Providing Technical Assistance
BD/PEPFAR Annual Newsletter
About the BD/PEPFAR Collaborations | Lab Strengthening Highlights | Safer Blood Collection Highlights
Safer Blood Collection Highlights
Why Safer Blood Collection
Program Objectives
2010 Highlights
Key Partners
Successes to Date
A Look Ahead
Why Safer Blood Collection?
In June 2010, BD (Becton, Dickinson and Company) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Department of Health and Human Services’ Centers for Disease Control and Prevention (CDC) launched a joint, multi-year initiative titled the “Kenya Safer Blood Collection Initiative” to help improve blood collection practices in African clinics and hospitals.
The overall aim of the BD/PEPFAR public-private partnership is to strengthen blood drawing practices to reduce preanalytical errors. The specific goals are to improve specimen quality, efficiency, enhance patient safety and protect healthcare workers from occupation exposure due to needlestick injuries and associated iatrogenic transmissions of HIV, Hepatitis and other bloodborne pathogen transmissions.
Increased access to antiretroviral therapy has resulted in increased blood drawing per patient, at least 3 to 4 blood draws per year. Blood collection, handling, storage and transportation in these clinical and lab settings are fundamental to good diagnosis, as diagnosis is only as good as the quality of specimen.
There are many reasons why blood drawing is considered a high-risk procedure. Studies show that 75% of lab errors occur in the preanalytical phase of lab testing. Documented evidence suggests that among clinical procedures, needles accessing veins pose the highest risk of infection transmission. Studies also document that the risk of HIV transmission is four times higher for HIV and up to 100 times higher for Hepatitis C for blood-filled needles when compared to other needles.
Many parts of emerging and developing regions lack familiarity with equipment for blood drawing. No comprehensive standard curriculum on phlebotomy exists in medical and nursing schools in Kenya, and this is typical of many other countries. Simple procedures such as tourniquet application are dealt with poorly. An investigation report in Kenya describes the tragic amputation of a one-year-old baby’s arm due to improper tourniquet release, due to lack of training and education.
Program Objectives
Partnership objectives can be summarized as follows:
- To provide training and education on proper blood drawing processes ??
- To establish surveillance of needlestick injuries among healthcare workers ??
- To support the development of policies, guidelines and standard operating procedures (SOPs) related to blood draws.
2010 Highlights
Kenya was chosen to be the first country based on leadership and support from Kenyan Centers for Disease Control and Prevention (CDC) and Ministry of Health (MOH). The program also aims to establish guidelines and policies for blood drawing in Kenya as none exist today. In Kenya, of the estimated 7 to 8 million blood draws, a significant number of collections are performed using a syringe and needle. Blood is then transferred into collection tubes, increasing the risk of accidental needlestick injuries and blood exposure.
According to the Kenya modes of transmission study, 2.5% of new HIV infections occur in health facilities due to unsafe blood transfusion including blood collections. The provinces chosen for the first phase of the collaboration cater up to 60% of Kenya’s population.
A country planning meeting was held between the partners and key stakeholders, and the following activities were mapped:
Training
- Baseline assessment in the eight health care facilities chosen by Kenyan CDC and MOH to establish current state of blood drawing practices.
- Develop Kenya-specific curriculum to train and educate health workers based on above findings.
- Provide mobile training tools including supplies, curriculum and other tools.
- Train healthcare workers through “teach and teach back” methodology; create a pool of 20 lead faculty in Kenya, target 529 healthcare workers from all eight facilities in the first year, target 800 across 11 sites covering the remaining four provinces in Kenya in Year 2 and national scale up in Year 3.
Surveillance
- Survey health facilities to track accidental needlestick injuries and blood exposure within the past year.
- Build on existing Post Exposure Prophylaxis (PEP) system to include key surveillance questions.
- With the help of University of Virginia, develop a customized automated system to help analyze surveillance and PEP data.
- Train Monitoring and Evaluation (M&E) teams in Kenya to analyze data locally.
Standards and Procedures
- Jointly develop SOPs and guidelines for facilities by Year 3 of the partnership.
In November 2010, BD deployed a technical officer to work with Kenya’s National AIDS/STD Control Programme (NASCOP) and CDC to further the goals of the partnership. BD staff also conducted a mid-term review to assess improvements. BD conducted a refresher training course for Kenya’s lead faculty. BD facilitated a workshop organized by the Kenya MOH to advance surveillance goals by bringing in the expertise of Dr. Janine Jagger, an international expert of healthcare worker safety surveillance.
