Implementing a Self Assessment and Continuous Quality Improvement Approach to Improve Hospital Infection Control Practices in

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1 Implementing a Self Assessment and Continuous Quality Improvement Approach to Improve Hospital Infection Control Practices in Africa and Latin America Wonder Goredema, 1 Mupela Ntengu, 2 Jane Briggs, 1 Christopher Ntege, 3 Terry Green, 1 Jacqueline Sekgothe, 4 Christine Gordon, 5 Thabsile Dlamini, 6 Silvia Palma de Ruiz, 7 Jean Pierre Sallet, 2 David Mabirizi, 3 Jude Nwokike, 1 and Mohan P. Joshi 1 1: Strengthening Pharmaceutical Systems (SPS) Program, Arlington, VA, USA; 2: SPS, South Africa; 3: SPS, Namibia; 4: Formerly with the National Department of Health, South Africa; 5: Ministry of Health and Social Services, Namibia; 6: Ministry of Health and Social Welfare, Swaziland; 7: Vice Minister of Health and Social Assistance, Guatemala Poster presented at the Third International Conference for Improving Use of Medicines (ICIUM 2011 ) November 14 18, 2011, Antalya, Turkey Acknowledgments: Guatemalan Ministry of Health and Social Assistance; Namibian Ministry of Health and Social Services; South African National Department of Health; Swaziland Ministry of Health and Social Welfare; United States Agency for International Development

2 Abstract Problem statement: Infection control (IC) is a fundamental intervention to prevent the emergence and spread ofantimicrobial resistance in hospitals. However, developing effective ICprograms in resource constrained constrained countries remains a challenge. Objective: The intervention was designed to improve hospital IC practices in resource constrained settings using the SPS Infection Control Self Assessment Tool (ICAT) and continuous quality improvement (CQI) approach. Design: Pre and post intervention surveys without control groups Setting and population: Eighteen hospital IC committees comprised mainly of nurses, pharmacists, physicians and environmental health officers in Guatemala, Namibia, South Africa, and Swaziland. Intervention: The SPS Program and its predecessor, Rational Pharmaceutical Management (RPM) Plus, collaborated with Ministries of Health (MOHs) to implement and evaluate the use of ICAT and CQI to improve IC practices in hospitals. IC teams conducted baseline surveys to assess their respective hospital s adherence to recommended IC standards and practices from approved national or World Health Organization guidelines. Committees then developed and implemented IC improvement plans. National partners and RPM Plus/SPS staff supported IC teams through site visits and telephone or e mail follow up. The teams conducted postintervention assessments, reviewed progress, shared experiences, and developed plans to scale up the approach. Outcome measures: Percentage improvement in adherence to ICstandards and practices and availability of IC supplies. Results: Pilot hospitals experienced measurable improvements over their initial 6 9 months of implementation. Guatemala Percentage of staff who washed hands according to procedures improved on average from 23% for 5 pilot hospitals to 77% three months post intervention. Availability of hand washing supplies rose from 36% at baseline to 84%. MOH expanded the approach to the national network of 43 hospitals. South Africa One hospital improved adherence to hand hygiene policies by 29 percentage points from a baseline of 57% to 86%; a second hospital increased its compliance with contaminated waste policies from 38% to 73%. Swaziland One hospital doubled its hand hygiene assessment score from 33% to 66%, and a second hospital s waste management score increased from 12% to 83%. Namibia Percentage of staff who washed hands according to internationally recognized procedures improved from 27% to 61% in one hospital. Supplies and equipment for hand washing improved from78% to 94%. Conclusions: The application of the ICAT coupled with CQI demonstrated improvement in IC practices. The combination is simple to apply, is sustainable, builds teamwork, and yields quantifiable improvements. Funding sources: RPM Plus and SPS through US Agency for International Development; MOH (Guatemala, Namibia, South Africa, Swaziland)

