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“Infection prevention and control idea challenge” contest: a fresh view on medical education and problem solving

“Infection prevention and control idea challenge” contest: a fresh view on medical education and... Background: Healthcare-associated infections (HAIs) challenge modern medicine. Considering their high prevalence in Iran, we aimed to provide knowledge on the subject, and to teach about the importance of infection prevention and control (IPC) to a broad audience of pre-graduate healthcare professionals, focusing on education as the cornerstone of IPC. Main body: We invited Iranian medical students to present ideas on “how to reduce HAIs.” Projects were eligible if being original and addressing the call. Accepted projects were quality assessed using a scoring system. Forty-nine projects were submitted, of which 37 met the inclusion criteria. They had a mean score of 69.4 ± 18.3 out of the maximum possible score of 115. Four reviewers assessed the 37 projects for clinical applicability, impact on patient safety, and innovation, and selected the best 12 to compete at the 2nd International Congress on Prevention Strategies for Healthcare-associated Infections, Mashhad, Iran, 2018. The competition took place in three rounds. The selected teams presented their projects in the first round and debated one by one in a knockout manner, while the jury reviewed their scientific content and presentation skills. In the second round, the top 5 projects competed for reaching the final stage, in which the teams presented their ideas in front of a panel of international IPC experts to determine the first three ranks. At the end of the contest, the participants gained valuable criticisms on how to improve their ideas. Moreover, by its motivating atmosphere, the contest created an excellent opportunity to promote IPC in medical schools. Conclusions: Using innovation contests in pre-graduates is an innovative education strategy. It sensitizes medical students to the challenges of IPC and antimicrobial resistance and drives them to think about solutions. By presenting and defending their innovations, they deepen their understanding on the topic and generate knowledge transfer in both ways, from students to teachers and vice versa. Keywords: Infection control, Healthcare-associated infections, Medical education, Problem solving, Antimicrobial resistance, Surgical site infection, Hand hygiene, Healthcare economy Background reported to be up to 15.5% in low and middle income Healthcare-associated infections (HAIs) and antimicrobial countries, and the number is growing [1–5]. On the other resistance are among the most serious challenges in mod- hand, 35 to 55% of HAIs can be reduced by applying ern medicine, affecting both patients and healthcare multimodal infection control measures [6]. workers (HCW). The global HAI prevalence has been Many barriers affect best practice of infection prevention and control (IPC) measures, but the lack of knowledge on implementing IPC strategies and low compliance with best * Correspondence: AelamiMH@mums.ac.ir; didier.pittet@hcuge.ch Infection Control and Hand Hygiene Research Center, Imam Reza Hospital, practice guidelines are among the most important. Various Mashhad University of Medical Sciences, Shariati Square, Mashhad, Iran ideas to increase compliance toward IPC guidelines have Infection Control Programme and World Health Organization Collaborating been published, most of which include educational pro- Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, 4 Rue Gabrielle-Perret-Gentil, 1211 Geneva, Switzerland grammes taking into account local contexts [7]. A Chinese Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 2 of 10 group reported their positive experience in implementing The “Infection Prevention and Control Idea Challenge” an educational intervention among nurses that significantly contest improved knowledge, practice, and behaviour related to The “Infection Prevention and Control Idea Challenge” universal precaution measures [8]. A one-day course on was advertised and promoted by MMMSRG on January 2, IPC practices regarding central venous catheter (CVC) 2018, on the congress website and via social media. Med- insertion for medical students and physicians in the US re- ical students, who were known to MMMSRG, were dir- sulted in a significant decrease of CVC-associated infections ectly addressed to act as ambassadors for the contest at 18 months after the event [9]. Education both for under- their local medical school. This promotional activity by it- and postgraduates is key, and the World Health self initiated a movement to organize IPC campaigns and Organization (WHO) emphasized the importance of formal workshops in different medical schools, to teach medical education in IPC in their guidelines [10]. students the basics of IPC, and to motivate and prepare Ex-cathedra education or training focusing on know- them to develop and submit projects to the contest. ledge alone is not sufficient for behaviour change, and the A panel of IPC experts, journal editors, and reviewers implementation of IPC strategies is most effective when designed formats for collecting ideas (Fig. 1), assessing applying a multimodal strategy [10, 11]. The multimodal their eligibility for oral presentation (Table 1) and evalu- approach of the Geneva hand hygiene model using system ating the projects and their presentations by the partici- change (move from hand washing to hand rubbing), edu- pating students (Table 2). Projects had to be submitted cational tools, reminders in the work environment, active using a pre-defined format (Fig. 1), addressing one of the participation of staff, surveillance and feedback, as well as four main areas of the contest: credible involvement of leaders not only improved hand hygiene compliance but also reduced HAI and cross- 1. Adherence to hand hygiene guidelines: “How can transmission of multi-drug-resistant organisms [12]. Con- we remove the barriers (to appropriate adherence sistently, WHO developed and promoted a multimodal to hand hygiene guidelines)?” implementation strategy for hand hygiene improvement 2. Antibiotic stewardship: “How do we manage that are feasible, sustainable, and adaptable to different antibiotic misuse and overuse?” contexts. The strategy was reported to improve both 3. Post-surgical and procedure-related infections: knowledge of and compliance with hand hygiene in both “What is the best solution (to prevent post-surgical different geographical regions and different healthcare set- and procedure-related infections)?” tings [13, 14]. Multimodal strategies were identified as one 4. The role of society and economy in IPC: “How can of the key components for effective IPC strategies in acute we advertise and get a return on investment in IPC?” care [15], and also were identified as one of the WHO core components for IPC, both at institutional and With 49 submitted projects, the resonance of the call national levels [10–14, 16, 17]. was unexpectedly high. A single reviewer reviewed the Compliance with best practice procedures differs among projects to check formal eligibility. Twelve projects were healthcare professions, with doctors often be less compli- excluded for plagiarism or not being submitted in the ant toward basic IPC measures such as hand-hygiene [18]. correct format. The 37 remaining projects were evalu- Thus, more effort should