Hand Hygiene Practices and Promotion in Public Hospitals in Western Sierra Leone: Changes Following Operational Research in 2021.

Hand hygiene is the most important intervention for preventing healthcare-associated infections and can reduce preventable morbidity and mortality. We described the changes in hand hygiene practices and promotion in 13 public hospitals (six secondary and seven tertiary) in the Western Area of Sierra Leone following the implementation of recommendations from an operational research study. This was a "before and after" observational study involving two routine cross-sectional assessments using the WHO hand hygiene self-assessment framework (HHSAF) tool. The overall mean HHSAF score changed from 273 in May 2021 to 278 in April 2023; it decreased from 278 to 250 for secondary hospitals but increased from 263 to 303 for tertiary hospitals. The overall mean HHSAF score and that of the tertiary hospitals remained at the "intermediate" level, while secondary hospitals declined from "intermediate" to "basic" level. The mean score increased for the "system change" and "institutional safety climate" domains, decreased for "training and education" and "reminders in the workplace" domains, and remained the same for the "evaluation and feedback" domain. Limited resources for hand hygiene promotion, lack of budgetary support, and formalized patient engagement programs are the persistent gaps that should be addressed to improve hand hygiene practices and promotion.

Improvement in Infection Prevention and Control Performance Following Operational Research in Sierra Leone: A Before (2021) and After (2023) Study.

INTRODUCTION: Infection prevention and control (IPC) is crucial to limit health care-associated infections and antimicrobial resistance. An operational research study conducted in Sierra Leone in 2021 reported sub-optimal IPC performance and provided actionable recommendations for improvement. METHODS: This was a before-and-after study involving the national IPC unit and all twelve district-level secondary public hospitals. IPC performance in 2021 (before) and in 2023 (after) was assessed using standardized World Health Organization checklists. IPC performance was graded as: inadequate (0-25%), basic (25.1-50%), intermediate (50.1-75%), and advanced (75.1-100%). RESULTS: The overall IPC performance in the national IPC unit moved from intermediate (58%) to advanced (78%), with improvements in all six core components. Four out of six components achieved advanced levels when compared to the 2021 levels. The median score for hospitals moved from basic (50%) to intermediate (59%), with improvements in six of eight components. Three of four gaps identified in 2021 at the national IPC unit and four of seven at hospitals had been addressed by 2023. CONCLUSIONS: The study highlights the role of operational research in informing actions that improved IPC performance. There is a need to embed operational research as part of the routine monitoring of IPC programs.

Improvement in Infection Prevention and Control Compliance at the Three Tertiary Hospitals of Sierra Leone following an Operational Research Study.

Implementing infection prevention and control (IPC) programmes in line with the World Health Organization's (WHO) eight core components has been challenging in Sierra Leone. In 2021, a baseline study found that IPC compliance in three tertiary hospitals was sub-optimal. We aimed to measure the change in IPC compliance and describe recommended actions at these hospitals in 2023. This was a 'before and after' observational study using two routine cross-sectional assessments of IPC compliance using the WHO IPC Assessment Framework tool. IPC compliance was graded as inadequate (0-200), basic (201-400), intermediate (401-600), and advanced (601-800). The overall compliance scores for each hospital showed an improvement from 'Basic' in 2021 to 'Intermediate' in 2023, with a percentage increase in scores of 16.9%, 18.7%, and 26.9% in these hospitals. There was improved compliance in all core components, with the majority in the 'Intermediate' level for each hospital IPC programme. Recommended actions including the training of healthcare workers and revision of IPC guidelines were undertaken, but a dedicated IPC budget and healthcare-associated infection surveillance remained as gaps in 2023. Operational research is valuable in monitoring and improving IPC programme implementation. To reach the 'Advanced' level, these hospitals should establish a dedicated IPC budget and develop long-term implementation plans.

High levels of surgical antibiotic prophylaxis: Implications for hospital-based antibiotic stewardship in Sierra Leone.

