Adherence to infection control practices in relation to neonatal care in major hospitals in a district of Sri Lanka

Introduction: Adherence to infection control practices are crucial for neonatal care. Objectives: To describe the adherence to clean birth and postnatal care practices by healthcare workers in selected procedures in major hospitals in a district of Sri Lanka Methods: This was a qualitative observational study . The study sample comprised healthcare workers (doctors, nurses and midwives) attached to the labour room (LR), postnatal ward (PNW), neonatal intensive care unit (NICU) and operating theatre (OT). A total of 70 healthcare workers from the LR, 90 from the PNW , 50 from the NICU and 60 from the OT were assessed in relation to each procedure they carried out. Four checklists were used to record the observations on infection control standards. The performance of each healthcare worker for each specific procedure was observed only once. Results: Hand washing practices among the healthcare workers in LR, NICU, PNW and OT varied, with better practices seen in NICU and PNW . Recapping of the needles was done by 18.6%, 18.0% and 31.2% in LR, NICU and PNW, respectively . Disposal of sharps to the bin was done by almost all healthcare workers in the LR, NICU and PNW, respectively . All the healthcare workers used 70% alcohol to disinfect the skin, of whom the majority used povidone iodine when drawing blood samples for blood culture in the NICU. Changing or washing gloves before cutting the umbilical cord was observed in the majority of healthcare workers in LR and the minority in OT . Conclusions: Adherence to infection control standards by healthcare workers in observed procedures was not up to the standard.


Introduction
Infection control is a series of procedures and guidelines that are followed to prevent healthcare associated infections. There are infections that are acquired by patients during their stay in hospital and infections that are acquired by healthcare workers while working in the hospital. These are known as hospitalacquired infections (HAI). Patients who require treatment for HAI must stay longer in hospitals, are treated with expensive antibiotics and have a high mortality. HAI may be transmitted by healthcare workers to patients, from patient to patient and from patient to healthcare workers (1)(2). For every 100 hospitalized patients, seven in the developed and 10 in developing countries will acquire at least one HAI (2). In low-and middle-income countries, the frequency of ICU-acquired infections is at least 2-3-fold higher than in high-income countries (2). New-borns are at higher risk of acquiring HAI in developing countries, with infection rates of 3-20 times higher than in highincome countries (2). It is estimated that at any given time, more than 1.4 million people worldwide are suffering from HAI (3). Infection control therefore has been identified as a model for the emerging patient safety movement.
There are various guidelines to achieve maximum control of HAI (4)(5)(6). These guidelines should always be followed by all healthcare workers when attending on patients, regardless of their diagnosis or presumed infectious status. These guidelines mainly address subjects such as hand hygiene, use of personal protective equipment, management of sharps, management of blood spills, and handling of blood, body fluids and specimens (6). A systematic review concluded that clean birth and postnatal care practices were effective in reducing neonatal mortality from sepsis (7).
HAI also impose a great burden on hospital resources. Adherence to the guidelines is therefore of paramount importance to prevent infections in the hospital setting. In a setting where resources are poor, infection can exceed 20% but the World Health Organisation (WHO) declares that available data are scanty, and more research is urgently needed to assess the burden of disease in developing countries (3). Therefore, it is important to find out the current situation on infection control practices among healthcare workers for the improvement of neonatal care. The objective of this study was to describe the adherence to infection control practices in relation to neonatal care by healthcare workers in selected procedures in the labour rooms (LR), neonatal intensive care units (NICU), postnatal wards (PNW) and operating theatres (OT) in secondary and tertiary care hospitals in a district of Sri Lanka.