3 Background The combination of highly susceptible or immunocompromised patients, prolonged and at times irrational use of antimicrobials, and poor infection control (IC) 1 makes hospitals focal centers for emergence of nosocomial infections caused by resistant pathogens. Resistant infections result in use of more expensive medicines, increased length of stay in hospitals, andincreased health care costs. Antimicrobial resistance (AMR) is a rapidly growing public health problem that renders many first line antimicrobial treatments ineffective. It is threatening t to reduce past gains in the treatment t tof infectious diseases of public health importance, such as HIV/AIDS, TB, and malaria. Interventions that strengthen IC programs are therefore critically needed. IC is a fundamental intervention to prevent the emergence and spread of AMR in hospitals. WHO s 2001 Global Strategy for Containment of AMR recommends IC among key interventions. 2 1 Orrett FA, Brooks PJ, Richardson EG Nosocomial Infections in a Rural regional Hospital in a Developing Country: Infection Rates by Site, Service, Cost, and Infection Control Practices. Infect Control Hosp Epidemiol. 19(2): WHO Global Strategy for Containment of Antimicrobial Resistance. Geneva: WHO.

4 Background (2) Implementing simple, effective, low cost IC practices, such as improvinghand hygiene, environmentalhygiene hygiene, andwaste management in health care facilities, helps reduce the spread of nosocomial infections Properly implemented IC programs result in reduced infection rates and decreased use of medicines in health facilities and ultimately improved quality of patient care and reduced health care related costs for patients and health systems Pittet, D Clean Hands Reduce the Burden of Disease. Lancet 366(9481): Luby, S. P., M. Agboatwalla, D, R, R. Feikin, et al Effect of Hand washing on Child Health: A Randomized controlled trial. Lancet 366(9481): WHO WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft). WHO/EIP/SPO/QPS/05.2. Geneva: WHO.

5 Objective and Methods The intervention was designed to improve hospital IC practices in resource constrained constrained settings by using the SPS Infection Control Self Assessment Tool (ICAT) and continuous quality improvement (CQI) approach Design Pre and post intervention surveys without control groups Setting and population Eighteen (18) hospitals with IC committees comprised mainly of nurses, pharmacists, physicians, i and environmental health staff in Guatemala, Namibia, South Africa, and Swaziland SPS = The USAID supported Strengthening Pharmaceutical Systems Program

6 Methods (2) The USAID funded approach involves Applying the ICAT to assess existing hospital IC practices. The ICAT consists of 21 modules covering various aspects of hospital IC; each module contains selfassessment questions, a scoring system, and reference notes that provide recommendations on best practices Using a continuous quality improvement (CQI) approach to conduct a baseline and implement suitable interventions Standard approach to improve infection control Application of the ICAT CQI Act Plan Test & Implement Study Team work: -Participation of various disciplines -Networking both within the hospital and between hospitals -Support from authorities Improved infection control practices Reduced rate of nosocomial infections Courtesy: Guatemala Ministry of Health and Social Assistance; adapted from Massoud, R., K. Askov, J. Reinke, et al A Modern Paradigm for Improving Healthcare. Quality QA Monograph Series 1(1). Bethesda, MD: Published for the U.S. Agency for International Development (USAID) by the Quality Assurance Project Do

7 Methods (3) The Strengthening th Pharmaceutical Systems (SPS) Program and its predecessor Rational Pharmaceutical Management (RPM) Plus collaborated with Ministries of Health (MOHs) to implement and evaluate the approach to improve IC practices in pilot hospitals in : Guatemala (5 hospitals), Namibia (7 hospitals and 1 health center), South Africa (3 hospitals), and Swaziland (4 hospitals). IC teams conducted ICAT assessments to determine challenges; developed interventions to mitigate the challenges; collected pre intervention data on indicators, such as adherence to hand hygiene and waste management policies, and availability of IC supplies; and implemented interventions. National partners and RPM Plus/SPS staff supported IC teams through site visits and telephone or e mail follow up. The IC teams reviewed progress; sharedexperiences; experiences; andcollected post intervention dataonthesame the performance indicators used in the pre intervention baseline. IC teams implemented ICAT/CQI cycles to measure the effectiveness of IC interventions and adjust the interventions, or develop and test new ones, as needed, to ensure and maintain improved practices.

