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The impact of asterile processing programin Northwest Tanzania: a mixed-methods study

The impact of asterile processing programin Northwest Tanzania: a mixed-methods study Background: Inadequate training of health care workers responsible for the sterilization of surgical instruments in low- and middle-income countries compromises the safety of workers and patients alike. Methods: A mixed methods research study was initiated in the Lake Zone areas of Northwestern Tanzania in the summer of 2018. The goal was to identify the impact of education and training on sterile processing practices at ten hospitals. Quantitative data analyzed included hospital assessments of sterile processing practices prior to and 4 months after training, as well as participant test scores collected at the beginning of training, after 5 days of classes, and 4 months after mentorship was completed. Thematic analysis of interviews with participants 4 months post- training was completed to identify associated impact of training. Results: Improvement in test scores were found to be directly related to sterile processing training. The greatest sterile processing practice changes identified through hospital assessments involved how instruments were cleaned, both at point of use and during the cleaning process, resulting in rusted and discoloured instruments appearing as new again. Themes identified in participant interviews included: changes in practice, challenges in implementing practice changes, resource constraints, personal and professional growth, and increased motivation, confidence and responsibility. Conclusions: Providing education and follow up support for workers in sterile processing resulted in increased knowledge of best practices, application of knowledge in practice settings, and awareness of issues that need to be overcome to decrease risks for patients and health care workers alike. Further research is needed to identify the impact of mentorship on hospital sterile processing practices in order to provide clear direction for future spending on training courses. Keywords: Sterile Processing, Decontamination, Sterilization, CSSD, Safe Surgery, Tanzania, Education, Mixed- methods, Mentoring Background strengthen global health and increase health coverage, The Lancet Commission found that 81 million indi- improved surgical services are needed. However, viduals “become impoverished seeking and receiving current resources are limited. Studies conducted in surgical care” [1]. Lack of access to surgery for many low- and middle-income countries (LMICs) indicate leadstolossofincomeastheyare unable to work or that the incidence of surgical site infections (SSIs) are care for their families due to extended illness, per- higher than in high income countries, citing rates manent debilitating injury or even death. To from 10.9 to 70% [2–4]. These studies link SSIs to equipment and instruments that are “often unusable or only partly usable owing to a lack of resources for * Correspondence: ofast@mtroyal.ca maintenance or replacement” (p. 17) [5]. Shah et al. Mount Royal University, 4825 Mount Royal Gate SW, Calgary, Alberta T3E 6K6, Canada (2012) [6]notethatSSIsare themostcommon Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Fast et al. Antimicrobial Resistance and Infection Control (2019) 8:183 Page 2 of 5 healthcare associated infection, the main cause of Data analysis which is the entrance of a microorganism during sur- Pre- and post-education and mentorship data, as well as gical intervention. Key areas have been identified in facility SP assessments, were compared to identify research papers for addressing infection prevention changes in practice and knowledge acquisition. Quanti- and control issues in African hospitals. These include: tative data from participant knowledge tests were ana- introducing appropriate infection control teaching for lyzed with the IBM Statistical Package for Social health care workers (HCWs), improving basic hygiene, Sciences (SPSS) Statistics 23 software, using the Wil- isolation precautions, sterilization and waste disposal; coxon paired test. To examine the hypotheses that the promoting good infection control practices related to treatments (training) had significant effects on the par- hand cleaning, dressing techniques and surgical pro- ticipants, we conducted non-parametric tests using Wil- cedures; identifying HCWs with specific responsibility coxon and Friedman statistics. In both tests, the for infection control; and developing surveillance net- improvements were considered statistically significant if works to increase data on facility infections [7]. the p-value ≤0.05. Clinical significance of our results was also determined using Cohen’s d described in Fast et al., Methods This mixed-methods research studied the impact of a Results sterile processing (SP) training course program pro- In both regions the results of the Wilcoxon test indicate vided for HCWs from 10 Tanzanian hospitals in 2018 that increases in SP knowledge of HCWs for the first by a charitable not-for-profit organization, Sterile Pro- and second tests respectively were because of the train- cessing Education Charitable Trust (SPECT). Quanti- ing received (Additional file 3: Table S1). We also ob- tative data collected involved hospital assessments of served that the effect in region A hospitals was SP practices using a Hospital (SP) Assessment Form significantly higher than the effect in the region B hospi- (See Additional file 1)bothprior to training and tals. Clinical effectiveness of treatment based on the first again at 4 months post mentoring visits. Safe Surgery and second post-tests indicate there was an