KENYA METHODIST UNIVERSITY

FACULTY OF HEALTH SCIENCES

DEPARTMENT OF NURSING

COURSE TITLE: COMMUNITY HEALTH 11

CLINICAL PLACEMENT AT MATERNAL CHILD HEALTH

AND FAMILY PLANNING CLINIC, EMBU PROVINCIAL

HOSPITAL: AUGUST 2009

CASE STUDY TOPIC: MAINTENANCE OF COLD

CHAIN

COURSE CODE: NRSG 331

LECTURER: MARY JOY

REPORT BY: DOROTHY MBAYA

REG. NUMBER: BSN 1- 0118-1/2007

Table of contents
Section 1: List of abbreviations and definitions
Section 2: Introduction
Section 3: Clinical report
Section 4: Case study
Section 5: Conclusion
Section 6: Recommendations
ABBREVIATIONS

1) MCH/FP: Maternal Child Health and family planning

2) CWC: Child Welfare Clinic
3) EPGH- Embu Provincial General Hospital
4) ANC: Ante Natal Clinic
5) PMTCT: prevention of mother to child transmission
6) KMTC: Kenya medical and training college
7) KEPI: Kenya expanded programme on immunization
INTRODUCTION

I was attached at Embu provincial general hospital for 3 weeks where I rotated and gained
experience in MCH/FP clinic.

A brief history of Embu provincial general hospital.

Embu town is one of the provincial headquarters founded in 1906. It servers as the provincial
headquarter of Eastern Province and also the District headquarter for Embu District. Embu
Provincial general hospital is located within Embu municipality along Nairobi-Meru highway. It
is the largest general hospital in Eastern province and serves other district as a referral hospital.

Currently the ministry of health has ranked hospitals in levels of 1-5; Level 5 being a referral
hospital to the lower levels. EPGH is ranked at level 5 acting as the referral for other hospitals
within the great Eastern province, this includes patient from other government hospitals and the
private hospitals mainly in Embu district and also as far from Kitui and Mbeere district.

The hospital also serves as a training institution for Doctors, Nurses, Clinical Officers and
medical laboratory from both Government and private institutions.

To ensure that the hospital has a good health care delivery system ,it have a well stated mandate,
vision and mission which is well distributed in working places within the hospital ( all
departments),.

Mandate

To formulate policies, set standards, provide health services, create an enabling environment and
regulate provision of health service delivery.

Vision

To be a leading health facility in the East African region by offering quality and passionate health
care that is acceptable and cost effective.

Mission.

To promote and provide quality curative and rehabilitative health care services with emphasis on
professionalism, innovation and use of new and safe technologies.
Core- values

 We insist on honesty, integrity and trustworthiness throughout the process of our service
delivery.
 We encourage staff initiative and involvement by creating opportunities for our people to
learn and grow.
 We are an “open” organization that encourages, seeks out and incorporates feedback from
our clients and stakeholders.
 We are satisfied with nothing less than the very best in everything we do and will always
Endeavour to provide timely services geared towards our clients satisfaction.

The hospital provides in patient and out patient services. The outpatient services include
maternity child health (mat) services, family planning services, comprehensive care for HIV
patients and other special schedule clinics. In the inpatient the hospital has a bed capacity of 565
beds distributed among the 17 wards. The wards consist of medical wards, maternity unit,
general surgical wards, gynecological wards, psychiatric department eye wards and amenity
wards. The hospital has a large team of medical and nursing staff at different ranks and cadre. It
has a total of 291 nurses. These comprise of:

Bachelor of Science nurses - 3

Kenya Registered Community nurses/Kenya registered nurse -68

Enrolled Community nurses - 220.

Total 291
STRUCTURAL ORGANIZATION OF THE UNIT.

