Effectiveness of Planned Teaching Programme on Knowledge regarding Hospital Acquired Infections and their prevention among the patients admitted in selected Hospitals - INTRODUCTION

 

INTRODUCTION

Hospital-acquired infection, (HAI) is also called a hospital acquired infections. This is an infection that first appears between  48 hours and four days after a patient is admitted to a hospital or other health-care facility. HAI can be caused by bacteria, viruses, fungi, or parasites. These microorganisms may already be present in the patient's body or may come from the environment, contaminated hospital equipment, health care workers, or other patients. Depending on the causal agents involved, an infection may start in any part of the body. A localized infection is limited to a specific part of the body and has local symptoms. A generalized infection enters the bloodstream and causes systemic symptoms such as fever, chills, low blood pressure, or mental confusion. This can lead to sepsis, a serious, rapidly progressive multi-organ infection, that results in death. The most common types of hospital-acquired infections are urinary tract infections (UTIs), ventilator-associated pneumonia, and surgical wound infections. The University of Michigan Health System reports that the most common sources of infection in their hospital were urinary catheters, central venous (in the vein) catheters, endotrachial tubes and the rhyles tube.¹

Hospital acquired infectionss occur worldwide, both in the developed and developing world. They are a significant burden to patients and public health. They are a major cause of death and increased morbidity in hospitalized patients. They may cause increased functional disability and emotional stress and may lead to conditions that reduce quality of life. Not only do they affect the general health of patients, but they cause a huge burden financially. The greatest contributors to these costs are the increased stays that patients with hospital acquired infectionss require. The increased length of stay varies from 3 days for gynecological procedures to 19.8 days for orthopedic procedures. ²

Hospital acquired infectionss are most frequently occurring infections of the urinary tract, surgical wounds, and the lower respiratory tract. A WHO prevalence study and other studies have shown that these infections most commonly occur in intensive care units and in acute surgical and orthopedic wards. Infection rates are also higher in patients with increased susceptibility due to old age, underlying disease, or chemotherapy.³

Patients are exposed to a variety of microorganisms during a hospital stay, but contact between a patient and an organism does not necessarily guarantee infection. Other factors influence the nature and frequency of infections. Organisms vary in resistance to antimicrobials and in intrinsic virulence. Bacteria, viruses, fungi, and parasites can all cause hospital acquired infectionss. There are multiple ways of acquiring such an organism. The organisms can be transferred from one patient to another (cross-infection). They can be part of a patient’s own flora (endogenous infection). They can be transferred from an inanimate object or from a substance recently contaminated by another human source (environmental transfer). The organisms that cause most hospital acquired infections are common in the general population, in which setting they are relatively harmless. They may cause no disease or a milder form of disease than in hospitalized patients. This group includes, Staphylococcus aureus, coagulase-negative staphylococci, enterococci, and Enterobacteria. Factors that increase a patient’s susceptibility to hospital acquired infectionss include young or old age, decreased immune resistance, underlying disease, and therapeutic and diagnostic interventions.⁴

The organisms that cause hospital acquired infectionss are often drug-resistant. The regular use of antimicrobials for treatment therapy or prophylaxis promotes the development of resistance. Through antimicrobial-driven selection and the exchange of genetic resistance elements, multi-drug resistant strains of bacteria emerge. Antimicrobial-sensitive microorganism that are part of the endogenous flora are suppressed, while the resistant strains survive. Many strains of pneumococci, staphylococci, enterococci, and tuberculosis are currently resistant to most or all antimicrobials which were once effective.⁵

Among the types, four most common types of hospital acquired infectionss are urinary infections, surgical site infection, nosocomial pneumonia, and nosocomial bacteremia. Urinary infections are by far the most common. Eighty percent of these infections are associated with the use of an indwelling catheter. They are associated with less morbidity than other infections but can sometimes lead to septicemia and death. Surgical infections are also frequent with an incidence varying from 0.5% to 15% depending on the type of surgery and the underlying patient status. A surgical infection is indicated by the presence of purulent discharge around the wound or the insertion site of a drain, or by the presence of cellulites which is emanating from the wound. Patients usually acquire the infection during the procedure itself, either endogenously from flora on the skin or in the operative site, exogenously from air, medical equipment, doctors, or other staff, or rarely, from blood given during the procedure. The extent of contamination during the surgery is the main risk factor. Contamination varies with the length of the procedure and the patient’s general condition.⁶

