IMPROVING INFECTION CONTROL PRACTICES AT

BULUBA HOSPITAL- MATERNITY WARD

BY

Wokali Olive Caroline. Dip Clinical Medicine

Kasadha Henry. BA Development Studies, Dip Educ

Nanyonga Rose Mary. Dip Midwifery

MEDIUM-TERM FELLOWS (HEALTH SERVICE IMPROVEMENT)

MENTORS

DR. KALENDE HENRY

DR. KAYITA GODFREY

FEBRUARY 2015

M A K E R E R E U N I V E R S I T Y

SCHOOL OF PUBLIC HEALTH (MakSPH-CDC FELLOWSHIP PROGRAM)

i

TABLE OF CONTENTS

List of Tables ................................................................................................................................................ ii

List of Figures ............................................................................................................................................... ii

DECLARATION ......................................................................................................................................... iii

ACRONYMS ................................................................................................................................................ v

EXECUTIVE SUMMARY/ABSTRACT.................................................................................................... vi

INTRODUCTION AND BACKGROUND.................................................................................................. 1

LITERATURE REVIEW .............................................................................................................................2

STATEMENT OF THE PROBLEM ............................................................................................................3

PROBLEM IDENTIFICATION AND PRIORITIZATION ........................................................................ 3

Baseline analysis of the poor infection control practices in Buluba Hospital...........................................4

GENERAL OBJECTIVES ...........................................................................................................................7

General Objective ......................................................................................................................................... 7

Specific Objectives ................................................................................................................................... 7

INTERVENTIONS....................................................................................................................................... 8

PROJECT OUTCOMES.............................................................................................................................11

LESSONS LEARNT AND CHALLENGES..............................................................................................13

Lessons learned ...........................................................................................................................................13

Challenges experienced and how they were overcome...............................................................................13

SUMMARY, CONCLUSION, RECOMMENDATIONS AND NEXT STEPS........................................14

Conclusions.................................................................................................................................................14

Recommendations.......................................................................................................................................14

Next steps (dissemination plan, follow-up/scale-up strategy) ....................................................................15

REFERENCES ...........................................................................................................................................16

Appendices..................................................................................................................................................17

Appendix 1: Attendance list of the CME on quality improvement............................................................17

Appendix 2; An invoice from JMS showing items which were purchased. ..............................................18

Appendix. 3; Attendance list for non-medical staff that were trained in infection control practices. Thiswas conducted on the 13th August 2014 ....................................................................................................19

Appendix 4; List of those who attended a follow-up meeting of the Q.I project........................................20

Appendix. 5; Attendance list of Infection control committee meeting held on the 15th of Jan 2015..........21

ii

List of Tables

Table 1: Problem identification ...................................................................................................... 4

Table 2; Assessment of wards on indicators affecting infection control (October 2013-

March2014)..................................................................................................................................... 5

List of Figures

Figure 1; showing baseline and Target ..........................................Error! Bookmark not defined.

Figure 2;Training on infection control being conducted by Dr. Martha Asiimwe. ............... Error!

Bookmark not defined.

iii

DECLARATION

I, Kasadha Henry, Wokali Caroline Olive and Nanyoga Rosemary do hereby declare that this

end-of project report entitled IMPROVING INFECTION CONTROL PRACTICES AT

BULUBA HOSPITAL- MATERNITY WARD has been prepared and submitted in fulfillment

of the requirements of the medium- term Fellowship Program at Makerere University School of

Public Health and has not been submitted for any academic or non-academic qualifications.

Signed ………………………………………………… Date ………………………………

Kasadha Henry, Medium-term Fellow

Project Coordinator

Signed ………………………………………………… Date ………………………………

Wokali Olive Caroline, Medium-term Fellow

Secretary for the Project

Signed ………………………………………………… Date ………………………………

Nanyonga Rose Mary, Medium-term Fellow

Accounting Officer for the project

Signed ………………………………………………… Date ………………………………

Dr. Kalende Henry

Deputy Medical Superintendent St Francis Hospital Buluba Hospital, Institution Mentor

Signed ………………………………………………… Date ………………………………

Dr. Kayita Godfrey

Ministry of Health, Academic Mentor

iv

ACKNOWLEDGEMENTS

We would like to extend our sincere gratitude to all who supported us during the design and

implementation of this project. We are grateful to the Deputy Medical superintendent Dr.

