KENYA METHODIST UNIVERSITY

FACULTY OF HEALTH SCIENCES

DEPARTMENT OF NURSING

COURSE TITLE: COMMUNITY HEALTH 11

CLINICAL PLACEMENT AT MATERNAL CHILD HEALTH

AND FAMILY PLANNING CLINIC, EMBU PROVINCIAL

HOSPITAL: AUGUST 2009

CASE STUDY TOPIC: MAINTENANCE OF COLD

CHAIN

COURSE CODE: NRSG 331

LECTURER: MARY JOY

REPORT BY: DOROTHY MBAYA

REG. NUMBER: BSN 1- 0118-1/2007

Table of contentsSection 1: List of abbreviations and definitionsSection 2: IntroductionSection 3: Clinical reportSection 4: Case studySection 5: ConclusionSection 6: Recommendations

ABBREVIATIONS

1) MCH/FP: Maternal Child Health and family planning2) CWC: Child Welfare Clinic3) EPGH- Embu Provincial General Hospital4) ANC: Ante Natal Clinic5) PMTCT: prevention of mother to child transmission6) KMTC: Kenya medical and training college7) KEPI: Kenya expanded programme on immunization

INTRODUCTION

I was attached at Embu provincial general hospital for 3 weeks where I rotated and gained experience in MCH/FP clinic.

A brief history of Embu provincial general hospital.

Embu town is one of the provincial headquarters founded in 1906. It servers as the provincial headquarter of Eastern Province and also the District headquarter for Embu District. Embu Provincial general hospital is located within Embu municipality along Nairobi-Meru highway. It is the largest general hospital in Eastern province and serves other district as a referral hospital.

Currently the ministry of health has ranked hospitals in levels of 1-5; Level 5 being a referral hospital to the lower levels. EPGH is ranked at level 5 acting as the referral for other hospitals within the great Eastern province, this includes patient from other government hospitals and the private hospitals mainly in Embu district and also as far from Kitui and Mbeere district.

The hospital also serves as a training institution for Doctors, Nurses, Clinical Officers and medical laboratory from both Government and private institutions.

To ensure that the hospital has a good health care delivery system ,it have a well stated mandate, vision and mission which is well distributed in working places within the hospital ( all departments),.

Mandate

To formulate policies, set standards, provide health services, create an enabling environment and regulate provision of health service delivery.

Vision

To be a leading health facility in the East African region by offering quality and passionate health care that is acceptable and cost effective.

Mission.

To promote and provide quality curative and rehabilitative health care services with emphasis on professionalism, innovation and use of new and safe technologies.

Core- values

We insist on honesty, integrity and trustworthiness throughout the process of our service delivery.

We encourage staff initiative and involvement by creating opportunities for our people to learn and grow.

We are an “open” organization that encourages, seeks out and incorporates feedback from our clients and stakeholders.

We are satisfied with nothing less than the very best in everything we do and will always Endeavour to provide timely services geared towards our clients satisfaction.

The hospital provides in patient and out patient services. The outpatient services include maternity child health (mat) services, family planning services, comprehensive care for HIV patients and other special schedule clinics. In the inpatient the hospital has a bed capacity of 565 beds distributed among the 17 wards. The wards consist of medical wards, maternity unit, general surgical wards, gynecological wards, psychiatric department eye wards and amenity wards. The hospital has a large team of medical and nursing staff at different ranks and cadre. It has a total of 291 nurses. These comprise of:

Bachelor of Science nurses - 3

Kenya Registered Community nurses/Kenya registered nurse -68

Enrolled Community nurses - 220.

Total 291

STRUCTURAL ORGANIZATION OF THE UNIT.

STAFFING AT MCHMCH unit acts as a referral point for other clinics and also serves the local people hence the clinic is usually very busy. It comprises of a total of 10 nurses. The ratios are usually good when the students especially KMTC are in session. They run the clinic from 8:00 Am to 6:30 Pm hence they work in shifts. Due to workload being heavy in the morning, at least, 3 staffs report in the morning and one or two in the afternoon.

Senior nursing officer in charge of hospital

Deputy senior nursing officer in charge of the hospital

Unit Nursing Officer

Ward In charge

Deputy Ward In charge

Nursing Staff

Students

USUAL DAILY ACTIVITIESI was actively involved in the daily activities which include the following:

I. Prescribing and administration of medicationsII. Monitoring vital signs

III. Health educationIV. Paediatric resuscitationV. Running FP clinic

VI. Running CWCVII. Running ANC clinic

VIII. PMTCT counselling

STANDARD SETTING AND MONITORING IN NURSING CARE

The hospital management has put in place high standards and quality assurance models of evaluating, enforcing and maintaining the quality of services offered in the hospital. It has a well established effective system of monitoring and evaluating its service provision with which it conducts a timely annual monitoring and evaluation of each and every service in every department and human resource base.

INTRODUCTION OF THE CASE STUDY.According to World Health Organization, in 2002 alone, 1.4 million deaths among children under the age of 5 could have been prevented by routine vaccinations. Expertise in the maintenance and support of Cold Chain (for effectively storing and transporting vaccines under chilled conditions from manufacturer to end-user), and medical waste management has been developed in direct response to this challenge.

During the placement l noted that cold chain maintenance was highly affected due to the electricity power rationing. This led to the KEPI office to withdraw most of the vaccines from the MCH fridge as the potency of the vaccines was questionable. Moreover, MCH clinic had to adjust to using gas instead of electricity during the rationing days. This led me to carry out this study so as to understand how the cold chain can be maintained despite the external interruptions.

