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Improvement Quality Project

Infection Control In Cardiology Department
At El Ranteesy Specialized Pediatric Hospital

Prepared by:
Heiam Elnuweiry
Mahmoud Alabsi

Supervised by:
Dr. Bassam Abu Hamad
BSN, MSC, PHD
2013

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Acknowledgment:
Special thanks go to Dr. Bassam Abu Hamad who helps us to bring our learnt
theory into practice.
Also we would like to express our gratitude to cardiology department staff in El
Ranteesy Specialized Pediatric Hospital who participated in this project and who
showed a real awareness for improvement.
Team member












Content:

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No. Item Page No.
1 Introduction 4
2 Context of problem 5
3 Justification of the problem 7
4 Over all aim 7
5 Specific objectives 7
6 Literature review 8
7 Methodology 8
8 Pre intervention tools and analytic results 10
9 Fish bone 14
10 Flow chart pre intervention 15
11 Pareto 16
12 Intervention 17
14 Limitation 24
15 Stability 24
16 Conclusion 24
17 Recommendation 24
18 Reference 25
19 Annex 26





1- Introduction:

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Children are a vulnerable group that needs more interesting and precaution when
dealing with it. Children are more threaten to get infection than any other population
age groups. Many of pediatric morbidities are due to infections and infectious
diseases. 10% of death in children under the age of five is due to infections or
infectious diseases (Palestine, Ministry of Health (MOH), 2011).
Integrated management health of childhood illness aims to reduce child mortality and
morbidity, and improve healthy growth and development of children. This requires a
well-organized health system with high quality of care at all levels, including good
health team services and environment health surrounded in hospitals.
Nosocomial infections are acquired during hospitalization. They are caused by
Candida albicans, Escherichia coli, hepatitis viruses, herpes zoster virus,
pseudomonas and staphylococcus. These pathogens are transmitted from one person
to another through direct or indirect contact. At any one time, 10% of in-patients have
a Hospital Acquired Infection (HAI) and the rate increased to 25% in developing
countries.
Nosocomial infection rates range from 1% in Europe and America to more than 40%
in some parts of Asia, Latin America and Sub-Saharan Africa.
The most frequent nosocomial infections occurring in developing countries are
Surgical Site Infections (SSI), urinary tract infections and lower respiratory tract
infections such as pneumonia.
Infection prevention and control (IPC) is an integral part of pediatric practice. All
employees should be educated; regarding the routes of transmission and techniques
used to prevent transmission of infectious agents, policies for infection control and
prevention should be written, readily available, annually updated and enforced.
Each health institution used to adopt specific infection control and prevention
activities or protocol. Employees working in pediatric hospitals are supposed to take
precautions to protect both clients and the staff likely to expose to potentially
infectious materials while in the job.
Infection prevention standard precautions represent a system of barriers precautions to
be used by all personnel for contact with all patients regardless of patients diagnosis,
and these precautions are slightly different according to the state policies and
protocols. The precautions are the standards of care but basically their components

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are: consider every person as potentially infectious; washing hands; wearing gloves;
using physical barriers; using safe work practices; process of instrument re-cleaning
and protect workers.
2- Context of the problem:
Cardiology Department in El Ranteesy Specialized Pediatric Hospital composed from
five rooms; two big rooms with five beds and the others three small rooms (Isolated
rooms). The natural of cardiology department more likely to acquire nosocomial
infection related to some reasons, cases admitted to the department mixed between
cardiac disease and respiratory disease and most of these cases complex and terminal
patients such as complex heart disease post operation and respiratory disease with
immunosuppression; therefore any exposure to any infection lead to high risk on their
patients such as septicemia, pneumonia, resistant to antibiotic, wasted resources and
the last high rate of mortality.
Another reasons for increased nosocomial infection are increase number of admitted
and readmitted cases to department with long time of stay in hospital on suction
procedure, urine catheter, medication giving, all of these procedures are good point of
source of nosocomial infection.
Lab. Technique were taken monthly three times of swab culture in cardiology
department randomly from patients beds, trolley medication, trolley emergency and
ambo bag, most of these swab are positive culture with different types of pathogens,
and this positive result lead to serious complication to patients in cardiology
department.
3- El Ranteesy Pediatric Specialized Hospital:
El Ranteesy Pediatric Specialized Hospital is the only specialized pediatric in Gaza
Strip, care of children with chronic disease. Building on an area about 2800m and
located in Al Nasser Street in Gaza City. Started work on April 23, 2008. It consists
of three floors and ground. On the first floor there are Emergency, pediatric intensive
care unit, dialysis and outpatient departments in addition to laboratory and radiology
departments. The second floor includes of five departments there are Oncology,
Cardiology, Nephrology, Neurology and Gastroenterology departments. The last floor

