الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Healthcare associated infections are one of the common problems and difficulties faced by hospitals in all countries around the world and are the most frequent adverse events in health care. They are associated with increased morbidity and mortality among hospitalized patients and predispose the HCWs to an increased risk of infections.)1)
An infection is considered as acquired in an ICU if it occurs in the ICU after more than 48 hours of admission.(2) Patients admitted to ICUs are at the greatest risk of acquiring HAIs partly because of the serious underlying diseases and their exposure to life-saving invasive procedures.(3) That is why the rates of infections in ICUs are approximately three times higher than elsewhere in hospitals and patients in ICUs have a higher risk of HAIs than those in non-critical care areas. Several years ago, numerous developments have been made in infection preventive strategies including planning and execution of infection control practices, training, monitoring, data collection, interpretation of data and modification in practices. The purpose of IC is to reduce the risk of HCWs exposure and HAIs, which can complicate existing diseases or injuries.(4)
The study was conducted to assess the IC procedures and practices of HCWs in ICUs in Althawra General Hospital in Sana’a, Republic of Yemen and to review the availability of resources.
A cross sectional survey was conducted. After obtaining the written approval of the Director of Althawra General Hospital in Sana’a, Republic of Yemen. The researcher visited all ICUs. All HCWs (200 physicians and nurses) in these ICUs and all managers (12 managers) of the ICUs and persons in charge (3 persons) for the specific services in the hospital namely sterilization and disinfection, isolation and standard precautions and waste management were included in the study.
Data were collected using the IC assessment tool designed by the USAID.(78) This tool is composed of IC assessment modules and observation checklists. Seven IC control assessment tool modules were applied once to each ICU (n=12). Managers were interviewed to complete the questions of the modules and three modules were applied once for specific services in the hospital. Persons in charge were interviewed to complete the questions of these modules. In addition, observation checklists for assessment of IC practices of HCWs in ICUs were used. Data entry was performed after coding using SPSS program and descriptive statistics were used for summarization. A scoring system was used for both the modules and the checklists.
The study revealed the following main results:
Results of IC assessment tool modules with managers and persons in charge:
Interviewing the managers of the ICUs and the persons in charge for the specific services (sterilization and disinfection unit, the waste management unit) revealed the following results:
ICU information module:
Concerning the type of patient admitted to the ICU, they were adults in 41.7% of the ICUs, children in 16.6% and both adults and children in 41.7% of the ICUs.
The number of beds per nurse was more than 5 beds per nurse in 8.3% of the ICUs, 3-5 beds per nurse in the same percent of ICUs and ≤ 2 beds per nurse in 83.4% of the ICUs.
Patients’ care areas were cleaned at least daily and between patients in all ICUs and only 8.3% performed hand hygiene prior to entering the ICU.
The same suction catheter was not used more than once in ventilated patients in all ICUs. The type of water used to fill the humidifier was distilled water in 41.7% of the ICUs. Tap water in one third of the ICUs and sterile water in one quarter of the ICUs. Also, in line bacterial filters were used in ventilator circuits in all ICUs.
Less than 50% of the ventilated patients received routine DVT prophylaxis in 41.7% of the ICUs. In one third of the ICUs, 50-75% of patients received routine DVT prophylaxis while more than 75% of patients received prophylaxis in a quarter of the ICUs.
Airway suctioning module:
The type of fluid instilled for airway suctioning was sterile saline. The fluid was dispensed through single dose drawn from a multi-dose container. The airway suction catheters were changed more than once per shift, and the suction catheters and masks were not used for more than one patient without reprocessing in all ICUs.
Medication nebulizers were mentioned to be changed approximately every day in 8.3% of the ICUs and were only changed for use in another patient in 91.7% of the ICUs.
Hand hygiene module:
The number of hand washing stations and beds was fewer than one hand washing station per two beds in all ICUs. The source of water for hand washing was running water from sinks in all ICUs.
Plain liquid soap was used in 91.7% of the ICUs. Liquid soap dispensers were refilled without cleaning in two thirds of the ICUs and were emptied, washed, and dried before refilling in one third of the ICUs.
Intravenous catheters module:
All patients required peripheral IV catheters in 41.7% of the ICUs.
Peripheral IV catheters were changed after or within 72 hours in 45.5% the ICUs.
Intravenous fluids and medications module:
The place of admixing IV fluids used in the ICU was where patient care is performed.
Single-dose vials were always used for injectable fluids/medications in 91.7% of the ICUs, and opened vials were not marked with date and time of expiration in 58.3% of the ICUs.
Injections module:
Auto-disable needles were never available in 83.3% of the ICUs and were sometimes available in 16.7% of the ICUs.
The tops of the multi-dose vials were not swabbed with alcohol before puncturing with a needle in 58.3% of the ICUs.
The needles were left in the multi-dose vials to withdraw the solution for multiple patients in 16.7% of the ICUs.
