Effectiveness of planned teaching programme on knowledge regarding hospital acquired infections and their prevention among the patients admitted in selected hospitals - REVIEW OF LITERATURE

REVIEW OF LITERATURE

The review of literature is a key step in research process. The review of literature in a research report is a summary of current knowledge about a particular practice problem includes, what is known and not known about the problem. The major literature and includes, what is known and not known about the problem. The major literature review is conducted at the beginning of the research process and limited reviews is conducted during the generation of the research report to identify new studies.²⁷

Review of literature involves the systematic identification, location, scrutiny and summary of written materials that contain information on research problem.

The major goal of the review of the literature is to develop a strong knowledge base to carry out research and other non-research scholarly activities in educational and clinical practice settings, in educational areas.

 The purpose of this chapter is to give on account of the literature reviewed by the investigator for studying the problem. Review of literature broadens the understanding and gives insight into the problem under study. This chapter attempts to present a broad review of studies done, the methodology adopted and conclusion arrived by earlier investigators and helps to study the problem in depths. It also serves as a valuable quick to understand, what has been done what is still unknown and untested. The present study is to assess the knowledge of patients regarding nosocomial infection and its prevention.

Related literature, both research and non-research was explored to broaden the understanding and gain an insight in to the selected problem under study.

In this study, the literature reviewed is presented under the following headings:

SECTION-I  Studies related to prevelance of hospital acquired infections

SECTION-II  Studies related to types of hospital acquired infections

SECTION-III Studies related to prevention of hospital acquired infections

SECTION-IV Studies related to effectiveness of planned teaching programme

SECTION-I  Studies related to prevelance of hospital acquired infections

Hospitalization itself can induce an environment where vulnerable patients are exposed and prone to various infection. Many studies have been carried out by various health centres with collaboration of their Hospital infection control committee to study the prevalence and to take appropriate measures to control them.

In Finland a prospective cohort study was carried out in (may2012-june2013) on Intensive care acquired infection. It revealed that of 335 patients, 80 developed ICU-acquired infection. The study findings concluded that among the patients with ICU-acquired infections, hospital mortality was always higher percentage, regardless of whether or not the patients had had infection on admission.²⁸

A prevalence survey was conducted in Calabria (Italy) to estimate the prevalence of hospital acquired infections (HAI). They also studied the effect of different variables on HAI in 888 patients present in a ward for at least 24 hours and not due for discharge or transfer on the day of the survey. The overall prevalence of hospital acquired infection was 1·7% and urinary tract and surgical wounds were the most frequent sites (each four patients, 26·7%). In only eight (53·3%) of the fifteen hospital acquired infection detected, had a microbiological examination been requested and the only two positive culture results involved Pseudomonas aeruginosa (surgical site) and Escherichia coli (urinary tract). This study reported that HAI differed significantly in prevalence between age groups, ward, and was higher in patients with urinary catheters and in those receiving antibiotics. ²⁹

In a (WHO) cooperative study (55 hospitals in 14 countries from four WHO regions), about 8.7% of hospitalized patients had hospital acquired infections. A 6-year surveillance study from 2012-2017 involving intensive care units (ICUs) in Latin America, Asia, Africa, and Europe, using CDC's NNIS definitions, revealed higher rates of central-line associated blood stream infections (BSI), ventilator associated pneumonias (VAP), and catheter-associated urinary tract infections than those of comparable United States ICUs. The survey also reported higher frequencies of methicillin-resistant Staphylococcus aureus (MRSA), Enterobacter species resistance to ceftriaxone, and Pseudomonas aeruginosa resistance to fluoroquinolones. Healthcare-associated infections result in excess length of stay, mortality and healthcare costs. In 2002, an estimated 1.7 million healthcare-associated infections occurred in the United States, resulting in 99,000 deaths. In March 2009, the CDC released a report estimating overall annual direct medical costs of healthcare-associated infections that ranged from $28-45 billion. ³⁰

A point prevalence study was conducted to evaluate HAIs in somatic (all admissions other than psychiatric) and psychiatric patients admitted to a tertiary university hospital in Oslo, before and after reorganization of the Norwegian healthcare system in 2002. The results shows that a total of 57 360 patients were studied over the whole time period: 80.5% in somatic wards and 19.5% in psychiatric wards. The HAI rate was 6.9%, of which 8.1% were somatic and 1.9% psychiatric. About 13.4% of operated patients had HAI, including 6.2% due to surgical wound infections. In somatic wards, 0.6–1% were re-admitted with HAI, 15.2–23% had infections and 18–23% used antibiotics. There was a reduction in HAI until 2012. From 2013 on, HAI increased (P ¼ 0.010) in somatic wards (P ¼ 0.002), in nonoperated patients (P ¼ 0.024) and in extra costs. ³¹

