient population- medical, surgical, paediatric, neonatal and oncology” #TechnicalTeam01 “When it comes to tertiary care hospitals in the country, we are fairly representative as we have geographical diversity, also a mix of private and public hospitals” #TechnicalTeam02 “We have used data from this surveillance to investigate HAI outbreaks, and control them in time” #TechnicalTeam03
Ensured regular ongoing IPC trainings with Quality Improvement (QI) projects	Shifted to online training Quick dissemination of COVID-19 IPC measures in network Every infection is accounted for Targeted recommendation to avoid each infection	“This IPC training and surveillance helped us in correct handling of COVID-19 patients during the pandemic” #ICN02” “With QI initiatives, I can say that, first we were just recording and showing the rates in the HICC (hospital infection control committee) meeting, now we are asking questions for every BSI reported and suggesting ways to avoid that infection.” #ResearchFellow06
Limited human resources	Limited staff allotted to surveillance Staff attrition	“Limited staff allotted to surveillance, so we are not expanding surveillance to all ICUs within the hospital” #Microbiologist03 “Difficult to retain trained staff once funding ends, impacts our data collection” #Microbiologist05 “Staff turnover impacts timeliness of data upload” #Microbiologist02
Lack of digitalization of medical and laboratory records	Patient tracking outside of ICU is difficult Tracking different culture reports is difficult End-of month validation difficult Deciphering handwritten notes is challenging	“Tracking samples from other body sites is difficult as no common book in ICU which has a list of all cultures sent for that day….it takes a lot of man-hours” #ICN03 “Accessing and deciphering handwritten notes from manual registers is time-consuming and inefficient” #ICN01 “Monthly validation of all blood cultures is not always done, difficult in centres with no LIS” # DEO (02)
Variable blood culturing practices	Lack of availability of culture bottles Patient unable to pay for blood cultures Clinician’s judgement	“Blood culture is paid, in our hospital social service organizations help poor patients but these are not present in all hospitals” #Microbiologist01 (private hospital) “In our hospital, blood culture is free, but sometimes patients must buy supplies’# Microbiologist03 (public hospital) “This is a tertiary care hospital, patients have already taken a lot of antibiotics and come in very sick, so we directly start on antibiotics empirically, only when patient does not respond, we send cultures.” #Microbiologist03
Inconsistent information sharing and data use	Staff not analysing data Analyzed data not shared with physicians Physicians may not accept recommendations	“Even though they have data, they (sites) are not analysing this data for antibiograms, nor sharing it (with their physicians)” # TechnicalTeam02 “Physicians many times do not accept the results of the data, or the IPC measures suggested possibly due to a difference in surveillance and clinical definitions” #TechnicalTeam03 “there’s a kind of hierarchy and defensiveness that can exist between the microbiology department and the clinical side, that’s been a bottleneck to the data actually being used.” # TechnicalTeam02
Funding and sustainability	Funding affects stability Further expansion of network depends on funding Institutionalization of IPC staff helps stability	“Difficult to retain trained staff once funding ends, impacts our data collection” #Microbiologist06 “If we have allocated budget either internal or external, we plan to expand the network by creating regional trainers and including tier 2 (secondary care) hospitals in the network.” #ProgramCoordinator “Hospitals with dedicated IPC staff continued surveillance despite drop in funding” #TechnicalTeam03
Impact of the COVID pandemic	Disrupted regular trainings and expansion Staff attrition Reduced reporting units Limited access of staff to COVID ICUs	“During the COVID-19 pandemic nobody was willing to support any intervention to improve CLABSI (infection rates) as there was staff shortage, now is not the right time, they said” #ReseachFellow05 “Many ICU were designated COVID ICU and surveillance stopped” # Program Coordinator “Surveillance staff were not allowed in COVID ICU” # ReseachFellow03
Awareness and acceptance of BSI surveillance among participating sites	Surveillance is useful Sites eager to join network Increase in blood cultures received after joining surveillance	“For a public hospital, where we have so much patient load, because of this surveillance, we can focus on areas to improve,” #Microbiologist02 “They (ICU physicians) have come to realise that without IPC, (BSI) rates cannot be reduced” #Microbiologist03 “Number of blood culture samples have increased significantly in the last 2 years after our trainings” #ICN02 “Sites are actively soliciting opportunity to participate in surveillance” #TechnicalTeam02