Routine training sessions for the HCWs about safe injection practices were conducted in only one quarter of the ICUs. WHO’s SIGN guidelines for safe use of needles were not followed in three quarters of the ICUs.
Urinary catheters module:
Straight urinary catheters were used in only 8.3% of the ICUs and were never reused in all ICUs. Indwelling urinary catheters were always available in 58.3% of the ICUs.
Catheter system was used for obtaining urine for analysis or culture in 91.7% of the ICUs, and for irrigation for bleeding/clots in half the ICUs.
Sterilization and disinfection – Equipment and IV fluids unit module:
Written facility policies and procedures for sterilizing materials and equipment, and decontamination of instruments before cleaning were available in an operations manual but were not actually used in daily practice.
Sterilization and disinfection of equipment was done in the central unit.
Isolation and standard precautions unit module:
There were no formal written policies for placing patients with potentially contagious infections in isolation rooms and for handling contaminated waste. Policy/procedures were communicated verbally only.
There were no policies for VHF. There were no single rooms or a separate ward or building and no dedicated toilet for patients with VHF.
Waste management unit module:
Facility staffs were not trained in handling/disposal of contaminated waste.
Infectious/contaminated waste was not stored separately from routine waste. Also, clearly labeled or designated receptacles or containers to differentiate between contaminated waste containers and routine waste containers were not used.
Results of HCWs IC observation checklists:
Before patient contact, hand hygiene was not performed in 71.5% of the observations (33.8% of doctors and 76.2% of nurses) and was performed using alcohol rub and hand washing in 17.5% of the observations (20% of doctors and 80% of nurses) while it was performed using hand washing in 11% of the observations (13.6% of doctors and 86.4% of nurses).
After patient contact, hand hygiene was not performed in 23.5% of the observations (25.5% of doctors and 74.5% of nurses) and was performed using alcohol rub and hand washing in 42% (22.6% of doctors and 77.4% of nurses) and 34.5% (18.8% of doctors and 81.2% of nurses) of the observations.
After body fluid exposure, hand washing was performed in less than half (41.5%) of the observations (22.9% doctors and 77.1% nurses), alcohol rub was used in 41% of the observations (23.2% of doctors and 76.8% of nurses) while hand hygiene was not performed in 17.5% of the observations (17.1% of doctors and 82.9% of nurses).
After contact with patient surroundings, hand hygiene was not performed in 60% of the observations (23.3% of doctors and 76.7% of nurses) while it was performed using alcohol rub and hand washing in 30% (20% of doctors and 80% of nurses) and 10% (20% of doctors and 80% of nurses) of the observations.
Before an aseptic procedure, hand hygiene was not performed in about two thirds (65.5%) of the observations (22.9% of doctors and 77.1% of nurses) while it was performed using alcohol rub and hand washing in 22% (25% of doctors and 75% of nurses) and 12.5% (12% of doctors and 88% of nurses) of the observations.
Hand hygiene was not practiced before injection in 65.5% of the observations (23.7% of doctors and 76.3% of nurses).
The vials of medication were not disinfected with alcohol in 32.5% of the observations (26.3% of doctors and 73.7% of nurses).
Sterile cotton or gauze was not used to break ampoules in 61.5% of the observations (23.4% of doctors and 76.6% of nurses).
Skin and IV ports were not disinfected with alcohol in 13.5% of the observations (18.5% of doctor and 81.5% of nurses).
Hand hygiene was not performed after giving the injections in 26% of the observations (26.9% of doctors and 73.1% of nurses).
Disposal of sharps in yellow sharp containers was not done in 92.5% of the observations (22.2% of doctors and 77.8% of nurses) and disposal of contaminated materials was not done in red containers in all observations.
In conclusion, IC practices and procedures of HCWs were poor regarding hand hygiene practices, hand hygiene before patient contact and after contact with patient surroundings, before an aseptic procedure and before injection. They were also poor concerning injection practices, policies and education, type of catheters used in ICUs, training of staff in sterilization units, sterilization and disinfection of instruments and equipment, isolation policies and precautions, precautions for viral hemorrhagic fever. Policies regarding contaminated waste, separation of contaminated waste, disposing sharps in yellow sharp containers and disposing contaminated materials in red containers were also poor.
The main recommendations of the study included:
Preparing and applying the national guidelines for IC in all hospitals and health centers.
Providing regular education and training to all HCWs about how infection is transmitted and the standard IC precautions.
Providing pocket IC manual or booklet to all HCWs.
Providing regular sufficient supply of PPE, safety boxes and medical waste disposal bags.
Providing clean and safe place for the preparation and storage of medicines.
Using a sterile set of equipment for each patient and avoiding sharing of instruments, medications or supplies between patients, and cleaning and disinfecting the patient station.
Investigating IC practices in other hospitals in Yemen to know the exact magnitude of the problem in Yemen.
Implementing further studies to assess the compliance with IC procedures and the factors associated with non-compliance.