Planning and Implementation of an Infection Control Training Program for Healthcare Providers in Latin America
Objective. The lack of well‐trained, dedicated infection control personnel prevents optimal control of nosocomial infections in Latin American pediatric oncology centers. We collaboratively planned and implemented a multinational training course in San Salvador, El Salvador, to address this need.
Methods. The course relied on its organizers’ experience in training international healthcare providers, the availability of the International Training Center for Nurses, previous infection control collaboration with the Hospital Nacional de Niños Benjamin Bloom, and resources available at the University of El Salvador. The 4‐week course consisted of lecture sessions combined with practical laboratory and hospital experience.
Results. Two courses, one conducted in 2005 and one in 2006, trained 44 professionals from 15 Latin American countries. Evaluations showed that course content and teacher performance met the trainees’ needs and that all trainees acquired the necessary knowledge and skills.
Conclusions. The course met the need for the training of Latin American infection control practitioners. Our experience can serve as a model for other organizations interested in strengthening infection control and prevention at international sites.
Received March 2, 2007; accepted June 13, 2007; electronically published October 22, 2007.
In developing countries, as many as one‐third of pediatric hematology‐oncology patients die of infection.1 Because systematic infection control is often deficient or lacking in Latin American pediatric oncology centers, we initiated a comprehensive, practical training program for infection control professionals that initially targeted hospitals with pediatric oncology centers but included other selected Latin American hospitals.
St. Jude Children’s Research Hospital, through its International Outreach Program (IOP), has participated for more than a decade in the care of immunocompromised children2,3 and the education of professionals at international sites. The IOP Infectious Diseases Program (IOP‐ID) has provided limited infection control education at international sites since 2001. To build self‐sustaining infection control capacity in facilities around the world, we designed a program to train dedicated infection control professionals (ICPs) from multiple countries simultaneously. Most participants were St. Jude partner hospitals, but others were included. Our collaborative experience may serve as a model for other organizations that are interested in strengthening infection control and prevention programs at international sites.
Training Program
Previous and ongoing international infection control training by the St. Jude IOP‐ID laid the basic foundation for this project.
Training at St. Jude
Ongoing visiting fellow program in infectious diseases. In this program, professionals involved in the diagnosis, treatment, and/or prevention of infections in immunosuppressed pediatric patients visit St. Jude for 1 month of training. The visit establishes links between their institutions and the Memphis centers (St. Jude and Le Bonheur Children’s Medical Center) that promote collaborative projects.4,5 Visitors observe methods of diagnosis and treatment, work one‐on‐one with experts, and use St. Jude educational resources. Their experience is broadened by observing practices at Le Bonheur and at the Regional Medical Center in Memphis. Over a 5‐year period, 50 professionals from 17 countries (most from Latin America) have participated.
Infection control training at St. Jude and Le Bonheur Children’s Medical Center. Three of the 51 visiting fellows (nurses from Chile and Venezuela and a physician from Brazil) have focused exclusively on infection control, a program that includes one‐on‐one teaching by infection control experts, reading assignments, and observation of daily infection control activities. Two of these visiting fellows subsequently initiated infection control programs at their institutions. The visiting fellowship program prompted members of the IOP‐ID to envision a 1‐month intensive training program for professionals from multiple international sites. However, the use of a US training site was precluded by visa problems, the language barrier, and dissimilarities between trainees’ and sponsors’ institutions.
Training at International Sites
Infection control education for health professionals. The IOP‐ID had provided training on infection control for immunocompromised children in El Salvador, Honduras, Mexico, Brazil, and Paraguay, although ongoing professional education was still lacking. The IOP‐ID also provides educational assistance to any interested international healthcare provider, especially those at St. Jude partner sites. Assistance (such as case consultations and guidance in establishing or improving infection control programs) is provided through online meetings,5 e‐mail, educational materials,6 and online lectures and conferences available via the Cure4Kids Web site.7
Web‐based training. The Cure4Kids Web site7 is a free learning tool developed, owned, and managed by St. Jude Children’s Research Hospital. It is both a repository for lectures and a tool for holding conferences. Educational content on infection control is offered in English and Spanish. The goal is to offer comprehensive training and continuing education for ICPs in Spanish; most such content is currently available only in English.8,9 This project will facilitate professional development and staff training at international healthcare institutions.10 However, until Web‐based comprehensive, multilingual training and testing are available, initial face‐to‐face training and support will be needed to establish self‐sustaining infection control programs.
