Abstract
To identify the current status and barriers of infection control in medical clinics in the Republic of Korea and establish foundational data for infection control support policies, the infection control survey system for hospital-level institutions during the first cycle was revised. Limitations of the self-administered online survey method (computer-assisted self-interviewing) were addressed by transitioning to an on-site survey format. The survey aimed to generate nationally representative statistics by ensuring the reliability and representativeness of infection control survey results from medical clinics. Stratified random sampling proportionally allocated samples according to the survey population ratio, selecting a final sample of 600 clinics based on regional and clinic characteristics. Infection control experts conducted on-site visits, verified documents, observed procedures, and interviewed staff. A staff survey assessed awareness of infection control to enhance policy acceptance. Of 34,958 medical clinics, 4,501 clinics (12.9%) participated in the online survey. Among these, 87.2% of staff indicated a need for infection control education, and 99.6% agreed on the effectiveness of hand hygiene in preventing healthcare-associated infections. Key educational topics identified were hand hygiene, safe injection practices, and measures for patients with infectious diseases. The Korea Disease Control and Prevention Agency plans to establish infection control surveys as a national survey system by improving on-site survey participation and ensure data reliability, addressing limitations identified during the operation of the infection control survey for medical clinics.
Keywords: Infection control, Medical clinics, Sample design, Survey, Research design
Key messages
① What is known previously?
An infection control survey of hospital-level institutions was conducted to support Healthcare-associated infections (HAIs) prevention policy development. The first cycle’s results were published and provided essential data for the second comprehensive HAIs prevention plan.
② What new information is presented?
The most necessary infection control education topics were “hand hygiene techniques” 1,682 clinics (37.4%), “safe injection practices” 904 clinics (20.1%), “response measures for patients with infectious diseases” 814 clinics (18.1%), and “cleaning, disinfection, and sterilization of medical instruments” 725 clinics (16.1%).
③ What are implications?
Switching the infection control survey for clinics to an onsite format improved the reliability of the results through immediate data consistency checks and error corrections. The integration of data collection, entry, and database creation also shortened the refinement time.
Introduction
The occurrence of healthcare-associated infections (HAIs) can be prevented and managed through the implementation of infection control measures by healthcare institutions and the enactment of supportive government policies [1]. To establish effective policies, it is crucial to first gain a comprehensive understanding of the current infection control practices in healthcare settings. In accordance with Article 17 of the Infectious Disease Control and Prevention Act, the Korea Disease Control and Prevention Agency (KDCA) conducted the first infection control survey of hospital-level healthcare institutions and published the results [2,3]. In the Republic of Korea (ROK), clinic-level healthcare institutions represent the largest number of healthcare facilities and are the most frequently utilized by healthcare consumers in terms of treatment volume. However, no survey on infection control practices at clinic-level healthcare institutions has been conducted. Instead, local health centers have merely carried out facility inspections. In response to the heightened awareness of infection control issues in clinic-level healthcare institutions—primarily due to outbreaks of hepatitis C caused by the reuse of disposable syringes and the coronavirus disease 2019 pandemic—the KDCA has established and is now operating a survey system to assess infection control practices at clinic-level healthcare institutions. This system aims to provide the KDCA with foundational data essential for developing policies to support infection control in clinic-level healthcare institutions.
To reduce the burden on healthcare facilities and clinic-level healthcare institutions, the number of survey items was minimized, sub-items were avoided to improve comprehension, and items containing multiple attributes were separated by attribute. Given the potential for inaccuracy in the survey results due to respondents self-completing the survey via an online self-report system, sample field surveys were conducted to ensure the reliability of the survey findings. Therefore, this study aims to present the infection control survey and operational system utilized by clinic-level healthcare institutions.