Objective: Despite the impact of inappropriate prescribing on antibiotic resistance, data on surgical antibiotic prophylaxis in sub-Saharan Africa are limited. In this study, we evaluated antibiotic use and consumption in surgical prophylaxis in 4 hospitals located in 2 geographic regions of Sierra Leone. Methods: We used a prospective cohort design to collect data from surgical patients aged 18 years or older between February and October 2021. Data were analyzed using Stata version 16 software. Results: Of the 753 surgical patients, 439 (58.3%) were females, and 723 (96%) had received at least 1 dose of antibiotics. Only 410 (54.4%) patients had indications for surgical antibiotic prophylaxis consistent with local guidelines. Factors associated with preoperative antibiotic prophylaxis were the type of surgery, wound class, and consistency of surgical antibiotic prophylaxis with local guidelines. Postoperatively, type of surgery, wound class, and consistency of antibiotic use with local guidelines were important factors associated with antibiotic use. Of the 2,482 doses administered, 1,410 (56.8%) were given postoperatively. Preoperative and intraoperative antibiotic use was reported in 645 (26%) and 427 (17.2%) cases, respectively. The most commonly used antibiotic was ceftriaxone 949 (38.2%) with a consumption of 41.6 defined daily doses (DDD) per 100 bed days. Overall, antibiotic consumption was 117.9 DDD per 100 bed days. The Access antibiotics had 72.7 DDD per 100 bed days (61.7%). Conclusions: We report a high rate of antibiotic consumption for surgical prophylaxis, most of which was not based on local guidelines. To address this growing threat, urgent action is needed to reduce irrational antibiotic prescribing for surgical prophylaxis.

Infection Prevention and Control in Three Tertiary Healthcare Facilities in Freetown, Sierra Leone during the COVID-19 Pandemic: More Needs to Be Done!

Infection Prevention and Control (IPC) measures are critical to the reduction in healthcare-associated infections, especially during pandemics, such as that of COVID-19. We conducted a hospital-based cross-sectional study in August 2021 at Connaught Hospital, Princess Christian Maternity Hospital and Ola During Children's Hospital located in Freetown, Sierra Leone. We used the World Health Organization's Infection Prevention and Control Assessment Framework Tool to assess the level of IPC compliance at these healthcare facilities. The overall IPC compliance score at Connaught Hospital was 323.5 of 800 points, 313.5 of 800 at Ola During Children's Hospital, 281 of 800 at Princess Christian Maternity Hospital, implying a 'Basic' IPC compliance grade. These facilities had an IPC program, IPC committees and dedicated IPC focal persons. However, there were several challenges, including access to safe and clean water and insufficient quantities of face masks, examination gloves and aprons. Furthermore, there was no dedicated budget or no healthcare-associated infection (HAI) surveillance, and monitoring/audit of IPC practices were weak. These findings are of concern during the COVID-19 era, and there is an urgent need for both financial and technical support to address the gaps and challenges identified.

Achieving Minimum Standards for Infection Prevention and Control in Sierra Leone: Urgent Need for a Quantum Leap in Progress in the COVID-19 Era!

INTRODUCTION: Good Infection prevention and control (IPC) is vital for tackling antimicrobial resistance and limiting health care-associated infections. We compared IPC performance before (2019) and during the COVID-19 (2021) era at the national IPC unit and all regional (4) and district hospitals (8) in Sierra Leone. METHODS: Cross-sectional assessments using standardized World Health Organizations IPC checklists. IPC performance scores were graded as inadequate = 0-25%, basic = 25.1-50%, intermediate = 50.1-75%, and advanced = 75.1-100%. RESULTS: Overall performance improved from 'basic' to 'intermediate' at the national IPC unit (41% in 2019 to 58% in 2021) and at regional hospitals (37% in 2019 to 54% in 2021) but remained 'basic' at district hospitals (37% in 2019 to 50% in 2021). Priority gaps at the national IPC unit included lack of: a dedicated IPC budget, monitoring the effectiveness of IPC trainings and health care-associated infection surveillance. Gaps at hospitals included no assessment of hospital staffing needs, inadequate infrastructure for IPC and lack of a well-defined monitoring plan with clear goals, targets and activities. CONCLUSION: Although there is encouraging progress in IPC performance, it is slower than desired in light of the COVID-19 pandemic. There is urgent need to mobilize political will, leadership and resources and make a quantum leap forward.

