Abstract

Background

The objective of the study is to establish a scientifically-based infection

prevention and control program in the Ministry of Health’s 12 Jeddah

hospitals and monitor its implementation through continuous auditing.

Material

From January 2009 to December 2011 an auditor from the infection

control team visits each hospital every four months on primarily

scheduled visits using an auditing tool comprised of performance

indicators covering four program areas: 1) general measures; 2)

application; 3) documents; and 4) staff. The auditing tool was inspired

by the British Infection Prevention Society’s auditing tool for monitoring

infection control standards and modified to reflect the clinical

environment of Jeddah’s hospitals. During the visits, the auditor scored

compliance rates by marking each performance indicator yes/no or

non-applicable. In total, 55 variables were tested. These variables were

distributed throughout the study according to their application.

Basic application variables were tested in the first year and other

variables that indicated more advanced applications were tested in the

second and/or third year. By the end of each year, the total compliance

rate was calculated for all hospitals combined. The total compliance

rate of the year of all twelve hospitals was obtained by summing the

total of 'yes' answers for the three visits combined in the twelve

hospitals in one year (Nominator) divided by the total number of the

'yes + no' of the 3 visits (Denominator) of the twelve hospitals in that

year multiplied by 100 excluding the non-applicable variables. Variables

that scored 60% and above were tested only once and were considered

accepted rates of compliance. Variables that scored less than 60%

were retested in the next year and/or the year after. After the end of the

three years, the overall compliance rate in all 12 hospitals was

calculated.

Results

The overall compliance of the IC program after 3 years of application

was 75% (1325/1759). The prevalence of Healthcare Associated

Infection decreased significantly from 2.9 in the first year to 1.7 in the

3rd year (P <0.01). Our study revealed that only 36% (37/104) of the

infection control departments (ICDs) in Jeddah hospitals are supervised

by specialized personnel, 44% (44/101) of the ICDs supervise and

manage the isolation rooms properly, 53% (55/104) of hospital sinks

are provided with all the required tools for hand hygiene, 45% (47/104)

of ICDs follow-up the infection control committee decisions and only

53% (55/104) of the infection control committee’s decisions are

implemented.

Conclusion

Instituting a standardized infection prevention and control program in

conjunction with regular audits and feedback has created a well

structured infection control program in Jeddah’s hospitals. We believe

that the program could serve as a template for improving infection

control practices in other regions both nationally and abroad.

Methodology

Study period: The study was conducted

from January 2009 to December 2011.

Hospitals: All MOH hospitals in Jeddah (12

in total) that serve around 60,000 patients a

year were included in the study.

The Establishment of an Infection Prevention and Control Program in Jeddah

Hospitals Saudi Arabia: A Three Year Project Muhammad A. Halwani, MSc, PhD, FJHMI. Nidal A.J. Tashkandy, MBBS. The Infection Control Sterilization and Waste Management.

Health Affairs, Ministry of Health, Jeddah, Saudi Arabia. mahalwani@cbahi.org

Data Collection

The principle of the data collection depended on regular

scheduled visits (once every 4 months) to all twelve hospitals

using an in-house made audit sheet. This audit sheet was made

based on the study's aim. A reviewer used the auditing sheet for

each visit to collect the required information. Data were collected

on various infection control items that covering four program

areas: 1) general measures that had 8 variables 2) application

which had 28 variables 3) documents which had 11 variables 4)

staff which had 8 variables (See Table 1). The auditing tool was

inspired by the British Infection Prevention Society’s auditing tool

for monitoring infection control standards and modified to reflect

the clinical environment of Jeddah’s hospitals.1, 2 Prevalence of

Healthcare Associated Infections (HAI) was determined for each

year based on the number of HAI divided by the total number of

admissions.3 Proportions were determined and the chi-square

test was used to explore the differences in the proportions of HAI

at a significance level of 5%. During the visits, the auditor scored

compliance by marking each performance indicator as yes/no or

non-applicable. The compliance rate was calculated by summing

the total of 'yes' answers of the three visits combined in the

twelve hospitals in one year (Nominator) divided by the total

number of the 'yes + no' of the 3 visits (Denominator) of the

twelve hospitals in that year multiplied by 100 excluding the non-

applicable.

In total, 55 variables were tested. At the end of each year, the

three best infection control departments who obtained the

highest total compliance rates between the twelve hospitals

were appreciated and acknowledged in a special ceremony.

Variables that scored 60% and above after combining the results

of three visits by the end of the year in all 12 hospitals were

considered as accepted rates of compliance and were tested

only once. Variables that scored less than 60% by the end of the

year in all 12 hospitals were retested during the second and/or

the year after by adding them to the next year's auditing tool.