Another Survey was conducted from from 1 April 2017 through 31st March 2018, to identify new onset of respiratory symptoms in patients hospitalized for more than72 hr and in health care workers in medicine and pediatric wards at 3 public tertiary care hospitals in Bangladesh. During 46,273 patient-days of observation,they recorded 136 episodes of hospital-acquired respiratory disease, representing 1.7% of all patient hospital admissions; rates by ward ranged from 0.8 to 15.8 cases per 1000 patient-days at risk. They identified 22 clusters of respiratory disease, 3 of which included both patients and health care workers. Of 226 of heath care workers who worked on their surveillance wards, 61 (27%) experienced a respiratory illness during the study period. Patients on these study wards frequently experienced hospital-acquired respiratory infections, including 1 in every 20 patients hospitalized for more than72 hr on one ward. ³²

A prospective study was undertaken among 498 in-patients at the medical college hospital in Goa, employing the clinico-bacteriologic criteria of CDC, Atlanta, in the representative medicine and surgery wards. The results shows that overall infection rate was 8.03/100 admissions, 33.6% of the catheterized patients developed hospital acquired urinary tract infection. Effect of gender was found to remain restricted to the development of hospital acquired urinary tract infection among females at an earlier age and earlier in time series compared to males, but no overall difference in incidence in the two sexes. The factors significantly associated with HAUTI included: duration of hospitalization, per urethral catheterization and the duration of catheterization. E. coli, Pseudomonas, Kebsiella, and Candida accounted for over 90% of the isolates, and 73.5% of these were resistant to all the antibiotics for which sensitivity was tested. The remaining isolates demonstrated sensitivity to amikacin and/or cefoperazone-sulbactam. High infection rate coupled with widespread isolation polyantimicrobial resistant nosocomial pathogens emphasizes the importance of meticulous surveillance of hospital acquired infections in the hospital, with due attention to antibiotic prescription practices. ³³

In a study conducted in intensive care units of seven Indian cities in 2017 showed that 10,835 patients hospitalized for 52, 518 days acquired 476 Health care associated infections, It showed an overall rate of 4.4%, and 9.06% health care associated infections, per 1000 ICU-days. The central venous catheter-related bloodstream infection rate was 7.92 per 1000 catheter-days the ventilator-associated pneumonia rate was 10.46 per 1000 ventilator-days; and the catheter-associated urinary tract infection rate was 1.41 per 1000 catheter-days. ³⁴

The above review of literature shows that prevalence of hospital acquired infection in USA was 1.7 million health care associated infections. In Italy 53.3% hospital acquired infection was detected and in India it was 9.06% health care associated infections per 1000 ICU days. This shows that prevalence of hospital acquired infection are high in both developed and developing countries.

SECTION-II  Studies related to types of hospital acquired infections

Since the late 1950’s the studies focus on control of hospital acquired hospital acquired infections. It has been shaped by the discipline of public health, with its emphasis on surveillance and epidemiologic methods. Hospital acquired infections are not only the most common type of adverse event in healthcare, they may also be the most studied.

Accordingly, infection control is unquestionably a critical component of patient safety. Transmission of infection within a hospital requires three elements: a source of infecting microorganisms, a susceptible host, and a means of transmission for the microorganisms.

The four general types of infection which account for more than 80 percent of all hospital acquired infections are

Ø  urinary tract infection,

Ø  surgical-site infection;

Ø  bloodstream infection, usually associated with the use of an intravascular device;

Ø  pneumonia, which is usually ventilator-associated.