Assessment of Infection Prevention and Control Measures at Points of Entry in Sierra Leone in 2021: A Cross-Sectional Study.

Implementing and monitoring infection prevention and control (IPC) measures at immigration points of entry (PoEs) is key to preventing infections, reducing excessive use of antimicrobials, and tackling antimicrobial resistance (AMR). Sierra Leone has been implementing IPC measures at four PoEs (Queen Elizabeth II Quay port, Lungi International Airport, and the Jendema and Gbalamuya ground crossings) since the last Ebola outbreak in 2014-2015. We adapted the World Health Organization IPC Assessment Framework tool to assess these measures and identify any gaps in their components at each PoE through a cross-sectional study in May 2021. IPC measures were Inadequate (0-25%) at Queen Elizabeth II Quay port (21%; 11/53) and Jendema (25%; 13/53) and Basic (26-50%) at Lungi International Airport (40%; 21/53) and Gbalamuya (49%; 26/53). IPC components with the highest scores were: having a referral system (85%; 17/20), cleaning and sanitation (63%; 15/24), and having a screening station (59%; 19/32). The lowest scores (0% each) were reported for the availability of IPC guidelines and monitoring of IPC practices. This was the first study in Sierra Leone highlighting significant gaps in the implementation of IPC measures at PoEs. We call on the AMR multisectoral coordinating committee to enhance IPC measures at all PoEs.

How Well Are Hand Hygiene Practices and Promotion Implemented in Sierra Leone? A Cross-Sectional Study in 13 Public Hospitals.

Healthcare-associated infections (HAIs) result in millions of avoidable deaths or prolonged lengths of stay in hospitals and cause huge economic loss to health systems and communities. Primarily, HAIs spread through the hands of healthcare workers, so improving hand hygiene can reduce their spread. We evaluated hand hygiene practices and promotion across 13 public health hospitals (six secondary and seven tertiary hospitals) in the Western Area of Sierra Leone in a cross-sectional study using the WHO hand hygiene self-Assessment framework in May 2021. The mean score for all hospitals was 273 ± 46, indicating an intermediate level of hand hygiene. Nine hospitals achieved an intermediate level and four a basic level. More secondary hospitals 5 (83%) were at the intermediate level, compared to tertiary hospitals 4 (57%). Tertiary hospitals were poorly rated in the reminders in workplace and institutional safety climate domains but excelled in training and education. Lack of budgets to support hand hygiene implementation is a priority gap underlying this poor performance. These gaps hinder hand hygiene practice and promotion, contributing to the continued spread of HAIs. Enhancing the distribution of hand hygiene resources and encouraging an embedded culture of hand hygiene practice in hospitals will reduce HAIs.

Hand Hygiene Compliance at Two Tertiary Hospitals in Freetown, Sierra Leone, in 2021: A Cross-Sectional Study.

Hand hygiene actions are essential to reduce healthcare-associated infections and the development of antimicrobial resistance. In this cross-sectional study at two tertiary hospitals, Freetown, Sierra Leone, we observed hand hygiene compliance (defined as using handwash with soap and water or alcohol-based hand rub (ABHR) amongst healthcare workers between June and August 2021. Using the WHO Hand Hygiene tool, observations were made in relation to the type of opportunity, different wards and types of healthcare worker. Overall, 10,461 opportunities for hand hygiene were observed, of which 5086 (49%) resulted in hand hygiene actions. ABHR was used more often than handwash (26% versus 23%, p < 0.001). Overall, compliance was significantly better: after being with a patient/doing a procedure than before (78% after body fluid exposure risk compared with 24% before touching a patient­p < 0.001); in Paediatric (61%) compared with Medical wards (46%)­p < 0.001; and amongst nurses (52%) compared with doctors (44%)­p < 0.001. Similar patterns of compliance were observed within each hospital. In summary, hand hygiene compliance was sub-optimal, especially before being with a patient or before clean/aseptic procedures. Improvement is needed through locally adapted training, hand hygiene reminders in wards and outpatient departments, uninterrupted provision of ABHR and innovative ways to change behaviour.