Key Partners
BD worked with CDC Atlanta, CDC Kenya, Ministry of Health, Kenya as primary partners. Other organizations involved with this collaboration include AmeriCares, University of Virginia (UVA), Management Sciences for Health (MSH) and Kenya Medical Training College (KMTC).
BD worked with AmeriCares, a nonprofit entity to ship supplies to these facilities. CDC Kenya is working with MSH and MOH to reach 800 health workers in the second year of the collaboration. BD is working with the International Health Care Worker Safety Center at UVA to introduce surveillance skills to MOH Kenya. A discussion has just begun to establish a school of phlebotomy and for other specimen collection at KMTC with the help and support of all partners.
Examples of roles and responsibilities of each partner organization include:
BD
- Provide trainers with technical expertise to work on sites in Kenya for 10 days.
- Provide supplies needed for training.
- Develop mobile tool kits for training including providing dummy training arms, training manuals and books.
- Serve as lead curriculum developer.
- Conduct and train MOH Kenya on baseline assessments across eight health facilities.
- Collaborate with CDC for data entry and analysis support as needed.
- Bring surveillance expertise and experts to the partnership.
- Strengthen waste disposal procedures.
CDC, Kenya & Atlanta
- Provide technical input in developing training curriculum and work plans.
- Work with NASCOP, MOH and other PEPFAR partners to create plans.
- Advocacy to prioritize safe phlebotomy in National health agenda and Kenya National Aids Strategic Plan 3.
- Develop assessment and analysis protocols and ensure clearance by ADS (Associate Director of Science) within CDC.
- Lead data analysis in collaboration with partners.
- Ensure country ownership and developing sustainable scale up strategies.
- Work with partnership members to author joint publication to share evidence-based studies and findings globally.
NASCOP, MOH
- Coordinate partnership activities within MOH Kenya.
- Select healthcare facilities in Kenya and develop national scale-up plans.
- Guide revision or development of guidelines, policies and SOPs.
- Support development, implementation and supervision of sharps injuries surveillance systems.
- Convene and chair safe phlebotomy technical working group.
- Advocacy and lobbying to gather support from top MOH officials to continue focusing on safe blood collection practices in national agenda.
- Support the logistics of the training programs and select appropriate lead trainers across Kenya health facilities.
Successes to Date
- Kenya’s ownership of this program helps ensure sustainability and replicability throughout the country. Working with KMTC to create a phlebotomy school demonstrates unique, creative, long-term solutions.
- The partnership’s innovative focus on improving blood draws – an unmet need that is often overlooked, but improved practices can have a huge impact on preventing the spread of disease, protecting healthcare workers and improving patient care.
- 20 Kenyans who have been trained by BD have been identified by MOH as lead faculty. MOH has taken a lead with support from CDC and BD to train 529 healthcare workers across the four provinces, reaching every healthcare worker across the eight facilities.
- Pre-training assessment scores improved from 45% to 85% post training. There is now new knowledge and skills related to blood collection.
- A mid-year assessment confirmed:
- Poor practices have been significantly reduced, such as femoral collection among children, improper disposal of sharps, improper tourniquet application, and appropriate using of gloves.
- Specimen rejection registers are being maintained.
- Healthcare workers feel more valued and confident using new techniques.
- As a result of this PPP, a new surveillance form is being piloted in these eight facilities. This form combines the format developed by MOH Kenya for post-exposure prophylaxis (PEP) tracking and includes questions from EPINet developed by Dr. Janine Jagger. BD funded the development of EPINet and continues to support the work.
"In the beginning, we were skeptical about the partnership. After all, we were drawing blood for several years, so we were wondering what was new. Thanks to this partnership, we went through a process of unlearning and then relearning. We now ask ourselves, why didn't we do this before? With the skills and knowledge that we now have, we are determined to stop all risky practices while handling blood. We are proud to take leadership and ownership in improving this practice. We are proud to tell the world that we are fixing what is not working. One day in the near future, we would like to be recognized as among the best when it comes to clinical practice." – Dr. Rachel Kamaou, NASCOP, MOH.
A Look Ahead
- MOH and CDC are finalizing a plan for Phase 2 to further train an estimated 800 workers across 11 facilities in the remaining provinces of Kenya.
- As an outcome of this partnership, UVA will customize not only the form for collection but will create program capabilities for analysis of information related to needlestick and PEP usage patterns.
- The Kenya Safer Blood Collection Initiative will expand to include up to four additional PEPFAR-supported countries. Country planning discussions are already in progress in Zambia which is the next site. MOH and CDC Zambia invited staff from CDC Kenya to learn from their experiences and build upon a proven model. This is a great example of South –South collaboration for learning and sharing best practices.