Table 1 Results of the 1st and 2nd questionnaire surveys

 Physician (full-time)

75

(47–128)

80

(48.5–137.5)

0.237

80

(50–140)

81

(50–137)

0.805

 Nurse (full-time)

336

(235–528.5)

360

(251–561)

0.066

368

(246–543)

371

(251–561)

0.629

 Laboratory technologist (full-time)

23

(16–34)

24

(17–36)

0.107

24

(17–36.5)

24.5

(17–37)

0.819

 Pharmacist (full-time)

19

(13–28)

20

(14–30)

0.066

19

(14–28)

20

(14–30)

0.360

 Dietitian

5

(4–8)

5

(4–8)

0.097

5

(4–8)

6

(4–8)

0.370

 Administrative staff

52

(32–86)

53.5

(32–87)

0.611

56

(33–87)

56

(33–89)

0.718

 Registered ICD (MD or PhD)

2

(1–4)

3

(2–4)

0.139

3

(2–4)

3

(2–4)

0.322

We have an active ICT.

674

(99.4%)

557

(99.6%)

0.843

436

(99.8%)

435

(99.5%)

0.607

Number of ICT member, crude

10

(8–16)

11

(7–16)

0.103

11

(8–17)

11

(7–17)

0.530

 Physician

2.5

(2–4)

3

(2–4)

0.153

3

(2–4)

3

(2–4)

0.576

 Nurse

2

(2–4)

2

(2–4)

0.488

2

(2–4)

2

(2–4)

0.757

 Pharmacist

2

(1–2)

2

(1–2)

0.255

2

(1–2)

2

(1–2)

0.242

 Laboratory technologist

2

(1–2)

2

(1–2)

0.230

2

(1–2)

2

(1–2)

0.709

 Dietitian

0

(0–0)

0

(0–0)

0.910

0

(0–0)

0

(0–0)

0.948

 Administrative staff

1

(0–2)

1

(0–1)

0.969

1

(0–2)

1

(1–2)

0.926

Number of ICT member, full-time equivalent

2.8

(1.3–4.3)

2.8

(1.8–4)

0.717

2.8

(1.6–4.3)

2.8

(1.8–4.1)

0.920

 Physician

2.5

(2–4)

3

(2–4)

0.951

3

(2–4)

3

(2–4)

0.830

 Nurse

0.8

(0.8–1.3)

0.8

(0.8–1.3)

0.675

0.8

(0.8–1.3)

0.8

(0.8–1.3)

0.693

 Pharmacist

0.5

(0–0.8)

0.5

(0–0.8)

0.725

0.5

(0–0.8)

0.5

(0–0.65)

0.531

 Laboratory technologist

0.5

(0–0.8)

0.5

(0–0.5)

0.953

0.5

(0–1)

0.5

(0–0.8)

0.931

 Dietitian

0

(0–0)

0

(0–0)

0.068

0

(0–0)

0

(0–0)

0.067

 Administrative staff

0

(0–0.5)

0

(0–0.5)

0.839

0

(0–0.5)

0

(0–0.5)

0.524

FTE per 100 beds

0.7

(0.4–1.0)

0.7

(0.4–1.0)

0.918

0.7

(0.4–1.0)

0.7

(0.4–1.0)

0.918

We performed bacterial culture, identification, and susceptibility tests basically in our hospital.

542

(79.9%)

466

(83.4%)

0.301

355

(81.2%)

367

(84.0%)

0.362

We participate in JANIS programs.

647

(95.4%)

548

(98.0%)

0.025

426

(97.5%)

432

(98.9%)

0.219

 Clinical laboratory division

636

(93.8%)

536

(95.9%)

0.103

421

(96.3%)

422

(96.6%)

0.855

 Antimicrobial-resistant bacterial infection division

311

(45.9%)

288

(51.5%)

0.048

228

(52.2%)

235

(53.8%)

0.635

 Surgical site infection division

366

(54.0%)

324

(58.0%)

0.161

249

(57.0%)

259

(59.3%)

0.493

 Intensive care unit division

116

(17.1%)

88

(15.7%)

0.519

80

(18.3%)

74

(16.9%)

0.595

 Neonatal intensive care unit division

74

(10.9%)

64

(11.4%)

0.766

56

(12.8%)

51

(11.7%)

0.606

 The head of our hospital attends ICC almost every time.