aggregate 2020 (SS2020) [8] hospital leaders were invited to drop in effectiveness of 10.53% between the first and send 2 to 5 HCWs directly involved in reprocessing second post-tests for region A hospitals. Region B hospi- practices or responsible for overseeing SP practices tals recorded an aggregate drop of 40.53%. To determine for a 5 day training program. All participants com- the overall (steady state) effect of the training we con- pleted a test (See Additional file 2) at the beginning ducted a Friedman test on the combined post-training and end of the training and again 4 months post test data (post-train 1 and 2). The results were also mentoring. SP pre- and post-knowledge tests were ad- found to be statistically significant for each of the two ministered, and facility assessment data were collected regions. to determine retention of learning and implementa- tion of changes in practice. Of those who attended the training, 2 to 5 HCWs Analysis of hospital assessment findings (Additional file 4) from each facility were selected for a 2 day Train- Point of use preparation ing of Trainers (ToT) workshop train the trainer ses- The greatest improvements in point of use preparation sions. Selection was based on engagement in the were the wiping of visible blood from contaminated in- theoretical component provided during the 5 days prior. struments (Pre 1; Post 9) and soaking of instruments in Following the classroom component of the program, water and detergent after use (Pre 1; Post 8). SPECT's educator visited each hospital twice, mentoring participants at their work sites to support them and pro- vide consultation services regarding on-site SP practices. Transport of items to decontamination area Qualitative data included 20–30 min semi-structured Flow of instruments from dirty to clean areas during interviews (See Additional file 3) conducted 4 months transportation proved difficult for many of the areas (Pre post mentoring to determine participants’ perceptions of 3; Post 5), as the structure of the facility and locations of the impact education and mentorship had on their prac- the areas often did not accommodate a one-way flow to tice. Interviews were conducted by the research assistant decrease the risk of cross-contamination. To mitigate this (TM) and recorded, then transcribed and translated problem, participants were instructed to cover contami- from Swahili to English. Participants are quoted using nated instruments during transport, and on post assess- their identification number and regions are identified al- ment it was noted that nine areas were following this phabetically. Data collection began March 2018 and con- practice, where only one area had been covering instru- cluded in January 2019. ments during the pre-training assessment. Fast et al. Antimicrobial Resistance and Infection Control (2019) 8:183 Page 3 of 5 Manual cleaning of instruments occur less frequently, but were still relevant to our find- The most substantial change in the cleaning process was ings, including: influence of formalized policy and guide- the elimination of 0.5% sodium hypochlorite solution to lines, reciprocal relationship and partnership building decontaminate instruments after use in 8 of the 13 areas, and perceived changes in SSI incidence rates. and those that still used it paid attention to limiting the immersion of instruments to less than 10 minutes. As Discussion SPECT had provided all participants with toothbrush- Findings in this study support evidence of SP practice sized brushes for manually cleaning surgical instruments, change from a short training program presented in simi- 11 areas used these brushes for cleaning purposes, lar studies in Benin and Ethiopia [9, 10]. While partici- whereas only one area had access to appropriate brushes pants showed retention of knowledge 4 months post- prior to training. training that was attributable to SPECT’s training, know- ledge retention was noted to be higher in region A than Inspection, assembly & packaging in clean area region B. An evaluation of interviews was undertaken to Inspection of instruments prior to packaging, to ensure account for the difference in retention. It was observed they were clean and functional, went from 10 areas to 13 that in participant interviews, substantially more partici- areas post-training, while two more areas moved instru- pants in region A spoke about infection control guide- ments away from the dirty area for package assembly lines and policy. Greater resistance by administration in (Pre 10; Post 12). Participants were taught to let instru- region A to practice changes was noted. It is surmised ments air dry if they did not have clean, lint free clothes that these factors may have increased participants need available. Thus, fewer areas hand dried instruments to articulate evidence for practice change, thereby re- post-training (Pre 7; Post 5). There was also an increase inforcing their own learning and increasing knowledge in the practice of ensuring hinged and ratchet instru- retention of SP. Knowledge increase post training in ments were placed in open and unlocked position during both the Benin and Ethiopia study indicated knowledge assembly (Pre 7; Post 11) to ensure full contact with retention, but did not evaluate its clinical significance. steam during the sterilization cycle. Our analysis shows that SPECT’s training was clinically significant (Additional file 3: Table S2). Sterilization Hospital assessments of each area indicated improve- The largest improvement in the sterilization process was ments in many aspects of the SP practice, most signifi- the use of chemical indicator tape placed on the outside cantly the cleanliness and functionality of