Infection prevention

During our time in Malawi we are expected to carry out an audit or project on a topic of interest or relevance. It was the idea of Dan our supervisor and some of the organisers back home to look into infection prevention practices in the medical department. So last week, Kate and I designed an audit, carried out observational data collection, and got some staff members to complete questionnaires. We are looking at the safe handling of sharps (needles ect), the use of personal protective equipment (PPE) (this is things like gloves, aprons, masks, eye protection etc), and hand washing – occurrence and technique. For those of you who have done the Cleanliness Champions programme in fifth year at Dundee, this will sound like your idea of hell. How anyone can really want to study more of this topic after doing a computer programme that eats at your soul will be beyond most of you, and to tell the truth, I was expecting to do a much more ‘exciting’ audit, based on something rare and complicated and tropical. And really, can we afford to focus on something like this is a setting which has countless ‘more important’ things to worry about, like people dying of curable illnesses left right and centre for example. However, as we all know, infection prevention is a massively important aspect of healthcare, even in a resource-poor setting. Hospital acquired infections are important causes of morbidity and mortality in the developed world, and may very well be in the developing world too, if data was available to show this. What with the increasing incidence of HIV and other blood-borne viruses worldwide, healthcare workers are at risk of acquiring such infections, and therefore safe handling of sharps is vital in all health-related workplaces.
We began our week by visiting the school of health sciences (where clinical officers are trained) and the nursing school to learn about the infection prevention curriculum. We visited the matron in the hospital who is head of all infection prevention issues, and learned about the training of staff members and the policies that exist in the hospital. Basically, education and policies do exist, and are of a very similar standard to back home. Staff training does happen, but the hospital can’t afford to train staff on a regular basis and by the sounds of things, this makes training quite erratic. We got to see the sharps injury record book, where every reported (many are not reported as staff are worried about being tested for HIV apparently) incident is recorded. There is no confidentiality, staff members names just appear in a list, with what happened, whether or not the patient’s HIV status was known, and whether post-exposure prophylaxis was given.
On the wards, we took note of the availability of facilities for safe handling of sharps, PPE, and hand washing facilities. Then we observed practice. We watched different members of staff carrying out different procedures and took a note of the PPE they used, how they disposed of sharps, and whether or not they washing their hands. We haven’t finished data collection yet, or analysed the data we have, but from our observations so far, if the hospital policies are anything to go by, the situation is pretty dire. There are no proper facilities for hand washing. There are sinks, but they rarely have soap and never have drying facilities. Staff members tend to use gloves as an alternative to hand washing, believing that if they wear gloves, they don’t need to wash their hands. Gloves are worn for pretty much everything, even examining patients (I am guilty of this too, sometimes patients just look so dirty). This is about the only item of PPE that is worn. Catheterisations are usually performed using non-sterile gloves, and even though sterile gloves are used for lumbar punctures, I wince as I watch them being contaminated as soon as they have been put on. No one apart from Kate and I wear eye-protection when performing procedures where there is a risk of splashing of bodily fluids. No aprons or masks are worn by anyone for procedures where we would wear them at home. The nurses get a plastic disposable apron each day, and wear it to do the drug round, and when someone dies (they only get a handful of aprons each day, so reuse them to make them last). They also wear masks when someone dies, but at no other time. As far as sharps are concerned, I think this is the most worrying observation. The sharps bins are cardboard boxes, made especially for the job, but have the potential to allow sharps to stick out of the sides of the box, waiting to stab someone as they walk past. No one takes sharps boxes to the bedside. Instead, they walk from one end of the ward to the other carrying dirty sharps in their hands. Whenever I see this I run in the opposite direction for fear of getting caught up in the complicated sharps injury process and being sent home to Dundee! Of course I also consider the 0.3% risk of contracting HIV through injury with an infected needle.
It’s been and interesting and eye-opening week, and has given me some issues to ponder over. I wonder whether all this infection prevention palava is just first world fuss and something not to be adopted by places like this, where there are just more important things to worry about, and where there isn’t an endless supply of money for gloves and aprons and masks and goggles and sturdy sharps bins. Kate and I have been discussing how we haven’t seen any hospital acquired infections while we’ve been here. We have never seen a cannula that has become red and inflamed for example, and you should see the dirt that we try and wash of the skin before sticking the needle in. Is that because hospital acquire infections don’t exist here? If so, why not? Are people’s immune systems more hardy that ours due to their upbringing in the African mud and sand? But being immunocompromised by HIV doesn’t do wonders for your immune system. We spoke to Dan about it, and Arthur, an infectious disease registrar from Ireland. They think that there are hospital acquired infections in these settings, just that there is no evidence or data to show it. MRSA has been isolated, and they think the incidence would be very high if it was measured because of the large quantities of unnecessary broad spectrum antibiotics that are prescribed. Still, MRSA doesn’t feel like a big priority when you are dealing with patients dying from malaria and meningitis on a daily basis. This antibiotic prescribing thing is an issue though.