Results
1. Establishment and Operation of the Clinic-level Healthcare Institution Infection Control Survey
The number of clinic-level healthcare organizations in ROK is approximately 34,000, encompassing a diverse range of institutions with varying characteristics, including medical specialties. This diversity poses significant challenges to conducting a comprehensive survey to assess the infection control status at clinic-level healthcare institutions. To address this, appropriate sample distribution methodologies were applied for each region and medical specialty to ensure representativeness in the selection of institutions and survey methodologies for the infection control survey of clinic-level healthcare institutions. Field surveys were conducted at selected institutions based on a sampling design that allowed for the identification of the infection control status of healthcare institutions that operate at least one high-risk department (e.g., inpatient rooms, operating rooms, endoscopy rooms, or artificial kidney rooms) prioritized for infection control. To facilitate infection control self-assessment among clinic-level healthcare institutions, the KDCA’s Integrated Disease and Health Management System (https://is.kdca.go.kr) provided an online self-assessment platform accessible through a computerized system. This initiative aimed to increase awareness of HAIs control and promote infection control practices across healthcare institutions. The Infection Control Consulting Network was commissioned to conduct an infection control survey of clinic-level healthcare institutions. A general steering committee comprising infection control experts, nominated by various academic societies, was established to guide and oversee the implementation of the infection control survey of clinic-level healthcare institutions. To facilitate a more comprehensive understanding of the implementation of field surveys in healthcare facilities, an Infection Control Council for Clinic-level Healthcare Institutions was established, comprising members nominated by the respective medical councils of each medical specialty. The purpose of the survey was to ascertain the current state of infection control in clinic-level healthcare organizations in ROK and to serve as a foundation for formulating infection control support policies. To ensure quality of the field surveys, a specialized field survey team was established, consisting of surveyors with professional knowledge in infection control and experience in medical fields. Furthermore, a survey guideline was also developed, and a field support center was operated to prevent arbitrary problem-solving during the survey process.
2. Sample Design for the Clinic-level Healthcare Institution Infection Control Survey
1) Survey population
The target population for the infection control survey of clinic-level healthcare institutions included 34,958 clinics, as defined under Article 3, Paragraph 2, Item 1 of the Medical Service Act, along with 34,739 clinics registered in the status report of nursing institutions under Article 43 of the National Health Insurance Act as of December 31, 2022. Clinics operating two or more special departments (e.g., inpatient rooms, operating rooms, artificial kidney rooms, or endoscopy rooms) were excluded from this population (n=219 clinics).
2) Stratification and sampling
To ensure the reliability of the data obtained from the field survey, the stratification criteria for sample allocation were initially divided into metropolitan and non-metropolitan areas and then further categorized by medical departments (internal medicine or surgery) and special departments (inpatient rooms, operating rooms, artificial kidney rooms, or endoscopy rooms). This stratification was determined in consultation with sample design experts and infection control specialists. Samples were selected from each stratum based on the proportion of the survey population distributed by region and specialty. The sample size was set at 600 clinics, considering factors such as level of statistical reporting, desired margin of error for the resulting statistics, available budget, and survey duration. Preliminary samples were randomly extracted at a rate of four times, which were then replaced with alternative samples. This sample size was calculated to ensure that the margin of sampling error for population ratio estimates would remain within approximately ±3.97 percentage points at the 95% confidence level.
3. Operation of the Clinic-level Healthcare Institution Infection Control Survey
1) Survey participants
The sample of clinics selected for the fieldwork comprised 210 clinics without specialty departments, 90 clinics with inpatient rooms, 125 clinics with operating rooms, 50 clinics with artificial kidney rooms, and 125 clinics with endoscopy rooms.
2) Survey items
To ascertain the infection control status of clinic-level healthcare organizations, a set of common items was devised based on infection control practices for outpatient care proposed by the US Centers for Disease Control and Prevention/Healthcare Infection Control Practices Advisory Committee [4,5]. Items for special departments were developed with consideration of both domestic and international regulations and guidelines. In this process, the opinions of infection control professional organizations and related organizations have been considered. To enhance comprehension and precision of the survey items among clinic practitioners, a preliminary field survey was conducted to assess the reliability and validity of the items. The survey questionnaire for infection control in clinics comprised 70 common items across nine domains, along with 60 items specific to four specialty departments (inpatient rooms, operating rooms, artificial kidney rooms, and endoscopy rooms) (Table 1).
