Gap analysis of infection control practices in low- and middle-income countries

BACKGROUND

Healthcare-associated infection rates are higher in low- and middle-income countries compared with high-income countries, resulting in relatively larger incidence of patient mortality and disability and additional healthcare costs.

OBJECTIVE

To use the Infection Control Assessment Tool to assess gaps in infection control (IC) practices in the participating countries.

METHODS

Six international sites located in Argentina, Greece, Hungary, India, Nepal, and South Africa provided information on the health facility and the surgical modules relating to IC programs, surgical antibiotic use and surgical equipment procedures, surgical area practices, sterilization and disinfection of equipment and intravenous fluid, and hand hygiene. Modules were scored for each country.

RESULTS

The 6 international sites completed 5 modules. Of 121 completed sections, scores of less than 50% of the recommended IC practices were received in 23 (19%) and scores from 50% to 75% were received in 43 (36%). IC programs had various limitations in many sites and surveillance of healthcare-associated infections was not consistently performed. Lack of administration of perioperative antibiotics, inadequate sterilization and disinfection of equipment, and paucity of hand hygiene were found even in a high-income country. There was also a lack of clearly written defined policies and procedures across many facilities.

CONCLUSIONS

Our results indicate that adherence to recommended IC practices is suboptimal. Opportunities for improvement of IC practices exist in several areas, including hospital-wide IC programs and surveillance, antibiotic stewardship, written and posted guidelines and policies across a range of topics, surgical instrument sterilization procedures, and improved hand hygiene.

Success in the South Pacific: a case study of successful diffusion of an infection prevention and control program

INTRODUCTION

The aim of this study was to explore the role of the Diffusion of Innovations framework in adopting an infection prevention and control program (IPCP) in a low and middle income (LMI) country, the Republic of Kiribati.

METHODS

Case-study methodology was used to examine and contextualise the analysis of the Republic of Kiribati's adoption of the IPCP from 2003 to 2010. Data were collected from multiple sources including semi-structured interviews, IPCP documentation, program evaluation and a healthcare worker survey. Data were subjected to thematic analysis and descriptive statistics where relevant to the study design.

RESULTS

It was found that the self-initiated progression of activities and stimuli has resulted in the successful adoption of a comprehensive IPCP. The process followed the staged model of the classic Diffusion of Innovations process in organisations described by Everett Rogers.

CONCLUSION

This case study provides an illustration of how a comprehensive IPCP can be adopted in a LMI country setting with little involvement from external agencies. It identifies key stimuli, opportunities and activities which could be similarly adopted and implemented by other LMI countries.

Impact of Switching from an Open to a Closed Infusion System on Rates of Central Line–Associated Bloodstream Infection: A Meta-analysis of Time-Sequence Cohort Studies in 4 Countries

Background.

We report a meta-analysis of 4 identical time-series cohort studies of the impact of switching from use of open infusion containers (glass bottle, burette, or semirigid plastic bottle) to closed infusion containers (fully collapsible plastic containers) on central line-associated bloodstream infection (CLABSI) rates and all-cause intensive care unit (ICU) mortality in 15 adult ICUs in Argentina, Brazil, Italy, and Mexico.

Methods.

All ICUs used open infusion containers for 6–12 months, followed by switching to closed containers. Patient characteristics, adherence to infection control practices, CLABSI rates, and ICU mortality during the 2 periods were compared by χ2test for each country, and the results were combined using meta-analysis.

Results.

Similar numbers of patients participated in 2 periods (2,237 and 2,136). Patients in each period had comparable Average Severity of Illness Scores, risk factors for CLABSI, hand hygiene adherence, central line care, and mean duration of central line placement. CLABSI incidence dropped markedly in all 4 countries after switching from an open to a closed infusion container (pooled results, from 10.1 to 3.3 CLABSIs per 1,000 central line-days; relative risk [RR], 0.33 [95% confidence interval {CI}, 0.24-0.46];P<.001). All-cause ICU mortality also decreased significantiy, from 22.0 to 16.9 deaths per 100 patients (RR, 0.77 [95% CI, 0.68-0.87];P<.001).

Conclusions.

Switching from an open to a closed infusion container resulted in a striking reduction in the overall CLABSI incidence and all-cause ICU mortality. Data suggest that open infusion containers are associated with a greatiy increased risk of infusion-related bloodstream infection and increased ICU mortality that have been unrecognized. Furthermore, data suggest CLABSIs are associated with significant attributable mortality.

Standardized Infection Ratios for Three General Surgery Procedures: A Comparison Between Spanish Hospitals and U.S. Centers Participating in the National Nosocomial Infections Surveillance System

Objectives:

To compare Spanish surgical wound infection (SWI) rates for three procedures with those published by the U.S. NNIS System, and to analyze quarterly trends.