On‐Site Resources
International Training Center for Nurses. In 2000, this center in San Salvador, El Salvador, was collaboratively established by St. Jude Children's Research Hospital, the Hospital Nacional de Niños Benjamin Bloom (Hospital Bloom), the Salvadoran Ministry of Health, and the local nursing society.11 The center has offered intensive courses in pediatric oncology, human immunodeficiency virus infection and acquired immunodeficiency syndrome (with the support of the World AIDS Foundation),4 and, more recently, infection control. The center is located in the headquarters of the local nursing society, which manages the training center. The site includes housing for 25 trainees, dining rooms, a classroom with Internet access and a projector, and individual computers with Internet access. The staff is experienced in facilitating the training of international healthcare professionals.
Infection control program at Hospital Bloom. Hospital Bloom is a 300‐bed pediatric referral center in the El Salvador public health system. The hospital’s infection control program includes a dedicated, trained pediatrician (L.D.), 2 designated infection control nurses, an administrative assistant, and an epidemiologist. The infection control committee meets monthly, and an infection control manual is available. The infection control staff provides periodic education to hospital staff. The St. Jude IOP‐ID participated in one such presentation.
Health Research Center at the University of El Salvador. The University of El Salvador’s health research center (El Centro de Investigación y Desarrollo en Salud [CENSALUD]) was established in 2003 to promote and conduct studies of laboratory medicine, clinical medicine, and public health. The center’s classrooms, laboratories, computer facilities, and libraries12 were available for our use.
Course Design and Development
Course Design
The curriculum, designed to provide the basic knowledge needed to practice infection control, was intended for current or prospective ICPs in Latin America. The course content is outlined in Table 1. Key resources and contacts had been established through international infection control training offered at St. Jude, the conduct of previous courses in El Salvador, and collaborations with Salvadoran individuals and institutions. Hospital Bloom agreed to let us conduct practical sessions in its wards and use its classrooms and conference rooms. CENSALUD provided classrooms, computers, microbiology laboratories, course accreditation, as well as some of the instructors.
Candidates were recommended by the director of an infectious diseases program or the candidate’s supervisor in a hematology‐oncology program that maintained a partnership with St. Jude; candidates were then nominated by the hospital director. Trainees were required to meet the following criteria: (1) they had to be or be planning to become full‐time ICPs, (2) they had to be able to complete the full month of training, and (3) they had to continue working as an ICP for at least 1 year after completing training; in addition, they had to bring their hospital’s infection control manual to the training program for evaluation. Nominating institutions were asked to approve 1‐month absences for candidates and to introduce the infection control changes suggested by trainees when they returned to work. The final selection of candidates was the task of an advisory board made up of educators and experts in the prevention and control of infection at collaborating institutions in El Salvador and the United States. The board also approved the training curriculum, course schedule, teaching materials, and evaluation methods, and they identified and recruited teachers and trainees.
The course instructors who were recruited were required to have expertise in the subject area, experience educating healthcare professionals, and proficiency in Spanish; most were ICPs. The courses in February 2005 and May 2006 were taught by 22 teachers from El Salvador, Paraguay, Mexico, Nicaragua, Guatemala, Venezuela, and the United States. A series of evaluations was designed to allow assessment of the course.
Course Development
We addressed course‐related issues (ie, curriculum, oversight, schedule, instructors, and educational materials), logistical issues (ie, housing, food, transportation, and computers), and instruction issues in 5 steps. We first defined the role and membership of the advisory board. Second, we defined teaching responsibilities, selected trainee candidates, obtained board approval of the curriculum, and revised the curriculum and schedule, as needed. Third, we prepared instructors via e‐mail, telephone, and online meetings. The course director (M.A.C.) strongly encouraged the use of up‐to‐date materials, such as those published by the World Health Organization,14 the Association for Professionals in Infection Control,15 and the Centers for Disease Control and Prevention9 and supplied them if necessary. The fourth step was to contact trainees, confirm their attendance, and finalize logistical arrangements (ie, visas, airline tickets, transportation to the training center, health screening, housing, and any schedule changes). Finally, we evaluated each trainee’s performance as an ICP and each trainee’s hospital infection control program at least 6 months and 12 months after completion of the course.