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is basement floor there are director's offices. The hospital contains 56 beds, the
service provided by the hospital for cardiology department. Cardiology department
found in El Ranteesy Pediatric Specialized Hospital since hospital opening, it consists
of five rooms, three isolation rooms with one bed and two with five beds (MOH,
2011).
About the distribution of staff cardiology department, the graph below shows the
percentages of each staff.

STAFF NUMBER PERCENTAGE %
Nursing 13 65%
Doctors 6 30%
Worker 1 5%


According to above diagram for distribution of staff in cardiology department
show us highest percentage of the staff is nursing about 65%, then followed by
30% doctors and the last 5% workers.

4- Justification of the study:
65% NURSE
30% Docrors
WORKER
5%
Distribution of Staff in Cardiology
Department

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Infection and sepsis are significant cause of mortality and long term morbidity in
cardiac patients, because cardiac patients are particularly more susceptible to infection
related to low immunity , during intensive care of them high risk for severe infection
and difficulty in making diagnoses result in widespread use of broad-spectrum
antibiotics therapy in cardiology department.
Cardiac patients infection is a major cause of morbidity and mortality in developing
countries and the main cause of death.
Quality in general means to perform properly in accordance to standards so, we
decided in our quality improvement assignment to try to improve infection control
practices at cardiology department in El Ranteesy Specialized Pediatric Hospital and
trying to reach the standards in nursing documentation practices.

5- Over all aim:
To improve good practices and interference among infection control in cardiology
department at El Ranteesy Specialized Pediatric Hospital.
6- Specific objectives:
1. Increase the awareness of the cardiology department staff to keep the area contact
with patients sterile as possible.

2. Minimizing the developing of infection among the patients in cardiology
department.
3. Increasing the awareness and practicing of infection control measures among the
staff in the cardiology department.

4. Address intervention to improve infection control in cardiology department.



7- Literature Review:

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Rayner C, (2008) talked about infection on patient who admitted in hospital. The best
clinical care in the world can be worthless if patients pick up other infections while
they are in hospital. Regardless of where the infection originates, it is surely the first
duty of every member of staff in a hospital to do everything they can to make sure
their patients are cared for, and returned to health, as quickly as possible and as free
from Healthcare. The Hippocratic Oath includes the vital words Do no harm.

In the study by Choe KW, (2007) Hospital infection control with surveillance was
first introduced in the Republic of Korea with the appointment of a full-time infection
control nurse, an infection control physician, and the organization of an infection
control unit at the Seoul National University Hospital (SNUH) in 1991.

Scheckler WE, et al. (2007) showed in his article development and application of
evaluation indices for hospital infection surveillance and control programs in the
Republic of Korea, the ultimate goal of surveillance in hospital infection control
programs is to protect patients, healthcare workers, and others from nosocomial
infection in a cost-effective manner.

8- Methodology:
8.1 Study design:
Cross sectional descriptive analytic study was conducted through face to face
interviews with all the team in cardiology department about the commitment to
infection control measure by using brain storming to investigate perceptions of staff
on issues of infection control and to determine the practice gaps that lead to
nosocomial infection between the patients in cardiology department.
Follow up the results of swab culture pre and post intervention process for handling
equipments in cardiology department.