A study conducted in Europe on the prevalence of nosocomial infection in intensive care units reveals that a total of 4501 patients (44.8%) were infected, and 2064 (20.6%) had ICUacquired infection. Pneumonia (46.9%), lower respiratory tract infection (17.8%), urinary tract infection (17.6%), and bloodstream infection (12%) were the most frequent types of ICU infection reported. ³⁵

Another prevalence study on (HAI) was carried out in 14 of 112 Greek hospitals. The study reveals that the overall prevalence of HAI was found to be 9.3%. The most common HAI recorded involved lower respiratory tract infections (30.3%), followed by urinary tract infections (22.7%), bloodstream infections (15.8%), and surgical site infections (14.8%). The greatest prevalence rate was found in the adult ICU (48.4%), followed by the neonatal ICU (30.3%). The duration of hospitalization, the number of operations, the total number of used devices and invasive procedures were significantly correlated with HAI. ³⁶

A Point prevalence surveys of healthcare-associated infection in 13 hospitals in Hubei Province, China, reveals that there was no significant difference between the overall prevalence of Health care associated infections in 2017 (4.14%) and 2008 (3.72%). Respiratory tract infection was the most common Health care associated infections (63.15%), followed by surgical site infection (9.60%) and urinary tract infection (8.64%). ³⁷

Another prevalence study was conducted to study the magnitude and determinants of devicerelated hospital acquired infections in intensive care units (ICU) and the study reveals that the most important determinants of infection were previous admission to an ICU, whether in the same or another hospital, and duration of stay. Overall, 38 patients developed 43 device-related hospital acquired infections (1.13 episodes per patient) and the main infections were ventilator associated pneumonia followed by catheter-related urinary tract infection and bloodstream infections. ³⁸

A prospective cohort study was conducted at the St Louis Children’s Hospital PICU on all patients who were admitted to the PICU and the study reveals that there were 34 episodes of ventilator-associated pneumonia in 30 patients of 911 admissions (3.3%) and 595 (5.1%) mechanically ventilated patients. The mean ventilator-associated pneumonia rate was 11.6/1000 ventilator days. ³⁹

A Prospective study was done in a tertiary care centre in Bangalore on community acquired urinary tract infection in elderly to find out the common presenting symptomatology and risk factors associated with UTI and distribution of isolated uropathogens and their resistance pattern.The study included elderly patients aged 65 years and above who were admitted, or visited the outpatient departments in the hospital, and had confirmed UTI.The results shows that fever (57/194 - 29.4%) and dysuria (52/194 - 26.8%) were the most common symptoms of UTI. Diabetes Mellitus (DM) was the most common risk factor associated with UTI. Extended Spectrum Beta-Lactamase (ESBL) producing Escherichia coli (E.coli) (93/194 - 47.94%) was the most commonly isolated pathogen. Of the total, 56.2% of the uropathogens showed ESBL positivity. Overall, the highest antibiotic resistance was recorded for Fluoroquinolones (79.9%). ⁴⁰

A study conducted at Mott Children's Hospital in Ann Arbor, Michigan, looked at surveillance practices at 10 PICUs reveals that blood stream infections are the most common hospital-associated infection (HAI) in pediatric intensive care units (PICU) and a significant source of in-hospital deaths, increased length of stay and added medical costs. Both adult and pediatric patients who have catheters inserted into their blood vessels face increased risk of an infection developing along the invasive plastic devices which can become life-threatening as they spread into the bloodstream. ⁴¹

Another study from Rhode Island Hospital has found that more than one in 10 catheterrelated bloodstream infections due to Staph aureus in hospitalized adults are caused by infected peripheral venous catheters (PVC). The study points out the substantial medical burden that arises from complications from these infections due to the large number of such catheters used in hospitalized patients. They performed a point-prevalence survey and found that 76 percent of hospitalized adult patients had a PVC. They also found a greater than expected number of PVCs associated with Staph aureus bloodstream infections were placed in the emergency department, or an outside hospital, were inserted in the antecubital fossa (the "elbow pit"), and were in for a longer period of time compared to uninfected PVCs. In fact, 46 percent of patients with PVC-related Staph bloodstream infections had their PVCs in place for greater than three days. The study suggests that hospitals should assess their risk of PVC-related infections and initiate interventions to mitigate risk if such infections are found. Further, minimizing PVC placement in the antecubital fossa, consideration for removing catheters within 24 hours if they were placed under emergency conditions, and strong consideration for replacing PVCs after a 72-hour dwell time will reduce the risk of infection in adult patients. ⁴²