Kalende Henry (institutional Mentor), Sr. Nakirya Harriet Hospital administrator ,Dr Asiimwe

Martha in-charge Maternity ward, Dr Nionzima Elisabeth - Medical Superintendent for the

continuous encouragement; and all the maternity staff at Buluba Hospital for the co-operation

accorded during the implementation process. We also thank our facilitators, Dr. Violet

Gwokyalya, Dr. Kayita Godfrey (Academic Mentor), Mr. Matovu Joseph and the whole

academic staff of Makerere University School of Public Health-CDC Fellowship program whose

contributions have offered us great support during this time.

Special thanks go to the Centre for Disease Control (CDC) and Makerere University School of

Public Health-CDC Fellowship office for the financial and technical support.

We are gratiful to all who availed useful data for this report to be completed and all the friends

who acted as a point of contact.

Our special gratitude to our families we left for long days while we attended contact sessions in

Kampala. We love you all and truly appreciate all your support.

v

ACRONYMS

ANC Antenatal Care.

CPD Continuous Professional Development

HCAI Health Care acquired Infections.

HIV Human Immuno Deficiency Virus

M&E Monitoring and Evaluation.

OPD Out-Patient Department.

SARS Severe Acute Respiratory Syndrome.

SOP Standard Operating Procedures.

Sr. Sister

UCMB Uganda Catholic Medical Bureau

TB Tuberculosis

VCT Voluntary Counseling and Testing.

WHO World Health Organization.

vi

EXECUTIVE SUMMARY/ABSTRACT

Effective implementation of infection control programs and adherence to standard precautions

are challenging in resource-limited settings. Buluba Hospital suffered poor infection control

practices which resulted in a number of mothers in maternity ward acquiring infection on ward.

The objective of this project was to improve infection control practices at Buluba Hospital with

special emphasis on maternity ward. The team achieved this by; training all hospital staff in

infection control, (ii) promoting adherence to national guidelines and protocols on infection

control, (iii) promoting proper waste segregation practices through procurement of appropriate

waste segregation bins, (iv) promoting use of personal protective equipment and (v)

establishment of an infection control office and infection control committee to support the

implementation of improvement measures.

During the implementation process, the team engaged the hospital management team frequently

to enhance support supervision activities, review project activities on a monthly basis through

compiling M&E reports and setting up the quality improvement team that met monthly to review

and assess implementation activities.

The project registered very significant improvements. Staff started utilizing and demanding for

protective equipment, waste segregation on maternity ward drastically improved, the ward now

holds monthly meetings to review the operations of the unit in addition to infection control

progress and other departments have been influenced through regular meetings with them. They

have incorporated infection control items in their budget. We hope that the success and lessons

learnt from maternity ward will be used to scale up infection control practices to foster

improvements in the whole Hospital.

1

INTRODUCTION AND BACKGROUND

Modern hospital infection control programs first began in the 1950s in England, where the

primary focus of these programs was to prevent and control hospital-acquired staphylococcal

outbreaks (Karen Hoffmann 2000). Today, infection control is well established in most

healthcare organizations and is a very pertinent issue within clinical circles, public health, and

among health service consumers. A number of reports on poor hospital hygiene have been

published, including reports about patients’ fear about safety in hospitals. A few patients have

sued health care facilities and providers for perceived infection stemming from treatment

received at these centers (http://www.jidc.org/index.php/journal/article/viewFile/24129625/92).

This should raise concerns among health care personnel, both qualified and in training, and

among administrators and educators. Infection control is necessary to reduce the high levels of

healthcare-acquired infections (HCAI) and to curb the proliferation of antibiotic resistant

bacteria.

The World Health Organization (WHO) developed guidelines to provide administrators and

health care workers with the tools to enable them to implement the infection control program

effectively in order to protect themselves and others from the transmission of infections.

