Evaluating the foundations that help avert antimicrobial resistance: Performance of essential water sanitation and hygiene functions in hospitals and requirements for action in Kenya

Abstract

Background: Water Sanitation and Hygiene (WASH) in healthcare facilities is critical in the provision of safe and quality care. Poor WASH increases hospital-associated infections and contributes to the rise of antimicrobial resistance (AMR). It is therefore essential for governments and hospital managers to know the state of WASH in these facilities to set priorities and allocate resources.

Methods: Using a recently developed survey tool and scoring approach, we assessed WASH across four domains in 14 public hospitals in Kenya (65 indicators) with specific assessments of individual wards (34 indicators). Aggregate scores were generated for whole facilities and individual wards and used to illustrate performance variation and link findings to specific levels of health system accountability. To help interpret and contextualise these scores, we used data from key informant interviews with hospital managers and health workers.

Results: Aggregate hospital performance ranged between 47 and 71% with five of the 14 hospitals scoring below 60%. A total of 116 wards were assessed within these facilities. Linked to specific domains, ward scores varied within and across hospitals and ranged between 20% and 80%. At ward level, some critical indicators, which affect AMR like proper waste segregation and hand hygiene compliance activities had pooled aggregate scores of 45 and 35% respectively. From 31 interviews conducted, the main themes that explained this heterogenous performance across facilities and wards included differences in the built environment, resource availability, leadership and the degree to which local managers used innovative approaches to cope with shortages.

Conclusion: Significant differences and challenges exist in the state of WASH within and across hospitals. Whereas the senior hospital management can make some improvements, input and support from the national and regional governments are essential to improve WASH as a basic foundation for averting nosocomial infections and the spread of AMR as part of safe, quality hospital care in Kenya.

Fig 1. Comparing the WASH-FIT and WASH-FAST tools.

Fig 2. Overall WASH performance.

The overall WASH facility performance based on all 65 indicators in four domains is shown by the upper vertical bars. The right horizontal bars summarise the performance of each domain across 14 hospitals. The tiles in the central grid are coloured according to the performance classification of each domain in each hospital, as shown in the colour legend.

Fig 3. Ward level WASH performance.

Horizontal scatter plot of the aggregate ward level scores of 116 wards (black shaded points) across 14 hospitals by domain. Also included is overall facility aggregate score(O) for each hospital by domain. The overall facility score includes assessment of inpatient wards and other service areas across the hospital. The blue vertical line in each domain represents the median ward score for that domain. The colour bars represent cut off values of red <40%, orange41-60%, yellow 61–80% and green 81–100%.

Fig 4. WASH performance for sanitation domain at ward level.

Shows overall service performance at the ward level for sanitation domain with 11 indicators shown by the vertical bars. The horizontal bars summarise the performance of each indicator across all the hospital wards. The tiles in the central grid are coloured according to the performance classification of each indicator in each hospital as per the colour legend. SOP: standard operating procedures, PPE: personal protective equipment.