Infection Prevention &

Control
January 2024 Report
By Isaac Naminya
IPC Officer
 Overall IPC Compliance 100
100
83 80
78 74
80
63
58
60
39
40 33
20
20

0
PVC Catheter SSI Waste mgt Infection Ctrl Hygiene Sterility Laundry Kitchen Compliance

• Overall IPC compliance still low at 63%.

• Sterility scored best. However, results for only OT (100%) were received. Departments
should comply to the environmental swabbing schedule.
• Care bundles are the worst scored with SSI scoring lowest.
• Slight improvement in the compliance of kitchen.
 Waste Management
100 92
85 85 85 85
90
80 69 69 69 69 69
70
60
50
40
30
20
10
0
WW MED CCK A&E ICU SCU LW PNW BCM BCU

Gaps
Recommendations;
• Mixing up of waste
• Procurement of more waste bins (black, yellow,
• Inappropriate bin liners e.g. yellow liner in a
red & brown)
black bin
• House keeping team should ensure that all bin
• Inappropriate bin colors in some units e.g. blue
liners are available for both day and night shifts.
bins in ICU
• Improve on waste segregation through CMEs
• Inadequate bins in some departments
 Infection Control
90 81 77
75 75 76 74 75 75
80 68
70 61
60
50
40
30
20
10
0
WW MED CCK A&E ICU SCU LW PNW BCM BCU

Gaps Recommendations
• PPEs like heavy duty gloves, gum boots, head caps are not being used • Daily damp dusting of
• Temperature monitoring for fridges is lacking in kitchen and other work surfaces/stations
departments (filled only once or twice a week) • Procurement of small
• Keeping multi-doe drugs in syringes in the fridge dose medicine eg vit K,
• IV lines not labelled and are kept hanging unprotected sildenafil
• Uncovered hair • Improve sharps handling
• Long artificial nails compromising hand hygiene practices and disposal
 Hygiene
95 91 89
90 86 86
83 82
85
80 80
80 77 77
75
70
WW MED CCK A&E ICU SCU LW PNW BCM BCU

Gaps Identified
• Dirty/stained walls
• Dusty work stations/surfaces
• Poor storage of cleaning tools – in sluice rooms,
washrooms
• Most sluice rooms have no hand washing sinks
• Use of bar soap for hand washing
• Bed pans & urinals left on ward
• Poor storage of linen in some units
Recommendations
• Cabinets for linen should have doors
• Surfaces around sinks should be cleaned
• Walls need painting
• Scrubbing should be done early in the
morning by night house keepers during
hours of low movements
Pest Control
• Fumigation started on 3rd December 2023 and still ongoing.
• Pending; ICU, SCU
• Partially done (not done); OPD (reception, rooms 2 & 3), Labor ward (offices,
reception & side rooms), Post natal ward (rooms 4, 6 & 13), BCM (nurses station,
corridor, rooms 1 - 5, 8, 10 - 12) & BCU (nurses station, rooms 7, 10, 11, 12 & 18)
Challenges
• Failure to expedite the process at once due to occupancy of rooms/wards made
hence affecting effectiveness.
• Poor hygiene and bushes enabled some pests to survive
• Service provider demanded for payment before fumigation would continue. This left
the process at a standstill.
• The dressings were intact, clean and dry
• There was no inflammation/extravasation on
PVC Care Bundle
patients with the PVCs
Absence of inflammation 100
Gaps Identified and or extravasation
• Hand hygiene is not performed before The access hub has been 0
accessing the lines cleaned with an…
• The access hubs are not cleaned with an Hand hygiene is 13
antiseptic containing 70% isopropyl alcohol performed before…
before accessing There is a record that the 0
• Drugs are administered without removing insertion site has been…

bandage The dressing is intact, 100

clean and dry
• Inconsistence in filling device care forms
• No labeling of giving sets and PVCs The clinical need for the 0
PVC has been reviewed…
• IV giving sets and burettes left hanging on
stands without being protected from 0 20 40 60 80 100
contamination
• The catheters are continuously connected Urinary Catheter Care
in a sterile closed system Bundle
• Most bags are situated below the bladder
level Is the drainage bag 100
situated below the…
Is the catheter securely
Gaps Identified strapped on the…
0

• Hand hygiene is not performed before any Is the bag emptied hourly 0
manipulations with the catheter as a separate…
• Some urine bags are left on patient beds Was meatal hygiene 0
• Emptying of bags is not done hourly as a performed (twice per…

separate procedure Is the catheter 100

continuously connected…
• Catheters are not securely strapped on
Is there a documented
patient thighs assessment for need of…
0

• Meatal hygiene is not performed twice

0 20 40 60 80 100
per 12- hour shift with soap & water
• Recording is poorly/not done on care
forms
• Antimicrobial prophylaxis given 60 minutes SSI Bundle
before cutting time but this is done in
theatre on table
Perioperative Glucose 0
control maintained

Gaps Identified Post operative 0

temperature (before…
• Surgical safety checklists are not filled for
some of the patients/procedures Intraoperative 0
Temperature
• Perioperative temperature monitoring is not
done Preoperative 0
Temperature
• Glucose monitoring only done for known
diabetic patients Antimicrobial 100
prophylaxis 60mins…
• Wound assessment and dressing change
done by the primary doctors 0 50 100
 Laundry
▪ Unrestricted entry of non-laundry staff into the
unit especially the clean area and allowing staff
to iron their personal clothes
▪ Poor waste segregation – no enough bins in the
socking area
▪ Inappropriate use of PPE
• Inconsistence in use of gloves, aprons, head
caps
• No knowledge on when to remove or
change gloves
• Heavy duty gloves not being used during
sorting
▪ No hand washing sink in the laundry area
▪ Use of same shoes for outside and inside the
unit
▪ Delivery of clean linen in the hands to units
Recommendations
• All linen delivery to various departments
should be done by the laundry team in a leak
proof closed hamper
• Written notice shared to all departments
indicating the new changes in the delivery of
linen.
• Training on the use of gloves and other PPE
• Engage facilities manager about fixing the sink
• Laundry manager to request for waste bins
• Procurement of foot wear for both inside and
outside
NOTE:
ALL LINEN SHOULD BE DELIVERED BY THE
LAUNDRY STAFF TO VARIOUS DEPARTMENTS AND
ON TIME AS PER SCHEDULE
Kitchen
• Slight improvement on hygiene noted
• Poor storage – no fridge temperature monitoring.
• Medical checkups of food handlers overdue
• Malfunctional air extractor
• Lack of pest barriers
• PPE use – lack of safety boots, head caps & aprons not being used
• Unrestricted access to the kitchen
• Green scourers are being used for washing utensils
• Not all kitchen staff are vaccinated against Hepatitis B
Accidental Exposures to body fluids
• No accidental exposures to blood and body fluids were reported
• No HAIs moted

Challenges
• Delayed procurement of required equipment
• Ineffective pest control in some departments
• Delayed health care to staff accidentally exposed to blood and body fluids through needle
picks and splashes