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After three months of quality improvement training and mentoring, one hospital's rate of surgical site infections dropped 50 percent.
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Using QI Tools to Reduce Surgical Site Infections

By Louis Ako-Egbe | Friday, February 26, 2021
Using QI Tools to Reduce Surgical Site Infections

Growing up, I experienced a lot of people dying in my village from ailments that I now know could be prevented or cured. I was raised by a single mother. Through farming and hair dressing, she sponsored my siblings and I through school and instilled into us the values of hard work, humility, honesty, and patience. My mother got ill the year I was admitted into university. Very unusually, after an ascitic tap [a procedure to drain fluid] for liver disease, she was sent home to nurse her drain because she couldn’t afford the bills. She deteriorated rapidly and died. Years later, my spouse’s mother had ascending paralysis of unknown etiology, and she couldn’t afford to consult a neurologist or internist. She became quadriplegic and died before her daughter could obtain a first degree.

I began my career in 2013 as a medical doctor serving in some of the most remote and hard-to-reach areas of Cameroon, where the gap between the quality of health care desired by users and what was available was very wide, and still is. Health care delivery in the public sector is constrained by poor infrastructure, inadequate human resources, and insufficient stock of medical supplies. Compassion, patient safety, patient-centeredness, and equity remain theoretical concepts in Cameroon with little commitment from relevant stakeholders to make substantial improvement. There is limited knowledge and capacity for quality improvement (QI) and patient safety among staff and leadership.

This was our inspiration to create a neutral space through which we could support both private and public health facilities. Favour Low-cost Healthcare Foundation (FALCOH) is an apolitical, not-for-profit community-based health and humanitarian organization created in 2014 with a mandate to enhance the quality of health care services for all populations during routine and emergency situations, and to alleviate suffering for less privileged groups and disadvantaged communities in Cameroon.

Ekona Sub Divisional Hospital is a referral facility in the crisis-affected South West Region of Cameroon. It serves a semi-urban population of over 100,000 inhabitants. On average, 65 surgical operations (including Cesarean sections) were carried out in the hospital per month between 2015–2018. An increase in surgical site infection (1 in every 5 cases) was recorded in the hospital in quarter three and four of 2018. The hospital leadership requested technical support from FALCOH Foundation to curb the rate of infections

The FALCOH team conducted a review of surgical records and processes and identified areas of weakness. Findings included poor Infection Prevention and Control (IPC) practices and inadequate staffing. At first, the team encountered resistance from staff to changing the work culture.

The FALCOH team organized a training for staff on aseptic techniques, standard IPC precautions, application of surgical checklists, and use of the Failure Modes and Effects Analysis (FMEA) tool for preventing harm to review post-operative infections. As part of this process, I reviewed and adapted existing tools like the WHO Surgical Safety Checklist to our setting. We planned and rolled out training for both clinical and non-clinical staff.

The team developed clinical algorithms to guide decision making. We developed job aides and posted them at points of care to remind staff of the steps for IPC; Water, Sanitation, and Hygiene (WASH); and standard operating procedures for surgery. We also provided onsite mentorship to strengthen staff capability for aseptic techniques.

The project was disrupted by COVID-19. Elective surgeries were cancelled, and some hospital staff were repurposed to support the COVID-19 response. In addition, the hallmarks of an ongoing armed conflict in the region over several years — ghost towns and lockdowns — caused a drop in outpatient consultations prior to the pandemic.

After three months of implementation, the rate of surgical site infections reduced by half (1 in 10 cases). All post-operative infections were reviewed using the FMEA tool and gaps were identified and resolved. We observed about a 90 percent adherence to the surgical checklist, delivery checklist, and asepsis protocols.

Between 2017–2020, FALCOH trained over 200 frontline health workers in clinical QI approaches. The foundation’s other work includes establishing a medical center, providing health education and screening, supporting national efforts to curb the spread of COVID-19, and donating life-saving equipment to regional COVID-19 treatment centers. We focus on health care delivery, humanitarian interventions, and public health research.

Through the QI project and other areas of work, we have learned the following lessons:

  • Public-private partnership, including the participation of civil society organizations, is critical to institute and sustain quality and patient safety in the health sector. Creating a private, non-governmental space is an important step to promote the culture of quality and safety in resource-limited settings.
  • Quality improvement in health care delivery is even more needed in fragile and conflict-affected settings where health infrastructure and livelihood have been disrupted. QI interventions are never too small to create an impact, even when the results are not obvious.
  • Peace-building is necessary to initiate and improve quality in fragile, conflict-affected, and vulnerable settings. There is a need to promote the humanitarian-development-quality nexus in the pursuit of quality and patient safety in a world that is overwhelmed by conflict and public health crises.
  • Political will and work culture of health care professionals need to be aligned with the national goals and aspirations for quality and patient safety. Substantial resources are required to institute and scale up QI interventions. Meanwhile, a progressive, results-driven organizational culture is critical to sustain the investments made in QI.

The FALCOH Foundation has conducted surveys to assess health care quality and culture of safety knowledge and skills in clinical practice; antimicrobial prescription and consumption in health care; and users’ perceptions about home-based care. The findings from these surveys are informing the foundation’s QI work and revealing new areas for collaboration with other organizations.

Louis Ako-Egbe, MD, MSPH, FiSQua is a public health physician and President and Co-founder of FALCOH Foundation.

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IHI Africa Forum (4–6 May 2021 | Online)

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