be invested in improving com- ated and scored by four reviewers (2 national and 2 pliance of doctors with best practice procedures. An inte- international IPC experts) based on pre-determined grated IPC curriculum during medical school would help evaluation criteria (Table 1). to achieve this goal. Although multimodal implementation The mean scores of the projects are summarised in strategies are the most effective way to improve IPC prac- Table 3. Of a maximum of 115, the mean (± standard devi- tices [13, 15, 17], it is difficult to communicate this concept ation) score of the 37 accepted projects was 69.4 (± 18.3), to medical students. ranging from 21.0 to 92.3 (Table 3). Based on consensus To overcome the challenge of sensitizing medical stu- among the organisers of the contest, the 12 projects with dents to the burden of HAI in Iran [3, 4, 19], and delivering the highest scores were selected to be presented at the concepts of best practice in a complex multidisciplinary conference. Details of these projects are summarized in work context, to which students have not been fully Table 4. exposed, the Mashhad Medical Microbiology Student Three rounds of project presentations were organised Research Group [MMMSRG] organized workshops, cam- during the conference to select three winners. The first paigns, and conferences on IPC [2]. Here,wedescribethe round grouped the selected 12 teams (Table 4)intosix “InfectionPreventionand ControlIdeaChallenge” contest, pairs based on the proximity of their project ideas. Each nd which was organized as part of the “2 International Con- team competed to the allocated other team. They were gressonPreventionStrategies for Healthcare-Associated allowed to see the abstracts of their competitors before Infections” in April 2018 in Mashhad, Iran. presentation for better criticism. Each project was discussed Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 3 of 10 Fig. 1 Project submission form of the “Infection Prevention and Control Idea Challenge” contest for 15 min: the team presented the main concepts of their comments raised by the jury members in preparation for project in the first 5 min; the competitor team had the the second round. opportunity to express criticism in the second 5 min; the In the second round, the teams had 5 min to present presenting team had time to address questions and con- their revised projects, which was followed by two mi- cerns raised by the competitors in the last 5 min. Content nutes during which all other competitors could express and presentation were assessed by a jury of 5 general practi- criticism and concerns. The presenting team then had tioners using a pre-defined evaluation form (Table 2). The another 5 min to address criticism and raised concerns. general practitioners have worked and published in the field The same jury from the first round also assessed the of IPC and infectious diseases, and they have worked in projects in the second round, using the same scoring both public and private hospitals. Of a maximum of 188, form (Table 2). The top three projects were invited to be the mean (± standard deviation) score was 129.7 (± 18.0), presented in the final round on the last day of the con- ranging from 105.4 to 161.2 (Table 3). Although it was ference to a mixed national (1) and international (3) ex- planned to select one team from each pair for the second pert panel (Table 3). The experts ranked the projects round, only the top five projects were selected because using the pre-defined evaluation form (Table 2). some presentations were poor and the knock-out strategy Table 4 summarises the 12 projects presented at the would have eliminated good projects. The teams of the five conference in descending order of the scores. The three selected projects had to modify their project based on the winning projects are summarised below: Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 4 of 10 Table 1 The primary evaluation rubric of the “Infection Prevention and Control Idea Challenge” contest 1. The next generation of alcohol-based handrub behaviour change toward hand hygiene needs not containers: The main innovative idea was to design only education but also motivation. an alcohol-based handrub container connected to a 2. An automatic hand-hygiene monitoring system: counter. This counter would not only show the This project was based on “monitoring and surveil- number of times the HCWs use it, but it would also lance” as an integral part of IPC. The innovative as- display an inspirational scientific fact about the im- pect of this idea was an electronic badge connected portance of hand-hygiene, HAIs, and IPC practices. to the handrub dispenser, which grants entrance to The main concept behind this idea was that patient rooms or triggers an alarm: Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 5 of 10 Table 2 The final evaluation rubric of the “Infection Prevention and Control Idea Challenge” contest Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 6 of 10 Table 3 Titles and attributed scores of the received ideas No Title of the Project Mean score of the Mean score of the Mean score of the Mean score ± SD of primary review (out 1st round (out of 2nd round (out of the final presentation of 115) 188) 188) 1 The next generation of antiseptics (revised: The 89.5 ± 10.60 151.2 ± 2.28 155 ± 5.78 160.5 ± 19.84 next generation of antiseptic Containers) 2 An automatic hand hygiene monitoring system 87 ± 24.04 161.2 ± 6.41 163.2 ± 6.37 153 ± 12.02 3 Using the pocket chart to reduce antibiotic resistance 88 ± 15.55 146.6 ± 5.98 153 ± 6.59 142. 5 ± 22.48 4 Post-operation patient care to prevent and control 92.25 ± 7.42 141.8 ± 5.49 135.6 ± 4.61 N/A infections through the use of a mobile application 5 Mobile handrub dispenser 88 ± 18.38 137.2 ± 5.71 140.2 ± 5.06 N/A 6 Developing an integrated antibiotic monitoring and 90.5 ± 14.84 130.6 ± 4.56 N/A N/A management governmental system to reduce resistance to antibiotics 7 Prevention of implant-associated infections by using 85 ± 2.82 122 ± 6.63 N/A N/A electrospun nanofibers 8 Produce and use of new yarn stitches based on silver 84.5 ± 17.67 122.2 ± 4.49 N/A N/A nanoparticles 9 Nanotechnology: the open way of infection control, 84.5 ± 13.43 115.2 ± 5.06 N/A N/A prospects 10 Bacteriotherapy for wound healing 82.5 ± 10.60 117.6 ± 3.04 N/A N/A 11 How can we manage healthcare-associated infections 82.5 ± 20.50 105.8 ± 6.41 N/A N/A in hospitals? 