Uganda also acknowledges that transmission of infections in health care facilities can be

prevented and controlled through the application of basic infection control precautions. As such

the country has developed the Uganda National Infection Prevention and Control Guidelines

2013 to ensure prevention and control of infectious diseases at health facilities through safe

practices and to provide guidance on infection prevention at household level. The Ministry of

Health (MoH) has also defined structures right up to the health facility level where we should

have the health facility infection control committee to oversee implementation of infection

control practices at the different levels.

St. Francis hospital Buluba is a missionary hospital was founded in 1934 as an isolation and

treatment center for leprosy patients. It is located in Mayuge district about 120km from Kampala.

In 2002, the special treatment center was accredited as a general hospital to provide general

outpatient and in-patient medical and surgical services as well as specialist services. As a result

of this scale up, the hospital has been faced with an ever increasing patient load, and increasing

volume of medical wastes on all wards.

2

LITERATURE REVIEW

Infection Control continues to be a major challenge in health care settings as noted by Kirega

Bruce et’al (2012) whose study revealed that effective implementation of infection control

programs and adherence to standard precautions are challenging in resource-limited settings.

Schlaich et’al (2013) also notes that sparse data suggest that Health Care Acquired Infections

are widespread in Sub-Saharan Africa, with surgical sites being the dominant focus of infection.

Kirega et’al (2012) also asserts that changing infection control practices in developing countries

will require a multifaceted approach that addresses resource availability, occupational safety,

good administrative skills and local understanding and attitudes about infection control.

The millennium development goal number 5, Improve Maternal Health by 2015, targets to

reduce the number of maternal deaths; women need access to good-quality reproductive health

care and effective interventions.. Good-quality care takes charge of reducing the rate of

infections acquired in a facility by the mother and the new born. This reduces the patient days at

the facility enabling the care takers to participate in productive activities. It is noted that various

complications and a small proportion of patient deaths each year are primarily attributable to

hospital acquired infections” (National Audit Office, 2000).

It is against this background that the project sought to improve infection control at Buluba

Hospital.

3

STATEMENT OF THE PROBLEM

The maternity ward at Buluba hospital suffered inadequate infection control practices. The ward

handled normal deliveries, post natal care, post-operative mothers as well as pregnancy related

admissions and post natal complications like puerperal sepsis. The ward has 10 beds and on

average 5 mothers are admitted daily with the average length of stay for an admitted mother

being 3 days. There are at least three deliveries every day of which 2 are caesarean sections. All

admissions for the above mentioned condition including fresh deliveries and post-operative

mothers were mixed in one ward and shared the 10 beds depending on who came first. No

separate rooms or cubicles for the various categories of patients were reserved. In addition there

was no examination room for the mothers in labor; these were examined directly in the labor

suite on the same beds used for delivery. The ward lacked linen for mothers in labour and those

delivering. Also the midwives lacked personal protective equipment and adequate hand washing

facilities. There were no color coded bins for waste segregation yet the ward contributes 70% of

the medical waste generated at the Hospital.

All the above posed a risk of infection transmission to both the mothers and the health workers.

Data analysed before project implementation showed that on avergae 2.4% of the total deliveries

at the hospital acquired sepsis while on the ward during the immediate post natal period.

Maternity ward accounts for over 90% of the sepsis reported at the facility. This situation needed

urgent attention. The proposed project aimed at improving infection control practices on

maternity ward and consequently reducing the risk of infection transmission to clients as well as

staff.

PROBLEM IDENTIFICATION AND PRIORITIZATION

Upon completion of the first module of the Health service improvement course, the fellows

sensitized the hospital staff about the objectives of the course and introduced the concepts of

quality improvement through a Continuous Medical Education (CME) session. During the CME,

members brainstormed on the problems that the hospital faced which affected its performance.