Senior nursing officer in charge of hospital

Deputy senior nursing officer in charge of the hospital

Unit Nursing Officer

Ward In charge

Deputy Ward In charge

Nursing Staff

Students

STAFFING AT MCH
MCH unit acts as a referral point for other clinics and also serves the local people hence the
clinic is usually very busy. It comprises of a total of 10 nurses. The ratios are usually good when
the students especially KMTC are in session. They run the clinic from 8:00 Am to 6:30 Pm
hence they work in shifts. Due to workload being heavy in the morning, at least, 3 staffs report in
the morning and one or two in the afternoon.
USUAL DAILY ACTIVITIES
I was actively involved in the daily activities which include the following:
I. Prescribing and administration of medications
II. Monitoring vital signs
III. Health education
IV. Paediatric resuscitation
V. Running FP clinic
VI. Running CWC
VII. Running ANC clinic
VIII. PMTCT counselling

STANDARD SETTING AND MONITORING IN NURSING CARE

The hospital management has put in place high standards and quality assurance models of
evaluating, enforcing and maintaining the quality of services offered in the hospital. It has a well
established effective system of monitoring and evaluating its service provision with which it
conducts a timely annual monitoring and evaluation of each and every service in every
department and human resource base.

INTRODUCTION OF THE CASE STUDY.

According to World Health Organization, in 2002 alone, 1.4 million deaths among children under
the age of 5 could have been prevented by routine vaccinations. Expertise in the maintenance and
support of Cold Chain (for effectively storing and transporting vaccines under chilled conditions
from manufacturer to end-user), and medical waste management has been developed in direct
response to this challenge.

During the placement l noted that cold chain maintenance was highly affected due to the
electricity power rationing. This led to the KEPI office to withdraw most of the vaccines from
the MCH fridge as the potency of the vaccines was questionable. Moreover, MCH clinic had to
adjust to using gas instead of electricity during the rationing days. This led me to carry out this
study so as to understand how the cold chain can be maintained despite the external
interruptions.
LITERATURE REVIEW
INTRODUCTION
The cold chain is a system of maintaining vaccines in a potent state fro the manufacturer to the
consumer. Vaccines are very delicate and easily loose their potency when exposed to high
temperatures, sunlight and freezing conditions.
The potency of vaccines can only be maintained by keeping them at required temperatures at all
times from the manufacturer till they reach the consumer {+2- +8o c}. Order of sensitivity to light
fro the most to the least sensitive{bottom to top} is; polio, measles, BCG, pentavalent, tetanus
toxoid, Hepatitis B.
An efficient cold chain requires 3 elements:
 Trained, skilled and motivated staffs.
 Efficient and reliable equipments.
 Efficient distribution of vaccines from one stage of cold chain to another.

COLD CHAIN SYSTEM

COLD CHAIN EQUIPMENTS
 Cold rooms and its accessories.
 Refrigerators and deep freezers.
 Cold boxes.
 Vaccine carriers.
 Ice packs.
 Thermometers

REFRIGERATORS
This can be powered by gas, electricity, and kerosene or solar. Most health centers have been
issued with refrigerators which work on both gas and electricity so that in case of power failure
the refrigerator can still work by switching it to gas system. Models of refrigerators include:
 RCW 42 EG
 Sibir S 2323
 RA 1300
 VR 50 solar

At the MCH we use RCW 42 EG type.

The vaccines are arranged in trays of different colors, The most sensitive to heat being polio. No
vaccines should be stored in the freezer compartment. Instead, only ice packs are stored there. A
sticker is posted on the front of the refrigerator to explain how to place them as follows:

Red tray Pentavalent Top most

Orange tray T.T 2nd
Yellow BCG 3rd
Green Measles 4th
Blue Polio Bottom.

Temperatures: {+2 to +8o c}.

Read and record the refrigerator temperature twice a day to include weekends. Record this on the
cold chain recording sheet.