12 Combination strategy (restriction-education) for antibiotic 79.5 ± 9.01 105.4 ± 7.02 N/A N/A stewardship program 13 Appropriate education of hand hygiene for children in 79 ± 21.21 N/A N/A N/A schools 14 Prevention and control of vaginal infections associated 78 ± 5.65 N/A N/A N/A with swimming pools 15 Establishing permanent workshops on skills and ideas 77.5 ± 0.70 N/A N/A N/A about prevention and control of infection in high schools 16 Ways to decrease the surgical site infection rate in Iran 75.5 ± 9.19 N/A N/A N/A 17 Side effects after surgery and recovery (make some 75.5 ± 20.50 N/A N/A N/A proprietary suture) 18 Training ways to control and prevent oral infections 75 ± 12.72 N/A N/A N/A in elementary students 19 Antimicrobial resistance, as big a risk as terrorism 75 ± 12.72 N/A N/A N/A 20 Strategies for improving hand hygiene, as a preventive 75 ± 16.97 N/A N/A N/A measure against hospital-acquired infections 21 Students as WHO health representatives in Iranian 73.5 ± 3.53 N/A N/A N/A schools; to modify previous strategies for better ones 22 Early diagnosis of prosthetic joint infections: focus on 70.5 ± 10.60 N/A N/A N/A biomarkers 23 Prevention of infection by diagnosing cancer through 68.5 ± 7.77 N/A N/A N/A biomarker levels and dielectric qualities as a minimally invasive and novel method 24 Placebo prescription and home remedies; a novel but 68 ± 7.07 N/A N/A N/A ignored method in Iran 25 Online medical network and acute infections control 67.5 ± 7.77 N/A N/A N/A 26 A traditional solution for antibiotic overuse 67.25 ± 18.03 N/A N/A N/A 27 Monitoring policy for antibiotics therapy 65 ± 0 N/A N/A N/A 28 Adherence to hand hygiene guidelines 60.5 ± 2.12 N/A N/A N/A 29 Fixing policies and education 56.5 ± 31.81 N/A N/A N/A 30 Our hands, where all things begin 55.5 ± 7.77 N/A N/A N/A Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 7 of 10 Table 3 Titles and attributed scores of the received ideas (Continued) No Title of the Project Mean score of the Mean score of the Mean score of the Mean score ± SD of primary review (out 1st round (out of 2nd round (out of the final presentation of 115) 188) 188) 31 Antibiotic stewardship: How do we manage antibiotic 55.25 ± 15.20 N/A N/A N/A misuse and overuse? 32 Surgery without infection 48.5 ± 13.61 N/A N/A N/A 33 Controlling respiratory infections in garrison 46 ± 14.31 N/A N/A N/A 34 Increasing the level of applied scientific information 40 ± 34.11 N/A N/A N/A of patients 35 Penicillin vs natural herbs esp. turnip 35.25 ± 33.58 N/A N/A N/A 36 Comparison of the effects and side effects of amoxicillin 24.25 ± 32.88 N/A N/A N/A and penicillin on teeth 37 Medical universities as an economic corporation 21 ± 23.51 N/A N/A N/A a. The dispenser connected to the patient room strategies to medical students might be challenging, an works as a door key, so the door will open only IPC contest can motivate students to engage in IPC and to if the HCW uses the handrub dispenser. invent innovative solutions. This adds to the main goal of b. An infection control area is defined around the medical education to have knowledgeable, skilled and patient (patient zone); if a HCW enters this up-to-date healthcare professionals who choose patients’ zone without using the handrub dispenser, an interests over their own [23]. However, patient safety, and alarm (beeping sound, flashing light, or particularly IPC is a long-term investment and maintaining vibration) issued by the personal badge notifies professional expertise needs continuous learning also after the HCW to perform hand hygiene before graduation [24]. approaching the patient. Overall, our IPC idea challenge contest had four main c. The data collected by the badge will be used to outcomes: monitor individual hand-hygiene compliance and may feed a reward-punishment system. 1. Sensitizing medical students for the problems 3. Using a pocket chart to reduce antibiotic resistance: around IPC and antimicrobial resistance This project focused on antibiotic stewardship. The 2. Integrating IPC and antimicrobial resistance in the main idea was to design a user-friendly chart called medical curricula “Pocket Chart,” which displays indications for starting 3. Fostering the creation of workshops and educational and stopping antibiotics combined with a detailed re- sessions on IPC and antimicrobial resistance port on local antibiotic resistance patterns. Although 4. Encouraging medical students to be solution- rather the main idea of using guidelines for an antibiotic pre- than problem-oriented when thinking about chal- scription is not novel, guidelines taking into account lenges in IPC and antimicrobial resistance local antimicrobial resistance are lacking in Iran. The team suggested that their “Pocket Chart” would be By inviting the students to participate in this programme, customized not only for each hospital but also for out- we challenged them to get interested in IPC but also to patient care. think critically in terms of basic concepts, strategies, inter- ventions, and implementation strategies. The high number Outcome and impacts of submitted projects of good quality combined with high Although HAIs are a significant challenge for healthcare motivation and investment by the medical students was a systems, it is believed that more than 30% of HAIs could success, and thus, contests may be an effective educational be prevented by correct IPC measures [6, 20]. Unfortu- strategy. nately, adherence to best practices and guidelines is very We reviewed all projects and provided feedback to low [10, 21]. Even in an environment with numerous pro- all participants to help them to improve their ideas motional campaigns on hand hygiene, compliance depends and make them more practical and implementable. more on “peer pressure and the perception of high self- The contest promoted education in both ways: from efficacy” than on reasoning [22]. Given that medical doc- students to peers and experts, and from experts to tors repeatedly have been reported with low compliance to students. The contest also provided an interactive en- IPC measures such as hand-hygiene, it seems essential to vironment via debates, in which participants learned integrate IPC in the curriculum of medical schools. How- to review projects and articulate concerns and con- ever, as communicating multimodal behaviour change structive criticism. Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 8 of 10 Table 4 Details of the 12 selected ideas presented orally Rank Title Main Idea 1 The next generation of antiseptics (revised: The main innovative idea of this team was to design an alcohol-based handrub container The next generation of antiseptic Containers) connected to a counter. This counter would not only show the number of times it is used by the HCWs, but it would also show an inspirational scientific fact about the importance of handrubs in hand-hygiene, hospital-acquired infections, and IPC practices. The main concept behind this idea was that increasing hand-hygiene adherence needs motivation and education. 2 An automatic hand hygiene monitoring system This project was based on “monitoring and surveillance” as an integral part of IPC. The innovative aspect of this idea was designing an electronic badge for HCWs that is connected to the handrub dispenser and they suggested an integrated plan consisted of three parts: 1. All entrance doors should be connected to a handrub dispenser that will work as a key to the door, so the doors will open only if the handrub dispenser is used by the HCWs. Besides, the use of handrubs will be recorded by the electronic badge as a monitoring device. 2. An infection control area will be defined around patients’ beds and if HCWs enter this area without using the handrub dispenser, an alarming signal (beeping sound, alarming light, or a vibration) via their badge will notify them to wash their hands before approaching to the patient. 3. The data collected by the badges will be used to monitor the hand-hygiene adherence among HCWs and may be used as a reward-punishment system to enforce this behaviour. 3 Using the pocket chart to reduce antibiotic This project was focused on antibiotic stewardship. The main idea was to design a resistance user-friendly chart, called “Pocket Chart”, including indications for starting antibiotics and antibiotic duration as well as a detailed report on antibiotic resistance patterns. Although the main idea of using guidelines for antibiotic prescription is not novel, local guidelines for different conditions are lacking in Iran. The team suggested that their Pocket Chart would be customized not only for each different hospital ward but also for different areas of the city for outpatients. 