instruments. of packages (Pre 5; Post 10) for visual assurance that Similar to the Benin and Ethiopia studies these changes items opened in the operating theater had gone through resulted in ability to perform safer surgery due to in- the sterilization process. To further verify that steam creased instrument functionality and sterility of instru- had reached the instruments, 6 hospitals were using ments. Of particular note is that participants learned folded pieces of indicator tape or type five internal without proper cleaning it is impossible to sterilize in- chemical integrators donated by SPECT inside instru- struments – a truth they had not previously understood. ment packages post-training, whereas none had done so The most significant impact of the training identified by pre-training. participants was that the instruments were noted to be clean and functional. This positive effect was a result of Sterile storage several improvements in SP practice, including the re- In 3 areas, sterilized instrument sets were moved from moval of 0.5% sodium hypochlorite solution to decontami- open spaces to enclosed cabinets for storage post- nant used surgical instruments, access to and use of training, to protect packages from contaminants prior to brushes and rust remover, as well as SP workers’ attention use (Pre 8; Post 11). to inspection and function testing of the instruments prior to packaging. “Chlorine was really destroying instruments. Thematic analysis of participant interviews (Additional file 5) Even now many instruments are functioning well, they Several themes were identified through qualitative ana- don’thave rust.”A12. lysis that highlighted successes of the training, challenges Because of the clean and sterile instruments, and in- in implementing practice changes, and issues that arose creased attention to sterile processing practices, surgical as a result of the training. Participants most frequently site infections were noted to be decreased. commented on the following five themes, from greatest to fewest: changes in practice, challenges in implement- “Before the training sepsis rates were very high. After ing practice changes, resource constraints, personal and a procedure a woman would come back with open professional growth, and increased motivation, confi- wounds. … Some stakeholders were asking why they dence and responsibility. Other themes were noted to do not see a sepsis report and we said we don’t have Fast et al. Antimicrobial Resistance and Infection Control (2019) 8:183 Page 4 of 5 [any] because patients don’t get gaps in wounds, HCWs as opposed to simply providing education in the infections and other things, because of the training we classroom. If the focus is on providing education only, not received.” B17 supporting HCWs to identify solutions to complex issues in their setting, then fewer positive impacts may be identi- Participants identified an increased motivation to fied in future. Increasing the focus on surgical support sys- change practice after training. B2 noted: “It is true, we tems, such as SP and related infection control practices, are better now. First you know how to protect yourself, needs to be part of any safe surgery initiative in LMICs to you are safe when you go to sterilize instruments - you keep patients and HCWs safe. go knowing what to do, not as before.” “I feel good, if you have a problem and are given Supplementary information Supplementary information accompanies this paper at https://doi.org/10. means to solve it, you must feel good.” A7. Not only did 1186/s13756-019-0633-0. satisfaction of sterile processors increase post training, but with their increased knowledge they were able to im- Additional file 1. SPECT Sterile Processing (SP) Facility Assessment Tool. prove the surgeon’s ability to perform safe surgery. B14 Additional file 2. SPECT – Participant Test. stated:” I am currently proud of my work frankly be- Additional file 3. Statistical Analysis. Table 1. Hypotheses Testing. cause everything is good. I have taught my fellow HCWs Table 2. Clinical Significance Test - Region A. Table 3. Clinical and they have accepted the changes.” Significance Test - Region B. Similar findings were noted in Benin and Ethiopia, Additional file 4. Facility Assessment Results. findings that increase the evidence of the need for fur- Additional file 5. Qualitative Analysis: Themes by Participant. ther attention to SP practices when working to decrease risk of SSIs. Abbreviations HCW: Health Care Workers; LMICs: Low- and Middle-Income Countries; Numerous challenges were also identified by partici- SP: Sterile Processors; SPECT: Sterile Processing Education Charitable Trust; pants, including resistance to practice changes from col- SSI: Surgical Site Infection leagues and administrators who had not received Acknowledgements training, lack of resources, including personnel and sup- Not applicable. plies, and structural limitations to improved flow from dirty to clean areas. A significant concern noted by par- Authors’ contributions ticipants involved a disconnect between Tanzanian SP OF and AD conceived and designed the study. CF implemented the SPECT training course and provided on-site mentoring. OF, TM, and DF acquired the guidelines that had been in place and SPECT training re- data. OF, FU and AC contributed to data interpretation and analysis. OF, FU and ceived. The issue was that while Tanzania had developed AC wrote the first draft of the manuscript and all authors were involved in crit- new infection control guidelines, they had not been dis- ical revision of the article and approved the final version for publication. tributed prior to SPECT’s training. While SPECT made Funding the new guidelines