Steps 1 and 2 were conducted during August–September 2004, and steps 3 and 4 were performed during October–December 2004. Step 5 occurred 6‐12 months after the course was completed. The first 2 courses were conducted in February 2005 and May 2006; a third course was planned for May 2007. At the time this study was completed, we had trained 44 ICPs from 15 countries (Table 2).
Course Structure
The 4‐week course consisted of four 10‐hour lecture modules and an assortment of small‐group practical sessions (Table 1). Each lecture module was taught for 2 hours daily over 1 work week (ie, 5 days), after which trainees completed a 20‐30‐item quiz. Each practical session involved 4 groups, each with 4‐5 trainees. These sessions addressed the “how to” of infection control through hands‐on activities in the microbiology laboratory and the hospital. On the first day of the course, each group was assigned to 1 of the 4 units at Hospital Bloom (pediatric intensive care, neonatal intensive care, surgery, or oncology). The specific content of the practical sessions is summarized below.
Nosocomial infection surveillance. For this practice, each group followed any new patient admitted to the ward to which the trainees had been assigned during the 4‐week course. Trainees were instructed to identify clinical factors (such as the presence of specific catheters or tubes, a history of surgery, the receipt of parenteral nutrition, or pulmonary aspiration of secretions) and environmental factors or practices that might increase the patient’s risk or the overall risk of infection. Risk factors and patient outcome (including whether any infections were hospital acquired) were recorded. At the end of the practice period, trainees analyzed the information and presented their findings and recommendations to the instructors and to the chiefs of the 4 wards. Findings included the number of patients surveyed; the number of nosocomial infections identified; the number and type of nosocomial infections per patient; the prevalence of nosocomial infection in each service; and the incidence, cumulative incidence, risk, and time line of acquisition of nosocomial infections. If an infectious organism was isolated, its antimicrobial susceptibility pattern and the antimicrobial therapy used to treat the infection were reported.
Design and development of infection control policies and procedures. Infection control policies and procedure documents ensure that consistent actions are taken to identify and reduce the risk of nosocomial infection. These documents must be up‐to‐date, appropriate for the needs of the organization, and available to all staff.16,17
Seven 45‐minute sessions provided a knowledge base and practice for the development of infection control policies and procedures. Trainees were taught how to create, format, and prioritize policies or procedures, as well as how to judge their applicability to an institution or service, research the sources and scientific validity of the policy or procedure, judge the practicality of implementation, create a distribution list, consider the practicality of the procedures for affected personnel, and perform periodic updates. Trainees were also taught to ensure that the procedure was consistent with available resources and was approved by the hospital administration.
During the practicum, team members identified a procedure in need of development or documentation; searched the appropriate scientific literature; evaluated the practicality, relevance, and feasibility of proposed guidelines; wrote the guidelines; established the frequency of evaluation and review; and evaluated whether the guidelines would be a useful resource for healthcare personnel. At the end of the practicum, each trainee conducted a slide presentation about the development of the procedure.
Evaluation of compliance with infection control policies and procedures. Because hand hygiene is the simplest and most effective way to prevent and control infection,18 trainees planned, executed, evaluated, and interpreted surveillance of hand hygiene in their assigned wards. After the planning phase, group members summarized their proposed monitoring and data collection plan. At the end of the hand hygiene evaluation, trainees presented a written report that included data analysis, identification of areas in need of improvement, an action plan, and a copy of the data collection tool. Each group shared its findings and recommendations with the hospital administration, participating wards, and nursing staff of Hospital Bloom.
Investigation of outbreaks. Trainees received 8 sessions of practical instruction in the verification, investigation, and control of infectious outbreaks, based on case scenarios. Each 1‐hour lecture and case discussion was followed by group activities that required the use of epidemiological tools. The trainees identified and confirmed the existence of an outbreak, identified the cases, calculated the risk of acquisition of the infection and the number of subjects at risk, and determined the date and place of the outbreak’s origin. Trainees also formulated and tested a hypothesis to explain the origin of the outbreak and compared this hypothesis to the available facts. During this practice, trainees learned how to plan and conduct a systematic study of a hospital outbreak, prepare a written report, and execute prevention and control measures for the outbreak.