A prospective, observational study was done in a tertiary care pediatric center to determine risk factors for the development of and outcomes from ventilator-associated pneumonia. All NICU and PICU patients mechanically ventilated for >24 hours were taken for the study. The most common ventilator-associated pneumonia organisms identified were Gram-negative bacteria (42%), Staphylococcus aureus (22%), and Haemophilus influenzae (11%). On multivariate analysis, female gender, postsurgical admission diagnosis, presence of enteral feeds, and use of narcotic medications were associated with ventilator-associated pneumonia. Patients with ventilator-associated pneumonia had greater need for mechanical ventilation (12 vs 22 median ventilator-free days), longer ICU length of stay (6 vs 13 median ICU-free days). The study reveals that critically ill children, those with ventilator-associated pneumonia had a prolonged need for mechanical ventilation, a longer ICU stay, and a higher mortality rate. Female gender, postsurgical diagnosis, the use of narcotics, and the use of enteral feeds were associated with an increased risk of developing ventilator-associated pneumonia in these patients. ⁴³

This section of review shows that the highest HAI are urinary tract infection, blood stream infection and surgical wound infection. Therefore adequate measures needs to be taken to curtail them.

SECTION-III Studies related to prevention of of hospital acquired infections

Health care–associated infections (HAIs) are the most common complication of hospital care. According to the Centers for Disease Control and Prevention (CDC), nearly 1.7 million HAIs occur yearly, leading to approximately 99,000 deaths every year. Such infections were long accepted by clinicians as an inevitable hazard of hospitalization. However, recent efforts have demonstrated that relatively simple measures can prevent the majority of common HAIs, and as a result, hospitals and providers are under intense pressure to reduce the burden of these infections. Four specific infections together account for more than 80% of all HAIs are Surgical site infections (SSI) ,Catheter-associated urinary tract infections (CAUTI) ,Central venous catheter–related bloodstream infections (CRBSI) .Ventilator-associated pneumonia (VAP). ⁴⁴

A study was conducted on role of hand hygiene in health care associated infection prevention and the study reveals that factors influencing hand hygiene compliance, the impact of hand hygiene promotion on healthcare-associated pathogen cross-transmission and infection rates, and challenging issues related to the universal adoption of alcohol-based hand rub as a critical system change for successful promotion. ⁴⁵

A study conducted in 21-bed MICU at Rush University Medical Center to assess the effectiveness or real-world effect of patient cleansing with CHG on rates of CVC associated BSI. The study results shows that bathing with CHG was associated with a statistically significant decrease in the rate of CVC-associated BSI (from 5.31 to 0.69 cases per 1,000 CVC-days; P = .006) and in the rate of blood culture contamination (from 6.99 to 4.1 cases per 1,000 patient-days; P = .04). Rates of secondary BSI, CDI, VAP, and UTI did not change significantly. The study concluded that daily bathing of MICU patients with CHG was effective at reducing rates of CVC-associated BSI and blood culture contamination. ⁴⁶

A prospective observational study was conducted to study the relationship between catheter care and urinary tract infection at Japanese general hospital.The study reveals that the use of a pre-connected closed system and daily cleansing of the perineal area would reduce the incidence of catheter associated urinary tract infection by 50%.⁴⁷

Another study was conducted to study the effect of chlorhexidine Alcohol versus povidone Iodine for surgical site antisepsis. The study reveals that preoperative cleansing of patient’s skin with chlorhexidine alcohol is superior to cleansing with povidone –iodine for preventing surgical site infection after clean contaminated surgery. ⁴⁸

An interventional study was conducted to reduce catheter-associated urinary tract infections in a medical intensive care unit by decreasing use of urinary catheters. For a 6-month intervention period, patients in a medical intensive care unit who had indwelling urinary catheters were evaluated daily by using criteria for appropriate catheter continuance. Recommendations were made to discontinue indwelling urinary catheters in patients who did not meet the criteria. Days of use of a urinary catheter and rates of catheter-associated urinary tract infections during the intervention were compared with those of the preceding 11 months. The results shows that with use of guidelines, duration of use was significantly reduced to a mean of 238.6 d/mo from the previous rate of 311.7 d/mo. The number of catheter-associated urinary tract infections per 1000 days of use was a mean of 4.7/mo before the intervention and zero during the 6-month intervention period. Implementation of an intervention to judge appropriateness of indwelling urinary catheters may result in significant reductions in duration of catheterization and occurrences of catheter-associated urinary tract infections. ⁴⁹

