the establishment of an infection prevention and control
TRANSCRIPT
Abstract
Background
The objective of the study is to establish a scientifically-based infection
prevention and control program in the Ministry of Health’s 12 Jeddah
hospitals and monitor its implementation through continuous auditing.
Material
From January 2009 to December 2011 an auditor from the infection
control team visits each hospital every four months on primarily
scheduled visits using an auditing tool comprised of performance
indicators covering four program areas: 1) general measures; 2)
application; 3) documents; and 4) staff. The auditing tool was inspired
by the British Infection Prevention Society’s auditing tool for monitoring
infection control standards and modified to reflect the clinical
environment of Jeddah’s hospitals. During the visits, the auditor scored
compliance rates by marking each performance indicator yes/no or
non-applicable. In total, 55 variables were tested. These variables were
distributed throughout the study according to their application.
Basic application variables were tested in the first year and other
variables that indicated more advanced applications were tested in the
second and/or third year. By the end of each year, the total compliance
rate was calculated for all hospitals combined. The total compliance
rate of the year of all twelve hospitals was obtained by summing the
total of 'yes' answers for the three visits combined in the twelve
hospitals in one year (Nominator) divided by the total number of the
'yes + no' of the 3 visits (Denominator) of the twelve hospitals in that
year multiplied by 100 excluding the non-applicable variables. Variables
that scored 60% and above were tested only once and were considered
accepted rates of compliance. Variables that scored less than 60%
were retested in the next year and/or the year after. After the end of the
three years, the overall compliance rate in all 12 hospitals was
calculated.
Results
The overall compliance of the IC program after 3 years of application
was 75% (1325/1759). The prevalence of Healthcare Associated
Infection decreased significantly from 2.9 in the first year to 1.7 in the
3rd year (P <0.01). Our study revealed that only 36% (37/104) of the
infection control departments (ICDs) in Jeddah hospitals are supervised
by specialized personnel, 44% (44/101) of the ICDs supervise and
manage the isolation rooms properly, 53% (55/104) of hospital sinks
are provided with all the required tools for hand hygiene, 45% (47/104)
of ICDs follow-up the infection control committee decisions and only
53% (55/104) of the infection control committee’s decisions are
implemented.
Conclusion
Instituting a standardized infection prevention and control program in
conjunction with regular audits and feedback has created a well
structured infection control program in Jeddah’s hospitals. We believe
that the program could serve as a template for improving infection
control practices in other regions both nationally and abroad.
Methodology
Study period: The study was conducted
from January 2009 to December 2011.
Hospitals: All MOH hospitals in Jeddah (12
in total) that serve around 60,000 patients a
year were included in the study.
The Establishment of an Infection Prevention and Control Program in Jeddah
Hospitals Saudi Arabia: A Three Year Project Muhammad A. Halwani, MSc, PhD, FJHMI. Nidal A.J. Tashkandy, MBBS. The Infection Control Sterilization and Waste Management.
Health Affairs, Ministry of Health, Jeddah, Saudi Arabia. [email protected]
Data Collection
The principle of the data collection depended on regular
scheduled visits (once every 4 months) to all twelve hospitals
using an in-house made audit sheet. This audit sheet was made
based on the study's aim. A reviewer used the auditing sheet for
each visit to collect the required information. Data were collected
on various infection control items that covering four program
areas: 1) general measures that had 8 variables 2) application
which had 28 variables 3) documents which had 11 variables 4)
staff which had 8 variables (See Table 1). The auditing tool was
inspired by the British Infection Prevention Society’s auditing tool
for monitoring infection control standards and modified to reflect
the clinical environment of Jeddah’s hospitals.1, 2 Prevalence of
Healthcare Associated Infections (HAI) was determined for each
year based on the number of HAI divided by the total number of
admissions.3 Proportions were determined and the chi-square
test was used to explore the differences in the proportions of HAI
at a significance level of 5%. During the visits, the auditor scored
compliance by marking each performance indicator as yes/no or
non-applicable. The compliance rate was calculated by summing
the total of 'yes' answers of the three visits combined in the
twelve hospitals in one year (Nominator) divided by the total
number of the 'yes + no' of the 3 visits (Denominator) of the
twelve hospitals in that year multiplied by 100 excluding the non-
applicable.
In total, 55 variables were tested. At the end of each year, the
three best infection control departments who obtained the
highest total compliance rates between the twelve hospitals
were appreciated and acknowledged in a special ceremony.
Variables that scored 60% and above after combining the results
of three visits by the end of the year in all 12 hospitals were
considered as accepted rates of compliance and were tested
only once. Variables that scored less than 60% by the end of the
year in all 12 hospitals were retested during the second and/or
the year after by adding them to the next year's auditing tool.