Nosocomial pneumonia is also a significant problem. About 3% of patients on ventilators acquire pneumonia, which in this circumstance, has a very high case-fatality rate. The source of the microorganism is often endogenous but may also be exogenous with transfer of an organism from the respiratory equipment. In one example of successful reduction of ventilator-associated pneumonia (VAP), the Owensboro Medical Health System was able to reduce their rate of VAP in the ICU to zero for eight months. They implemented the Ventilator Bundle, a series of interventions related to ventilator care. The main interventions include elevation of the head of the bed, assessment of the readiness for extubation, daily “sedation” vacations, peptic ulcer prophylaxis, and deep venous thrombosis prophylaxis. The Owensboro team particularly noted the importance of elevating the head of the bed, citing an observed association of inability to elevate the head of the bed due to clinical condition and VAP. The team also noted the importance of getting “buy-in” from the nursing staff, making changes as easy as possible for the nursing staff and teaching new staff members the importance of the ventilator bundle. Besides ventilator-associated pneumonia, there are also problems with viral bronchiolitis in children’s units and influenza with secondary bacterial pneumonia in institutions for the elderly.⁷

Nosocomial bacteremia, a fourth type of hospital acquired infections, represents about 5% of hospital acquired infectionss. Although they are only a small proportion of hospital acquired infectionss, they have high case-fatality rates, sometimes greater than 50%. These infections may occur at the entry site of the intravascular device or along the path of a catheter (tunnel infection). The sources of infection-causing microorganism for these infections are endogenous. Besides these four most common and important types of infections, there can also be skin and soft tissue infection, gastroenteritis, endometritis, sinusitis and other enteric infections.⁸

Infection control is the discipline concerned with preventing nosocomial or healthcareassociated infection, a practical (rather than academic) sub-discipline of epidemiology. Infection control addresses factors related to the spread of infections within the health-care setting (whether patient-to-patient, from patients to staff and from staff to patients, or amongstaff), including prevention (via hand hygiene/hand washing, cleaning/disinfection/sterilization, vaccination, surveillance), monitoring/investigation of demonstrated or suspected spread of infection within a particular health-care setting (surveillance and outbreak investigation), and management (interruption of outbreaks). The Centers for Disease Control and Prevention (CDC) has stated that, “It is well documented that the most important measure for preventing the spread of pathogens is effective handwashing.”⁹

In the United States, Occupational Safety and Health Administration (OSHA) standards require that employers must provide readily accessible hand washing facilities, and must ensure that employees wash hands and any other skin with soap and water or flush mucous membranes with water as soon as feasible after contact with blood or other potentially infectious materials.¹⁰

 

 

 

 

 

NEED FOR THE STUDY

Health care associated infections (HAI), Hospital acquired infectionss are a world wide problem, they represent infections acquired during or associated with delivery  of care in contrast to infections present or incubating at the time of  delivery care episode. Hospital acquired infections are among the leading causes of death they cause significant morbidity among patients who receive health care .these complications of care require expensive use of health care resourses and often lead to increased use of medication and supplies to more laboratory studies, and to increased duration of hospitalization they also may impair the quality of life  of the patient with a hospital acquired infections even after treatment. Prevention of hospital acquired infections is therefore cost effective and achievable even when resources are limited. Further the wide spread use of antimicrobials especially over –or inappropriate use of antibiotics, has contributed to an increased incidence of antimicrobial resistant microorganisms. Factors associated with transmission of resistant strains of these microorganisms include poor attention to hygiene, over crowding, lack of an effective infection control programme and shortage of trained infection control providers. There is a misconception that infection control programmes are expensive and are therefore beyond the reach of most hospitals. In fact the opposite is true. Infection control is based on common sense and on safe practice and can be implemented with minimal cost.¹¹