The same thing was done during the second and third year to

obtain that specific year's total compliance rate. After every first

visit to any hospital, the compliance rate is immediately sent to

the hospital surveyed. During the second visit of each hospital,

only the variables that were marked as 'no' in the previous visit

were rechecked. Variables that indicated compliance in this visit

were changed to 'yes' and the rate of that visit was based on the

new changes. The same thing was done during the third visit. By

the end of the third year, the overall compliance rate of the three

years was calculated by summing up all the 'yes' answers for the

last rate obtained of all the variables that reached 60% and

above. For the variables that were left below the accepted

compliance rate < 60% after the three years visits, the final

number obtained after the third visit was used in the calculation.

Results

The total compliance rate of the first year was 63% (1482/930). The total

compliance rate of the second year was 67% (615/921) and the total compliance

rate of the third year was 65% (217/336). The overall compliance rate of the

three years combined was 75 % (1325/1759). The prevalence rate HAI declined

respectively from 2.9 % during the first year to 2.6% on the second year to 1.7%

on the third year (see Table 2).

Out of the 55 variables tested in three years, only five variables 9% (5/55) did

not reach the accepted compliance rate (see Table 3).

Acknowledgment

We are grateful to the Cure Development Limited Company in Saudi Arabia for the Travel

Grant to this Conference.

Introduction

The governmental health system in the

Kingdom of Saudi Arabia is run by different

sectors: the National Guard, the Armed

Forces, the Ministry of Interior, and the

Ministry of Health. Each sector has its own

hospitals and its own infection prevention

and control program. Therefore, the

implementation is never the same and the

quality of practice may have a significant

variability. Under the Ministry of Health,

which is the largest sector of all, the

infection prevention and control program in

its hospitals was never standardized.

Moreover, each region and even each city

hospital has been known to have their own

plans, programs, and targets. Jeddah is the

second main city in the Kingdom of Saudi

Arabia with a population of 3.2 million. It is

located on the western coast of the

Kingdom. It is an important commercial hub

in the country and the principal gateway to

the two holy cities; Makkah and Medina.

The health system of the city is run by the

Ministry of Health and the provided services

are free of charge. The infection control

program in Jeddah hospitals (12 in total) is

run by a specialized administration that

supervises this service in all these

hospitals. The infection control program in

the city was never standardized or based

on focused, scientific guidelines. Different

attempts were conducted in previous years

but never standardized or monitored on a

frequent basis which led us to believe that

such a program is needed¹ ². The objective

of this study; therefore, is to establish a

scientifically-based infection prevention and

control program in Jeddah hospitals and to

monitor its enforcement through continuous

auditing.

Discussion & Conclusion

The study succeeded in establishing a proper

scientifically-based infection control program at the

infrastructure level using frequent auditing. This

was clear from the overall compliance rate that

reached 75% and the prevalence rate obtained; it

decreased significantly from the first year to the

third year. However, the 5 variables that did not

reach the accepted rate of compliance need to be

improved. The study helped the hospitals involved

to become more orderly in the way they manage

infection control related issues. Finally, the study

also helped standardize the process of infection

control according to international standards. It is

worth pointing out that this study did not need

many resources except for manpower, dedication,

and continuous follow-up. We feel that the

methodology we applied is relatively simple,

straightforward, and can be used as a template in

any other hospital.

Table 2: The prevalence rate of healthcare associated

infections during the three year study period

Table 3: Variables that did not reach the accepted rate

of compliance after the three years

Year Number

of HAI

Number of

Admissions

Prevalence

Rate

P Chi

Square

test

Confidence

Interval

2009 1510 50733 2.9 - - - -

2010 1427 54704 2.6 <0.01 1.1 1.06 1.2

2011 912 53604 1.7 <0.01 1.7 1.6 1.9

Variables Rate

Lack of Specialized Personnel to Lead the Infection Control

Departments

36% (37/104)

Poor Supervision of the Infection Control Departments to the

Isolation Rooms in the Hospitals

44% (44/101)

Hospital Sinks were Short of the Required Tools for Hand Hygiene

(anti-bacterial soap, tissue papers, foot operated garbage container,

step-by-step hand washing poster)

53% (55/104)

Incomplete Follow-up from the ICDs to the Infection Control

Committee's Decisions

45%(47/104)

Improper Implementation of the Infection Control Committee

Decisions

53%(55/104)

Table 1: Variables Tested and their Rate of Compliance Variable

GENERAL MEASUERS 2009 2010 2011 TOTAL

The IC department is in proper place and accessible to the hospital staff (13/36) 36% (22/34) 64%