The same thing was done during the second and third year to
obtain that specific year's total compliance rate. After every first
visit to any hospital, the compliance rate is immediately sent to
the hospital surveyed. During the second visit of each hospital,
only the variables that were marked as 'no' in the previous visit
were rechecked. Variables that indicated compliance in this visit
were changed to 'yes' and the rate of that visit was based on the
new changes. The same thing was done during the third visit. By
the end of the third year, the overall compliance rate of the three
years was calculated by summing up all the 'yes' answers for the
last rate obtained of all the variables that reached 60% and
above. For the variables that were left below the accepted
compliance rate < 60% after the three years visits, the final
number obtained after the third visit was used in the calculation.
Results
The total compliance rate of the first year was 63% (1482/930). The total
compliance rate of the second year was 67% (615/921) and the total compliance
rate of the third year was 65% (217/336). The overall compliance rate of the
three years combined was 75 % (1325/1759). The prevalence rate HAI declined
respectively from 2.9 % during the first year to 2.6% on the second year to 1.7%
on the third year (see Table 2).
Out of the 55 variables tested in three years, only five variables 9% (5/55) did
not reach the accepted compliance rate (see Table 3).
Acknowledgment
We are grateful to the Cure Development Limited Company in Saudi Arabia for the Travel
Grant to this Conference.
Introduction
The governmental health system in the
Kingdom of Saudi Arabia is run by different
sectors: the National Guard, the Armed
Forces, the Ministry of Interior, and the
Ministry of Health. Each sector has its own
hospitals and its own infection prevention
and control program. Therefore, the
implementation is never the same and the
quality of practice may have a significant
variability. Under the Ministry of Health,
which is the largest sector of all, the
infection prevention and control program in
its hospitals was never standardized.
Moreover, each region and even each city
hospital has been known to have their own
plans, programs, and targets. Jeddah is the
second main city in the Kingdom of Saudi
Arabia with a population of 3.2 million. It is
located on the western coast of the
Kingdom. It is an important commercial hub
in the country and the principal gateway to
the two holy cities; Makkah and Medina.
The health system of the city is run by the
Ministry of Health and the provided services
are free of charge. The infection control
program in Jeddah hospitals (12 in total) is
run by a specialized administration that
supervises this service in all these
hospitals. The infection control program in
the city was never standardized or based
on focused, scientific guidelines. Different
attempts were conducted in previous years
but never standardized or monitored on a
frequent basis which led us to believe that
such a program is needed¹ ². The objective
of this study; therefore, is to establish a
scientifically-based infection prevention and
control program in Jeddah hospitals and to
monitor its enforcement through continuous
auditing.
Discussion & Conclusion
The study succeeded in establishing a proper
scientifically-based infection control program at the
infrastructure level using frequent auditing. This
was clear from the overall compliance rate that
reached 75% and the prevalence rate obtained; it
decreased significantly from the first year to the
third year. However, the 5 variables that did not
reach the accepted rate of compliance need to be
improved. The study helped the hospitals involved
to become more orderly in the way they manage
infection control related issues. Finally, the study
also helped standardize the process of infection
control according to international standards. It is
worth pointing out that this study did not need
many resources except for manpower, dedication,
and continuous follow-up. We feel that the
methodology we applied is relatively simple,
straightforward, and can be used as a template in
any other hospital.