Five problems were identified and these were scored as listed below in order of priority;

4

Table 1: Problem identification

No Identified problems Score

1 Long waiting time 19

2 Rehabilitation 00

3 Poor infection Control 06

4 Poor record keeping 00

5 Lack of directions at the hospital 01

From the above score, long waiting time initially emerged as the priority problem. It was during

the root cause analysis that the following were identified as causing long waiting time.

i. Lack of accommodation for staff which caused late coming

ii. Lack of motivation

iii. Absenteeism of staff from duty stations because of multiple Jobs

iv. Understaffing caused by high staff attrition

v. System related causes like computers when they have network break downs

vi. Scattered buildings

vii. Complicated patient flow with back and forth movements especially at the cashier’s

office.

It was noted that most of the causes generated were administrative, not system related, beyond

the fellowship team’s control and couldn’t be implemented within a span of five months. The

team also noted that Infection control was more important and deserved to be handled first.

Baseline analysis of the poor infection control practices in Buluba Hospital

A situation analysis was conducted to derive the baseline status of infection control practices at

the hospital. The analysis showed that all wards in Buluba Hospital had poor waste segregation

with no colour coded bins. They all utilized ordinary buckets for all categories of waste including

domestic waste, infectious waste, non-infectious waste and highly infectious waste. However

they all had safety boxes for disposing the sharps. With an aim to select the priority ward i.e. one

affected most by poor infection control practices, we analyzed the indicators below.

5

Table 2; Assessment of wards on indicators affecting infection control (October 2013-

March2014)

Wards

Children’s Male Female MaternityIndicators looked at in picking the priority

ward to implement project

1 Admissions 938 392 356 720

2 Number of beds per ward 40 35 35 10

3 No of surgical and non-surgical procedures. 0 35 37 554

4 Infections acquired on wards 0 0 0 10

5 Distribution of Waste bins. 15% 15% 15% 15%

6 % of isolations rooms 80% 75% 75% 5%

7 Average Bed Occupancy 51.375 42.33 28.816 123.5

The statistics above show that children’s ward has got the highest number of admissions

followed by maternity ward. Though the admissions on children’s ward are high, most cases are

medical illness like malaria, anemia, diarrhea diseases and respiratory tract infections and are

characterized by a short duration of hospital stay.

Maternity ward on the other hand faces a huge number of cases most being surgical procedures

including normal deliveries, caesarians section, evacuations and other pregnancy related

illnesses. In the last six months, maternity had a total of 554 procedures giving a percentage of

74% of the total admissions. In reference to the total procedures at maternity, 10 mothers

acquired sepsis while on ward accounting for 2% with in a period of six months

Maternity ward has a bed capacity of 10 and this is clearly low compared to the number of

admissions. In addition prior to project implementation, maternity ward had no isolation room;

all mothers with different conditions were admitted together in one room/ward. This posed a

higher risk of the mothers acquiring infections (as evidenced by the reported cases of sepsis

acquired on ward) hence prioritizing maternity ward for our project implementation.

6

Pictures showing some of the baseline infection control practices on maternity ward

Root cause analysis of poor infection control practices on maternity ward.

SurroundingSkills/Staff

Supplies

Knowledge gapon ordering

Inadequatesupply of linen

Poorplanning

Poorinfectioncontrolpractices

Systems

Un sensitized/careless caretakers

Septic proceduresby TBA’s

Lack of protocols

Lack of capacitybuilding

Lack of Supervision

Lack of isolation room

Inadequate space

Lack of codedbins

Knowledge gap

Improvised bins

A non functional sink meantfor hand washing

7

GENERAL OBJECTIVES

General Objective

To improve infection control practices at the Maternity Ward of Buluba Hospital by December

2014 .

Specific Objectives

1. To improve staff awareness (from 30% to 75%) on infection control practices by

December 2014

2. To improve staff adherence to the recommended infection control practices

3. To establish a proper waste segregation system in maternity ward by December 2014.

8

INTERVENTIONS

The project was implemented in collaboration with the managers and staff of Buluba Hospital

and specifically those involved in maternity ward. The project utilized participatory methods

from design stage and throughout the implementation phase. This was intended to create buy –in

from all staff and management. Awareness was created though trainings conducted with support

from the maternity ward In – Charge. The trainings were equally participatory in nature to ensure

ownership.