8 Results Key outcome measures were Percentage improvement in adherence to IC standards and practices, such as adherence to hand hygiene and waste management policies Availability of IC supplies Pilot hospitals experienced measurable improvements over initial 6 9 months of implementation

9 Results for Guatemala In a pilot trial of the tool in 5 hospitals Percentage of staff who washed hands according to procedures improved on average from 23% to 77% three months post intervention. Availability of hand washing supplies rose from 36% at baseline to 84% As a result of this success, the Ministry of Health and Social Assistance produced a Guatemalan version of the ICAT and user manual and rolled out the approach to the national network of 43 hospitals and primary level facilities Many ICAT modules applied twice (Dec 2009 and Dec 2010) in most hospitals Guidelines for infection prevention and control are being revised and a surveillance system for nosocomial infections is being implemented Hand washing during ICAT training i in one Guatemala hospital New IC guidelines and poster developed as part of ICAT implementation in one Guatemala hospital Waste classification posters, printed by SPS/USAID and distributed to all hospitals Courtesy: Guatemala Ministry of Health and Social Assistance

10 Results for Namibia IC team meetings and staff training Rundu Courtesy: Namibia Ministry of Health and Social Services The Namibian Ministry i of Health and Social Services (MOHSS) adopted and implemented the ICAT and CQI approach in 8 health facilities fromaugust 2009to July 2010 Percentage of staff who washed hands according to internationally recognized procedures improved from 27% to 61% in 1 hospital Supplies and equipment for hand washing improved from 78% to 94% in another hospital The Namibian MOHSS has adopted the ICAT as the official tool for IC, has developed an IC manual, and plans to implement ICATin all the country s 34 district hospitals; 7 new hospitals already completed as of August 2011

11 Results for South Africa (1) The National Department of Health (NDOH) adopted and implemented the tool in 3 pilot hospitals, starting in 2007 One hospital improved adherence to hand hygiene policies by 29 percentage points from a baseline of 57% to 86% A second hospital increased its compliance with contaminated waste policies from 38% to 73% SPS seconded an IC specialist to the NDOH for 1 year The NDOH developed a national infection prevention and control manual that includes the ICAT adapted to the local context Hand Hygiene Campaign at a Provincial Hospital in South Africa. Courtesy: South African National Department of Health

12 Results for South Africa (2) National/provincial QI plans for 2011/12 were developed and initiated to prevent the development and spread of nosocomial infections. BSc Honors degree students in IC at the Nelson Mandela Medical School, University of KwaZulu Natal, are using the ICAT for research. The ICAT has been adapted for use in Emergency Medical Services (EMS) facilities in the Free State Province. ICAT implementation has been rolled out to many public hospitals countrywide.

13 Results for Swaziland One hospital before ICAT implementation One hospital doubled its hand hgieneassessment hygiene score from 33% to 66%, and a second hospital s waste management score increased from 12% to 83% Hospital IC committees have been established ICAT has been introduced into 8 hospitals Results of ICAT implementation activities showed improved hand hygiene practices in 2 additional hospitals Same hospital during ICAT implementation Courtesy: Swaziland Ministry of Health and Social Welfare

14 Conclusions and Policy Implications Stakeholders from the 4 countries have embraced the ICAT and CQI approach as useful, adapted it to the local context, and assumed ownership, thereby motivating staff and promoting an IC culture in their hospitals. Despite facing similar challenges, such as a shortage of human, financial, and materialresources resources, the hospitals in the pilot countries managed to obtain improvements with simple, locally appropriate, low cost interventions. Health facility IC teams feel empowered because of the tools that help them develop and test low cost interventions; they use the data generated as a powerful advocacy tool to obtain buy in and support of hospital management and staff. WHO Global Strategy and ICIUM 2004 recommended IC as a key intervention to support AMR containment. In this regard, the current results demonstrate that local stakeholders in resource constrainedconstrained countries arelikelyto implement simple, low cost, and sustainable IC quality improvement interventions that yield quantifiable results. This is especially true if the approach promotes teamwork and the locally led interventions are supported with some initial technical capacity building assistance. Therefore, all stakeholders including development partners and donors interested in AMR containment should support infection prevention and control activities.