4 Post-operation patient care to prevent and control The main idea of this project was to design an app to monitor patients after surgery infections through the use of a mobile application and develop a platform for easy communication between patients and doctors. The app would have 4 parts, i.e. patient’s profile, notification panel, messaging, and question and answer part. The app would be supported by an online server containing medical records of the patients. The application would also make possible for different patients to communicate with each other and share their experiences. The application would gather information on patients’ condition after surgery and notify their doctors in case any red flag signs occur. 5 Mobile handrub dispenser This project focused on increasing the accessibility of the alcohol-based handrub solutions by designing a wearable handrub dispenser. The design included a wearable dispenser designed as a bracelet or armlet with a refillable container and a handrub container mounted on the walls that could be used to refill the bracelet/armlet. 6 Developing an integrated antibiotic monitoring This idea suggested an integrated monitoring and management system that oversees and management governmental system to the antibiotic prescription and usage. This system includes three parts: reduce resistance to antibiotics 1. Developing a two-part visit strategy for doctors, in which all patients with an indication for antibiotic use will be prescribed with the appropriate antibiotic. After a few days, the patient’s condition and response to antibiotic therapy will be evaluated 2. Developing an electronic system to record the amount of antibiotics prescribed for each patient and monitor their antibiotic use 3. Making strict rules for selling over-the-counter antibiotics Although these strategies are common in many developed healthcare system, in Iran we do not have an integrated system for antibiotic prescription monitoring 7 Prevention of implant-associated infections by In this project, the contestants aimed to develop a polymeric dressing with tunable drug using electrospun nanofibers release to be used in orthopaedic surgeries. The designed dressing would be made through electrospinning process and contain desired antibiotics. They suggested that their dressing would be applied on the implant site before closing the wound in the operation room. 8 Production and use of new yarn stitches based This team designed suture threads coated with silver nanoparticles to prevent surgical site on silver nanoparticles infection. 9 Nanotechnology: the open way of infection This team designed a urinary catheter coated with silver nanoparticles to prevent urinary control, prospects tract infections. 10 Bacteriotherapy for wound healing This project was mainly focused on a wound dressing that contains Lactobacillus rhamnosus GG and Lactobacillus plantarum isolates and prevents infections related Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 9 of 10 Table 4 Details of the 12 selected ideas presented orally (Continued) Rank Title Main Idea to diabetic foot. 11 How can we manage healthcare-associated Designing an electronic device containing patients’ files and charts to replace infections in hospitals? conventional charts was the focus. The device would scan HCWs’ hands and give access only to those with low bacterial contamination. 12 Combination strategy (restriction-education) This team developed an executive plan for antibiotic stewardship in three steps: for antibiotic stewardship program A. developing an electronic medical record software for monitoring antibiotic use, B. imposing strict rules with severe fines for over-the-counter antibiotic selling and C. mass education programs for general population. Another important outcome of our contest was linking Availability of data and materials The datasets used and/or analysed during the current study are available students to their supervisors for identifying innovative from the corresponding author on reasonable request. ideas in IPC and to prepare a competitive project. The contest helped medical students to do both learn about a Ethics approval and consent to participate Not applicable. problem and come up with solutions. The opportunity to compete with peers from other universities in Iran, and Consent for publication attending an international conference probably were im- Not applicable. portant incentives and drivers for investing in the contest. Competing interests The authors declare that they have no competing interests. Conclusions Author details Using innovation contests in pre-graduates is an innova- 1 Surgical Oncology Research Center, Mashhad University of Medical Sciences, tive education strategy. It sensitizes medical students to Mashhad, Iran. Mashhad Medical Microbiology Student Research Group, Mashhad University of Medical Sciences, Mashhad, Iran. Orthopaedic the challenges of IPC and antimicrobial resistance and Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. drives them to think about solutions. By presenting and 4 Student Research Committee, Mashhad University of Medical Sciences, defending their innovations, they deepen their under- Mashhad, Iran. Nuclear Medicine Resident, Mashhad University of Medical Sciences, Mashhad, Iran. Department of Neurology, McGovern Medical standing on the topic and generate knowledge transfer School, University of Texas Health Science Center at Houston, Houston, TX, in both ways, from students to teachers and vice versa. 7 USA. Infection Control Programme and World Health Organization Collaborating Centre on Patient Safety, University of Geneva Hospitals and Abbreviations Faculty of Medicine, 4 Rue Gabrielle-Perret-Gentil, 1211 Geneva, Switzerland. AMR: Antimicrobial resistance; CVC: Central venous catheter; HAI: Healthcare- Infection Control and Hand Hygiene Research Center, Imam Reza Hospital, associated infections; HCW: Healthcare workers; IPC: Infection prevention and Mashhad University of Medical Sciences, Shariati Square, Mashhad, Iran. control; MMMSRG: Mashhad Medical Microbiology Student Research Group; WHO: The World Health Organization Received: 3 September 2019 Accepted: 27 January 2020 Acknowledgements References We want to acknowledge Prof. John Conly, Dr. Amin Bojdi, Dr. Freshteh 1. Allegranzi B, Nejad SB, Combescure C, Graafmans W, Attar H, Donaldson L, Sheibani, Prof. Ling Moi Lin, Prof. Petra Gastmeier, Dr. Mehdi Asadi and Mrs. et al. 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Determinants of good adherence to hand hygiene among healthcare workers who have extensive exposure to hand hygiene campaigns. Infect Control Hosp Epidemiol. 2007;28:1267–74. 23. Swanwick T. Understanding Medical Education: Evidence, Theory and Practice. Hoboken: Wiley; 2011. p. 464. 24. Westerveld H, Briet J, Houwaart E, Legemaate J, Meerman TJ, Breetvelt E, et al. Dutch medical oath. Neth J Med. 2005;63:368–72. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Antimicrobial Resistance & Infection Control Springer Journals

“Infection prevention and control idea challenge” contest: a fresh view on medical education and problem solving

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Abstract