Table 2: The prevalence rate of healthcare associated
infections during the three year study period
Table 3: Variables that did not reach the accepted rate
of compliance after the three years
Year Number
of HAI
Number of
Admissions
Prevalence
Rate
P Chi
Square
test
Confidence
Interval
2009 1510 50733 2.9 - - - -
2010 1427 54704 2.6 <0.01 1.1 1.06 1.2
2011 912 53604 1.7 <0.01 1.7 1.6 1.9
Variables Rate
Lack of Specialized Personnel to Lead the Infection Control
Departments
36% (37/104)
Poor Supervision of the Infection Control Departments to the
Isolation Rooms in the Hospitals
44% (44/101)
Hospital Sinks were Short of the Required Tools for Hand Hygiene
(anti-bacterial soap, tissue papers, foot operated garbage container,
step-by-step hand washing poster)
53% (55/104)
Incomplete Follow-up from the ICDs to the Infection Control
Committee's Decisions
45%(47/104)
Improper Implementation of the Infection Control Committee
Decisions
53%(55/104)
Table 1: Variables Tested and their Rate of Compliance Variable
GENERAL MEASUERS 2009 2010 2011 TOTAL
The IC department is in proper place and accessible to the hospital staff (13/36) 36% (22/34) 64%
The IC department is sign posted (11/36) 30% (21/34)62%
There is a telephone and extension number for the IC department (36/36) 100%
The IC department is chaired by a specialised personal (13/36) 36% (10/34) 29% (14/34) 41% (37/104) 36%
The staff number is adequate with the hospital size (34/36) 94%
The working staff are trained/experienced in the IC (26/36) 72%
Infection control clinical notes form are available and in use by IC (26/36) 72%
There is a strong link between the microbiology lab and infcetion control Dept (31/31) 100%
APPLICATIONS
Surveillance is applied actively (22/30) 73%
Staff are aware of surveillance and skilled enough with its conduction (20/30) 67%
Surveillance data are checked daily and analyzed by the IC head (22/30) 73%
Cases of Healthcare associated infection are reported directly to the affected department. (20/30) 67%
Monthly rates are prepared on time and clearly organized. (27/30) 90%
Trend of increase are reported to the affected department for action (20/30) 67%
There is an indication of the action taken to solve related problems (19/30) 63%
The IC department/unit manage outbreaks as required (21/30) 70%
The departmnet replaced the hospital wide surveillnce with targetted survillance (16/24) 67%
The IC monitor the application of Standard Precautions before CVC insertion regularly (8/15) 53% (16/18) 89%
The IC monitor the application of SP before wound dressing change regularly (13/27) 48% (28/31) 90%
The IC monitor the application of SP before urinary catheter insertion regularly (10/26) 38% (23/28) 82%
The IC monitor the management of urinary catheter regularly (5/26) 19% (23/27) 85%
The IC monitor the SP in dialysis department weekly (3/12) 25% (11/16) 69%
The IC monitor the linen collection, transportation to the Landry to prevent cross-infection weekly (10/36) 27% (26/33) 79%
The IC monitor the SP in the kitchen at least weekly (20/36) 55% (28/31) 90%
The IC monitor the cleaning/ disinfection of endoscopes in endoscopy unit weekly (5/9) 55% (7/11) 64%
IC follow up the hand hygiene application in the hospital on regular basis (23/36) 36% (29/34) 85%
Feedback of auditing results are discussed in the ICC (18/36) 50% (7/34) 20% (25/34) 74%
Designated isolation room are provided and managed by IC (14/33) 42% (15/34) 43% (15/34) 43% (44/101) 44%
There is an actively functioning infection control committee (25/36) 69%
Members are from the departments that have direct impact on IC (26/36) 72%
The committee minutes are written and prepared as it should be (13/36) 36% (20/34) 59% (22/34) 65%
The committee meet regularly ( not less than 4 meetings a year is the minimum ) (21/36) 58% (21/34) 62%
The committee decision are implemented (16/36) 44% (19/34) 56% (20/34) 59% (55/104)53%
IC department follow up the committee decisions (11/36) 31% (17/34) 50% (19/34) 56% (47/104) 45%
MRSA screening policy are known and applied the hospital (20/31) 65%
Antibiotic restriction policy is available and followed in the hospital precisely (15/34) 44% (21/34) 62%
DOCUMENTS
Surveillance sheet is available and proper (25/30) 83%
Checklists available are properly prepared and filled as they should be (28/34) 82%
A proper hand hygiene procedure instructions poster is available beside the hospital sinks (30/36) 83%
Hospital sinks seen are provided with all required tools (16/36) 44% (17/34) 50% (19/34) 56% (52/104) 50%
The provided liquid soap must are single use cartridge dispensers (19/36) 52% (26/34) 76%
Alcohol product is available in all hospital wards (36/36) 100%
Isolation cards are available and up to standards (23/33) 66%
Appropriate leaflets about the required precautions are available to patients companions
and relatives before admission to isolation room (16/33) 48% (24/32) 75%
The required PPE are available and in sufficient number (33/36) 92%
Leaflets that contain the required measures of precautions that need to be taken during a
patient visit is available and distributed (24/34) 71%
Etiquette policy are applied and available in the hospitals especially in the waiting areas
and common meeting rooms (25/34) 74%
STAFF
Internal continues education between the infection control staff is going on (24/34) 71%
Staff are aware of the PPE use and their benefits (29/36) 81%
The IC staff updated the hand hygiene application accrodring to the recent updates (31/34) 91%
The IC department is active in educational sessions in general (28/36) 77%
There is a continuous IC program for the hospital staff (26/36) 72%
The IC department is involved in the orientation program of new staff (33/35) 94%
The IC department do have an educational program for the medical students (16/27) 59% (19/27) 70%
Staff are given the chance to attend IC courses (29/36) 81%
References
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