Changing use of surgical antibiotic prophylaxis in Thika Hospital, Kenya: a quality improvement intervention with an interrupted time series design.

INTRODUCTION: In low-income countries, Surgical Site Infection (SSI) is a common form of hospital-acquired infection. Antibiotic prophylaxis is an effective method of preventing these infections, if given immediately before the start of surgery. Although several studies in Africa have compared pre-operative versus post-operative prophylaxis, there are no studies describing the implementation of policies to improve prescribing of surgical antibiotic prophylaxis in African hospitals. METHODS: We conducted SSI surveillance at a typical Government hospital in Kenya over a 16 month period between August 2010 and December 2011, using standard definitions of SSI and the extent of contamination of surgical wounds. As an intervention, we developed a hospital policy that advised pre-operative antibiotic prophylaxis and discouraged extended post-operative antibiotics use. We measured process, outcome and balancing effects of this intervention in using an interrupted time series design. RESULTS: From a starting point of near-exclusive post-operative antibiotic use, after policy introduction in February 2011 there was rapid adoption of the use of pre-operative antibiotic prophylaxis (60% of operations at 1 week; 98% at 6 weeks) and a substantial decrease in the use of post-operative antibiotics (40% of operations at 1 week; 10% at 6 weeks) in Clean and Clean-Contaminated surgery. There was no immediate step-change in risk of SSI, but overall, there appeared to be a moderate reduction in the risk of superficial SSI across all levels of wound contamination. There were marked reductions in the costs associated with antibiotic use, the number of intravenous injections performed and nursing time spent administering these. CONCLUSION: Implementation of a locally developed policy regarding surgical antibiotic prophylaxis is an achievable quality improvement target for hospitals in low-income countries, and can lead to substantial benefits for individual patients and the institution

Effect of the Free Maternity Programme on the Access and Outcomes of Maternal and Newborn Health (MNH) In the County of Kiambu

Project Report Submitted to the Chandaria School of Business in Partial Fulfillment of the Requirement for the Degree of Global Executive Masters in Business Administration (GEMBA)Maternal and newborn health (MNH) includes the provision of adequate nutrition, improved hygiene practices, antenatal care, and skilled health workers assisting at births, emergency obstetric and newborn care, and post-natal visits for both mothers and newborns. Most of the pregnancy-related maternal and newborn health issues have been proved to be preventable by the access to essential maternity and basic health-care services. Mothers and newborns health is usually related so preventing deaths and health complications usually requires employing the same interventions. The implementation of the free maternity program has brought about various issues. Accessibility, utilization and the various challenges that are affecting the implementation of the free maternity program are some of the emerging issues that have frequently faced the implementation and utilization of the free maternity program. The purpose of this study was to assess the effect of the free maternity programme on the access and outcomes of maternal and newborn health (MNH) in the County of Kiambu. This study was guided by the following research questions: Estimate the access and utilization of maternity services within public and private health facilities in the County of Kiambu, How has the introduction of free maternity services affected mortality and morbidity rates in Kiambu County? What are the challenges associated with the free maternity program implementation? The study employed a descriptive research design to access the effects of the free maternity programme on the access and outcomes of maternal and newborn health (MNH) in the county of Kiambu. A target population is the researcher’s population of interest. This study targeted level four and level five hospitals in Kiambu County. In total, there are two level five hospitals and four level four hospitals with a total staff of 800 including doctors, medical surgeons, nurses, laboratory technicians, allied health professionals and other hospital staff. The study adopted simple random sampling to select a sample size of 171 members of staff out of the total 800 staff available. The study collected both primary and secondary data. The research instruments adapted in this study to collect primary data were questionnaires. Data from questionnaires were summarized, coded, tabulated and analyzed. Editing was done to improve the quality of data for coding. Coded data was then fed into the statistical package for social sciences (SPSS) version 21 for analysis. The completed questionnaires were edited for completeness and consistency, checked for errors and omissions and then coded and analyzed qualitatively and quantitatively. Qualitatively the data was sought into themes, categories and patterns. The study found out that the high transportation costs impacts on patients need to access our facility, free maternal health service was shunned for fear of poor quality of health care, maternal healthcare user fees hinders access healthcare increasing mortality rate, lack of facilities to handle deliveries leads to high maternal morbidity and mortality rates, women deeply rooted in their tribes’ traditions rarely visit our health facilities for maternal care, poor infrastructure at our facility affect utilization of maternal health care. The study concludes that low level of education impacted negatively on women’s use of our facility’s maternal services, poor economic status affected the use of hospitals for delivery of children. Antenatal (ANC) utilization rate is still low due to lack of ANC services at our hospital facility, maternal healthcare user fees hinders access healthcare increasing mortality rate, lack of facilities to handle deliveries leads to high maternal morbidity and mortality rates, free maternal healthcare has reduced mortality rates, the introduction of free skilled care delivery services has improved the access to health services for the poor, high transportation costs impacts on patients need to access our facility, free maternal health service was shunned for fear of poor quality of health care, the risk of infections like HIV/AIDS by health workers is another challenge, low morale among the working staff is a hindrance to free maternal healthcare. The study recommends that education and literacy programmes should be set aside among women in Kenya concerning maternal care, the government should reduce the transportation costs of women seeking maternity care through provision of ambulance services, the management of health units should expand and grow their facilities to reduce congestion, the national government should subsidies the maternal healthcare fees to make the facility attractive and affordable to women of low economic status, health units should be properly with adequate facilities to handle deliveries

