Published: January 9, 2019
Nkwan Jacob Gobte, BNS, MPH, is a nurse and Director of Baptist Training School for Health Personnel (BTSHP) Banso, and Infection Prevention Supervisor, Cameroon Baptist Health Services , International Ambassador for the Society for Health Care Epidemiology of America (SHEA). Nkwan Jacob is an international advocate for hand hygiene and serves as Chair, Infection Control African Network WASH Working Group. His work in hand hygiene started in Banso Baptist Hospital in 2002, and now covers more than 37 facilities of the Cameroon Baptist Convention Health Services (CBCHS).
Nkwan’s introduction to IPC – and an immediate crisis
Nkwan was appointed as the infection prevention and control (IPC) nurse at Banso Baptist Hospital (BBH) in 2002. Following his appointment, he researched IPC guidelines and information on the impact of IPC. He recalls, “I came to understand that infection prevention was really the right thing to do. As a nurse, we want to provide care that is as safe as possible. I have a passion in seeing people live happily. With my passion and my background as a nurse, I developed interest [in IPC].”
At the time of his appointment, he faced a challenging situation. In 2002, the hospital was experiencing frequent outbreaks of neonatal sepsis in its 30-bed postpartum unit. Neonatal sepsis is caused by bacteria and is one of the leading causes of infant mortality worldwide. Poor hand hygiene and disinfection practices often lead to infections that cause sepsis.
In this unit, “We had only one sink, which was supposed to be for handwashing. But at that time, it was reserved only for drinking. There was a letter by the sink prohibiting handwashing. They had a portable handwashing station, but it was reserved only to be used by the physician during rounds.” Sharing of bathing supplies like soap and petroleum jelly between babies was also common. Nkwan found drug-resistant staph and Pseudomonas bacteria on these supplies and on nurses’ hands, meaning these were likely major sources of spread of infection.
Improving hand hygiene to save babies’ lives
Nkwan and his colleagues used three key ingredients to change IPC behavior in the maternal unit and throughout the hospital: information, supplies, and leadership.
At first, most people did not understand the importance of IPC, or what they needed to do to keep their patients safe. Nkwan found that “a lot of the resistance [to changing practices] was due to not knowing.” After trainings, education sessions, and one on one discussions, about 80% of the staff understood the importance of IPC and the basic concepts involved. This, he says, encouraged people to make efforts to improve their behavior and laid the foundation for future behavior change.
Still, Nkwan and his colleagues knew they needed to make it convenient for health workers to clean their hands at the 5 key moments. For this, they needed handrub. While there are still moments where handwashing with soap is required (click here to learn more), handrub can save much-needed time: health workers do not need to walk to a sink, wait for others to clean their hands, or spend as much time scrubbing their hands.
There was no handrub available at the hospital, and nowhere to buy it locally. So, Nkwan decided to make it. Handrub can be safely made using this WHO formula with locally available ingredients, and by following specific safety procedures. Within a few months, the hospital staff was making enough handrub to place containers on all workstations and points of care. They also removed all shared items, like soap and petroleum jelly, and replaced them with single-use items.
The project continued over four years, with steady improvements in hand hygiene. For Nkwan, the true impact was shown in the changes in newborn sepsis. He says, “In 2002 we saw about 86 cases per 1,000 live births, and in 2006 it had dropped to only about 20 cases per 1,000. Now in 2018 we had no cases [of newborn sepsis] in that particular unit.”
Sustaining and expanding the project
With the supplies and knowledge in place, Nkwan looked to the piece that would allow the improvements to be sustained – ownership. He convinced the top leadership of Cameroon Baptist Health Services to prioritize IPC in their facilities. Their CEO, Prof Tih Pius Muffih, announced his commitment that “Our vision is quality care for all, and quality care begins with infection prevention.” This buy-in resulted in two major policy changes: each facility had an IPC nurse appointed, and a policy was passed that every clinical staff should carry handrub in their pocket for use at points of care. The network’s policy document also now states that everyone in the facilities should be able to promote infection prevention.
Nkwan left the hospital to study at the University of Buea from 2006- 2012, and there was a gap in handrub production in his absence. In 2012, he returned and relaunched the project. This time, building on the success of earlier work, he was ready to expand it to more hospitals within the Cameroon Baptist Convention Health Services network. He moved production of handrub to the network’s central pharmacy, which also manages other quality improvement work. Now, the pharmacy staff can mix handrub in large quantities and distribute it across all 37 facilities in the CBC Health Services network.
At each facility, CBC Health Services led trainings on the WHO 5 moments framework for hand hygiene and trained more than 1,000 staff. According to Nkwan, “The driver of success [at each facility] is the commitment of the people involved and the support we have from people at the top.” Each facility leader has signed a commitment to promote hand hygiene and handrub use, and they read it publicly, in front of all staff. In the few facilities where leadership has been less committed, they see fewer requests for handrub and higher risks of stock outs. Data from the first unit showing the dramatic reduction in newborn sepsis helped others see the potential in embracing hand hygiene.
Overall, CBC Health Services facilities now have about 60 – 70% compliance with correct hand hygiene, while the global estimate is around 40%. Staff use spot checks to see how many staff have handrub in their pockets as required, and keep records of how often people refill (Nkwan says that when used correctly, a 100 ml bottle should last staff no more than 14-19 days).
Advocating for better hand hygiene everywhere
As on 2018, CBC Health Services has moved from no handrub use at all to coverage in all their facilities without using any external resources. The project was not easy. There was a gap in services from 2006- 2012, when Nkwan left the hospital and had not yet built up the facility-wide commitment to sustain the work in his absence. A partnership with a South Africa-based handrub company helped lower costs of raw materials, but it’s still a large investment to keep handrub in stock. They still grapple with issues getting handrub to facilities with poor road access, and pharmacy staff still mix the handrub manually, which exposes them to irritants.
When Nkwan and his colleagues started their project, there was not a large international push for hand hygiene in health facilities. Now, their program is serving as a model for other facilities, organizations, and governments. When I asked Nkwan to think about his key message for others considering a similar project, he had two. First, it is possible to make handrub locally, in CBC’s case without external resources. Second, “if you want to prevent infections, the most important thing is to promote hand hygiene, and specifically handrub.”
Editorial note: Learn more about hand hygiene and find tools to promote hand hygiene on our knowledge hub. We will continue to feature success stories on hand hygiene throughout 2019. If you know a hand hygiene leader we should profile, please contact us at email@example.com.
Photo courtesy of Nkwan Jacob Gobte.
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