available to participants and adminis- Funding for this research was received by Assist International and Mount trators alike, other government departments had not yet Royal University. received the guidelines, specifically the Hospital Ac- Availability of data and materials creditation Department. A2 noted: “[We are restricted] The datasets generated during and/or analysed during the current study are from implementing no use of chlorine because once it is available from the corresponding author on reasonable request. inspection season … all places [will] prepare chlorine … Ethics approval and consent to participate because they are things that marks are provided for, so if Approval to conduct the study was obtained from the Ministry of Health in we tell them about soap they will deduct marks.” While Tanzania in February 2018. Regional Health Board representatives in both the loss of marks during inspections prevented some ad- regions approved the use of the SS2020 facilities’ data in the study. Ethics approval was obtained from Mount Royal University Research Ethics Board ministrators from supporting changes to practice, other (101469), Catholic University of Health and Allied Sciences (CREC/280/2018) administrators saw the benefit of the training and noted and the National Institute for Medical Research (MR/53/100/539). Individuals that a decrease in SSI incidence post-training was evi- chosen by the hospital directors to attend SPECT training were invited to participate in the research project at the beginning of the training by the dence enough to support the practice. research assistant (TM). The study was explained to the participants and informed consent was obtained. Conclusion Consent for publication The impact of a SP program in Tanzania has been identi- All participants have consented to have anonymized data published. fied in this paper. As in other areas of healthcare, practice is constantly changing in efforts to improve patient out- Competing interests comes. Ensuring HCWs are supported to improve their OF is chair of SPECT; CF is SPECT’s founder and executive director. Safe Surgery 2020 (SS2020) is a collaboration of foundations, non-profits, educa- SP practices with education and training is a key step in tional institutions, and local governments that seek to make surgery safer supporting safer surgery. Further research, however, needs across the globe. The research reported is part of the monitoring and evalu- to be done on the difference on-site mentorship has on ation aspect of a SS2020 initiative, funded by GE Foundation, between Sterile Fast et al. Antimicrobial Resistance and Infection Control (2019) 8:183 Page 5 of 5 Processing Education Charitable Trust (SPECT), Assist International and the Tanzanian Ministry of Health. Author details Mount Royal University, 4825 Mount Royal Gate SW, Calgary, Alberta T3E 6K6, Canada. Mount Royal University, University of Calgary, O’Brien Institute for Public Health, Calgary, Canada. Sterile Processing Education Charitable Trust, Calgary, Canada. Mount Royal University, University of Calgary, O’Brien Institute for Public Health, Calgary, Canada. Catholic University of Health and Allied Sciences, Bugando, Mwanza, Tanzania. Received: 11 June 2019 Accepted: 22 October 2019 References 1. Davies J, Meara JG. Global surgery – going beyond the lancet commission. Lancet. 2015;386:507–8. 2. World Health Organization. Safe Surgery Saves Lives. Secondary Safe Surgery Saves Lives. Geneva: WHO Press; 2009. Retrieved from http://apps. who.int/iris/bitstream/10665/44185/1/9789241598552_eng.pdf 3. Feglo P, Afriyie-Asante A. Environmental impact on postoperative wound infection in a privately-owned facility in Ghana. Afr J Microbiol Res. 2014; 8(15):1620–6. 4. Ogwang M, Paramatti D, Molteni T, Ochola E, Okello TR, Ortiz Salgado JC, et al. Prevalence of facility-associated infections can be decreased effectively in developing countries. J Facility Infect. 2013;84:138–42. 5. World Alliance for Patient Safety. Summary of the evidence on patient safety: implications for research. Geneva: WHO Press; 2009. Retrieved from https://www. who.int/patientsafety/information_centre/Summary_evidence_on_patient_safety.pdf 6. Shah MA, Mustapha MS, Gousuddin M, Kaur S. Root cause analysis in surgical site infections (SSIs). Int J Pharm Sci Invent. 2012;1(1):11–5 Retrieved February 16, 2016 from http://www.ijpsi.org/VOl(1)1/C111115.pdf. 7. Fast O, Fast C, Fast D, Veltjens S, Salami Z, White MC. Limited sterile processing capabilities for safe surgery in low-income and middle-income countries: experience in the republic of Congo, Madagascar and Benin. BMJ Glob Health. 2017;2(Suppl 4):e000428. https://doi.org/10.1136/bmjgh-2017-000428. 8. Safe Surgery 2020. Available from http://www.safesurgery2020.org/. Accessed 10 Aug 2019. 9. Fast OM, Gebremedhin Teka H, Alemayehu/Gebreselassie M, Fast CMD, Fast D, Uzoka F-ME. The impact of a short-term training program on workers’ sterile processing knowledge and practices in 12 Ethiopian hospitals: a mixed methods study. PLoS One. 2019;14(5):e0215643. https://doi.org/10. 1371/journal.pone.0215643. 10. Fast O, Fast C, Fast D, Veltjns S, Salami Z, White MC. Mixed methods evaluation of the impact of a short term training program on sterile processing knowledge, practice, and attitude in three hospitals in Benin. Antimicrob Resist Infect Control. 2018;7:20. https://doi.org/10.1186/s13756-018-0312-6. 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The impact of asterile processing programin Northwest Tanzania: a mixed-methods study

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Springer Journals
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Copyright © 2019 by The Author(s).