Design:

This was a 4-year prospective analysis of SWI using data from a Spanish nosocomial infection surveillance network based on CDC classification criteria. SWI rates were computed as standardized infection ratios (SIRs). Trends for both SWIs and SIRs were evaluated by linear regression.

Setting:

Forty-three Spanish hospitals during 1997 through 2000.

Patients:

Those undergoing cholecystectomy (n = 7,631), appendectomy (n = 5,780), and herniorrhaphy (n = 9,864).

Results:

For cholecystectomy patients, the SWI rate was 4.38% and the SIR was 3.32. Both of these variables showed a slightly rising, although nonsignificant, linear trend during the study period. For appendectomy patients, the SWI rate was 7.94% and the SIR was 2.86. The linear trend was increasing for both, but only the SWI rate attained significance. For herniorrhaphy patients, the SWI rate was 1.77% and the SIR was 1.64. Both of these variables showed a significant descending tendency during the 4 years.

Conclusions:

Because the SIR takes into account the patient risk category, it is the best indicator of the trend shown by the SWI rate over time for a given surgical procedure. According to our comparison of SIRs with reference NNIS System values, SWI rates for cholecystectomy and appendectomy were high. Monitoring of the SIR will provide a basis for the design of infection control measures and the assessment of their effectiveness.

Educational innovation for infection control in Tanzania: bridging the policy to practice gap

The incidence of hospital acquired infection in developing countries is between two to 20 times higher than in developed countries and is attributable to multiple causes. Evidence-based international policies and guidelines developed to improve infection prevention and control are often not used in practice in these countries. To combat this challenge, this article presents an innovative educational framework used to bridge the gap between policy written by global health agencies and the realities of practice in Tanzania.

Building hospital management capacity to improve patient flow for cardiac catheterization at a cardiovascular hospital in Egypt

BACKGROUND

Quality improvement (QI) has been shown to be effective in improving hospital care in high-income countries, but evidence of its use in low- and middle-income countries has been limited to date. The impact of a QI intervention to reduce patient waiting time and overcrowding for cardiac catheterization-the subset of procedures associated with the most severe bottlenecks in patient flow at the National Heart Institute in Cairo-was investigated.

METHODS

A pre-post intervention study was conducted to examine the impact of a new scheduling system on patient waiting time and overcrowdedness for cardiac catheterization. The sample consisted of 628 consecutive patients in the pre-intervention period (July-August 2009) and 1,607 in the postintervention period (September-November 2010).

RESULTS

The intervention was associated with significant reductions in waiting time and patient crowdedness. On average, total patient waiting time from arrival to beginning the catheterization procedure decreased from 208 minutes to 180 minutes (13% decrease, p < .001). Time between arrival at registration and admission to inpatient ward unit decreased from 33 minutes to 24 minutes (27% decrease, p < .001). Patient waiting time immediately prior to the catheterization laboratory procedure decreased from 79 minutes to 58 minutes (27% decrease, p < .001). The percentage of patients arriving between 7:00 A.M. and 9:00 A.M. decreased from 88% to 44% (50% decrease, p < .001), reducing patient crowding.

CONCLUSION

With little financial investment, the patient scheduling system significantly reduced waiting time and crowdedness in a resource-limited setting. The capacity-building effort enabled the hospital to sustain the scheduling system and data collection after the Egyptian revolution and departure of the mentoring team in January 2011.

Hospital quality improvement in Ethiopia: a partnership-mentoring model

BACKGROUND AND OBJECTIVE

Quality improvement efforts are increasingly common in the United States; however, their use in developing countries is limited. We sought to evaluate the impact of a large-scale intervention on several key management indicators through hospital quality improvement efforts.

DESIGN

Pre-post-descriptive study of 14 hospitals in Ethiopia.

SETTING

Six regions and two city administrations in Ethiopia.

PARTICIPANTS

Hospital leaders and management mentors in participating hospitals.

INTERVENTION

In collaboration with the Ministry of Health and the Clinton HIV/AIDS Initiative, we implemented a countrywide quality improvement initiative in which 24 mentors with hospital administration experience were placed for 1 year in Ethiopia to work side-by-side with hospital management teams. We also provided a professional development course to enhance quality improvement skills.

MAIN OUTCOME MEASURE

s) Presence of 75 key management indicators; reported management skills of hospital leaders by the mentors.

RESULTS

In pre-post analysis, we found improvement in 45 of the 75 (60%) key management indicators between August 2006 and May 2007. The changes reflected a total of 105 management indicators improved across the 14 hospitals, which equates to a per-hospital mean of 7.5 (standard deviation 5.9) improvements. Reported management skills of hospital leaders improved in several management domains, although their reported confidence in these skills remained largely unchanged.

CONCLUSIONS

Our findings indicate that quality improvement efforts can be effective in improving hospital management in developing countries. Longer follow-up is required to assess the sustainability of the hospital improvements accomplished.