Background: Healthcare-associated infections (HAIs) challenge modern medicine. Considering their high prevalence in Iran, we aimed to provide knowledge on the subject, and to teach about the importance of infection prevention and control (IPC) to a broad audience of pre-graduate healthcare professionals, focusing on education as the cornerstone of IPC. Main body: We invited Iranian medical students to present ideas on “how to reduce HAIs.” Projects were eligible if being original and addressing the call. Accepted projects were quality assessed using a scoring system. Forty-nine projects were submitted, of which 37 met the inclusion criteria. They had a mean score of 69.4 ± 18.3 out of the maximum possible score of 115. Four reviewers assessed the 37 projects for clinical applicability, impact on patient safety, and innovation, and selected the best 12 to compete at the 2nd International Congress on Prevention Strategies for Healthcare-associated Infections, Mashhad, Iran, 2018. The competition took place in three rounds. The selected teams presented their projects in the first round and debated one by one in a knockout manner, while the jury reviewed their scientific content and presentation skills. In the second round, the top 5 projects competed for reaching the final stage, in which the teams presented their ideas in front of a panel of international IPC experts to determine the first three ranks. At the end of the contest, the participants gained valuable criticisms on how to improve their ideas. Moreover, by its motivating atmosphere, the contest created an excellent opportunity to promote IPC in medical schools. Conclusions: Using innovation contests in pre-graduates is an innovative education strategy. It sensitizes medical students to the challenges of IPC and antimicrobial resistance and drives them to think about solutions. By presenting and defending their innovations, they deepen their understanding on the topic and generate knowledge transfer in both ways, from students to teachers and vice versa. Keywords: Infection control, Healthcare-associated infections, Medical education, Problem solving, Antimicrobial resistance, Surgical site infection, Hand hygiene, Healthcare economy Background reported to be up to 15.5% in low and middle income Healthcare-associated infections (HAIs) and antimicrobial countries, and the number is growing [1–5]. On the other resistance are among the most serious challenges in mod- hand, 35 to 55% of HAIs can be reduced by applying ern medicine, affecting both patients and healthcare multimodal infection control measures [6]. workers (HCW). The global HAI prevalence has been Many barriers affect best practice of infection prevention and control (IPC) measures, but the lack of knowledge on implementing IPC strategies and low compliance with best * Correspondence: AelamiMH@mums.ac.ir; didier.pittet@hcuge.ch Infection Control and Hand Hygiene Research Center, Imam Reza Hospital, practice guidelines are among the most important. Various Mashhad University of Medical Sciences, Shariati Square, Mashhad, Iran ideas to increase compliance toward IPC guidelines have Infection Control Programme and World Health Organization Collaborating been published, most of which include educational pro- Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, 4 Rue Gabrielle-Perret-Gentil, 1211 Geneva, Switzerland grammes taking into account local contexts [7]. A Chinese Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 2 of 10 group reported their positive experience in implementing The “Infection Prevention and Control Idea Challenge” an educational intervention among nurses that significantly contest improved knowledge, practice, and behaviour related to The “Infection Prevention and Control Idea Challenge” universal precaution measures [8]. A one-day course on was advertised and promoted by MMMSRG on January 2, IPC practices regarding central venous catheter (CVC) 2018, on the congress website and via social media. Med- insertion for medical students and physicians in the US re- ical students, who were known to MMMSRG, were dir- sulted in a significant decrease of CVC-associated infections ectly addressed to act as ambassadors for the contest at 18 months after the event [9]. Education both for under- their local medical school. This promotional activity by it- and postgraduates is key, and the World Health self initiated a movement to organize IPC campaigns and Organization (WHO) emphasized the importance of formal workshops in different medical schools, to teach medical education in IPC in their guidelines [10]. students the basics of IPC, and to motivate and prepare Ex-cathedra education or training focusing on know- them to develop and submit projects to the contest. ledge alone is not sufficient for behaviour change, and the A panel of IPC experts, journal editors, and reviewers implementation of IPC strategies is most effective when designed formats for collecting ideas (Fig. 1), assessing applying a multimodal strategy [10, 11]. The multimodal their eligibility for oral presentation (Table 1) and evalu- approach of the Geneva hand hygiene model using system ating the projects and their presentations by the partici- change (move from hand washing to hand rubbing), edu- pating students (Table 2). Projects had to be submitted cational tools, reminders in the work environment, active using a pre-defined format (Fig. 1), addressing one of the participation of staff, surveillance and feedback, as well as four main areas of the contest: credible involvement of leaders not only improved hand hygiene compliance but also reduced HAI and cross- 1. Adherence to hand hygiene guidelines: “How can transmission of multi-drug-resistant organisms [12]. Con- we remove the barriers (to appropriate adherence sistently, WHO developed and promoted a multimodal to hand hygiene guidelines)?” implementation strategy for hand hygiene improvement 2. Antibiotic stewardship: “How do we manage that are feasible, sustainable, and adaptable to different antibiotic misuse and overuse?” contexts. The strategy was reported to improve both 3. Post-surgical and procedure-related infections: knowledge of and compliance with hand hygiene in both “What is the best solution (to prevent post-surgical different geographical regions and different healthcare set- and procedure-related infections)?” tings [13, 14]. Multimodal strategies were identified as one 4. The role of society and economy in IPC: “How can of the key components for effective IPC strategies in acute we advertise and get a return on investment in IPC?” care [15], and also were identified as one of the WHO core components for IPC, both at institutional and With 49 submitted projects, the resonance of the call national levels [10–14, 16, 17]. was unexpectedly high. A single reviewer reviewed the Compliance with best practice procedures differs among projects to check formal eligibility. Twelve projects were healthcare professions, with doctors often be less compli- excluded for plagiarism or not being submitted in the ant toward basic IPC measures such as hand-hygiene [18]. correct format. The 37 remaining projects were evalu- Thus, more effort should be invested in improving com- ated and scored by four reviewers (2 national and 2 pliance of doctors with best practice procedures. An inte- international IPC experts) based on pre-determined grated IPC curriculum during medical school would help evaluation criteria (Table 