576

(85.0%)

473

(84.6%)

0.027

379

(86.7%)

369

(84.4%)

0.018

 We have a comprehensive hospital infection control manual that can be used all around our hospital.

677

(99.9%)

559

(100.0%)

0.364

437

(100.0%)

437

(100.0%)

–

 We hold a workshop regarding countermeasures against hospital infection more than once a year.

677

(99.9%)

559

(100.0%)

0.364

437

(100.0%)

437

(100.0%)

–

 We have tools, such as the intranet and bulletin boards, to inform our staff of hospital infection-related matters.

671

(99.0%)

556

(99.5%)

0.397

434

(99.3%)

436

(99.8%)

0.317

 We hold a regular ICT meeting.

628

(92.6%)

534

(95.5%)

0.042

410

(93.8%)

416

(95.2%)

0.353

 We provide consultation as an activity of the ICT.

633

(93.4%)

516

(92.3%)

0.274

412

(94.3%)

407

(93.1%)

0.333

 We have an AST (a member can work for both ICT and AST).

542

(79.9%)

373

(66.7%)

<.001

355

(81.2%)

305

(69.8%)

<.001

 We monitor the uses of antibiotics to assure their propriety.

652

(96.2%)

544

(97.3%)

0.476

420

(96.1%)

431

(98.6%)

0.064

 We intervene to assure appropriate uses of antibiotics.

631

(93.1%)

527

(94.3%)

0.177

410

(93.8%)

415

(95.0%)

0.317

 We have established criteria of interventions, such as their administration duration and selection, for patients administered antibiotics.

466

(68.7%)

399

(71.4%)

0.589

304

(69.6%)

310

(70.9%)

0.691

 We have criteria for the uses of anti-MRSA antibiotics.

433

(63.9%)

361

(64.6%)

0.964

267

(61.1%)

278

(63.6%)

0.594

 We record the used amount of anti-MRSA antibiotics.

667

(98.4%)

554

(99.1%)

0.508

432

(98.9%)

432

(98.9%)

0.788

 We have a reporting system (1st survey: “registration system”) for the use of anti-MRSA antibiotics.

390

(57.5%)

542

(97.0%)

<.001

259

(59.3%)

425

(97.3%)

<.001

 We have a preauthorization and/or restriction system for the use of anti-MRSA antibiotics.

321

(47.3%)

208

(37.2%)

<.001

206

(47.1%)

169

(38.7%)

0.035

 We have criteria for the uses of broad-spectrum antibiotics such as carbapenems.

355

(52.4%)

287

(51.3%)

0.369

217

(49.7%)

224

(51.3%)

0.305

 We have a reporting system (1st survey: “registration system”) for the use of broad-spectrum antibiotics.

391

(57.7%)

530

(94.8%)

<.001

251

(57.4%)

415

(95.0%)

<.001

 We have a preauthorization and/or restriction system for the use of broad-spectrum antibiotics.

258

(38.1%)

131

(23.4%)

<.001

157

(35.9%)

111

(25.4%)

0.003

 We record the used amount of broad-spectrum antibiotics.

667

(98.4%)

550

(98.4%)

0.935

429

(98.2%)

431

(98.6%)

0.777

 We have a reference system, such as the intranet of a booklet, for the antibiogram.

562

(82.9%)

482

(86.2%)

0.238

371

(84.9%)

383

(87.6%)

0.499

 We performed TDM for basically all cases.

423

(62.4%)

362

(64.8%)

0.273

273

(62.5%)

287

(65.7%)

0.193

 We record the vaccination proportion of employees who are HBsAg-negative.