Establishing hospital-based trauma registry systems: Lessons from Kenya

Objective In the developing world, data about the burden of injury, injury outcomes, and complications of care are limited. Hospital-based trauma registries are a data source that can help define this burden. Under the trauma care component of the Bloomberg Global Road Safety Partnership, trauma registries have been implemented at three sites in Kenya. We describe the challenges and lessons learned from this effort. Methods A paper-based trauma surveillance form was developed, in collaboration with local hospital partners, to collect data on all trauma patients presenting for care. The form includes demographic information, pre-hospital care given, and patient care and clinical information necessary to calculate estimated injury surveillance. The type of data collected was standardized across all three sites. Frequent reviews of the data collection process, quality, and completeness, in addition to regular meetings and conference calls, have allowed us to optimize the process to improve efficiency and make corrective actions where required. Results Trauma registries have been implemented in three hospitals in Kenya, with potential for expansion to other hospitals and facilities caring for injured patients. The process of establishing registries was associated with both general and site-specific challenges. Problems were identified in planning, data collection, entry processes, and analysis. Problems were addressed when identified, resulting in improved data quality. Conclusions Trauma registries are a key data source for defining the burden of injury and developing quality improvement processes. Trauma registries were implemented at three sites in Kenya. Problems and challenges in data collection were identified and corrected. Through the registry data, gaps in care were identified and systemic changes made to improve the care of the injured. © 2013 Elsevier Ltd

Financial and other impacts associated with provision of surgical antibiotic prophylaxis, per 100 operations.

<p>Exchange rate of Ksh85 =  US$1 used.</p>†<p>based on documented prescriptions and number of doses administered in these time-periods.</p>*<p> = based on an assumption of 10 mins nursing time/dose of iv antibiotics.</p

Surgical patients in SSI surveillance between August 2010 and November 2011.

*<p>Medical Officer = junior doctor; Medical Officer Intern = junior doctor in first year after qualification; Registered Clinical Officer = vocationally-trained medical professional.</p

Weekly prescribing practices for surgical antibiotic prophylaxis.

<p>Weekly prescribing practices for surgical antibiotic prophylaxis.</p

Overall risk of SSI with and without use of pre-operative antibiotic prophylaxis.

<p>a = p-value from χ²-test with 1 degree of freedom.</p><p>b = no RR calculated for all SSI combined as these represent diverse forms of infection.</p

Monthly risk of SSI in Thika Hospital, 2010–11.

<p>Monthly risk of SSI in Thika Hospital, 2010–11.</p