8.2 Indicators:

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1. Percentage of positive cultures in the cardiology department for the patients
and equipments in the cardiology department.
2. Percentage of cardiology department staff who apply the measures of infection
control in the cardiology department during contact with patients.
3. Percentage of cardiology team member knowledge about infection control
protocol.
8.2 Data collection:
The data collection was collected culture swabs from the equipment in cardiology
department (patients beds, trolley emergency, trolley medication, ambo bag) during
eight weeks four times with good coordination with lab.
Professional and use sterile technique and these taken pre and post
intervention.
o 25 swab cultures were taken from patients beds in cardiology department.
o 10 swab cultures were taken from medication and emergency trolley in
cardiology department.
Other data collected from cardiology department staff by two methods:
o Direct observation (chick lets) at least four times pre and post intervention.
o Face to face interview with cardiology department team (cross sectional
quantitative study) about to commitment to infection control measures and
practice in cardiology department.
8.4 Sample size:
Components from cardiology department team, (13 nurses, 6 doctors and 1 cleaner).
8.5 Ethical consideration:
Nursing director agreement was obtained to perform our study; also the
infection control committee was agreeing to do this program.
Confidentiality was maintained and oral agreement was obtained from
employees who participate in the study.

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9- Pre intervention tools and results analysis:
By observation (chick list) pre intervention for all members of cardiology department
team during work the results were:
27.5% of cardiology team aware about infection control protocol.
47.2% of cardiology team hand washing done.
53.3% done scrubbing.
46.6% use sharp box for sharp instrument.

The percentage of sharp box used for infection control by cardiology department
team (doctors and nurses) 46.6%, and not used sharp box was 53.4%.
42
44
46
48
50
52
54
Yes No
Sharp Box Using Pre-Intervention
Sharp Box Using

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The percentage of scrubbing done for infection control by cardiology department
team (doctors and nurses) 53.3%, and not done scrubbing was 46.7%.


The percentage of hand washing done by cardiology department team (doctors
and nurses) 47.2%, and not done hand washing was 52.8%.

42
44
46
48
50
52
54
Yes No
Scrubbing Done Pre-Intervention
Scrubbing
44
45
46
47
48
49
50
51
52
53
54
Yes No
Hand Washing Done Pre-Intervention
Hand washing pre-
intervention

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The percentage of protocol knowledge by cardiology department team (doctors
and nurses) 27.5% and not knowledge of protocol was 72.5%.
According to swab culture the results were:
14 swab positive cultures from 25 samples from patients beds 56%.
2 swab positive cultures from 10 samples from emergency and medication
trolley 20%.

The percentage of positive swab culture for medication and emergency trolley in
cardiology department 20% and negative swab culture was 80%.
0
10
20
30
40
50
60
70
80
Yes No
Protocol Knowledge Pre-Intervention
Protocol knowledge pre-
intervention
0
10
20
30
40
50
60
70
80
90
Positive Negative
Medication and Emergency Swab
Culture Pre-Intervention
Medication and emergency
swab culture pre-
intervention

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The percentage of positive swab culture for pt. beds in cardiology department
was 56% and negative swab culture was 44%.
Swab cultures from cardiology department supplies (beds, emergency trolley and
medication trolley) are very important because beds directly contact with patients,
also medication and emergency trolley that medication prepared on it and any
contaminated directly reach to patients that high positive swab can lead to highly
nosocomial infection so about this results intervention necessary to decrease the
number of positive results and reduce of nosocomial infection.