LITERATURE REVIEWINTRODUCTIONThe cold chain is a system of maintaining vaccines in a potent state fro the manufacturer to the consumer. Vaccines are very delicate and easily loose their potency when exposed to high temperatures, sunlight and freezing conditions.The potency of vaccines can only be maintained by keeping them at required temperatures at all times from the manufacturer till they reach the consumer {+2- +8o c}. Order of sensitivity to light fro the most to the least sensitive{bottom to top} is; polio, measles, BCG, pentavalent, tetanus toxoid, Hepatitis B.An efficient cold chain requires 3 elements:

Trained, skilled and motivated staffs. Efficient and reliable equipments. Efficient distribution of vaccines from one stage of cold chain to another.

COLD CHAIN SYSTEM

COLD CHAIN EQUIPMENTS Cold rooms and its accessories. Refrigerators and deep freezers. Cold boxes. Vaccine carriers. Ice packs. Thermometers

REFRIGERATORSThis can be powered by gas, electricity, and kerosene or solar. Most health centers have been issued with refrigerators which work on both gas and electricity so that in case of power failure the refrigerator can still work by switching it to gas system. Models of refrigerators include:

RCW 42 EG Sibir S 2323 RA 1300 VR 50 solar

At the MCH we use RCW 42 EG type.The vaccines are arranged in trays of different colors, The most sensitive to heat being polio. No vaccines should be stored in the freezer compartment. Instead, only ice packs are stored there. A sticker is posted on the front of the refrigerator to explain how to place them as follows:

Red tray Pentavalent Top mostOrange tray T.T 2nd Yellow BCG 3rd Green Measles 4th Blue Polio Bottom.

Temperatures: {+2 to +8o c}.Read and record the refrigerator temperature twice a day to include weekends. Record this on the cold chain recording sheet.

VACCINE COLD BOXES AND CARRIERSThese equipments are designed to keep cold air inside and prevent warm air from entering. Use frozen ice packs to keep vaccines within the recommended temperatures. There must be a thermometer inside.Vaccine carriers collect small quantities of vaccines to be used for one day only.

How to pack vaccines in a vaccine carrierPlace full frozen ice packs around the inside walls of the carrier. Place vaccines and diluents carefully into the carrier. Place plastic foam or packing materials between DPT, TT HB vaccines to prevent them from being frozen.Place a thermometer inside but at the top of the vaccine carrier, secure the lid tightly.

Ice packsThese are plastic bottles filed with water and frozen in the refrigerator or freezer. During vaccine session, vaccine vials are placed on the ice packs to avoid the frequent opening of the cold boxes and vaccine carriers which would raise their internal temperatures.

ThermometersUsed to monitor vaccine temperatures.

METHODDuring the placement l noted that cold chain maintenance was highly affected due to the electricity power rationing. This led to the KEPI office to withdraw most of the vaccines from the MCH fridge as the potency of the vaccines was questionable. Moreover, MCH clinic had to adjust to using gas instead of electricity during the rationing days. This led me to carry out this study so as to understand how the cold chain can be maintained despite the external interruptions.

INTERVENTIONS Together with the staffs we ensured that the cold chain temperature chart was filled twice

a day; I n the morning when opening the fridge and in the evening when returning vaccines.

Connecting gas to run the fridge and disconnecting the electricity supply especially during power rationing days. I gave health education on the same.

I ensured that every staff working at MCH was conversant with the DVIs {Division of Vaccine & Immunization} regulation of checking the potency of vaccines using the outlined color codes.

Vaccines to be used during the day are put in vaccine carriers to avoid frequent opening of the fridge hence maintaining cold chain.

I ensured that BCG and measles vaccines were used within 6hrs of reconstitution and any that remained discarded.

CONCLUSION.The cold chain is a system of maintaining vaccines in a potent state from the manufacturer to the consumer. Vaccines are very delicate and easily loose their potency when exposed to high temperatures, sunlight and freezing conditions.The potency of vaccines can only be maintained by keeping them at required temperatures at all times from the manufacturer till they reach the consumer {+2- +8o c}. Order of sensitivity to light from the most to the least sensitive {bottom to top} is; polio, measles, BCG, pentavalent, tetanus toxoid, Hepatitis B.

The vaccines are arranged in trays of different colors. No vaccines should be stored in the freezer compartment. Instead, only ice packs are stored there. A sticker is posted on the front of the refrigerator to explain how to place them as follows:Red tray Pentavalent Top mostOrange tray T.T 2nd Yellow BCG 3rd Green Measles 4th Blue Polio Bottom.

Read and record the refrigerator temperature twice a day to include weekends. Record this on the cold chain recording sheet.

Together with other staffs we ensured that the cold chain temperature chart was filled twice a day; in the morning when opening the fridge and in the evening when returning vaccines.

Connecting gas to run the fridge and disconnecting the electricity supply especially during power rationing days. I gave health education on the same.

I ensured that every staff working at MCH was conversant with the DVIs {Division of Vaccine & Immunization} regulation of checking the potency of vaccines using the outlined color codes.

Vaccines to be used during the day are put in vaccine carriers to avoid frequent opening of the fridge hence maintaining cold chain.

I ensured that BCG and measles vaccines were used within 6hrs of reconstitution and any that remained discarded.

LIST OF REFERENCE

http://www.create.org.in/aboutus.htm August 18, 2009 11:50 Am

Ministry of Health (2007), Division of Vaccines and Immunization: Performance Monitoring Handbook

Wong B, 2001, Pediatric Nursing, Baltimore: Mosby Publishers.

M.O.H. (2000), Operational level training manual, for Health workers: Kenya.

M.O.H. (1992), Kenya expanded programme on immunization, National immunization coverage survey, Kenya.