1). to achieve this goal. Although multimodal implementation The mean scores of the projects are summarised in strategies are the most effective way to improve IPC prac- Table 3. Of a maximum of 115, the mean (± standard devi- tices [13, 15, 17], it is difficult to communicate this concept ation) score of the 37 accepted projects was 69.4 (± 18.3), to medical students. ranging from 21.0 to 92.3 (Table 3). Based on consensus To overcome the challenge of sensitizing medical stu- among the organisers of the contest, the 12 projects with dents to the burden of HAI in Iran [3, 4, 19], and delivering the highest scores were selected to be presented at the concepts of best practice in a complex multidisciplinary conference. Details of these projects are summarized in work context, to which students have not been fully Table 4. exposed, the Mashhad Medical Microbiology Student Three rounds of project presentations were organised Research Group [MMMSRG] organized workshops, cam- during the conference to select three winners. The first paigns, and conferences on IPC [2]. Here,wedescribethe round grouped the selected 12 teams (Table 4)intosix “InfectionPreventionand ControlIdeaChallenge” contest, pairs based on the proximity of their project ideas. Each nd which was organized as part of the “2 International Con- team competed to the allocated other team. They were gressonPreventionStrategies for Healthcare-Associated allowed to see the abstracts of their competitors before Infections” in April 2018 in Mashhad, Iran. presentation for better criticism. Each project was discussed Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 3 of 10 Fig. 1 Project submission form of the “Infection Prevention and Control Idea Challenge” contest for 15 min: the team presented the main concepts of their comments raised by the jury members in preparation for project in the first 5 min; the competitor team had the the second round. opportunity to express criticism in the second 5 min; the In the second round, the teams had 5 min to present presenting team had time to address questions and con- their revised projects, which was followed by two mi- cerns raised by the competitors in the last 5 min. Content nutes during which all other competitors could express and presentation were assessed by a jury of 5 general practi- criticism and concerns. The presenting team then had tioners using a pre-defined evaluation form (Table 2). The another 5 min to address criticism and raised concerns. general practitioners have worked and published in the field The same jury from the first round also assessed the of IPC and infectious diseases, and they have worked in projects in the second round, using the same scoring both public and private hospitals. Of a maximum of 188, form (Table 2). The top three projects were invited to be the mean (± standard deviation) score was 129.7 (± 18.0), presented in the final round on the last day of the con- ranging from 105.4 to 161.2 (Table 3). Although it was ference to a mixed national (1) and international (3) ex- planned to select one team from each pair for the second pert panel (Table 3). The experts ranked the projects round, only the top five projects were selected because using the pre-defined evaluation form (Table 2). some presentations were poor and the knock-out strategy Table 4 summarises the 12 projects presented at the would have eliminated good projects. The teams of the five conference in descending order of the scores. The three selected projects had to modify their project based on the winning projects are summarised below: Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 4 of 10 Table 1 The primary evaluation rubric of the “Infection Prevention and Control Idea Challenge” contest 1. The next generation of alcohol-based handrub behaviour change toward hand hygiene needs not containers: The main innovative idea was to design only education but also motivation. an alcohol-based handrub container connected to a 2. An automatic hand-hygiene monitoring system: counter. This counter would not only show the This project was based on “monitoring and surveil- number of times the HCWs use it, but it would also lance” as an integral part of IPC. The innovative as- display an inspirational scientific fact about the im- pect of this idea was an electronic badge connected portance of hand-hygiene, HAIs, and IPC practices. to the handrub dispenser, which grants entrance to The main concept behind this idea was that patient rooms or triggers an alarm: Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 5 of 10 Table 2 The final evaluation rubric of the “Infection Prevention and Control Idea Challenge” contest Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 6 of 10 Table 3 Titles and attributed scores of the received ideas No Title of the Project Mean score of the Mean score of the Mean score of the Mean score ± SD of primary review (out 1st round (out of 2nd round (out of the final presentation of 115) 188) 188) 1 The next generation of antiseptics (revised: The 89.5 ± 10.60 151.2 ± 2.28 155 ± 5.78 160.5 ± 19.84 next generation of antiseptic Containers) 2 An automatic hand hygiene monitoring system 87 ± 24.04 161.2 ± 6.41 163.2 ± 6.37 153 ± 12.02 3 Using the pocket chart to reduce antibiotic resistance 88 ± 15.55 146.6 ± 5.98 153 ± 6.59 142. 5 ± 22.48 4 Post-operation patient care to prevent and control 92.25 ± 7.42 141.8 ± 5.49 135.6 ± 4.61 N/A infections through the use of a mobile application 5 Mobile handrub dispenser 88 ± 18.38 137.2 ± 5.71 140.2 ± 5.06 N/A 6 Developing an integrated antibiotic monitoring and 90.5 ± 14.84 130.6 ± 4.56 N/A N/A management governmental system to reduce resistance to antibiotics 7 Prevention of implant-associated infections by using 85 ± 2.82 122 ± 6.63 N/A N/A electrospun nanofibers 8 Produce and use of new yarn stitches based on silver 84.5 ± 17.67 122.2 ± 4.49 N/A N/A nanoparticles 9 Nanotechnology: the open way of infection control, 84.5 ± 13.43 115.2 ± 5.06 N/A N/A prospects 10 Bacteriotherapy for wound healing 82.5 ± 10.60 117.6 ± 3.04 N/A N/A 11 How can we manage healthcare-associated infections 82.5 ± 20.50 105.8 ± 6.41 N/A N/A in hospitals? 12 Combination strategy (restriction-education) for antibiotic 79.5 ± 9.01 105.4 ± 7.02 N/A N/A stewardship program 13 Appropriate education of hand hygiene for children in 79 ± 21.21 N/A N/A N/A schools 14 Prevention and control of vaginal infections associated 78 ± 5.65 N/A N/A N/A with swimming pools 15 Establishing permanent workshops on skills and ideas 77.5 ± 0.70 N/A N/A N/A about prevention and control of infection in high schools 16 Ways to decrease the surgical site infection rate in Iran 75.5 ± 9.19 N/A N/A N/A 17 Side effects after surgery and recovery (make some 75.5 ± 20.50 N/A N/A N/A proprietary suture) 18 Training ways to control and prevent oral infections 75 ± 12.72 N/A N/A N/A in elementary students 19 Antimicrobial resistance, as big a risk as terrorism 75 ± 12.72 N/A N/A N/A 20 Strategies for improving hand hygiene, as a preventive 75 ± 16.97 N/A N/A N/A measure against hospital-acquired infections 21 Students as WHO health representatives in Iranian 73.5 ± 3.53 N/A N/A N/A schools; to modify previous strategies for better ones 22 Early diagnosis of prosthetic joint infections: focus on 70.5 ± 10.60 N/A N/A N/A biomarkers 23 Prevention of infection by diagnosing cancer through 68.5 ± 7.77 N/A N/A N/A biomarker levels and dielectric qualities as a minimally invasive and novel method 24 Placebo prescription and home remedies; a novel but 68 ± 7.07 N/A N/A N/A ignored method in Iran 25 Online medical network and acute infections control 67.5 ± 7.77 N/A N/A N/A 26 A traditional solution for antibiotic overuse 67.25 ± 18.03 N/A N/A N/A 27 Monitoring policy for antibiotics therapy 65 ± 0 N/A N/A N/A 28 Adherence to hand hygiene guidelines 60.5 ± 2.12 N/A N/A N/A 29 Fixing policies and education 56.5 ± 31.81 N/A N/A N/A 30 Our hands, where all things begin 55.5 ± 7.77 N/A N/A N/A Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 7 of 10 Table 3 Titles and attributed scores of the received ideas (Continued) No Title of the Project Mean score of the Mean score of the Mean score of the Mean score ± SD of primary review (out 1st round (out of 2nd round (out of the final presentation of 115) 188) 188) 31 Antibiotic stewardship: How do we manage antibiotic 55.25 ± 15.20 N/A N/A N/A misuse and overuse? 