581

(85.7%)

485

(86.8%)

0.415

369

(84.4%)

378

(86.5%)

0.096

 We perform IGRAs for employees who are in contact with tuberculosis patients.

616

(90.9%)

503

(90.0%)

0.772

404

(92.4%)

397

(90.8%)

0.556

 We record employees’ immunization statuses for measles, rubella, chickenpox, and mumps (2nd survey: “for all of measles, rubella, chickenpox, and mumps”).

572

(84.4%)

340

(60.8%)

<.001

371

(84.9%)

273

(62.5%)

<.001

 We have a manual and a reporting system of needle punctures and sharp object injuries.

678

(100.0%)

559

(100.0%)

–

437

(100.0%)

437

(100.0%)

–

 Needle puncture and sharp object injuries are reported to a relevant department, such as ICT.

463

(68.3%)

391

(69.9%)

0.177

301

(68.9%)

307

(70.3%)

0.408

 ICT and/or ICPs check the number of isolated antimicrobial-resistant organisms and other microorganisms that are relevant to infection control on a daily basis

436

(64.3%)

357

(63.9%)

0.409

281

(64.3%)

286

(65.4%)

0.110

 ICT and/or ICPs record the species and trends of isolated microorganisms on a type-of-sample and a ward-by-ward basis.

636

(93.8%)

530

(94.8%)

0.142

413

(94.5%)

414

(94.7%)

0.257

 We have a direct and fast reporting system to the doctor-in-charge, such as e-mail and telephone, when microorganisms are isolated from a sample that is supposed to be aseptic (e.g., a blood sample).

653

(96.3%)

550

(98.4%)

0.068

422

(96.6%)

431

(98.6%)

0.088

 We perform surveillance for surgical site infections.

510

(75.2%)

446

(79.8%)

0.038

334

(76.4%)

355

(81.2%)

0.119

 We perform surveillance for ventilator-associated pneumonia.

238

(35.1%)

219

(39.2%)

0.254

162

(37.1%)

175

(40.0%)

0.422

 We perform surveillance for central line-associated bloodstream infections.

508

(74.9%)

440

(78.7%)

0.190

330

(75.5%)

351

(80.3%)

0.088

 We perform surveillance for catheter-associated urinary tract infections.

345

(50.9%)

310

(55.5%)

0.275

224

(51.3%)

258

(59.0%)

0.063

 We perform active surveillance cultures.

334

(49.3%)

273

(48.8%)

0.905

228

(52.2%)

219

(50.1%)

0.831

 We have an established manual for outbreaks.

637

(94.0%)

534

(95.5%)

0.370

417

(95.4%)

419

(95.9%)

0.947

 We have a manual for the outbreak of tuberculosis.

675

(99.6%)

559

(100.0%)

0.290

435

(99.5%)

437

(100.0%)

0.368

 We have a manual for the outbreak of measles.

623

(91.9%)

513

(91.8%)

0.175

398

(91.1%)

401

(91.8%)

0.222

 We have a manual for the outbreak of chickenpox.

612

(90.3%)

502

(89.8%)

0.161

393

(89.9%)

395

(90.4%)

0.222

 We provide N95 masks at the outpatient emergency department and other outpatient departments.

664

(97.9%)

551

(98.6%)

0.648

429

(98.2%)

432

(98.9%)

0.661

 We put a surgical mask on patients with suspected airborne infections while transporting.

677

(99.9%)

558

(99.8%)

0.361

436

(99.8%)

436

(99.8%)

0.368

 Wearing an N95 mask is mandatory while entering the ward of a patient with suspected tuberculosis.

676

(99.7%)

558

(99.8%)

0.680

436

(99.8%)

436

(99.8%)

1.000

 We have a manual for the outbreak of influenza.

674

(99.4%)

555

(99.3%)

0.736

435

(99.5%)

435

(99.5%)

1.000

 Wearing a surgical mask while entering the ward of a patient with a droplet infection is instructed by a manual.

