An audit of the infection prevention and control program at Port Shepstone Regional Hospital.

Abstract

BACKGROUND

Infectious diseases are the leading cause of death in South Africa. The treatment of these diseases and their complications consume huge amounts of already limited healthcare resources. Antibiotic resistance is growing global concern and the strategy to contain it has 3 main components; Infection Prevention and Control (IPC) programs, microbiological resistance testing and antibiotic stewardship programs (ASP). South Africa has recently embarked on a journey to upgrade and develop its own Antimicrobial Program which encompass these 3 components. Emphases have been placed on developing antibiotic stewardship programs and recent literature reflects this. At the 400 bed Port Shepstone Regional Hospital (PSH), in contrast, the most developed of these components is the IPC program. We aim to describe the core component of PSH’s antimicrobial program and compare its IPC program with that of an established program. OBJECTIVE

To use the CDC’s Infection Control Assessment Tool for Acute Care Hospitals (USA) to evaluate the infection control program at PSH and report on the Core Elements of the hospital’s Antibiotic Stewardship Program METHOD

A prospective descriptive study with a quantitative component was conducted at PSH between February to March 2018. The first part of the study determined which of the CDCs 17 core components of an infection control program were operative at PSH. The assessed components were leadership commitment, pharmacy services, laboratory services, a dedicated specialist team, infection control policy, guidelines for antibiotic use, antibiotic rotation, personal protective equipment policies, protocols for prevention of catheter-related UTI, protocols for central line use, protocols for injection safely, protocols for prevention of ventilator-associated events, protocols for surgical site infection, services for environmental cleaning , infrastructure for isolation of contagious patients, policies for clostridium difficile infection, and policies for tracking of infective patients between institutions. In the second part, in each of the 11 adult long-stay wards, responders (nurses) were identified for completion of 5 selected elements of the CDC tool. The tool elicited if responders knew which policies were in place, their knowledge of the protocol, the level of education and training and the ongoing auditing practices. These areas were Handwashing (15 questions), Personal protection equipment (19Q), Catheter-associated Urinary Tract Infections (38Q), Injection safety (16 Q) and surgical site infection (31Q) After collection, the data was entered into an excel workbook. A positive answer received a score of 1 while a negative or unknown received a 0. Overall performance was graded arbitrarily into excellent (>80%), good (60 to 80%) and poor (<60%)

RESULTS

Part 1

The infection control program at PSH has 10 of the 17 components that were considered important. It has leadership commitment, pharmacy services, laboratory services, infection control policy, guidelines for antibiotic use, personal protection equipment, a protocol for prevention of catheter- related UTI, protocols for injection safely, protocols for surgical site infection, and services for environmental cleaning PSH does not have a dedicated specialist team, infrastructure for isolation of contagious patients, policies for the prevention of central line-associated bloodstream infection, policies for clostridium difficile infection, antibiotic rotation, a protocol for prevention of ventilator-associated events, or tracking of infective patients between institutions. Part 2: Comparison of 11 wards in 5 components

Handwashing: The score per ward ranged from 11 to 15 (68% to 100%). The questions where respondents performed poorly were because of poor initial education and poor auditing skills or systems. Personal protective equipment: The score ranged from 16-19 (84% to 100%). The worst scoring questions were because PSH did not have a respiratory protection program.

Catheter-associated Urinary tract infections (CAUTI) – The scores ranged from 20 to 34 (52% to 89%). PSH does not have a system in place for a CAUTI database. There is no ongoing collection of data and thus no dissemination of information back to the wards. Injection Safety: The score ranged from 10 to 14 (62% to 87%) Poor performance was due to lack of any protocol to identify tampering and on-going education. The Surgical Site Infections: Lowest score being 0 and highest 31 (0% - 85%). Non -surgical wards did not know the process so could not answer questions at all. The surgical wards were poor in the auditing process. OVERALL PERFORMANCE.

The total possible score was 119. The highest scoring ward was the gynaecology ward 110 (95%). The lowest was in the psychiatric ward, which scored 64 (53%). 8 wards had excellent performance (>80% [total score>95]): High care, ICU, Post-natal, Gynaecology, Labour ward, Surgical male, Surgical female, Orthopaedic. 2 Wards had a Good performance (60%-80% [71-95]): Medical Male, Medical Female One ward performed poorly <60% [71]): Psychiatry

The best overall performance was in handwashing. The worst performance was surgical site infections. Poor auditing practices were identified. Wards with a surgical focus performed the best. This is probably related to the fact that the staff working in surgical wards has to have additional familiarity with protocols and processes related to wound care. Units with no surgical expertise (medicine and psychiatry) do not usually have surgical patients under their care so do not have much-specialised knowledge. The psychiatric ward additionally usually does not often deal with patients that have any infectious diseases, so the staff is understandably less knowledgeable.

CONCLUSION

The South African literature is scanty and tends to favour Antibiotic Stewardship Programs above Infection Prevention and Control programs. Core strategies and coordination of audits and research are in the early stages. This audit is timely in the assessment of an IPC program in a provincial hospital in the public sector. The results of the audit performed at PSH are encouraging and the strengthening of the entire IPC program should be possible. To achieve the proper application of the IPC program more emphasis needs to be placed on constantly auditing existing practice and giving feedback to staff.