Table 1. Medical clinics healthcare-associated infection control assessment tools .
| Variables | Category | |
|---|---|---|
| Common questions | Hand hygiene, personal protective equipment, injection practice for infection prevention, disinfection and sterilization, infection control in the environment, infection control guideline, infection control education and training, early detection and response to infectious diseases, employee health and infection control | |
| Special department | Inpatient room | Hand hygiene, ventilation, cleaning and disinfection, Isolation , laundry management |
| Operating room | Facilities and structure, equipment, infection control guidelines, staff training, environment management | |
| Artificial kidney room | Dialysis water testing, infection control guidelines, facilities and structure, environmental management, catheter management | |
| Endoscopy room | Endoscope type, disinfection training, pre-wash, disinfection, dry, accessories, custody, facilities and space, personal protective equipment, guideline, disinfection inspection | |
3) Survey method
To enhance participation and raise awareness of the survey among the sampled lawmakers, information sheets were produced and distributed in advance, and two infection control experts were assigned to visit the lawmakers in person. In accordance with the investigation plan, supporting data for the investigation items were reviewed, on-site observations were conducted, and employees were interviewed. To ensure the reliability of the investigation results, quality control was implemented by standardizing the investigation criteria and methods. The self-report online survey was conducted via the KDCA’s Integrated Disease and Health Management System, an online self-assessment tool for infection control. This system allows infection control personnel in healthcare organizations to determine whether they are meeting their infection control responsibilities, including those related to organization and personnel.
4. Statistical Estimation Methods
1) Weights and non-responses
The final weight was calculated by multiplying the design weight by the non-response adjustment weight. The sample design weights were calculated by multiplying the reciprocal of the sampling rate for each sampling area by the reciprocal of the institutional survey completion rate in each sampling area, with a non-response weight of “1” because no item non-response occurred in the field survey.
2) Estimates and sampling errors
The primary estimates were the population ratio and population mean, which were calculated using weighted estimates. Additionally, the standard error and relative standard error for the population ratio and population mean estimates were calculated.
5. Results of Operating the Clinic-level Healthcare Institution Infection Control Survey
1) Survey participation status
A total of 600 clinics were selected as sample institutions for field surveys, and 4,501 out of 34,958 clinics participated in the survey on infection control awareness in clinics using the online self-check system, yielding a participation rate of 12.9%.
2) Survey results
Of the 600 clinics in the sample that completed the field survey, 34 clinics (5.7%) had inpatient rooms, 160 clinics (26.7%) had operating rooms, 46 clinics (7.7%) had artificial kidney rooms, 121 clinics (20.2%) had endoscopy rooms, 22 clinics (3.7%) had two or more specialty departments, and 217 clinics (36.2%) had no specialty departments (Table 2). There were differences in the operation status of special departments at clinics. The sample design was based on clinics registered in the status report of healthcare institutions under Article 43 of the National Health Insurance Act as of December 31, 2022. However, due to cessation of operations of certain special departments during the field survey and errors in reporting to the Health Insurance Review and Assessment Service, the number of clinics in the sample design and the type of operation of the special departments at clinics that completed the survey varied. The mean number of employees by profession at the participating clinics was 1.67 physicians, 1.41 nurses, and 4.37 nursing assistants. The primary specialties were internal medicine 256 clinics (42.7%), obstetrics and gynecology 115 clinics (19.2%), family medicine 102 clinics (17.0%), otolaryngology 82 clinics (13.7%), and orthopedics 77 clinics (12.8%).
Table 2. Status of special departments in field survey participating institutions.
| Total | Inpatient room | Operating room | Artificial kidney room | Endoscopy room | Not operating | Operating two or more |
|---|---|---|---|---|---|---|
| 600 (100.0) | 34 (5.7) | 160 (26.7) | 46 (7.7) | 121 (20.2) | 217 (36.2) | 22 (3.7) |
Unit: clinics (%).
3) Infection control perception
Given the pivotal role of institutional leadership in formulating policies that facilitate infection control in clinic-level healthcare institutions, a computer-assisted self-interviewing (CASI) survey was conducted to assess perceptions related to infection control among clinic directors. Among the physicians, 85.8% had recently completed continuing education on HAIs, and more than 90% agreed that handwashing is an effective method for preventing HAIs and that education on HAIs is necessary (Table 3). The most essential infection control training was reported by 1,682 clinics (37.4%) regarding “hand hygiene practices”, 904 clinics (20.1%) regarding “safe injection practices”, 814 clinics (18.1%) regarding “response to individuals with infectious diseases”, and 725 clinics (16.1%) “concerning the cleaning, disinfection, and sterilization of medical equipment” (Table 4). The necessity of implementing infection control guidelines, investigating hand hygiene practices, providing and wearing personal protective equipment correctly, disinfecting and sterilizing medical devices, providing infection control training, and preventing staff exposure to infectious diseases was acknowledged by healthcare practitioners at the clinic level. Additionally, the importance of government support in enhancing infection control at clinic-level healthcare institutions was recognized.