A prospective study was conducted on central line–associated bloodstream infections (CLABSIs) to study the significant cause of mortality in hospitalized patients. The study reveals that CLABSI rate ranged from 1.6 to 44.6 cases per 1000 central line days in adult and pediatric intensive care units (ICUs) and from 2.6 to 60.0 cases per 1000 central line days in neonatal ICUs and is associated with significant extra mortality, with an odds ratio ranging from 2.8 to 9.5. The results of 6 sequential prospective interventional studies showed that hand hygiene and educational programs were related to a significant reduction in CLABSI rates. ⁵⁰

An interventional study to determine the effect of implementing a comprehensive oral and dental care system and protocol on the rateof ventilator-associated pneumonia among patients more than 18 years old receiving mechanical ventilation for more than 48 hours in a medical intensive care unit at a university-affiliated medical center were studied in 2 consecutive 24-month periods. Patients in the group studied before the intervention (n = 779) had no oral assessments, no suctioning of the subglottic space, no tooth brushing, and suctioning of secretions in the oral cavity as needed. The group studied during the intervention (n = 759) included patients treated under a protocol whereby the oral cavity was assessed, deep suctioning was done every 6 hours, oral tissue cleansing was done every 4 hours or as needed, and tooth brushing was done twice daily. The results shows that compliance with protocol components exceeded 80%. The rate of ventilator-associated pneumonia was 12.0 per 1000 ventilator days before the intervention and decreased to 8.0 per 1000 ventilator days during the intervention . The study suggests that the use of advanced tools, a comprehensive oral care protocol, and staff compliance with the protocol can significantly reduce rates of ventilator associated pneumonia and associated costs. ⁵¹

A quantitative study was conducted among 84 neonatal nurses working in seven governmental hospitals in the West Bank of Palestineon the basis of JCI to assess the nurse’s performance in the Neonatal Intensive Care Units (NICU) based on a group of standards of care which are documented and developed by professionals. The results of this study showed that the overall level of application of standards of quality care standards was moderate in the following areas: newborn assessment, neonatal nursing care, medication management and use, patient and family education, infection prevention and control and qualification and education. It also reveals that the neonatal nurses who are older, had more years of experience, and had more educational degrees applied standards of quality care more often than younger, less experienced, and less educated nurses. ⁵²

In November 2018, an expert panel of the Joint commission on accreditation of health care organization (JCAHO) released their revised standards for infection control in healthcare facilities. The JCAHO 2015 Infection Control Standards address the areas of ambulatory care, behavioral healthcare, home care, hospital laboratory and long-term care organizations. The revised standards are designed to raise awareness that health care associated infections are a national concern that can be acquired within any care, treatment or service setting. Therefore, prevention represents one of the major safety initiatives that a health care organization can undertake. The JCAHO panel's revised standards focus on development and implementation of procedures to prevent and control infections. The approved standards require organizations to:

Ø  Incorporate an infection control program as a major component of safety performance improvement programs

Ø  Perform an ongoing assessment to identify the risks for the acquisition and transmission of infectious agents

Ø  Use an epidemiological approach, including collecting and interpreting data

Ø  Implement infection prevention and control processes

Ø  Educate and collaborate with leaders across the organization to design and implement infection control programs. ⁵³

This section of review of literature shows that HAI are more in patients with urinary catheter and those on antibiotics are more prone to develop them. Other factors like duration of hospital stay, and use of invasive procedures also have significant impact on the prevalence rate of hospital acquired infection.

SECTION-IV Studies related to effectiveness of planned teaching programme

   A comparative study to assess the knowledge of nosocomial infection in student nurses at Mangalore. 100 samples were selected by using purposive sampling technique. The tool used was structured questionnaire. The mean pre test was 2.3! +- 1.25 by students whereas staff nurses mean score was 9.43 +- 2.18.⁵⁴

            A study evaluated the effectiveness of PTP on knowledge of breast cancer and breast self examination among college girls in Kerala. The data were collected from 49 samples using questionnaire and observation check list, the finding has shown the effectiveness of planned teaching programme through a significant increase in the post test scores.⁵⁵

A study was conducted on 4721 registered nurses to assess the knowledge and skills about caring patients with HIV/ AIDS in osum state. A self administrated questionnaire was used. The result showed that majority(80.3%) of nurses specially in that teaching hospitals were knowledgeable about HIV/AIDS and were skill full in caring for patients with HIV/AIDS. However knowledge deficit was recovered on the organisms targeted HIV/AIDS viruses available, diagnostic tests and drug used for treating patients with HIV/AIDS. The majority (60%) felt that there was  a need to update their knowledge and skills in the care of patients with HIV/AIDS. ⁵⁶