32 Surgery without infection 48.5 ± 13.61 N/A N/A N/A 33 Controlling respiratory infections in garrison 46 ± 14.31 N/A N/A N/A 34 Increasing the level of applied scientific information 40 ± 34.11 N/A N/A N/A of patients 35 Penicillin vs natural herbs esp. turnip 35.25 ± 33.58 N/A N/A N/A 36 Comparison of the effects and side effects of amoxicillin 24.25 ± 32.88 N/A N/A N/A and penicillin on teeth 37 Medical universities as an economic corporation 21 ± 23.51 N/A N/A N/A a. The dispenser connected to the patient room strategies to medical students might be challenging, an works as a door key, so the door will open only IPC contest can motivate students to engage in IPC and to if the HCW uses the handrub dispenser. invent innovative solutions. This adds to the main goal of b. An infection control area is defined around the medical education to have knowledgeable, skilled and patient (patient zone); if a HCW enters this up-to-date healthcare professionals who choose patients’ zone without using the handrub dispenser, an interests over their own [23]. However, patient safety, and alarm (beeping sound, flashing light, or particularly IPC is a long-term investment and maintaining vibration) issued by the personal badge notifies professional expertise needs continuous learning also after the HCW to perform hand hygiene before graduation [24]. approaching the patient. Overall, our IPC idea challenge contest had four main c. The data collected by the badge will be used to outcomes: monitor individual hand-hygiene compliance and may feed a reward-punishment system. 1. Sensitizing medical students for the problems 3. Using a pocket chart to reduce antibiotic resistance: around IPC and antimicrobial resistance This project focused on antibiotic stewardship. The 2. Integrating IPC and antimicrobial resistance in the main idea was to design a user-friendly chart called medical curricula “Pocket Chart,” which displays indications for starting 3. Fostering the creation of workshops and educational and stopping antibiotics combined with a detailed re- sessions on IPC and antimicrobial resistance port on local antibiotic resistance patterns. Although 4. Encouraging medical students to be solution- rather the main idea of using guidelines for an antibiotic pre- than problem-oriented when thinking about chal- scription is not novel, guidelines taking into account lenges in IPC and antimicrobial resistance local antimicrobial resistance are lacking in Iran. The team suggested that their “Pocket Chart” would be By inviting the students to participate in this programme, customized not only for each hospital but also for out- we challenged them to get interested in IPC but also to patient care. think critically in terms of basic concepts, strategies, inter- ventions, and implementation strategies. The high number Outcome and impacts of submitted projects of good quality combined with high Although HAIs are a significant challenge for healthcare motivation and investment by the medical students was a systems, it is believed that more than 30% of HAIs could success, and thus, contests may be an effective educational be prevented by correct IPC measures [6, 20]. Unfortu- strategy. nately, adherence to best practices and guidelines is very We reviewed all projects and provided feedback to low [10, 21]. Even in an environment with numerous pro- all participants to help them to improve their ideas motional campaigns on hand hygiene, compliance depends and make them more practical and implementable. more on “peer pressure and the perception of high self- The contest promoted education in both ways: from efficacy” than on reasoning [22]. Given that medical doc- students to peers and experts, and from experts to tors repeatedly have been reported with low compliance to students. The contest also provided an interactive en- IPC measures such as hand-hygiene, it seems essential to vironment via debates, in which participants learned integrate IPC in the curriculum of medical schools. How- to review projects and articulate concerns and con- ever, as communicating multimodal behaviour change structive criticism. Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 8 of 10 Table 4 Details of the 12 selected ideas presented orally Rank Title Main Idea 1 The next generation of antiseptics (revised: The main innovative idea of this team was to design an alcohol-based handrub container The next generation of antiseptic Containers) connected to a counter. This counter would not only show the number of times it is used by the HCWs, but it would also show an inspirational scientific fact about the importance of handrubs in hand-hygiene, hospital-acquired infections, and IPC practices. The main concept behind this idea was that increasing hand-hygiene adherence needs motivation and education. 2 An automatic hand hygiene monitoring system This project was based on “monitoring and surveillance” as an integral part of IPC. The innovative aspect of this idea was designing an electronic badge for HCWs that is connected to the handrub dispenser and they suggested an integrated plan consisted of three parts: 1. All entrance doors should be connected to a handrub dispenser that will work as a key to the door, so the doors will open only if the handrub dispenser is used by the HCWs. Besides, the use of handrubs will be recorded by the electronic badge as a monitoring device. 2. An infection control area will be defined around patients’ beds and if HCWs enter this area without using the handrub dispenser, an alarming signal (beeping sound, alarming light, or a vibration) via their badge will notify them to wash their hands before approaching to the patient. 3. The data collected by the badges will be used to monitor the hand-hygiene adherence among HCWs and may be used as a reward-punishment system to enforce this behaviour. 3 Using the pocket chart to reduce antibiotic This project was focused on antibiotic stewardship. The main idea was to design a resistance user-friendly chart, called “Pocket Chart”, including indications for starting antibiotics and antibiotic duration as well as a detailed report on antibiotic resistance patterns. Although the main idea of using guidelines for antibiotic prescription is not novel, local guidelines for different conditions are lacking in Iran. The team suggested that their Pocket Chart would be customized not only for each different hospital ward but also for different areas of the city for outpatients. 