Health care-associated infections (HCAIs) are common in health care delivery worldwide, and contribute to significant morbidity, mortality and financial losses in health care systems. The risk of acquiring HCAIs in Africa is estimated to be 2 to 20 times higher than the risk for patients receiving care in hospitals in developed countries. The standard of hand hygiene in healthcare facilities is important when considering the role of infection control in this context. A study by Yawson and Hesse, 2013a, showed that hand hygiene compliance among doctors ranged from 9.2% to 57% and 9.6% to 54% among nurses. Alcohol hand rub and liquid soap dispensers were shown to be deficient, and the introduction of these as accessible and effective hand hygiene facilities were recommended.
During a point prevalence survey in selected hospitals in the ten regions of Ghana, we made a few observations on the general attitude of healthcare workers towards infection control activities, and how they promote Infection prevention and control(IPC) practices in the context of resource scarcity. This is part of a larger multi-methods project that was conducted between August and December 2016. It represents findings from informal and in-depth semi-structured interviews, casual interactions and unobtrusive observations of healthcare staff in ten different hospitals in the ten regions of Ghana.
The field work involved a ‘walk-through’ in various hospitals, presentations to health worker groups, group discussions and further interactions with health personnel who were available and willing to engage in informal conversations. Relevant points were jotted down in field notes and compiled at the end of the survey. Field notes were compiled, and combined with discussion points and minutes of meetings, to gain a better understanding of IPC practices in relation to healthcare associated infections.
Central Region: SFX Hospital
The team visited a CHAG facility located in the Central region of Ghana with a large catchment area within the Assin Fosu township. The hospital is a 139 bed facility with about a 100 patients estimated on admission of the day of the survey.
The environment looked well kept, with no obvious signs of littering. Lawns appeared trimmed, and the general condition in the hospital represented some state of orderliness. At the time of the visit, the hospital held the leading position on the Central regional Peer Review league table, where environmental standards, IPC standards, Clinical care standards and other parameters are reviewed.
The HAI_Ghana team met health workers across all cadres- doctors, nurses, midwives, laboratory technicians- from the Regional hospital, and neighbouring hospitals for a presentation on HAI and IPC. The presentation on the general concept of Healthcare Associated Infections was followed by an interactive session, seeking to discuss the perspectives of health workers about HAI and practical ways of observing IPC practices in the ward setting at the hospital.
Staff acknowledged the importance of healthcare associated infections with statements like
“When they come to us to get well, we don’t have to introduce more sickness”.
As part of discussions, staff were asked to give examples of situations in which they would normally wash their hands, while at work. They gave instances such as: before eating: to protect themselves from taking in germs, and after using the washroom. This is consistent with findings in other studies where the health workers own protection is a motivation for hand washing. Self-protection has often been considered the primary reason for the performance of hand hygiene (Salmon and McLaws, 2015).
At the maternity ward, we observed from general patient records that some mothers were given antibiotics after delivery with no written indication. In a few cases where the mothers had perineal tears which were sutured, the indication was implied. At the medical ward, polypharmacy, was found to be quite common too. The ‘irrational’ use of antibiotics is an important issue in the discussion of antibiotic resistance, and also has implications for HAI
Eastern Region of Ghana: ERX Hospital
Volta Region of Ghana :ABC Hospital
Koforidua is the capital of the Eastern region of Ghana.
It is also a potential site for further studies for the HAI-Ghana project. The general environment of the hospital appeared well kept. There were ongoing structural renovations in some areas and on some of the wards.
The administration block had the offices of most of the managers. The team was welcome by the Medical Superintendent of the hospital, and other members of the management team including the administrator, pharmacist, biomedical scientist, and some members of the Quality Assurance team.
Arrangements had been made to enable the team to meet the staff in the conference room by midday for a presentation on Healthcare-associated infections and Infection Prevention and Control (IPC). There was an interactive session, after which we had a training session for five selected people who would assist us in carrying out the survey.
The team started work the following day from the medical ward and proceeded to the surgical, Obstetrics/Gynaecology and Paediatric wards. Over 250 admission folders were assessed.
There were interactions with ward nurses when clarification was needed, and a few times there were indirect interactions with patients e.g. to check if they had IV lines or other devices in situ.
Further details were documented for all patients perceived to have Healthcare associated infections including date and type of infection and any relevant devices in-situ.
At the end of our survey we met with the Medical Director and Administrator to give feedback on how the survey went. They mentioned that all new staff who joined the facility were taken through some form of IPC training. In previous years, all health facility staff have been taken through IPC training, but due to the high cost usually involved, this was not conducted in 2016.
The Medical Director mentioned that sometimes, after investing so much time to train some staff, they end up moving on to other facilities, which becomes a loss to the hospital.
Another issue which came up for discussion was the non-availability of Blood Culture test results in most of the folders assessed. There was a general concern about the laboratory technicians not being forthcoming with lab results especially on weekends. This issue had been discussed on several occasions in several meetings but without much improvement.
One doctor narrated, that on one occasion, after a long day’s shift, he sent labs requests to the lab only to be told by the technician who had just come on afternoon shift that this could not be done till the following day.
“I mean…. We have bought the reagents and everything for them to run the labs; we have discussed it in meetings over and over again… it just doesn’t make sense that they won’t do the lab. I have been here working all day and you, you have just come for night shift and you are giving all sorts of excuses”
It was only after the head of the laboratory was called from home that the lab technician was persuaded, or instructed to process the blood sample. Further discussions revealed that this attitude has been noted, even in the teaching hospitals.
