Building on the success of the Lucina Project, WSIS launched an expanded implementation effort targeting district level hospitals in Kenya.

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Why?

One Size Doesn’t Fit All

 

Infection prevention programs in high income countries have resulted in significant reduction of SSI. However, the reduction of SSI has not been reliably replicated on a large scale in LMIC. The World Health Organization has recommended use of surgical unit safety programs (SUSP) programs, which work to strengthen safety culture and teamwork, for these regions, but we hypothesize that the complexity and personnel requirements make SUSP very difficult to implement in resource limited settings, particularly at government hospitals.

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“A recently published study in The Lancet reported that the most common procedure
in 25 countries in Africa was caesarean section (33%), and infections were the most
common complication resulting from overall surgeries. Among patients who died as
a result of surgery, about 8% were as a result of a caesarean surgery.”

–Source: Global Maternal Sepsis Study

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Developing a scalable, sustainable surgical infection intervention bundle that is effective at this type of facility is a crucial global health objective because district level hospitals often serve a greater population than larger referral hospitals, and patient safety improvement programs developed in high-income regions or large referral hospitals in LMIC are often not feasible due to resource constraints.  Simple and low-cost quality improvement interventions are available and can be implemented at high coverage in LMICs. One such intervention is the administration of pre-operative antibiotics, which is established as extremely effective in lowering SSI rates, and was shown to be in the Lucina Project.

 

What?

Project Goals

 

With the information gathered in our previous study, we believe that the following elements are key in improving in clinical outcomes (reduced SSI):

• Presence of executive, surgical/obstetrical, and nursing champions

• Adherence to the strong recommendations in the WHO guideline for the prevention of surgical site infections

• Existence of a hospital wide infection control program with adequate staffing

• Adequate sterilization

• Adequate water, sanitation and hygiene

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Results

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All facilities had infection prevention and control  programs supported by leadership and professional teams, though only some had specific budgets for these programs. Access to microbiological labs varied, with facilities having either on-site or off-site options. Hospital-acquired infection surveillance was common, particularly for SSIs. Most facilities had reliable water and power, but practices like bed-sharing and placing beds in non-room areas were observed. WHO-recommended preoperative practices were often not followed.

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For personnel, nearly half the facilities had no certified surgeons on site. Almost all facilities had medical officers available to perform cesarean operations. The number of nurses in surgical and OBGYN wards ranged from 4 to 101, with an average 27 years of experience. 

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All facilities use systematic prophylaxis, with all administering antibiotics post-operatively. Common systemic antibiotics included ceftriaxone, metronidazole, and gentamicin, which are antibiotics that were not recommended as first-line prophylactic antibiotics for cesarean section by the World Health Organization and the American College of Obstetricians and Gynecologists.

 

Conclusions

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The surveyed facilities demonstrate a strong commitment to IPC programs, with substantial leadership support and professional IPC teams in place. However, the lack of specific IPC budgets and varied access to microbiological laboratories highlight areas for improvement. While HAI surveillance is relatively common, adherence to WHO-recommended preoperative practices is notably low.

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The distribution of surgical expertise is uneven, with nearly half of the facilities lacking certified surgeons, though medical officers frequently perform cesarean sections. The wide range in nursing staff numbers and experience further illustrates disparities in resources and staffing.

 

Systemic antibiotic prophylaxis is widely practiced, both pre- and postoperatively, with a consistent use of certain antibiotics. The practices utilized at these facilities are not aligned with guidelines by the World Health Organization and  American College of Obstetricians and Gynecologists.

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Overall, while there are strengths in IPC program implementation and antibiotic prophylaxis practices, there are significant gaps in budget allocation, adherence to best practices, and the availability of certified surgical staff that need to be addressed to improve patient outcomes and infection control.

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