4 Post-operation patient care to prevent and control The main idea of this project was to design an app to monitor patients after surgery infections through the use of a mobile application and develop a platform for easy communication between patients and doctors. The app would have 4 parts, i.e. patient’s profile, notification panel, messaging, and question and answer part. The app would be supported by an online server containing medical records of the patients. The application would also make possible for different patients to communicate with each other and share their experiences. The application would gather information on patients’ condition after surgery and notify their doctors in case any red flag signs occur. 5 Mobile handrub dispenser This project focused on increasing the accessibility of the alcohol-based handrub solutions by designing a wearable handrub dispenser. The design included a wearable dispenser designed as a bracelet or armlet with a refillable container and a handrub container mounted on the walls that could be used to refill the bracelet/armlet. 6 Developing an integrated antibiotic monitoring This idea suggested an integrated monitoring and management system that oversees and management governmental system to the antibiotic prescription and usage. This system includes three parts: reduce resistance to antibiotics 1. Developing a two-part visit strategy for doctors, in which all patients with an indication for antibiotic use will be prescribed with the appropriate antibiotic. After a few days, the patient’s condition and response to antibiotic therapy will be evaluated 2. Developing an electronic system to record the amount of antibiotics prescribed for each patient and monitor their antibiotic use 3. Making strict rules for selling over-the-counter antibiotics Although these strategies are common in many developed healthcare system, in Iran we do not have an integrated system for antibiotic prescription monitoring 7 Prevention of implant-associated infections by In this project, the contestants aimed to develop a polymeric dressing with tunable drug using electrospun nanofibers release to be used in orthopaedic surgeries. The designed dressing would be made through electrospinning process and contain desired antibiotics. They suggested that their dressing would be applied on the implant site before closing the wound in the operation room. 8 Production and use of new yarn stitches based This team designed suture threads coated with silver nanoparticles to prevent surgical site on silver nanoparticles infection. 9 Nanotechnology: the open way of infection This team designed a urinary catheter coated with silver nanoparticles to prevent urinary control, prospects tract infections. 10 Bacteriotherapy for wound healing This project was mainly focused on a wound dressing that contains Lactobacillus rhamnosus GG and Lactobacillus plantarum isolates and prevents infections related Arianpoor et al. Antimicrobial Resistance and Infection Control (2020) 9:26 Page 9 of 10 Table 4 Details of the 12 selected ideas presented orally (Continued) Rank Title Main Idea to diabetic foot. 11 How can we manage healthcare-associated Designing an electronic device containing patients’ files and charts to replace infections in hospitals? conventional charts was the focus. The device would scan HCWs’ hands and give access only to those with low bacterial contamination. 12 Combination strategy (restriction-education) This team developed an executive plan for antibiotic stewardship in three steps: for antibiotic stewardship program A. developing an electronic medical record software for monitoring antibiotic use, B. imposing strict rules with severe fines for over-the-counter antibiotic selling and C. mass education programs for general population. Another important outcome of our contest was linking Availability of data and materials The datasets used and/or analysed during the current study are available students to their supervisors for identifying innovative from the corresponding author on reasonable request. ideas in IPC and to prepare a competitive project. The contest helped medical students to do both learn about a Ethics approval and consent to participate Not applicable. problem and come up with solutions. The opportunity to compete with peers from other universities in Iran, and Consent for publication attending an international conference probably were im- Not applicable. portant incentives and drivers for investing in the contest. Competing interests The authors declare that they have no competing interests. Conclusions Author details Using innovation contests in pre-graduates is an innova- 1 Surgical Oncology Research Center, Mashhad University of Medical Sciences, tive education strategy. It sensitizes medical students to Mashhad, Iran. Mashhad Medical Microbiology Student Research Group, Mashhad University of Medical Sciences, Mashhad, Iran. Orthopaedic the challenges of IPC and antimicrobial resistance and Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. drives them to think about solutions. By presenting and 4 Student Research Committee, Mashhad University of Medical Sciences, defending their innovations, they deepen their under- Mashhad, Iran. Nuclear Medicine Resident, Mashhad University of Medical Sciences, Mashhad, Iran. Department of Neurology, McGovern Medical standing on the topic and generate knowledge transfer School, University of Texas Health Science Center at Houston, Houston, TX, in both ways, from students to teachers and vice versa. 7 USA. Infection Control Programme and World Health Organization Collaborating Centre on Patient Safety, University of Geneva Hospitals and Abbreviations Faculty of Medicine, 4 Rue Gabrielle-Perret-Gentil, 1211 Geneva, Switzerland. AMR: Antimicrobial resistance; CVC: Central venous catheter; HAI: Healthcare- Infection Control and Hand Hygiene Research Center, Imam Reza Hospital, associated infections; HCW: Healthcare workers; IPC: Infection prevention and Mashhad University of Medical Sciences, Shariati Square, Mashhad, Iran. control; MMMSRG: Mashhad Medical Microbiology Student Research Group; WHO: The World Health Organization Received: 3 September 2019 Accepted: 27 January 2020 Acknowledgements References We want to acknowledge Prof. John Conly, Dr. Amin Bojdi, Dr. Freshteh 1. Allegranzi B, Nejad SB, Combescure C, Graafmans W, Attar H, Donaldson L, Sheibani, Prof. Ling Moi Lin, Prof. Petra Gastmeier, Dr. Mehdi Asadi and Mrs. et al. Burden of endemic health-care-associated infection in developing Nasrin Khosravi Zenyani for their participation and support. We also would countries: systematic review and meta-analysis. Lancet. 2011;377:228–41. like to thank the executive team for their invaluable support to hold this 2. Arianpoor A, Estaji F, Naderinasab M, Askari E. Antimicrobial susceptibility contest. pattern of Staphylococcus aureus isolates against newly marketed antibiotics: a report from imam Reza Hospital of Mashhad, Iran. Razavi Int J Authors’ contributions Med. 2015;3:e31568. AAr: Contest design and management; writing and revision of the 3. Eshrati B, Asl HM, Afhami S, Pezeshki Z, Seifi A. Health care-associated manuscript. AZa: Data acquisition; writing and revision of the manuscript. infections in Iran: a national update for the year 2015. Am J Infect Control. EAs: Substantial contributions to contest and study design. AAR: Data 2018;46:663–7. acquisition and analysis. 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