Evaluation of Nosocomial Infection Control Programs in health services 1

OBJECTIVES: to evaluate the Nosocomial Infection Control Programs in hospital institutions regarding structure and process indicators. METHOD: this is a descriptive, exploratory and quantitative study conducted in 2013. The study population comprised 13 Nosocomial Infection Control Programs of health services in a Brazilian city of the state of São Paulo. Public domain instruments available in the Manual of Evaluation Indicators of Nosocomial Infection Control Practices were used. RESULTS: The indicators with the highest average compliance were "Evaluation of the Structure of the Nosocomial Infection Control Programs" (75%) and "Evaluation of the Epidemiological Surveillance System of Nosocomial Infection" (82%) and those with the lowest mean compliance scores were "Evaluation of Operational Guidelines" (58.97%) and "Evaluation of Activities of Control and Prevention of Nosocomial Infection" (60.29%). CONCLUSION: The use of indicators identified that, despite having produced knowledge about prevention and control of nosocomial infections, there is still a large gap between the practice and the recommendations.


Introduction
According to the Ministry of Health (1) , nosocomial infection is the infection acquired after the client's admission to hospital and manifested during hospitalization or after discharge, provided that it can be related to hospitalization or hospital procedures. Since infections are not limited to the hospital environment, the terminology Healthcare-Associated Infection has been considered more appropriate.
Nosocomial infections (NI) are of great epidemiological relevance by raising the morbidity and mortality rates, extending the length of stay of patients in hospital and thus burdening the cost of treatment (2)(3) .
Estimates of developed countries indicate that at least 5% of patients in hospitals acquire infection (4) . In Brazil, research (5)  attributes of a given process or system, are becoming a useful tool for assessing the health services (6) .
Although there is national legislation recommending the establishment of nosocomial infection control programs (NICPs) in health facilities, the current evaluation system does not favor the measuring, interpretation and qualification of the evaluation, which should be considered insufficient to determine the quality of care practices (7) . In this context, it was considered appropriate to carry out the present study, which aimed to evaluate the structure and process indicators of NICPs in hospitals of the city of Ribeirão Preto.

Methods
This is a descriptive and exploratory study with a quantitative approach, performed in the city of Ribeirão Preto, in 2013. The Nosocomial Infection Control Committees of health services were identified by using the National Health Facilities Cadaster (NHFC) for reference, which categorizes the hospitals as public, private and non-profit, general or specialized.
Health services for treatment of mental illness were excluded.
In the data collection period, the city of Ribeirão When analyzing the Indicator "Evaluation of technical and operational structure of the NICP", the average compliance of institutions was 75%, six programs had 100% compliance in the items and only one had 20% (Table 1).
Three components of the indicator were considered in partial compliance, one was related to the bylaws, that is, an institution declared to have them but did not present them during the interview and evaluation; another one related to the physical space had a defined area, but it was not exclusive to the service and to the conduction of regular meetings. The institutions presented minutes, but with the date of the year before. The hospitals that presented written routine and manuals, although outdated, i.e., prepared two years before or more were categorized as partial compliance.
The evaluation of this indicator as specialized services, with day-hospital inpatients, had some components that did not apply to this process ( Table 2).
The Indicator "Evaluation of the Epidemiological Surveillance System of NI" had an average compliance of 82%, six programs had 100% of compliance items and only one had 11% (Table 3).

The Indicator "Evaluation of Control and Prevention
Activities of NI" had an average compliance of 60.29%.
It is highlighted that six institutions achieved 100% of compliance in the items and one did not presented compliance in any item ( Table 4).
The NICCs that reported performing inspection, orientation upon spontaneous demand or assessment

Discussion
There was adherence of 81.2% of the institutions in Ribeirão Preto to this investigation. A similar survey conducted in the city of São Paulo had a participation percentage of 31% (7) . Thus, it was considered that the results reflect the diagnosis of NICP in this city.
The best performance was obtained in the Indicators "Evaluation of technical and operational structure" and "Evaluation of the epidemiological surveillance system." It is highlighted that, in the first indicator, most items encompassed national legal requirements, including human resources for composition of NICCs, physical space and implementing activities (1) , which explains the high compliance rate.
Research conducted in Ontario, Canada, showed a deficit of hours/professionals for activities for the control of nosocomial infection per 100 beds, providing evidence that this ratio was appropriate in only 22.6% (8) .
On the other hand, when analyzing the development and updating of manuals of rules, routines and recommendations for control of NI, it was observed that there has been compliance in more than half of the institutions (59.4%), although much of the NICCs do not meet this minimum requirement for realization of safe care, which also constitutes a legal requirement.
Effective programs should meet the minimum established by law and still have, in its scope, actions such as collection system, management, analysis and reporting of data with a continuous improvement plan; formal policies and procedures; study programs, education and training (9) .
For the indicator "Evaluation of the epidemiological surveillance system", the items include forms of surveillance, diagnostic criteria of NI and preparation of technical and scientific reports. Although the indicator has reached a high compliance rate, it was observed that the items "existence of predetermined criteria for diagnosis of infection" and "correlation of results with control and prevention strategies" had the highest rates of non-compliance. Deviating data were highlighted in a study conducted in São Paulo, but it should also be considered that all participating institutions were accredited (7) .
Another component with low compliance was A similar research has found that this item had lower compliance rate, but with a much higher average (64%) (7) . The institutions that used outsourced infections, which require studies with robust design to provide strong scientific evidences (11) .
Another item with low compliance rate was the participation in technical decisions for specification and purchase of consumer products (38.46%). The material management comprises a complex process involving costs and quality of care. Thus, with increasingly tight budgets, it is vital to adopt technical criteria to justify the selection and acquisition of materials without compromising professionals and customers safety (12) .
For an NICP to be considered as performing well, it is necessary that the indicators are in compliance.  (13)(14)(15) .
Well-structured programs can reduce nosocomial infection rates and, consequently, the economic burden of these events (16) .
The work of experienced professionals with expertise in this subject has a substantial impact on the quality of this service. It is noteworthy that Brazil has a lack of specialized courses in NI control (17) , which

Conclusion
The use of indicators identified that, despite having much knowledge produced on prevention and control of nosocomial infections, there is still a large gap between the practice and the recommendations.
This research identified that the evaluation indicators of the NICP are is feasible and can be used both by these programs and the units that carry out inspection in health institutions, as a tool to improve the activities carried out.