The figure above shows the percentages of procedures done by (doctors, nurses
and swab cultures) pre intervention on infection control in cardiology
department.
0
10
20
30
40
50
60
Positive Negative
Pt. Beds Swab Culture Pre-Intervention
Pt. beds swab culture pre-
intervention
0
10
20
30
40
50
60
Pre-intervention
result
Pre-Intervention

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Infection control protocol knowledge deficit need to more knowledge about it by
frequency presentations and lectures about infection control tools, aims, processing
and strategies. Health providers directly contact with patients so they are the main
source of nosocomial infection and hand washing important to done during contact
with them.
Scrubbing and use sharp box are important that patients need to clean environment.
So the work must concerned on the main problem that we faced in our project and
need to intervention, we used some tools to detect the main problem, fish bone, brain
storming, pareto, and the results were concerned on skills and knowledge.
10- fishbone:




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From the fish bone we identified the following causes of non-
following of infection control practices:
1. Lack of knowledge and absence of training.
2. Skills in performing some of procedures as aseptic techniques.
3. Lack of supervision and follow up.
4. Shortages of nurses and load of work over the staff.
5. Lack of equipment.
6. Misunderstandings of some concept as aseptic technique cross infection.

11- Flow chart pre-intervention:


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Flowchart above demonstrate the processing admission of patient with cardiology
disease to cardiology department, when arrived emergency department with his
family, emergency nurse have vital signs then emergency doctor check him, lab.
Investigation done; if the patient didn`t need admission giving instruction then leave
to home, if need admission calling cardiology department team to notified and
preparing to received case, if patient need isolated room preparing isolated room in
department and put patient in isolated room without special nurse, if not need isolated
put patient in normal room in department and the physician must have to perform the
clinical examination, also taking history and fill the history sheet, and prescribe the
other required laboratory tests, then medication giving and observation done.
12- Pareto:
Using pareto in defining the priorities in problem to be
under intervention.


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According to pareto possible causes were identified as contributing factors to the
occurrence of nosocomial infection in the cardiology department, and ranking
according to main cause as following that indicated to concern on knowledge and
skills.
12. Intervention:
According the pre intervention results cardiology department need to intervention to
decrease the positive swab results and prevent nosocomial infection and use Pareto
diagram to select main cause of nosocomial infection and put plan to start project.
Firstly; the team of project met infection control committee and discuss the main
problems with them and put them on the risk of problem.
Then, support from infection control committee to provide supplies for the
implementation of prevent infection and continuous follow up.
Second; start to action work and continuous instruction cardiology team by:
12.1 Education and promotion:
Education is the important point in the intervention processing that only third of the
cardiology team knew that there is a Palestinian IPC protocol, while no copy of
protocol found in the department, that indicate to arrangement of lectures directed
toward the staff including physicians, nurses, technicians, porters, and cleaners aimed
to elevate the awareness level about protocol infection control, the aseptic measures,
these lectures were prepared with the cooperation with the infection control
committees in the hospital.
Distribution of pamphlets papers to the cardiology department team demonstrating the
proper manners to use in the cardiology department concerning on proper hand
washing process, address sterile gloves, sharp box and other measures to prevent cross
infection inside cardiology department.
12.2 Hand washing:
Hand washing is the single most effective measure of preventing infections, and it is a
major component of the standard precautions, hand washing program aimed at

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changing the cardiology team culture by short depth interview education with every
member in department about hand washing procedure and the important to prevent
nosocomial infection. Posters in cardiology department about right hand washing
procedure used. Training about hand washing with it six steps.

12.3 Hospital management support:
Motivation and education program about prevention nosocomial infection need to
involve senior management support.
Meeting with infection control committee in Al Ranteesy pediatric specialized
hospital and all head nurse departments in the hospital including to put strategies to
improvement prevention nosocomial infection and applied this project to all
departments in the hospital instead to this continuous follow up and monitoring.

12.4 Scrubbing and sterilization:
Provide good scrubbing for all non-disposable parts and equipments during and after
discharge the patients lead to decrease nosocomial infection, which need to more
education and knowledge to change behavior and attitude of staff in cardiology
department.