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Biomedicine; Medical Microbiology; Drug Resistance; Infectious Diseases
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Abstract

Background: Inadequate training of health care workers responsible for the sterilization of surgical instruments in low- and middle-income countries compromises the safety of workers and patients alike. Methods: A mixed methods research study was initiated in the Lake Zone areas of Northwestern Tanzania in the summer of 2018. The goal was to identify the impact of education and training on sterile processing practices at ten hospitals. Quantitative data analyzed included hospital assessments of sterile processing practices prior to and 4 months after training, as well as participant test scores collected at the beginning of training, after 5 days of classes, and 4 months after mentorship was completed. Thematic analysis of interviews with participants 4 months post- training was completed to identify associated impact of training. Results: Improvement in test scores were found to be directly related to sterile processing training. The greatest sterile processing practice changes identified through hospital assessments involved how instruments were cleaned, both at point of use and during the cleaning process, resulting in rusted and discoloured instruments appearing as new again. Themes identified in participant interviews included: changes in practice, challenges in implementing practice changes, resource constraints, personal and professional growth, and increased motivation, confidence and responsibility. Conclusions: Providing education and follow up support for workers in sterile processing resulted in increased knowledge of best practices, application of knowledge in practice settings, and awareness of issues that need to be overcome to decrease risks for patients and health care workers alike. Further research is needed to identify the impact of mentorship on hospital sterile processing practices in order to provide clear direction for future spending on training courses. Keywords: Sterile Processing, Decontamination, Sterilization, CSSD, Safe Surgery, Tanzania, Education, Mixed- methods, Mentoring Background strengthen global health and increase health coverage, The Lancet Commission found that 81 million indi- improved surgical services are needed. However, viduals “become impoverished seeking and receiving current resources are limited. Studies conducted in surgical care” [1]. Lack of access to surgery for many low- and middle-income countries (LMICs) indicate leadstolossofincomeastheyare unable to work or that the incidence of surgical site infections (SSIs) are care for their families due to extended illness, per- higher than in high income countries, citing rates manent debilitating injury or even death. To from 10.9 to 70% [2–4]. These studies link SSIs to equipment and instruments that are “often unusable or only partly usable owing to a lack of resources for * Correspondence: ofast@mtroyal.ca maintenance or replacement” (p. 17) [5]. Shah et al. Mount Royal University, 4825 Mount Royal Gate SW, Calgary, Alberta T3E 6K6, Canada (2012) [6]notethatSSIsare themostcommon Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Fast et al. Antimicrobial Resistance and Infection Control (2019) 8:183 Page 2 of 5 healthcare associated infection, the main cause of Data analysis which is the entrance of a microorganism during sur- Pre- and post-education and mentorship data, as well as gical intervention. Key areas have been identified in facility SP assessments, were compared to identify research papers for addressing infection prevention changes in practice and knowledge acquisition. Quanti- and control issues in African hospitals. These include: tative data from participant knowledge tests were ana- introducing appropriate infection control teaching for lyzed with the IBM Statistical Package for Social health care workers (HCWs), improving basic hygiene, Sciences (SPSS) Statistics 23 software, using the Wil- isolation precautions, sterilization and waste disposal; coxon paired test. To examine the hypotheses that the promoting good infection control practices related to treatments (training) had significant effects on the par- hand cleaning, dressing techniques and surgical pro- ticipants, we conducted non-parametric tests using Wil- cedures; identifying HCWs with specific responsibility coxon and Friedman statistics. In both tests, the for infection control; and developing surveillance net- improvements were considered statistically significant if works to increase data on facility infections [7]. the p-value ≤0.05. Clinical significance of our results was also determined using Cohen’s d described in Fast et al., Methods This mixed-methods research studied the impact of a Results sterile processing (SP) training course program pro- In both regions the results of the Wilcoxon test indicate vided for HCWs from 10 Tanzanian hospitals in 2018 that increases in SP knowledge of HCWs for the first by a charitable not-for-profit organization, Sterile Pro- and second tests respectively were because of the train- cessing Education Charitable Trust (SPECT). Quanti- ing received (Additional file 3: Table S1). We also ob- tative data collected involved hospital assessments of served that the effect in region A hospitals was SP practices using a Hospital (SP) Assessment Form significantly higher than the effect in the region B hospi- (See Additional file 1)bothprior to training and tals. Clinical effectiveness of treatment based on the first again at 4 months post mentoring visits. Safe Surgery and second