Methods
This was a qualitative observational study carried out in all four major hospitals in the district of Gampaha, namely Colombo North Teaching Hospital, District General Hospital Gampaha, District General Hospital Negombo and Base Hospital Wathupitiwala from July 2010 to February 2011. In the four hospitals, there were seven LR, five NICU, nine PNW and six OT conducting caesarean section. The study sample comprised healthcare workers in the relevant units, namely doctors, nursing sisters, nursing officers and midwives.
Ten healthcare workers were selected from each unit of the four hospitals to assess the adherence to infection control related to procedures, thus a total of 70 healthcare workers from LR, 90 from PNW, 50 from NICU and 60 from OT were recruited. The performance of each healthcare worker on each identified procedure was observed only once. Seven types of procedures were observed in the LR; seven in the NICU; two in the PNW; and five in the OT.
Four checklists were developed to record the observations on infection control standards in the four types of units. The checklists were prepared using the following documents; WHO Essential New-born Care Course, Integrated Management of Pregnancy and Childbirth (8), the LR Management Guidelines of the Ministry of Health (9) and Infection Control Manual by the College of Microbiologists (6). Essentially, the checklist assessed the use of personal protective equipment (PPE) by healthcare workers, adherence to infection control standards when performing normal vaginal delivery and caesarean section, hand hygiene and management of sharps, provision of new-born care including cord care and breastfeeding management and practices, management of blood spills, examination of new born babies, blood drawing/IV cannulations for neonates, and management of specimens such as blood Jayasinghe C & Abeysena C. JCCPSL 2019, 25 (4) Open Access and urine samples and procedures when performing BCG vaccinations. The checklists were reviewed by a group of experts including specialists in paediatrics, microbiology, public health and gynaecology. The face & content validity and the appropriateness of the checklists were assessed by the experts. The check lists were further pre-tested in a hospital in Colombo District for feasibility and appropriateness.
It was decided to observe selected procedures from each unit on randomly selected dates. All units were visited during shifts according to a roster prepared in advance. During each shift, only one or two procedures were observed from the same unit. Staff in the institution was unaware of the dates the observations were carried out. Ten such observations were made for each selected procedure from each unit. Procedures were selected to represent all relevant categories of staff. The checklist was filled shortly after the procedure was over.

Data analysis
Data analysis was done using the Statistical Package for Social Sciences (SPSS) version 16. Each item of the checklists included only two responses (Yes or No) and descriptive analysis was carried out.

Adherence to infection control standards in the labour room
As shown in Table 1, all healthcare workers (n=70; 100.0%) wore sterile gloves before attending on deliveries in the LR. Change of shoes before entering the LR was practised by 62.9%. Before attending on deliveries, aprons were worn by 80% while only 57.1% washed their hands using either bar soap or liquid soap. Removal of bangles, rings and watches was practised by 52.5% (n=21) while 100% washed over the surface of the hands. Majority (n=39; 97.5%) washed the back of the hands, 77% (n=31) washed inter-digital spaces, 75% (n=30) washed back of the fingers, 62.5% (n=25) washed their thumbs separately and 70.0% (n=28) washed the tip of fingers. The majority (n=37; 95.7%) of healthcare workers used single use sterile towels to wipe their hands after washing.
The used sharps were disposed into sharp bins by 90% of healthcare workers, whereas recapping before disposing was done by only 18.6% of healthcare workers. The majority (92.9%) of them dried the baby immediately but only 41.4 % of babies were kept over the abdomen for skin to skin contact. All healthcare workers used sterile instruments to cut umbilical cords, whereas 7.1% umbilical cords were cut without proper clamping of the cords. Umbilical cord stump observation for oozing was done for 75.7% of deliveries.
Leaving the baby over the mother's chest was done during 36.8% of the deliveries and covering the baby well in 92.9% deliveries. Although removing of vernix is not practised now, it was observed in four neonates (5.7%). Even though the best practice of breastfeeding is to initiate it during 30 minutes to onehour period, it was observed only in 65.7% of neonates. More than 80% of mothers were helped to position the neonates for breastfeeding by the healthcare staff. TCL on blood spilled floor was applied only 11.4% of the times. Separate mops to wipe out the contaminated places were used 71.4% of the times.