12.5 Isolated room:
Shortage of cardiology department nursing team leads to work with isolated case and
others cases with the same nurse which increases nosocomial infection, so we need
frequency hand washing after any contamination with patients.
12.6 Gloves use:
Removing gloves important when contact with the same patient if it contaminated
with blood or body fluids, and most important to change gloves between patients.








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13. Post intervention results:
By observation post intervention for all members of cardiology department team
during work the results were:
Increase in the knowledge about infection control protocol.
Increase the using of sharp box and team is aware about the risk of sharp
instrument on patients and the team work.
Decrease the positive swab cultures results that scrubbing done to the field
were patient found and dealing with them.
No clear change in the result of scrubbing that the dimension of nursing team
about scrubbing not responsible to them.


The figure above shows the percentages of procedures done by (doctors, nurses
and swab cultures) post intervention on infection control in cardiology
department.

80% of cardiology team aware about infection control protocol.
79.3% of cardiology team hand washing.
65.4% done scrubbing.
90% use sharp box for sharp instrument.



0
10
20
30
40
50
60
70
80
90
100
Post Intervention Results
Pos-Intervention

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0
20
40
60
80
100
Post Intervention
Results
Pos-
Intervention

The figure above shows the percentages of comparison procedures done by (doctors,
nurses and swab cultures) pre and post intervention on infection control in cardiology
department that observed good improvement in procures like protocol knowledge,
using sharp box, hand washing and slightly improvement in scrubbing done, in
another hand there is good improvement in cultures swab results that observed
decrease in positive swab cultures for pt. beds and negative swab cultures in
emergency and medication trolley.
The figures below shows the percentages of procedures done by (doctors, nurses and
swab cultures) pre & post intervention on infection control in cardiology department


0
20
40
60
80
100
Axis Title
Compaire Results Between Pre and Post
Intervention
Pre-Intervention
Pos-Intervention
0
10
20
30
40
50
60
Pre-intervention
result
Pre-
Intervent

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The above diagrams obtain the using of sharp box increased in short time due to high
awareness about important safety box and other procedures continuous to improve
during next period as our planning.


The figure above shows the percentage of comparison done by (doctors, nurses
and swab cultures) pre and post intervention on protocol knowledge.


The figure above shows the percentage of comparison done by (doctors, nurses
and swab cultures) pre and post intervention on hand washing done.

0
10
20
30
40
50
60
70
80
90
Pre-intervention Post-intervention
Protocol knowledge
Protocol knowledge
0
10
20
30
40
50
60
70
80
90
Pre-intervention Post-intervention
Hand Washing Done
Hand washing

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The figure above shows the percentage of comparison done by (doctors, nurses
and swab cultures) pre and post intervention on sharp box using.


The figure above shows the percentage of comparison done by (doctors, nurses
and swab cultures) pre and post intervention on scrubbing done.



According to swab culture the results were:
4 swab positive cultures from 25 samples from patients beds 16%.
Swab culture from 10 samples from emergency and medication trolley negative.

0
10
20
30
40
50
60
70
80
90
100
Pre-intervention Post-intervention
Sharp Box Using
Sharp box
0
10
20
30
40
50
60
70
Pre-intervention Post-intervention
Scrubbing Done
Scrubbing

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The figure above shows the percentage of comparison done by laboratory pre
and post intervention on pt. bed swab cultures.


The figure above shows the percentage of comparison done by laboratory pre
and post intervention on pt. bed swab cultures.







0
10
20
30
40
50
60
Pre-intervention Post-intervention
Positive Pt. Bed Swab Culture
Pt. bed swab culture
0
10
20
30
40
50
Pre-intervention Post-intervention
Positive Medication and Emergency
Swab Culture
Medication and
emergency swab culture

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14. Limitation:
During our working in implementation project many obstacles facing us:
Time constraints.
Lack of equipments.
15. Stability:
To keep infection control program continuous need long period time and
follow up and monitoring from the head nurse of department and the infection
control committee.
Working to apply infection control protocol in the department with team.