post-tests indicate there was an aggregate 2020 (SS2020) [8] hospital leaders were invited to drop in effectiveness of 10.53% between the first and send 2 to 5 HCWs directly involved in reprocessing second post-tests for region A hospitals. Region B hospi- practices or responsible for overseeing SP practices tals recorded an aggregate drop of 40.53%. To determine for a 5 day training program. All participants com- the overall (steady state) effect of the training we con- pleted a test (See Additional file 2) at the beginning ducted a Friedman test on the combined post-training and end of the training and again 4 months post test data (post-train 1 and 2). The results were also mentoring. SP pre- and post-knowledge tests were ad- found to be statistically significant for each of the two ministered, and facility assessment data were collected regions. to determine retention of learning and implementa- tion of changes in practice. Of those who attended the training, 2 to 5 HCWs Analysis of hospital assessment findings (Additional file 4) from each facility were selected for a 2 day Train- Point of use preparation ing of Trainers (ToT) workshop train the trainer ses- The greatest improvements in point of use preparation sions. Selection was based on engagement in the were the wiping of visible blood from contaminated in- theoretical component provided during the 5 days prior. struments (Pre 1; Post 9) and soaking of instruments in Following the classroom component of the program, water and detergent after use (Pre 1; Post 8). SPECT's educator visited each hospital twice, mentoring participants at their work sites to support them and pro- vide consultation services regarding on-site SP practices. Transport of items to decontamination area Qualitative data included 20–30 min semi-structured Flow of instruments from dirty to clean areas during interviews (See Additional file 3) conducted 4 months transportation proved difficult for many of the areas (Pre post mentoring to determine participants’ perceptions of 3; Post 5), as the structure of the facility and locations of the impact education and mentorship had on their prac- the areas often did not accommodate a one-way flow to tice. Interviews were conducted by the research assistant decrease the risk of cross-contamination. To mitigate this (TM) and recorded, then transcribed and translated problem, participants were instructed to cover contami- from Swahili to English. Participants are quoted using nated instruments during transport, and on post assess- their identification number and regions are identified al- ment it was noted that nine areas were following this phabetically. Data collection began March 2018 and con- practice, where only one area had been covering instru- cluded in January 2019. ments during the pre-training assessment. Fast et al. Antimicrobial Resistance and Infection Control (2019) 8:183 Page 3 of 5 Manual cleaning of instruments occur less frequently, but were still relevant to our find- The most substantial change in the cleaning process was ings, including: influence of formalized policy and guide- the elimination of 0.5% sodium hypochlorite solution to lines, reciprocal relationship and partnership building decontaminate instruments after use in 8 of the 13 areas, and perceived changes in SSI incidence rates. and those that still used it paid attention to limiting the immersion of instruments to less than 10 minutes. As Discussion SPECT had provided all participants with toothbrush- Findings in this study support evidence of SP practice sized brushes for manually cleaning surgical instruments, change from a short training program presented in simi- 11 areas used these brushes for cleaning purposes, lar studies in Benin and Ethiopia [9, 10]. While partici- whereas only one area had access to appropriate brushes pants showed retention of knowledge 4 months post- prior to training. training that was attributable to SPECT’s training, know- ledge retention was noted to be higher in region A than Inspection, assembly & packaging in clean area region B. An evaluation of interviews was undertaken to Inspection of instruments prior to packaging, to ensure account for the difference in retention. It was observed they were clean and functional, went from 10 areas to 13 that in participant interviews, substantially more partici- areas post-training, while two more areas moved instru- pants in region A spoke about infection control guide- ments away from the dirty area for package assembly lines and policy. Greater resistance by administration in (Pre 10; Post 12). Participants were taught to let instru- region A to practice changes was noted. It is surmised ments air dry if they did not have clean, lint free clothes that these factors may have increased participants need available. Thus, fewer areas hand dried instruments to articulate evidence for practice change, thereby re- post-training (Pre 7; Post 5). There was also an increase inforcing their own learning and increasing knowledge in the practice of ensuring hinged and ratchet instru- retention of SP. Knowledge increase post training in ments were placed in open and unlocked position during both the Benin and Ethiopia study indicated knowledge assembly (Pre 7; Post 11) to ensure full contact with retention, but did not evaluate its clinical significance. steam during the sterilization cycle. Our analysis shows that SPECT’s training was clinically significant (Additional file 3: Table S2). Sterilization Hospital assessments of each area indicated improve- The largest improvement in the sterilization process was ments in many aspects of the SP practice, most