As per a report by WHO outlined the problem of  hospital acquired infections that patient safety incidents occur in 4% to 16%  of all hospitalized patients, and that  hospital acquired infections affects Hundreds of millions patients globally. High income countries had pooled health care acquired infection rates of 7.6%. Hospital – wide prevalence of health care acquired infections varies from 5.7% to 19.1% with a pooled prevalence of 10.1% with higher quality studies  providing higher incidence rates.¹² 

Research on hospital acquired infections in India reveals several concerning trends. In Indian ICUs, the rate of vancomycin resistant enterococcus a dangerous hospital infection is five times the rates in the rest of the world. According to a report by Global Antibiotic Resistance Partnerniship Research estimates that of the approximately 190,000 neonatal deaths in India each year occur due to sepsis. Over 30% are attributable to antibiotic resistance.¹³

A prospective study of 71 burn patients at post graduate institute in Chandigarh found that up to 59 patients (83%) had hospital acquired infections .35% of pathogens isolated from wounds and blood were staphylococcus aureus ,24% were pseudomonas aeruginosa and 16% were β-hemolytic streptococci. ¹³

A six month study conducted in 2001 of the intensive care units at All India institute of medical sciences in new Delhi found that 140 of 1,253 patients (11%) had hospital acquired infections where pseudomonas aeruginosa made up 21%of isolates, 23% were staphylococcus aureus, 16% klebsiella, 15%acinetobactor baumanni and 8% Escherichia coli further a study of 493 patients in a tertiary teaching  hospital in goa also found that 103 patients (21%) developed 169 infections. ¹³ 

A study was conducted on practice of universal precautions among health workers in Nigeria. The objective of this study was to assess the observance of universal precautions by healthcare workers. In this study the respondents were doctors, trained and auxiliary nurses laboratory scientists and domestic staff. They were selected through a multistage sampling technique from public and private healthcare facilities within the metropolis. The instrument was an interviewer –administered semi structured questionnaire that assessed the practice of recapping and disposal of used needles, use of barrier equipment, handwashing and screening of transfused blood. The finding of this study was that there were 433 respondents, 211 of which were trained nurses. About a third of all respondents always recapped used needles. Compliance with none recapping of used needles was highest among trained nurses and worst with doctors. Less than two thirds of respondents always used personal protective equipment and more than half of the respondents had never worn goggles during deliveries and at surgeries. A high percentage of Health care workers obsevered hand washing after handling patients. The use of barrier equipment was variable in the institutions studied. Recapping of used needles is prevalent in the health care facilities studied, non compliance with universal precautions place Nigerian Health care workers at significant health risks. So this research suggests that training programmes and other relevant measures should be put in place to promote the appropriate use of protective barrier equipment by Health care workers at all times.¹⁴

An international survey of prevalence of hospital acquired infection was conducted in 14 countries in different regions’ of the world between 2013 &2014. The results of this survey, which covered 28861 patients who were observed by local teams of doctors and nurses in their own hospital. showed a wide range of hospital acquired infections with prevalence varying from 3% to 21% in individuals hospital. ¹⁵

A study was conducted on use of precautions by nurse midwives to prevent occupational infections with HIV and other blood borne disesaes.There is a particular need for compliance with universal precaution  although it must be recognized that some midwives  may feel  interference with the midwife –client relationship .The findings of this research suggesting that strategies need to be developed for midwives that will increase the use of universal precautions and minimize the frequency of adverse exposures ,while maintaining a caring midwife client relationship. Therefore this research supports the importance of infection control strategies (universal precaution) refresher course on a regular basis.¹⁶