Adherence to infection control standards in NICUs
As shown in Table 2, the majority (96.0%) of healthcare workers changed their shoes when entering the NICU. No one wore sterile caps while in the NICU. Only 60% of healthcare workers washed hands before entering the NICU. While all healthcare workers washed their hands with soap after touching the sick neonates, only 80% of them did so before touching the neonates. A Majority (81.6%, n=34) of healthcare workers washed the back of the fingers, whereas only 76.8% (n=32) workers washed the thumbs separately and the tip of fingers. All of them washed over the surfaces of their hands, 94.7% (n=39) washed back of the hand, and 87.5% (n=36) inter digital spaces. There were 78.1% (n=32) of healthcare workers who wiped their hands using a single use sterile towel, whereas 21.9% (n=9) wiped their hands using disposable towels.
All the healthcare workers performed cannulation after disinfection of the skin with 70% alcohol. Hands were washed by 86.0% before the insertion of cannula, whereas 50.0% wore sterile gloves. All the healthcare workers used 70% alcohol for skin disinfection and sterile needles before drawing blood for blood culture.    There were 96.0% of healthcare workers who washed their hands prior to wearing gloves. All the health care workers disposed the sharps into sharp bins and all of them did not separate the needle from syringes. No one (0%) changed the sharps from person to person, whereas 18.0% did the recapping of needles. Twentyseven mothers (54.0%) were advised by nurses to wash their hands before handling their sick neonates in the NICU. Only 10.0% of mothers were supervised by the healthcare workers for hand washing. All placed the specimens in the leak proof container whereas 18.0% of specimens were contaminated outside the container. Only 42% of specimens were transported securely to prevent spillage.

Adherence to infection control standards in the postnatal wards
As shown in Table 3, there were 82.5% of healthcare workers who washed their hands before attending the neonates in the postnatal wards. Among those who washed hands before attending to the neonates in the postnatal wards, 23.8% (n=17) removed bangles, 60.8% (n=40) used soap, 39.2% (n=26) used hand rubs, 49% (n=35) closed the tap by using their elbow or through someone else and 57.5% (n=38) wiped their hands after washing. Out of the 66 observations of hand washing and hand rubs, 71.4% (n=47) washed over the surface of the hand, 92.7% (n=61) washed the back of the hands, 72.9% (n=48) washed back of the fingers, 71.4% (n=47) washed inter digital spaces, 63.8% (n=42) washed thumbs separately, and 60.8%, (n=40) washed the tips of the fingers.

Adherence to infection control practices related to neonatal care in operating theatre
As shown in Table 4, the majority (83.3%) of healthcare workers used nail brushes for the first time for the scrub. All healthcare workers used antiseptic solutions for hand washing. Of them, 76.7% removed or did not wear jewellery such as rings.

Practices when entering the Operation Theatre
Completely changed into the theatre clothes Fifty-two (86.7%) healthcare workers had completely changed into theatre clothes when carrying out caesarean section, while 55 (91.7%) and 73.3% of workers properly wore caps and masks, respectively. All the birth attendants were public health midwives from the relevant wards. None of them changed their uniform when entering the surgical theatre but all changed shoes. Only 33.3% of birth attendants washed their hands before wearing sterile gloves for handling the neonates.
A majority (76.7%) of nursing officers wiped the eyes of neonates immediately and the mouth of 83.3% of neonates. Baby was dried immediately by 81.7%. Only 31.7% birth attendants changed or washed their hands before cutting the umbilical cord. An observation for oozing was done by 71.7% of birth attendants. Discarding of wet clothes was done immediately by 86.7% of birth attendants. All the neonates were started on breastfeeding in the theatre itself, whereas only 10.6% of the neonates were kept in contact with the mothers' skin inside the theatre. Thirty-eight mothers (63.3%) had brought caps and socks for their neonates but only 43.3% of them had washed them before dressing the neonates.