671

(99.0%)

558

(99.8%)

0.152

432

(98.9%)

437

(100.0%)

0.081

 We provide surgical masks in the wards of patients with droplet infections.

589

(86.9%)

486

(86.9%)

0.716

374

(85.6%)

380

(87.0%)

0.336

 We have a manual for cases in which MRSA is isolated from a patient.

667

(98.4%)

551

(98.6%)

0.661

429

(98.2%)

433

(99.1%)

0.400

 Wearing disposable gloves and a gown is mandatory while entering the ward of a patient with suspected contagious diseases.

618

(91.2%)

508

(90.9%)

0.966

399

(91.3%)

401

(91.8%)

0.793

 We provide alcohol-based hand sanitizers in all wards except for some special wards, such as the psychiatric ward.

657

(96.9%)

546

(97.7%)

0.525

427

(97.7%)

428

(97.9%)

0.607

 We provide alcohol-based hand sanitizers in all outpatient departments.

624

(92.0%)

529

(94.6%)

0.151

404

(92.4%)

415

(95.0%)

0.224

 We adopt closed urine drainage systems.

644

(95.0%)

544

(97.3%)

0.112

419

(95.9%)

426

(97.5%)

0.412

 We do not change catheters without blockages or infections regularly.

512

(75.5%)

418

(74.8%)

0.619

322

(73.7%)

323

(73.9%)

0.904

 We have a manual for the maintenance of ventilators.

583

(86.0%)

499

(89.3%)

0.221

376

(86.0%)

388

(88.8%)

0.424

 We adopt closed tracheal suction systems.

568

(83.8%)

476

(85.2%)

0.799

382

(87.4%)

381

(87.2%)

0.931

 We use sterile water for humidifiers.

658

(97.1%)

544

(97.3%)

0.120

428

(97.9%)

426

(97.5%)

0.311

 We perform regular oral cleansing for intubated patients in approximately 100% of relevant cases.

524

(77.3%)

425

(76.0%)

0.225

340

(77.8%)

333

(76.2%)

0.226

 We have a manual for the maintenance of central line catheters.

654

(96.5%)

542

(97.0%)

0.108

418

(95.7%)

425

(97.3%)

0.294

 We insert central line catheters under maximal barrier precautions in approximately 100% of relevant cases.

254

(37.5%)

210

(37.6%)

0.086

163

(37.3%)

167

(38.2%)

0.150

 We prepare intravenous hyperalimentation admixtures on clean benches in approximately 100% of relevant cases.

277

(40.9%)

225

(40.3%)

0.415

182

(41.6%)

175

(40.0%)

0.335

 We use transparent dressings on the sites of catheter insertion to make them easy to inspect visually in approximately 100% of relevant cases.

563

(83.0%)

486

(86.9%)

0.224

357

(81.7%)

380

(87.0%)

0.112

 We instruct new employees in hand hygiene by practical training sessions for all professions.

361

(53.2%)

290

(51.9%)

0.955

229

(52.4%)

222

(50.8%)

0.700

 We evaluate the implementation of hand hygiene instructions of all wards at least once a year.

603

(88.9%)

523

(93.6%)

0.018

389

(89.0%)

411

(94.1%)

0.028

 We instruct new employees of all professions how to put on and remove PPE.

532

(78.5%)

426

(76.2%)

0.638

347

(79.4%)

330

(75.5%)

0.255

 We instruct all employees in PPE by practical training sessions every year.

135

(19.9%)

107

(19.1%)

0.281

85

(19.5%)

80

(18.3%)

0.126

 We provide hand sanitizers at the entrance of all wards.

656

(96.8%)

544

(97.3%)

0.407

426

(97.5%)

426

(97.5%)

0.593

 All medical devices (e.g., thermometers, stethoscopes) of single isolation rooms are patient-dedicated.