1. Training

In abid to create awareness on infection control and ensure that all team members were

knowledgeable about infection control practices and guidelines, trainings were developed and

held. A pre-test for the medical staffs were administered to assess knowledge on infection

control and prevention. This was intended to support the development of content for the training.

The first training was conducted for medical staff for a period of two days and later we trained

support staff. The trainings majorly tackled appropriate use of PPE, hand washing, waste

segregation and general hospital hygiene for the support staffs who were given inputs in the

areas of mixing jik, spot

cleaning among others.

A total of 76 staff were

trained 46 qualified staff

and 30 support staff

Figure 1; Training on

infection control being

conducted by Dr.

Martha Asiimwe

9

2. Procurement of materials

The project team was cognizant of the fact that training alone would not yield results if the staff

did not have the required materials to help curb infections in the hospital. Procurement of

infection control equipment meant for the project implementation was done through generating a

list of items and quotations from Joint Medical Stores. The project then procured materials

including Jik, Gum boots,

Bins, Bin liners, caps, face

masks, Vim, Buckets some of

which are shown in the photo

to help in the cleaning and

mops. The procured materials

were handed over to the senior

nursing officer and the staff at

the project site were oriented

on how to use them and were

encouraged to utilize them

always. We also obtained an

up-to-date National Infection prevention and control guidelines 2013 that are being used to guide

the Infection Control Committee of the hospital, and Standard Operating procedures which we

put on the walls as demonstrated below.

10

3. Establishment of standards

To ensure compliance and guidance in implementation of infection control practices in the

hospital as well as sustainability, the project team developed standard operating procedures about

hand washing, developed checklists to monitor the project and advocated for monthly review

meetings on maternity ward which are still operating.

The hospital is in the process of instituting an infection control office in place to support the

works of the committee. In addition an infection control committee for the hospital was

launched and currently it will be meeting every last Wednesday of every month to review its

activities and to support health workers to adhere to standards

4. Quality Improvement Team

In order to sustain the gains and create accountability mechanisms in the hospital,a Quality

Improvement Team was established and charged with monitoring activities and lead

performance review meetings.

We designed hand washing protocols, established a client flow system, initiated monthly

meetings in maternity to review improvements and lobbied for an isolation room and washing

facility for clients (especially that some of them would go straight from home to the delivery

room without washing)

11

PROJECT OUTCOMES

Attainment of knowledge by the hospital staff. As a result of the training, 80% of the medical

and non-medical staff where reached with infection control messages. This has resulted in a

change of attitude and practices. There is already a high demand for the personal protective

equipment. This is as a result of building capacity of the medical staff.

We noticed an improvement in waste segregation on maternity ward and at some extent on

other wards. Mixing of waste drastically reduced. The ward had all the recommended waste

bins and could regularly request for bun liners.

A midwife preparing for a procedure A support staff fully dressed and ready for work

12

The team noted that over the six months of project implementation, the maternity ward has

registered one mother who acquired sepsis on the ward.

Because of the implementation of the project, the maternity staff have demanded for more

delivery and evacuation packs for the department. This demonstrates high vigilance by the

maternity staff on practicing infection control.

The department now holds monthly meetings not only to analyze infection control practices

but also to review the quality of services offered to clients and specific clients to discuss.

We witnessed the greater involvement of the hospital management team in the project

implementation and this actually helped us a lot in causing change.

Different departments have been called upon to budget for infection control gadgets.

Color coded bins in use on the ward

13

LESSONS LEARNT AND CHALLENGES

Lessons learned

Utilization of data for decision making is critical for quality improvement

Always to implement projects in the departments where you are involved.

Team work is key coordinate and harness group efforts

Creativity and innovativeness

Need for sustainability of project even after end of implementation period.

Challenges experienced and how they were overcome

• Poor Attitude of the health workers at maternity. The medical Superintendent helped a lot

in causing individual meetings to cause some change.

• Neonatal Infections (Mothers come with infections and pass them to unborn baby). In this

the maternity has been called upon to improve on the quality of care to the mothers and

the babies but we note that a neonatal unit for babies from 0-7days. The budget process is

in the process to see the unit functioning son.