            A study was conducted on uptake of guidelines to avoid and report exposure to blood and body fluids. The objective of this study was to identify strategies to minimize professional risks of acquiring blood borne infections during exposure- prone procedures. The method of study was all surgeons, theatre and delivery nurses suites were surveyed by postal questionnaire. Content analysis was undertaken on the one open –ended question. The findings of this study were that the response rate was 72.5%. Only 1.5% of respondents adopted universal precautions for all patients irrespective of whether their blood borne viral status was known. On average only half the recommended theatre –specific precautions were always adopted. Most respondents admitted making judgements related to nationality, lifestyle when making decisions about protective clothing. Many respondents reported sustaining an inoculation injury in the 10 years prior to the study. The conclusions of this study were that strategies must be developed to improve compliance with universal precautions and reporting guidelines by all health care professionals.¹⁷

Sepsis – a very severe infection – is the second most frequent cause of maternal death. It can be eliminated if aseptic techniques are respected and if early signs of infection are recognized and treated in a timely manner.  Every day 1500 women die from pregnancy –or child birth related complications. In the year 2005 there were an estimated 536000 maternal deaths worldwide.¹⁸

The rate of maternal deaths in the world is  1 death in  every 8mins.¹⁹

World bank  has reported that the maternal mortality in the  India in the year 2018 is 230/100,000 live  births.²⁰  

Where as in Karnataka it is found to be 213000 per lakh per year.²¹

The major cause of these deaths have been identified as hemorrhage   (25%), eclampsia  (12%), indirect causes (20%), obstructed lab our (8%), Infections (15%) and  unsafe abortion (13%) & other direct cause (8%).²²

In 2021 the health protection agency reported the prevalence rate of HAI is England was 6.4%in 2011 against a rate of 8.2% in 2016 with respiratory tract urinary tract and surgical site  infections the most common type of HAI reported.the centers for disease control and prevention(CDC)estimated roughly 1.7 million hospital-associated infections from all type of bacteria combined cause or contribute to 99.000 death each year other estimates indicate 10% or 2 million patients a years become infected with the annul cost ranging from $4.5 billion to $11 billion in USA the most frequent type of infection (36%)followed by surgical site infection (20%) and blood stream infection and pneumonia developing countries including India revealed an overall rate of 14.7% HAI corresponding to 22.5 infection per 1000 ICU days (7)in 2017 the INICC conducted a prospective surveillance in India cities to determine the rate of HAI microbiological profile and related aspect in india date for total of 10.835 patients hospitalized for a total for a total of 52.518days from 12 ICU at 7 different were evaluated^.   Incident rate of hospital acquired infections in Karanataka in MICU patient was 17.7% (23/130)of which 34.8%(81/130)was urinary tract infection (UTI) being the most frequent followed by pneumonia 21.7%(5/130)17.4 (4/130)surgical site infection 13.0%(3/130)gastroenteritis 13.0%(3/130)blood stream infection and meningitis.²³

A study was conducted in a 10 bed medical ICU with daily monitoring of severity of illness and therapeutic activity scores and with analysis of the contribution of hospital acquired infectionss to patient out comes the study ran for one year and data carefully taken the objective of the study was to define the interrelationships between underlying disease severity of illness therapatic activity and hospital acquired infectionss in ICU patients out come it clearly explains why the rate of infection is high in the ICU this high rate is attributed to various factors the immune system of most patients in ICU is always low.similarly these patients are exposing most medical procedures like organ transplant,catheter xenotransplantations among other ,take place the research also accounts for the effects of technology and other factors that affect these infections it accounts for the findings given reasons based on concrete facts as result its a dependable research that can be used to study hospital acquired infectionss especially in the ICU this study concluded that improved hygiene especially hand washing overall advance in control of infections diseases negligence of hygiene is also portrayed as a major challenge to the efforts of control of hospital acquired infections the study was recommended that join forces and work together with medical personnel on implementation of existing infection control technologies needed.²⁴

The investigator observed and felt that the prevention of hospital acquired infections by planned teaching programme is utmost importent step to prevent incidents of noscomial in patients this type of preventive planned teaching programme for patient will be more effective in gaining more knowledge on prevention of hospital acquired infections. Hence this planned teaching programme will be useful to provide appropriate knowledge and information on prevention of hospital acquired infections the above fact and research work earlier shows that there is a need for such planned teaching programs among patients ,as prevention is better than cure,the investigator feels that there is a need for this study.