Discussion
In the present study, hand washing practices observed among healthcare workers varied across the study units. It was higher in NICU and PNW. It is a well-known fact that HAI spread due to cross infection from poor hand hygiene of healthcare workers, and therefore a simple hand washing procedure is of great consequence in preventing them. The low rates of hand washing reported by midwives might be due to lack of facilities for hand washing in the theatres other than scrubbing area. One Sri Lankan study (10) found that hand washing practices before assisting in the delivery was done by 65% of the birth attendants. Another study (11) revealed that it was 85.3%. In previous studies, the quality of hand washing had not been evaluated but in the present study, it is found to be poor. The proportion of workers who adhere to the steps of hand washing correctly varied in different settings. When considering the step of washing thumbs separately, the practices in PNW was low. Almost all had used either soap or disinfectant for this purpose, whereas few of them from LR and PNW did not wipe their hands after washing. According to another Sri Lankan study (12), only 10% of the healthcare workers had overall good practice of hand washing in the ICU set up of a teaching hospital. Doebbling et al. (13) found that the hand washing rate by ICU medical staff was 12.4% before contact with the patient and 10.65% after contact. Marito and colleague (14) in Italy also revealed that even after intervention, compliance to hand washing in the NICU among doctors was 50.5% and 40.7% among nurses. Another study from Brazil (15) reported that hand hygiene adherence in terms of technique and frequency according to the WHO recommendations was deficient in NICU.
When entering an LR, majority of them wore aprons and minority wore masks. In the NICU, less than 50% of them wore sterile gowns and few wore masks. In Georgia, the gown and glove compliance in the surgical ICU among doctors was 40%, whereas among nurses it was 68%. In the medical ICU, it was 84% among nurses and 70% among doctors (16).
When considering the management of sharps and disposal of sharps, recapping of needles was done by minority of workers in all the units. Disposal of sharps to the sharp bin was done by almost all in the LR, NICU and PNW. One Sri Lankan study (10) also found that only 21% of healthcare workers practised recapping of needles.
Drawing of blood for cultures is important when managing sepsis babies. When considering the steps in drawing blood, all of the healthcare workers used 70% alcohol to disinfect the skin, majority of them allowed to dry and used povidone iodine in the NICU.
Skin to skin contact of mother and baby and early initiation of breastfeeding are two important practices to prevent infections in new-borns. In the present study, it was revealed that the majority of neonates were started on breastfeeding within the first hour of delivery, vast majority of healthcare workers helped to position the baby. A study from Sri Lanka (11) found that 98.9% commenced breastfeeding within the LR while 64.6% of healthcare workers helped the mothers to breastfeed.
Direct observations using checklists were common practice in similar kind of studies (10)(11)17). The presence of an observer while carrying on the procedures may have influenced the practice of the healthcare provider towards favourable direction. To Jayasinghe C & Abeysena C. JCCPSL 2019, 25 (4) Open Access minimize this issue, at the beginning of the study, only the nursing officer in-charge was explained regarding the observation of the procedures, but the healthcare providers were unaware of the particular day the observations were carried out. One of the limitations of this study was the inability to obtain in-depth information underling their behaviour. Focus group discussions would be more appropriate for this, in addition to observing the behaviour.

Conclusions & Recommendations
The adherence to infection control standards by healthcare workers in observed procedures were not up to the expected standards. During the basic training period, it is necessary to stress on infection control standards for all categories of health staff. At the same time, it is compulsory to introduce regular in-service programmes and conduct routine reviews and evaluations for all types of staff categories regarding infection control.

Public Health Implications
The adherence to different process of infection control standards by healthcare workers varied.
It is compulsory to introduce regular in-service programmes and conduct routine reviews and evaluations for all types of staff categories regarding infection control.

Author Declarations
Competing interests: The authors declare that they have no conflicts of interests in this study.

Ethics approval and consent to participate: The Ethics
Review Committee of the Faculty of Medicine, University of Kelaniya granted ethical clearance. Administrative clearance for the data collection was obtained from the Regional Director of Health Services of Gampaha District and directors of the relevant hospitals prior to data collection. Prior approval was obtained from the consultants in charge of the gynaecology and paediatric wards and the NICU.