653

(96.3%)

529

(94.6%)

0.152

423

(96.8%)

414

(94.7%)

0.174

 We check expiry dates of sterilized medical devices daily.

638

(94.1%)

528

(94.5%)

0.949

415

(95.0%)

416

(95.2%)

0.987

 We check expiry dates of unused medications.

664

(97.9%)

551

(98.6%)

0.516

429

(98.2%)

430

(98.4%)

0.741

 We have established guides for the expiry dates of opened medications.

649

(95.7%)

542

(97.0%)

0.285

421

(96.3%)

422

(96.6%)

0.514

 All wards have at least one infection control link nurse.

669

(98.7%)

547

(97.9%)

0.535

432

(98.9%)

429

(98.2%)

0.571

 Medical professions do not change their shoes while entering ICU.

548

(80.8%)

425

(76.0%)

0.123

363

(83.1%)

335

(76.7%)

0.037

 Medical professions are not recommended to wear gowns while entering ICU.

548

(80.8%)

425

(76.0%)

0.116

361

(82.6%)

337

(77.1%)

0.128

 We have handwashing sinks at the entrance of ICU.

397

(58.6%)

320

(57.2%)

0.085

259

(59.3%)

248

(56.8%)

0.107

 We provide hand sanitizers at the entrance of ICU.

549

(81.0%)

426

(76.2%)

0.114

362

(82.8%)

338

(77.3%)

0.095

 We advise the patients’ families to use hand sanitizers or wash hands before and after entering ICU.

545

(80.4%)

428

(76.6%)

0.016

362

(82.8%)

339

(77.6%)

0.066

 We do not change stretchers while entering operating rooms.

518

(76.4%)

449

(80.3%)

0.046

334

(76.4%)

352

(80.5%)

0.211

 Medical professions do not change their shoes while entering operating rooms.

395

(58.3%)

356

(63.7%)

0.102

263

(60.2%)

285

(65.2%)

0.299

 We do not provide sticky mats at the entrance of operation rooms.

670

(98.8%)

552

(98.7%)

0.734

434

(99.3%)

432

(98.9%)

0.715

 We have established standards of surgical hand preparation.

579

(85.4%)

492

(88.0%)

0.331

375

(85.8%)

381

(87.2%)

0.553

 We do not recommend the use of a brush for surgical hand preparation.

641

(94.5%)

534

(95.5%)

0.424

419

(95.9%)

420

(96.1%)

0.867

 We use electric clippers or depilatory creams for patients who need to remove their hair before surgery in all departments.

651

(96.0%)

532

(95.2%)

0.572

420

(96.1%)

418

(95.7%)

0.271

 We advise patients who can take a shower to take a shower on the night before or the morning of the day of surgery.

638

(94.1%)

526

(94.1%)

0.865

410

(93.8%)

410

(93.8%)

0.478

 We recommend the administration of prophylactic antibiotics 30 min to 1 h before the incision.

640

(94.4%)

522

(93.4%)

0.582

421

(96.3%)

406

(92.9%)

0.710

 We have manuals to establish the duration of prophylactic antibiotics administration in all departments.

304

(44.8%)

266

(47.6%)

0.532

188

(43.0%)

214

(49.0%)

0.230

 We adopt dry kitchen systems for hospital meals.

508

(74.9%)

453

(81.0%)

0.005

330

(75.5%)

356

(81.5%)

0.040

 We distinguish infectious waste from other waste and store it in a place inaccessible to non-authorized people.

667

(98.4%)

546

(97.7%)

0.667

428

(97.9%)

427

(97.7%)

0.607

 We do not pre-clean or pre-disinfect medical devices in wards.

549

(81.0%)

463

(82.8%)

0.526

355

(81.2%)

368

(84.2%)

0.501

 We clean and disinfect endoscopes in accordance with the manuals or check them regularly.

582

(85.8%)

472

(84.4%)

0.498

375

(85.8%)

372

(85.1%)

0.885