• Often time’s staffs expected some bit of payment and we had to explain to them the

importance of the project.

• Follow up of recommendations at Maternity Ward and general Hospital – We always

assigned some body to follow up and give a report in the next meeting.

• Expensive coded bins on the market visa ve our budget. So we opted for buckets to fill

the gap.

14

SUMMARY, CONCLUSION, RECOMMENDATIONS AND NEXT STEPS

Conclusions

Infection control practices in Buluba Hospital improved due to building the capacity of staff,

procurement of required tools and strengthening the supervision. Achievement required team

work, administrative support and the involvement of clients. Continuous capacity building

through trainings, mentorship and provision of protective gear is vital for ensuring infection

control. In addition, it enhances health worker confidence about their safety therefore provision

of better quality services. Improvements will be sustained through regular trainings, orientation

of new staff, and continuous review of efforts by the IC committee.

Lessons Learnt

Adherence to infection control practices greatly reduces transmission of hospital acquired

infections making health service delivery a friendly experience.

Implementation of infection control programs in resource limited settings is a challenge.

However, it is essential to prioritize and allocate resources for such activities.

It is important for all hospital staff to have knowledge and good attitude to observe the

infection control guidelines and policies.

Hand washing is the most important infection control measure which must be observed

by all health workers.

Recommendations

To the Institution; Supplies necessary for adherence to Standard Precautions should be readily available

(Note: This includes hand hygiene products, waste segregation bins and liners, personal

protective equipment, and injection safety equipment.)

Institutions and their top managers should allocate funds for infection control.

Capacity building for all health workers on infection control is required.

Establishment and functionalization of infection control committee for the hospital.

Enhance the use of the error reporting forms provided to the institution by MoH and

UCMB. These forms help in reporting hazards hence provide information as to where the

15

system is breaking down. It also helps institutions to target quality improvement activities

and reduces the likelihood of injury to patients.

Comprehensive monitoring of the health system and proper hand over of responsibilities.

The institution should adopt a multifaceted approach that addresses resource availability,

occupational safety, and local understanding and attitudes about infection control.

Improvement in structures to avail isolation rooms in an effort to prevent cross infection

onwards.

MakSPH-CDC Fellowship Program.

Continuous support and tracking of how well the fellows and programs initiated are

moving on.

Carrying out trainings of the top managers of institutions/hospitals by the School of

Public Health.

Next steps (dissemination plan, follow-up/scale-up strategy)

The infection control committee will continue meeting every month to reinforce current

standards of infection prevention and control practices, emphasizing the importance of

hand hygiene.

The facility will continue holding bi-monthly CPD’s on infection control to reinforce

knowledge

The team is working on a system for orientation of all new staff upon recruitment so that

current practices can be sustained

There are current efforts to negotiate with supporting partners (UPHS, UCMB ) to train

other staff in quality improvement

16

REFERENCES

1. Adriane Kamulegeya, Alex Nninda Kizito, Hannington Balidawa, 2013. Ugandan medical

and health sciences interns’ infection control knowledge and practices

2. Clara Schlaich, 2013.Healthcare-associated infections in sub-Saharan Africa. University of

Malawi, College of Medicine, Department of Medicine, Blantyre, Malawi.

3. Guide to infection prevention for outpatient settings: Minimum Expectations for Safe Care

http://www.cdc.gov/HAI/prevent/present_pubs.html

4. Uganda National Infection Prevention and Control Guidelines 2013. Downloaded from

http://www.wales.nhs.uk/sites3/Documents/739/RCN%20infection%20control.doc.pdf

17

Appendices

Appendix 1: Attendance list of the CME on quality improvement.

18

Appendix 2; An invoice from JMS showing items which were purchased.

19

Appendix. 3; Attendance list for non-medical staff that were trained in infection control

practices. This was conducted on the 13th August 2014.

20

Appendix 4; List of those who attended a follow-up meeting of the Q.I project

.

21

Appendix. 5; Attendance list of Infection control committee meeting held on the 15th of Jan

2015.