Incidence and risk factors of surgical site infections and related antibiotic resistance in Freetown, Sierra Leone: a prospective cohort study.

BACKGROUND: There is limited information on surgical site infections (SSI) and the related antibiotic resistance needed to guide their management and prevention in Sierra Leone. In this study, we aimed to establish the incidence and risk factors of SSI and the related antibiotic resistance among adults attending a tertiary hospital, and a secondary health facility in Freetown, Sierra Leone. METHODS: This is a prospective cohort study designed to collect data from adult (18 years or older) patients who attended elective and emergency surgeries at two hospitals in Freetown between February and July, 2021. Data analysis was done using STATA version 16. RESULTS: Of 338 patients, 245 (72.5%) and 93 (27.5%) had their surgeries at the tertiary and secondary hospitals, respectively. Many were males 192 (56.8%), less than 35 years 164 (48.5%), and 39 (11.5%) developed an SSI. Of the 39 patients who acquired an SSI, 7 (17.9%) and 32 (82.1%) had their surgeries at the secondary and tertiary hospitals, respectively. The incidence of SSI is higher in contaminated 17 (43.6%) than in clean-contaminated 12 (30.8%) and clean 10 (25.6%) wounds. Wound swabs were collected in 29 (74.4%) patients, of which 18 (62.1%) had bacterial growth. In total, 49 isolates of 14 different bacteria including gram-negative 41 (83.7%) and gram-positive 8 (16.3%) isolates were identified. Of these, 32 (65.3%) were Enterobacteriaceae, 9 (18.4%) were Non-fermenting gram-negative bacilli and 10 (12.2%) were Enterococci. The most common isolates were Escherichia coli (12, 24.5%), Klebsiella pneumoniae (10, 20.4%), Acinetobacter baumannii (5, 10.2%), Klebsiella oxytoca (4, 8.2%) and Enterococcus faecalis (4, 8.2%). The Enterobacteriaceae were either resistance to carbapenems (4, 8.2%) or were extended-spectrum beta-lactamase (ESBL) producing organisms (29, 59.2%). Male sex [p = 0.031], an ASA score ≥ 2 [p = 0.020), administration of general anaesthesia [p = 0.018] and elevated fasting glucose [p = 0.033] were predictive of SSI. CONCLUSION: The incidence of SSI in this study is comparable to other low- and middle-income countries, but a substantial proportion of these postoperative wounds have an ESBL-producing Enterobacteriaceae. Therefore, routine surveillance of SSI and related antibiotic resistance is required in resource-limited settings.

An Intra-COVID-19 Assessment of Hand Hygiene Facility, Policy and Staff Compliance in Two Hospitals in Sierra Leone: Is There a Difference between Regional and Capital City Hospitals?

Although hand hygiene (HH) is the most effective intervention to reduce the spread of infections, there are limited data on HH facilities, policy, and compliance in sub-Saharan Africa. This cross-sectional study is aimed at assessing HH using the WHO HH self-assessment framework, HH technical reference manual, and a modified infection control self-assessment tool in two hospitals in Sierra Leone. Only 10% and 9% of regional and capital city hospitals had running tap water, respectively. Veronica buckets were the resources for HH in 89% of units in the regional hospital and 92% of units in capital city hospital. Constant supply of soap and alcohol-based hand rub was available in 82% and 68%; and 74% and 79% of units in the capital city and regional hospitals, respectively. Only 10% of the units in both hospitals had hand-drying facilities and functional sinks. Overall HH compliance for the two hospitals was 18.6% and was higher in the regional (20.8%) than the capital city (17.0%) hospitals. The HH levels for the capital city and regional hospitals were 277.5 and 262.5 respectively. Despite the COVID-19 pandemic, there are still challenges with HH compliance in Sierra Leone. It is, therefore, necessary to strengthen the HH multi-modal strategy.