16. Conclusion:
Good intervention and implementation of infection control protocol plays a
vital role in reducing nosocomial infection that decrease morbidity, mortality
and cost resulting in cardiology department instead of hospital in general.
The main causes of nosocomial infection hand washing, sharp box and
scrubbing that need to more implementation and culture change.
The main causes of nosocomial infection in cardiology department among
staff lack of knowledge, misunderstanding about infection control, lack of
managerial support and difficult facility of equipment.
The nature of hospital cases complex disease with immunodeficiency that
needs caution in dealing with it.
Supervision and infection control committee play a role in implementation of
infection control by motivation team work and encourage them by follow up
and enhance them.

17. Recommendation:
Rebuilding control infection protocol committee by sharing work team in their
work and build link between all sectors in hospital.
Motivation and encourage work team to apply control infection processes by
more training and lecture made by selves.
Provide the necessary tools as much as possible.
Monitoring and follow up from head nurses in the department of hospitals and
infection control committee.

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18. Reference:
19. Rayner C, (2008) preventing infection on the frontline Patients Association.
20. Choe KW, Oh HS, Yi SE, (2007). Epidemiological characteristics of
occupational blood exposures of health care workers in a university hospital in
South Korea for 10 years. J Hosp Infect 2005; 60:269-275.
21. Scheckler WE, et al. (2007) Requirements for infrastructure and essential
activities of infection control and epidemiology in hospitals: a consensus
panel report.
22. 2012, principle of infection control, Management of multi- resistant
organisms, Government of South Australia.
23. Palestinian of Ministry Health, Palestinian infection control protocol 2004.
24. Palestinian of Ministry of Health .
25. Prevention of hospital-acquired infections, a practical guide, 2nd edition,
WHO/CDS/CSR/EPH/2002.1
26. Practical Guidelines for Infection Control in Health Care Facilities, SEARO
Regional Publication No. 41.
27. Advisor, Infection Prevention and Control (PAHO/13/FT34), November 2013.











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Annex:
1. posters



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2. pamphlet

-



3 .


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4. questionaire

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1
2
3
4
5
6

7
8
9
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Assessment checklist of physical environment











No. Item Yes No
1. There is a copy of the ICP protocol in the department.
2. Patient units are clean (no blood, dust, or other dirty).
3. Nursing room (Medication trolley, reception bed, medical
instruments, .. etc.) is clean (no blood, dust, or other dirty).

4. The unit in general is clean (kitchen, bathroom, toilette etc.
5. There are sufficient disposables and linen to prevent re use.
6. There are sharp disposal containers in each room
7. There are covered waste containers for contaminated wastes.
8. Suction tubes and suction bottles are clean.
9. There are separated room for different disease
10. There is Isolation room in the department.

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Observation checklist for health care providers
No Item Yes No
1. Uniform
Health care provider wears uniform during duty.

2. Hand washing
Hand washing immediately on arrival to the unit.

3. Hand washing before and after working with patients.
4. Hand washing before leaving the unit.
5. Hand washing before performing a septic invasive procedures.
6. Hand washing between tow procedures for the same patient.
7. Hand washing after touching blood or body fluids.
8. Hand washing before wearing gloves.
9. Hand washing after removing gloves.
10. Removing jewelry, hand watch, and ring when washing hands.
11. Washing hands for 15-30 seconds with soap and running water
12. Drying hands with clean paper towel.
13. Turn of water after hand washing using paper towel.
14. Wearing gloves
Wear gloves when contact with blood or other body fluids.

15. Use clean gloves when handling contaminated instrument.
16. Wearing sterile gloves in appropriate way.
17. Wearing sterile gloves when doing invasive procedure.
18. Sharp disposal
Do not remove used needles from syringes before disposal.

19. Do not bend or break used needles prior disposal.
20. Do not recapping used needles.
21. Dispose sharp disposable container when 3/4 full
22. Dispose all sharps in puncture resistance containers.
23. Labeling and separating waste disposals.




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