Help or hindrance? Is current infection control advice applicable in low- and middle-income countries? A review of the literature

BACKGROUND

High-income countries with established infection control programs have demonstrated effective control of infection transmission in health care settings. The guidelines and advice underlying these effective control programs have been produced by high-income countries for their own social, economic, and health environments. These have also been adopted by low- and middle-income (LMI) countries, but these countries appear to have a limited ability to apply these principles using the same methods.

METHODS

A systematic search for literature published in English was conducted exploring the relationship between the available infection prevention and control advice and the capacity of LMI countries to apply this guidance in their health care settings. Articles relevant to this exploration were identified and subsequently informed further search terms and identified other significant documents.

RESULTS

Infection control guidelines designed for high-income countries are being utilized by LMI countries, with varying degrees of success mainly because of physical, environmental, and socioeconomic factors. There is a lack of published studies exploring the implementation of comprehensive infection control advice and programs, including the minimal advice, which is designed specifically for resource-limited settings.

CONCLUSION

What is evident from the literature is that there is a need for the development of infection control and prevention guidelines based on evidence but adapted to the specific needs of health care workers in LMI countries. This must be done in collaboration with those same LMI countries' health care workers. Equally, because of finance and health priorities, health care facilities should choose those interventions most relevant to the needs of their population and workers to prevent infection transmission. Opportunities for further research into application of available infection control advice in LMI countries are identified. Through such research, more appropriate advice may be devised to assist with the development of infection control programs in these settings.

Introduction of a quality improvement program in a children's hospital in Tehran: design, implementation, evaluation and lessons learned

BACKGROUND AND OBJECTIVE

Reports addressing continuous quality improvement (CQI) methods in developing countries are scant and there are questions about the applicability of quality improvement methods in such settings. The structure and output of a formal quality improvement program implemented in a teaching hospital affiliated with the Tehran University of Medical Sciences is presented. OBJECTIVE METHOD: During a nine-month period, a multi-stage quality improvement program was implemented. It comprised: (i) training workshops; (ii) a steering committee; (iii) weekly consultation and facilitation of improvement projects; and (iv) a day-long demonstration and recognition meeting. Four cycles of workshops were held in which 132 employees were trained in the basics of CQI.

RESULTS

Thirty improvement projects were initiated. Twenty-five of the projects were completed. In an evaluation survey more than 70% of respondents assessed a 'positive impact' on organizational culture, work efficiency and quality of services. More than 90% believed that the changes were sustained, and more than 60% reported that they have implemented additional improvement projects.

CONCLUSION

Our quality improvement package supported rapid implementation of multiple projects. The underlying 'change structure' comprised the improvement teams, top management and the university's quality improvement office; it integrated project management, support and facilitation functions by the respective participant. Organization-wide change was more limited than anticipated. To institutionalize the program and ensure sustainability, a local structure for change should be organized, management coaching should be sustained, local facilitators should be developed, incentives should be established and physician involvement should be emphasized.

Risk-adjusted infection rates in surgery: a model for outcome measurement in hospitals developing new quality improvement programmes

Assessment of healthcare quality is a major challenge in countries such as Hungary where there is limited experience with measurement of patient outcomes. We sought to develop the capacity for valid outcome measurement in Hungarian hospitals using surgical site infection (SSI) surveillance as a model and to identify areas for improvement by comparing SSI rates in Hungarian hospitals to benchmarks published by the United States Centers for Disease Control and Prevention's National Nosocomial Infection Surveillance (NNIS) System. We surveyed the incidence of SSI among 5126 patients undergoing 6006 procedures in 20 public hospitals in Hungary during 1996 using the Hospitals in Europe Link for Infection Control through Surveillance (HELICS) protocol, a protocol consistent with the methods used by the NNIS System. Cholecystectomy, herniorrhaphy, appendectomy, and open reduction of fracture--four of the five most commonly performed procedures in Hungary in 1996--comprised 85% of the procedures analysed. Cumulative SSI rates for herniorrhaphy and appendectomy were comparable to NNIS System benchmarks. Cumulative SSI rates for cholecystectomy were significantly higher in Hungarian hospitals among risk categories that included open procedures. Nearly half of the hospitals had SSI rates for cholecystectomy that were high outliers (>90% percentile) compared to NNIS System benchmarks. Cumulative SSI rates for open reduction of fracture and mastectomy were significantly higher in Hungarian hospitals due to high rates in a few hospitals. The duration of surgery for all procedure types was substantially shorter in Hungarian hospitals compared with NNIS System hospitals. Future work should focus on optimizing prevention strategies for patients undergoing cholecystectomy, open reduction of fracture, and mastectomy. The effect of the utilization of open vs. laparoscopic cholecystectomy, short procedure duration, and procedure volume on SSI rates should be evaluated further. This programme expanded the capacity of Hungarian hospitals to perform surgical site infection surveillance and can serve as a model for hospitals in other countries with limited experience with outcome measurement.