On the use of antibiotics, we noted a case where a child with malaria had been given an antibiotic, Ceftriaxone in addition to the antimalarial. A staff commented that this is commonly done when the child has seizures as well. He stated that taking a sample and waiting for results would take too much time.
“If you come here with malaria, and you show the least sign of seizures, you will be put on Ceftriaxone”
Upper West Region of Ghana: WRX Hospital:
During the discussion sessions, logistic issues were mentioned as a key challenge in most health facilities, with non-availability of hand sanitizers being a major issue.
Staff in the hospital we visited in UWR admitted that personal attitudes such as laziness are also a factor.
“Sometimes you just don’t feel like washing your hands”, Nurse, WRX Hospital.
Patient load was mentioned as one of the factors which affects how often staff perform hand hygiene. One health worker commented:
“When there are many patients waiting for you to attend to them and you get up to go and wash your hands, they will beat you…” Nurse
Questions were asked about the role of visitors in infection prevention and control.
“They come and visit the patients, touch them, and touch all sorts of things, and they go away without washing their hands; we don’t know what they are carrying”…comments from pharmacist at the WRX Hospital.
In WRX hospital, one doctor spoke passionately about how these relatives become a part of the hospital when their relatives are on admission, stating that sometimes the entire household would take turns to stay with the relative throughout the admission, with some even bringing their mattresses to sleep over.
Greater Accra Region of Ghana: KBX Hospital
The point prevalence survey was carried out from the 1st to 3rd December, 2016.
It was an opportunity to walk through key departments and wards of the hospital in which the main ethnographic study for the project will be carried out.
The team met a section of key staff from the various departments for a presentation on Healthcare-associated infections. This included the Ward in-charges from the Surgical, Medical, Paediatric and Obstetrics and Gynaecology Ward. From the interactions, we got to know that some of the staff had recently been trained in Infection Prevention and Control and also had some knowledge about Healthcare Associated Infections.
During the interactions, some of the staff spoke of challenges in their daily practice which had to do with lack of regular supply of logistics. Some wards had not been supplied with Alcohol hand rubs in a long time. Almost all the wards have a regular flow of running water, but sometimes they do not have enough soap and other detergents.
Surgical department. he VIP (6th floor) ward was clean, had few patients and the environment was serene. The ward had a nice smell and the open space was air-conditioned. There were about 6 patients on admission. There were 2 male nurses on duty, one at the nurses’ station, and the other moving around the ward.
At the one of the other wards we engaged some of the doctors in an informal discussion and they pointed out that some of the protective clothing they are being asked to wear cause more harm than good. One doctor pointed out:
“Look at this coat, it’s been hanging here for the past 2 weeks. The doctor comes to wear it for ward rounds. After the rounds, he removes it, hangs it here and goes home. It hasn’t been washed in a long time. Are we really preventing infections or carrying infections to the ward? Sometimes when the policy makers ask us to do things in a certain way, they should also make sure the means to do it is there…”
On this same unit we observed a health care assistant creating an improvised sharp disposal box out of an old box. According to him there had been no supply of the standard sharp disposal boxes as long as he had been on that ward (over 3 months).
Some of the other wards had a number of old beds, some abandoned.
The washroom in one of the wards was briefly observed and it appears not much attention is paid to keeping the place kempt. A portion of it was being used as a storage area for wheelchairs and some equipment which are out of order.
Neonatal Intensive Care Unit. The NICU has a veronica bucket at the entrance, with soap and single use towels available for handwashing by anyone entering the ward.
At the entrance to the ward were 2 benches facing each other, with some women, some of whom were mothers of babies on admission sitting on them.
Caregivers and mothers of the babies washed their hands at a sink at the entrance before going in to see their babies. However no one is at the entrance to supervise. No one asked any of the team members who entered the NICU to wash their hands or wear any protective clothing.
We were given a room behind the nurses’ station to sit and carry out our work. From there we could observe nurses engaged in various discussions while going about their duties.
At a side room on the same ward was the office on the in-charges. There were a number of logistic items including diapers and cotton wool filling over half of the room.
There were 3 large rooms assigned as cubicles for patients on admission. At the extreme corner round the ward was a room assigned for Kangaroo Mother Care, where mothers with preterm babies could stay and nurse their patients in direct contact with themselves. This room had a decent washroom and bathroom annexed to it.
For most of the other mothers whose babies were on admission, we were informed that they came in 3hourly to feed their babies and express milk for them. They would usually spend about an hour on the ward.
We observed mothers come in during feeding time. Some of them sat in a row in the middle of the ward, cup in hand, expressing milk into cups for their babies. They didn’t seem to enjoy much privacy. Right across the nurses station a mother sat changing her baby’s diapers in the open.
A father walked in to have a discussion with one doctor about procedures that needed to be carried out on his babies- a set of twins. It was an open conversation, to the hearing of everyone, with the doctor explaining why labs had to be done for both babies, as they shared common risk factors. We observed that both babies shared a common incubator.
We engaged some nurses in informal interactions to find out their perceptions of HAIs and the role of the patient. The role of the patient in influencing hand hygiene is often not taken so seriously. Some health staff perceive patients as having low levels of education and unable to understand:
“When we even tell them to wash their hands they don’t understand and they don’t take us serious”.
By: Gifty Sunkwa Mills (Ethongraphy Work package)