Table 3. Results of infection control awareness at medical clinics.
| Category | Number of responses | |
|---|---|---|
| Yes | No | |
| Physician maintenance training on healthcare-related infection control within the past 3 years | 3,908 (86.8) | 593 (13.2) |
| Necessity of infection control training for clinic workers | 4,375 (97.2) | 126 (2.8) |
| Help with work activities through medical-related infection control education | 4,331 (96.2) | 170 (3.8) |
| Hand hygiene is effective in preventing medical-related infections | 4,486 (99.7) | 15 (0.3) |
Unit: clinics (%).
Table 4. Infection control training most needed for medical clinics.
| Total | Hand hygiene | Safe injection practices | How to respond to infectious diseases | Employee infection control | Disinfection and sterilization | Infection control of environment | etc |
|---|---|---|---|---|---|---|---|
| 4,501 (100.0) | 1,682 (37.4) | 904 (20.1) | 814 (18.1) | 336 (7.5) | 725 (16.1) | 36 (0.8) | 4 (0.1) |
Unit: clinics (%).
Conclusion
In accordance with Article 17 of the Infectious Disease Control and Prevention Act and Article 15 of the Enforcement Rules of the same Act, the KDCA conducts infection control surveys by type of healthcare institution every three years. The objective of these surveys is to provide foundational data for establishing and implementing healthcare-related prevention and management policies. The results of these surveys are subsequently published. In June 2021, amendments were made to the Enforcement Rules of the Medical Service Act, expanding the scope of healthcare institutions required to designate infection control personnel and establish infection control offices. The amendments extended this requirement to hospital-level healthcare institutions with 100 beds or more. However, clinic-level healthcare institutions are not legally obligated to operate an infection control organization and workforce. It is therefore anticipated that the majority of these institutions will not have an established infection control system in place. Consequently, a clinic-level healthcare institution infection control survey was conducted on-site to ensure the reliability of the survey results [6]. The infection control survey of clinic-level healthcare institutions is not a one-time survey conducted in a short period of time. Rather, it is a large-scale, cyclical survey that will be conducted every three years for a total of 34,000 clinics. Furthermore, the infection control survey of clinic-level healthcare institutions represents the inaugural nationwide field survey. To ensure the reliability of the field survey results, the input of healthcare institutions was excluded by the surveyors when conducting the survey, in contrast to the first-cycle hospital-level healthcare institutions infection control survey, which was conducted based on the CASI method of directly responding to online surveys. The formation of a field investigation committee comprising infection experts and the subsequent investigation were expected to enhance comprehension of infection control in healthcare institutions. Additionally, the committee is expected to facilitate the recognition of the significance of infection control among healthcare institutions lacking experience in this domain.
Upon commencement of the field survey, several issues were identified that were not present during the sample design phase, such as changes in the population or sample, non-responses, and identification of outliers. This confirmed the necessity of anticipating such problems in advance of the field survey and preparing relevant guidelines for appropriate post-survey management, sample management, data editing, replacement, weighting, and statistical management. The first field surveys of clinic-level healthcare institutions were constrained by the fact that only a limited number of institutions were selected as survey targets. This resulted in an inability to gain a comprehensive understanding of the infection control practices of medical departments across a diverse range of clinics. Accordingly, the scope of the survey targets was progressively refined and expanded. Given the pivotal role of healthcare institutions in the successful implementation of infection control surveys at the clinic level, it is imperative to review policy incentives for promoting the survey and encouraging active participation from clinics. The KDCA will undertake a comprehensive review of the efficacy of the ongoing infection control survey operation system, with the objective of incorporating the findings of the survey on infection control in healthcare institutions into its policies. In addition, the KDCA will devise and implement measures to enhance the objectivity and reliability of the survey results.
Acknowledgments
None.
Declarations
Ethics Statement: Not applicable.
Funding Source: 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: NYK, JSS. Methodology: SKP, JSS, NYK. Project administration: SKP, JSS, NYK. Supervision: SKP. Validation: SKP, JSS. Writing – original draft: NYK, JSS. Writing – review & editing: SKP, JSS.
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