signifi- the use of chemical indicator tape placed on the outside cantly the cleanliness and functionality of instruments. of packages (Pre 5; Post 10) for visual assurance that Similar to the Benin and Ethiopia studies these changes items opened in the operating theater had gone through resulted in ability to perform safer surgery due to in- the sterilization process. To further verify that steam creased instrument functionality and sterility of instru- had reached the instruments, 6 hospitals were using ments. Of particular note is that participants learned folded pieces of indicator tape or type five internal without proper cleaning it is impossible to sterilize in- chemical integrators donated by SPECT inside instru- struments – a truth they had not previously understood. ment packages post-training, whereas none had done so The most significant impact of the training identified by pre-training. participants was that the instruments were noted to be clean and functional. This positive effect was a result of Sterile storage several improvements in SP practice, including the re- In 3 areas, sterilized instrument sets were moved from moval of 0.5% sodium hypochlorite solution to decontami- open spaces to enclosed cabinets for storage post- nant used surgical instruments, access to and use of training, to protect packages from contaminants prior to brushes and rust remover, as well as SP workers’ attention use (Pre 8; Post 11). to inspection and function testing of the instruments prior to packaging. “Chlorine was really destroying instruments. Thematic analysis of participant interviews (Additional file 5) Even now many instruments are functioning well, they Several themes were identified through qualitative ana- don’thave rust.”A12. lysis that highlighted successes of the training, challenges Because of the clean and sterile instruments, and in- in implementing practice changes, and issues that arose creased attention to sterile processing practices, surgical as a result of the training. Participants most frequently site infections were noted to be decreased. commented on the following five themes, from greatest to fewest: changes in practice, challenges in implement- “Before the training sepsis rates were very high. After ing practice changes, resource constraints, personal and a procedure a woman would come back with open professional growth, and increased motivation, confi- wounds. … Some stakeholders were asking why they dence and responsibility. Other themes were noted to do not see a sepsis report and we said we don’t have Fast et al. Antimicrobial Resistance and Infection Control (2019) 8:183 Page 4 of 5 [any] because patients don’t get gaps in wounds, HCWs as opposed to simply providing education in the infections and other things, because of the training we classroom. If the focus is on providing education only, not received.” B17 supporting HCWs to identify solutions to complex issues in their setting, then fewer positive impacts may be identi- Participants identified an increased motivation to fied in future. Increasing the focus on surgical support sys- change practice after training. B2 noted: “It is true, we tems, such as SP and related infection control practices, are better now. First you know how to protect yourself, needs to be part of any safe surgery initiative in LMICs to you are safe when you go to sterilize instruments - you keep patients and HCWs safe. go knowing what to do, not as before.” “I feel good, if you have a problem and are given Supplementary information Supplementary information accompanies this paper at https://doi.org/10. means to solve it, you must feel good.” A7. Not only did 1186/s13756-019-0633-0. satisfaction of sterile processors increase post training, but with their increased knowledge they were able to im- Additional file 1. SPECT Sterile Processing (SP) Facility Assessment Tool. prove the surgeon’s ability to perform safe surgery. B14 Additional file 2. SPECT – Participant Test. stated:” I am currently proud of my work frankly be- Additional file 3. Statistical Analysis. Table 1. Hypotheses Testing. cause everything is good. I have taught my fellow HCWs Table 2. Clinical Significance Test - Region A. Table 3. Clinical and they have accepted the changes.” Significance Test - Region B. Similar findings were noted in Benin and Ethiopia, Additional file 4. Facility Assessment Results. findings that increase the evidence of the need for fur- Additional file 5. Qualitative Analysis: Themes by Participant. ther attention to SP practices when working to decrease risk of SSIs. Abbreviations HCW: Health Care Workers; LMICs: Low- and Middle-Income Countries; Numerous challenges were also identified by partici- SP: Sterile Processors; SPECT: Sterile Processing Education Charitable Trust; pants, including resistance to practice changes from col- SSI: Surgical Site Infection leagues and administrators who had not received Acknowledgements training, lack of resources, including personnel and sup- Not applicable. plies, and structural limitations to improved flow from dirty to clean areas. A significant concern noted by par- Authors’ contributions ticipants involved a disconnect between Tanzanian SP OF and AD conceived and designed the study. CF implemented the SPECT training course and provided on-site mentoring. OF, TM, and DF acquired the guidelines that had been in place and SPECT training re- data. OF, FU and AC contributed to data interpretation and analysis. OF, FU and ceived. The issue was that while Tanzania had developed AC wrote the first draft of the manuscript and all authors were involved in crit- new infection control guidelines, they