VACCINE COLD BOXES AND CARRIERS

These equipments are designed to keep cold air inside and prevent warm air from entering. Use
frozen ice packs to keep vaccines within the recommended temperatures. There must be a
thermometer inside.
Vaccine carriers collect small quantities of vaccines to be used for one day only.
How to pack vaccines in a vaccine carrier
Place full frozen ice packs around the inside walls of the carrier. Place vaccines and diluents
carefully into the carrier. Place plastic foam or packing materials between DPT, TT HB vaccines
to prevent them from being
frozen.
Place a thermometer inside but at the top of the vaccine carrier, secure the lid tightly.

Ice packs
These are plastic bottles filed with water and frozen in the refrigerator or freezer. During vaccine
session, vaccine vials are placed on the ice packs to avoid the frequent opening of the cold boxes
and vaccine carriers which would raise their internal temperatures.

Thermometers
Used to monitor vaccine temperatures.

METHOD
During the placement l noted that cold chain maintenance was highly affected due to the
electricity power rationing. This led to the KEPI office to withdraw most of the vaccines from
the MCH fridge as the potency of the vaccines was questionable. Moreover, MCH clinic had to
adjust to using gas instead of electricity during the rationing days. This led me to carry out this
study so as to understand how the cold chain can be maintained despite the external
interruptions.

INTERVENTIONS
 Together with the staffs we ensured that the cold chain temperature chart was filled twice
a day; I n the morning when opening the fridge and in the evening when returning
vaccines.
 Connecting gas to run the fridge and disconnecting the electricity supply especially
during power rationing days. I gave health education on the same.
 I ensured that every staff working at MCH was conversant with the DVIs {Division of
Vaccine & Immunization} regulation of checking the potency of vaccines using the
outlined color codes.
 Vaccines to be used during the day are put in vaccine carriers to avoid frequent opening
of the fridge hence maintaining cold chain.
 I ensured that BCG and measles vaccines were used within 6hrs of reconstitution and any
that remained discarded.
CONCLUSION.
The cold chain is a system of maintaining vaccines in a potent state from the manufacturer to the
consumer. Vaccines are very delicate and easily loose their potency when exposed to high
temperatures, sunlight and freezing conditions.
The potency of vaccines can only be maintained by keeping them at required temperatures at all
times from the manufacturer till they reach the consumer {+2- +8o c}. Order of sensitivity to light
from the most to the least sensitive {bottom to top} is; polio, measles, BCG, pentavalent, tetanus
toxoid, Hepatitis B.

The vaccines are arranged in trays of different colors. No vaccines should be stored in the freezer
compartment. Instead, only ice packs are stored there. A sticker is posted on the front of the
refrigerator to explain how to place them as follows:
Red tray Pentavalent Top most
Orange tray T.T 2nd
Yellow BCG 3rd
Green Measles 4th
Blue Polio Bottom.

Read and record the refrigerator temperature twice a day to include weekends. Record this on the
cold chain recording sheet.

Together with other staffs we ensured that the cold chain temperature chart was filled twice a
day; in the morning when opening the fridge and in the evening when returning vaccines.

Connecting gas to run the fridge and disconnecting the electricity supply especially during power
rationing days. I gave health education on the same.

I ensured that every staff working at MCH was conversant with the DVIs {Division of Vaccine &
Immunization} regulation of checking the potency of vaccines using the outlined color codes.

Vaccines to be used during the day are put in vaccine carriers to avoid frequent opening of the
fridge hence maintaining cold chain.

I ensured that BCG and measles vaccines were used within 6hrs of reconstitution and any that
remained discarded.
LIST OF REFERENCE

http://www.create.org.in/aboutus.htm August 18, 2009 11:50 Am

Ministry of Health (2007), Division of Vaccines and Immunization: Performance Monitoring

Handbook

Wong B, 2001, Pediatric Nursing, Baltimore: Mosby Publishers.

M.O.H. (2000), Operational level training manual, for Health workers: Kenya.

M.O.H. (1992), Kenya expanded programme on immunization, National immunization coverage

survey, Kenya.