Use of Epi Info. Epi Info is a free epidemiological software package that supports survey and questionnaire design and reporting, as well as data entry and simple statistical analysis.19 Trainees received 16 hours of lecture and practice related to the use of this tool. They learned how to use specific features of the program, including the basic design of graphics for reporting infection control data, by using data generated in the practical sessions about surveillance, evaluation of compliance, and outbreak investigation and control described above.
Planning, design, and development of training. One of the basic roles of ICPs—the education and training of healthcare professionals—can be fulfilled by using a well‐defined teaching plan, building on trainees’ past experiences, and maximizing the use of available resources.20 During this 4‐hour session, each trainee learned to apply the principles of adult learning to create and use instructional materials.21 During the second half of the session (ie, teaching practice), the trainees used a flip‐chart poster on hand hygiene prepared by the IOP‐ID team,6 packaged with instructions on delivering the information and a quiz to evaluate the knowledge transmitted. Using these materials, the trainees taught hand hygiene to the nursing staff of the 4 participating wards, evaluated the results, and obtained feedback.
Microbiology laboratory. An understanding of the basic principles of the collection and processing of diagnostic microbiology samples and the reporting of microbiology results provides a foundation for good infection control practice.22 Trainees received 5 sessions (1.5 hours each) of instruction in the collection, transportation, and culture of microbiology specimens. A specific practical exercise required trainees to culture 1 mL of “glove juice” on an agar plate before and after cleansing the hands with nonmedicated detergent or alcohol‐based hand rub. This practice provided first‐hand knowledge about hand ecology and the effectiveness of hand hygiene.
Course Evaluation and Feedback
Evaluation was conducted during and after the course. Specific areas that were evaluated were as follows.
Course logistics and content. During the course, a trainee representative communicated logistical needs to the on‐site course coordinator, who informed the advisory board. After each lecture, trainees completed a brief, anonymous questionnaire on the quality of the content, the teacher’s performance, and the methods used to achieve the objective (Table 3).
Trainee knowledge. Knowledge acquisition was evaluated through the following series of tests: (1) a 55‐item multiple‐choice exam given at the start and the end of training that covered all the topics addressed, (2) a 20‐ to 30‐item test at the completion of each 1‐week module, and (3) grades for trainees’ practical projects and participation. A mean score of 65% was required to demonstrate proficiency. Trainees who did not demonstrate proficiency completed additional assignments to gain the needed knowledge or skills. On the 55‐item multiple‐choice exam, overall knowledge increased by 11.4% (95% confidence interval [CI], 11.3%–11.4%) (
). The scores for the exams and projects completed at the end of the modules and practical sessions are summarized in Table 4. Trainees also completed a 25‐item questionnaire about how well the course had met their educational needs and how much it had increased their knowledge and skills.
Future Direction and Sustainability
We plan to publish the classroom lectures on our Cure4Kids Web site7 to facilitate the participation of interested professionals and to allow potential trainees to acquire a knowledge base before attending the course. If trainees gain significant knowledge via the Web site, the course can then focus more on the practical aspects of infection control, making optimal use of the available time.
The support of local institutions5 and the growing financial and regulatory support of Latin American governments23 will help sustain these infection control programs. Effective infection control programs will reduce the morbidity and mortality of nosocomial infections24 and the costs associated with these infections.25 However, uniform data are needed for meaningful assessment of infection control interventions and rates of nosocomial infection.26 An online network of ICPs brought together by the infection control courses can lay the groundwork for uniform data collection methods. The IOP‐ID interacts with this online network of ICPs and their institutions via a monthly electronic newsletter—Red de Control de Infecciones para America Latina (Latin American Infection Control Network)—that provides an open forum where members can share information. This nascent network can be a potent force for the further strengthening of infection control programs by disseminating new information, emphasizing priorities in infection control and prevention, and sharing information about infection control initiatives and/or projects implemented by members.
Acknowledgments
We thank the Hospital Nacional de Niños Benjamin Bloom, the CENSALUD of the University of El Salvador, the teachers of this course, the members of the Sociedad de Enfermeras Profesionales de El Salvador (SODEPROE), and the trainees. Marcela Hill and Alicia Rodriguez provided excellent administrative assistance, James Okuma provided statistical support, and Sharon Naron provided excellent editorial advice.
Financial support. This study was supported by the American Lebanese Syrian Associated Charities (ALSAC).
Potential conflicts of interest. All authors report no conflicts of interest relevant to this article.
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