had not been dis- ical revision of the article and approved the final version for publication. tributed prior to SPECT’s training. While SPECT made Funding the new guidelines available to participants and adminis- Funding for this research was received by Assist International and Mount trators alike, other government departments had not yet Royal University. received the guidelines, specifically the Hospital Ac- Availability of data and materials creditation Department. A2 noted: “[We are restricted] The datasets generated during and/or analysed during the current study are from implementing no use of chlorine because once it is available from the corresponding author on reasonable request. inspection season … all places [will] prepare chlorine … Ethics approval and consent to participate because they are things that marks are provided for, so if Approval to conduct the study was obtained from the Ministry of Health in we tell them about soap they will deduct marks.” While Tanzania in February 2018. Regional Health Board representatives in both the loss of marks during inspections prevented some ad- regions approved the use of the SS2020 facilities’ data in the study. Ethics approval was obtained from Mount Royal University Research Ethics Board ministrators from supporting changes to practice, other (101469), Catholic University of Health and Allied Sciences (CREC/280/2018) administrators saw the benefit of the training and noted and the National Institute for Medical Research (MR/53/100/539). Individuals that a decrease in SSI incidence post-training was evi- chosen by the hospital directors to attend SPECT training were invited to participate in the research project at the beginning of the training by the dence enough to support the practice. research assistant (TM). The study was explained to the participants and informed consent was obtained. Conclusion Consent for publication The impact of a SP program in Tanzania has been identi- All participants have consented to have anonymized data published. fied in this paper. As in other areas of healthcare, practice is constantly changing in efforts to improve patient out- Competing interests comes. Ensuring HCWs are supported to improve their OF is chair of SPECT; CF is SPECT’s founder and executive director. Safe Surgery 2020 (SS2020) is a collaboration of foundations, non-profits, educa- SP practices with education and training is a key step in tional institutions, and local governments that seek to make surgery safer supporting safer surgery. Further research, however, needs across the globe. The research reported is part of the monitoring and evalu- to be done on the difference on-site mentorship has on ation aspect of a SS2020 initiative, funded by GE Foundation, between Sterile Fast et al. Antimicrobial Resistance and Infection Control (2019) 8:183 Page 5 of 5 Processing Education Charitable Trust (SPECT), Assist International and the Tanzanian Ministry of Health. Author details Mount Royal University, 4825 Mount Royal Gate SW, Calgary, Alberta T3E 6K6, Canada. Mount Royal University, University of Calgary, O’Brien Institute for Public Health, Calgary, Canada. Sterile Processing Education Charitable Trust, Calgary, Canada. Mount Royal University, University of Calgary, O’Brien Institute for Public Health, Calgary, Canada. Catholic University of Health and Allied Sciences, Bugando, Mwanza, Tanzania. Received: 11 June 2019 Accepted: 22 October 2019 References 1. Davies J, Meara JG. Global surgery – going beyond the lancet commission. Lancet. 2015;386:507–8. 2. World Health Organization. Safe Surgery Saves Lives. Secondary Safe Surgery Saves Lives. Geneva: WHO Press; 2009. Retrieved from http://apps. who.int/iris/bitstream/10665/44185/1/9789241598552_eng.pdf 3. Feglo P, Afriyie-Asante A. Environmental impact on postoperative wound infection in a privately-owned facility in Ghana. Afr J Microbiol Res. 2014; 8(15):1620–6. 4. Ogwang M, Paramatti D, Molteni T, Ochola E, Okello TR, Ortiz Salgado JC, et al. Prevalence of facility-associated infections can be decreased effectively in developing countries. J Facility Infect. 2013;84:138–42. 5. World Alliance for Patient Safety. Summary of the evidence on patient safety: implications for research. Geneva: WHO Press; 2009. Retrieved from https://www. who.int/patientsafety/information_centre/Summary_evidence_on_patient_safety.pdf 6. Shah MA, Mustapha MS, Gousuddin M, Kaur S. Root cause analysis in surgical site infections (SSIs). Int J Pharm Sci Invent. 2012;1(1):11–5 Retrieved February 16, 2016 from http://www.ijpsi.org/VOl(1)1/C111115.pdf. 7. Fast O, Fast C, Fast D, Veltjens S, Salami Z, White MC. Limited sterile processing capabilities for safe surgery in low-income and middle-income countries: experience in the republic of Congo, Madagascar and Benin. BMJ Glob Health. 2017;2(Suppl 4):e000428. https://doi.org/10.1136/bmjgh-2017-000428. 8. Safe Surgery 2020. Available from http://www.safesurgery2020.org/. Accessed 10 Aug 2019. 9. Fast OM, Gebremedhin Teka H, Alemayehu/Gebreselassie M, Fast CMD, Fast D, Uzoka F-ME. The impact of a short-term training program on workers’ sterile processing knowledge and practices in 12 Ethiopian hospitals: a mixed methods study. PLoS One. 2019;14(5):e0215643. https://doi.org/10. 1371/journal.pone.0215643. 10. Fast O, Fast C, Fast D, Veltjns S, Salami Z, White MC. Mixed methods evaluation of the impact of a short term training program on sterile processing knowledge, practice, and attitude in three hospitals in Benin. Antimicrob Resist Infect Control. 2018;7:20. https://doi.org/10.1186/s13756-018-0312-6. 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