The IC department is sign posted (11/36) 30% (21/34)62%

There is a telephone and extension number for the IC department (36/36) 100%

The IC department is chaired by a specialised personal (13/36) 36% (10/34) 29% (14/34) 41% (37/104) 36%

The staff number is adequate with the hospital size (34/36) 94%

The working staff are trained/experienced in the IC (26/36) 72%

Infection control clinical notes form are available and in use by IC (26/36) 72%

There is a strong link between the microbiology lab and infcetion control Dept (31/31) 100%

APPLICATIONS

Surveillance is applied actively (22/30) 73%

Staff are aware of surveillance and skilled enough with its conduction (20/30) 67%

Surveillance data are checked daily and analyzed by the IC head (22/30) 73%

Cases of Healthcare associated infection are reported directly to the affected department. (20/30) 67%

Monthly rates are prepared on time and clearly organized. (27/30) 90%

Trend of increase are reported to the affected department for action (20/30) 67%

There is an indication of the action taken to solve related problems (19/30) 63%

The IC department/unit manage outbreaks as required (21/30) 70%

The departmnet replaced the hospital wide surveillnce with targetted survillance (16/24) 67%

The IC monitor the application of Standard Precautions before CVC insertion regularly (8/15) 53% (16/18) 89%

The IC monitor the application of SP before wound dressing change regularly (13/27) 48% (28/31) 90%

The IC monitor the application of SP before urinary catheter insertion regularly (10/26) 38% (23/28) 82%

The IC monitor the management of urinary catheter regularly (5/26) 19% (23/27) 85%

The IC monitor the SP in dialysis department weekly (3/12) 25% (11/16) 69%

The IC monitor the linen collection, transportation to the Landry to prevent cross-infection weekly (10/36) 27% (26/33) 79%

The IC monitor the SP in the kitchen at least weekly (20/36) 55% (28/31) 90%

The IC monitor the cleaning/ disinfection of endoscopes in endoscopy unit weekly (5/9) 55% (7/11) 64%

IC follow up the hand hygiene application in the hospital on regular basis (23/36) 36% (29/34) 85%

Feedback of auditing results are discussed in the ICC (18/36) 50% (7/34) 20% (25/34) 74%

Designated isolation room are provided and managed by IC (14/33) 42% (15/34) 43% (15/34) 43% (44/101) 44%

There is an actively functioning infection control committee (25/36) 69%

Members are from the departments that have direct impact on IC (26/36) 72%

The committee minutes are written and prepared as it should be (13/36) 36% (20/34) 59% (22/34) 65%

The committee meet regularly ( not less than 4 meetings a year is the minimum ) (21/36) 58% (21/34) 62%

The committee decision are implemented (16/36) 44% (19/34) 56% (20/34) 59% (55/104)53%

IC department follow up the committee decisions (11/36) 31% (17/34) 50% (19/34) 56% (47/104) 45%

MRSA screening policy are known and applied the hospital (20/31) 65%

Antibiotic restriction policy is available and followed in the hospital precisely (15/34) 44% (21/34) 62%

DOCUMENTS

Surveillance sheet is available and proper (25/30) 83%

Checklists available are properly prepared and filled as they should be (28/34) 82%

A proper hand hygiene procedure instructions poster is available beside the hospital sinks (30/36) 83%

Hospital sinks seen are provided with all required tools (16/36) 44% (17/34) 50% (19/34) 56% (52/104) 50%

The provided liquid soap must are single use cartridge dispensers (19/36) 52% (26/34) 76%

Alcohol product is available in all hospital wards (36/36) 100%

Isolation cards are available and up to standards (23/33) 66%

Appropriate leaflets about the required precautions are available to patients companions

and relatives before admission to isolation room (16/33) 48% (24/32) 75%

The required PPE are available and in sufficient number (33/36) 92%

Leaflets that contain the required measures of precautions that need to be taken during a

patient visit is available and distributed (24/34) 71%

Etiquette policy are applied and available in the hospitals especially in the waiting areas

and common meeting rooms (25/34) 74%

STAFF

Internal continues education between the infection control staff is going on (24/34) 71%

Staff are aware of the PPE use and their benefits (29/36) 81%

The IC staff updated the hand hygiene application accrodring to the recent updates (31/34) 91%

The IC department is active in educational sessions in general (28/36) 77%

There is a continuous IC program for the hospital staff (26/36) 72%

The IC department is involved in the orientation program of new staff (33/35) 94%

The IC department do have an educational program for the medical students (16/27) 59% (19/27) 70%

Staff are given the chance to attend IC courses (29/36) 81%

References

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