RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

SYNOPSIS PROFORMAFOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / MERIN MARY MATHEW. M.Sc NURSING I YEAR,PRAGATHI COLLEGE OF NURSING, #33 BYRATHI (EXT), NEAR EBENEZAR HOSPITAL, HENNUR BEGALUR MAIN ROAD, KOTHANUR POST, BANGALORE-77
2. / NAME OF THE INSTITUTION / PRAGATHI COLLEGE OF NURSING, #33 BYRATHI(EXT),NEAR EBENEZAR HOSPITAL,HENNUR BEGALUR MAIN ROAD ,KOTHANUR POST, BANGALORE-77
3. / COURSE OF
STUDYAND SUBJECT / DEGREE OF MASTERS IN NURSING
CHILD HEALTH NURSING.
4. / DATE OF ADMISSON TO THE
COURSE / 15/11/2010
5. / TITTLE OF THE TOPIC / “EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME REGARDING KNOWLEDGE ON MANAGEMENT AND PREVENTION OF NOSOCOMIAL PNEUMONIA AMONG STAFF NURSES WORKING IN PEDIARIC WARD IN SELECTED HOSPITALS, BANGALORE.”
BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
Nosocomial infections are infections that are a result of treatment in a hospital or a healthcare service unit. Infections are considered nosocomial if they first appear 72 hours or more after hospital admission or within 30 days after discharge.
Nosocomial infections are commonly transmitted when hospital officials become complacent and personnel do not practice correct hygiene regularly. Also, increased use of outpatient treatment means that people who are hospitalized are more ill and have more weakened immune systems than may have been true in the past. Moreover, some medical procedures bypass the body's natural protective barriers. Since medical staff moves from patient to patient, the staff themselves serves as a means for spreading pathogens.
Hospitals have sanitation protocols regarding uniforms, equipment sterilization, washing, and other preventative measures. Thorough hand washing and/or use of alcohol rubs by all medical personnel before and after each patient contact is one of the most effective ways to combat nosocomial infections. More careful use of antimicrobial agents, such as antibiotics, is also considered vital
In the United States, the Centers for Disease Control and Prevention estimates that roughly 1.7 million hospital-associated infections, from all types of bacteria combined, cause or contribute to 99,000 deaths each year. In Europe, where hospital surveys have been conducted, the category of Gram-negative infections are estimated to account for two-thirds of the 25,000 deaths each year. Nosocomial infections can cause severe pneumonia and infections of the urinary tract, bloodstream and other parts of the body. Many types are difficult to attack with antibiotics, and antibiotic resistance is spreading to Gram-negative bacteria that can infect people outside the hospital.
In a representative sample of US general hospitals, the authors found that the establishment of intensive infection surveillance and control programs was strongly associated with reductions in rates of nosocomial urinary tract infection, surgical wound infection, pneumonia, and bacteremia between 2000 and 2005–2006, after controlling for other characteristics of the hospitals and their patients. Essential components of effective programs included conducting organized surveillance and control activities and having a trained, effectual infection control physician, an infection control nurse per 250 beds, and a system for reporting infection rates to practicing surgeons. Programs with these components reduced their hospitals' infection rates by 32%. Since relatively few hospitals had very effective programs, however, only 6% of the nation's approximately 2 million nosocomial infections were being prevented in the mid-2000s, leaving another 26% to be prevented by universal adoption of these programs. Among hospitals without effective programs, the overall infection rate increased by 18% from 1990 to 2006.
Currently, about 180 hospitals participate in the National Nosocomial Infections Surveillance (NNIS) system. From January 1980 through April 1998, 127,200 fungal isolates causing nosocomial infections were reported from these hospitals; Candida species accounted for 19,621 (72.1%) of these isolates. Immunocompromised patients are at particularly high risk for candidemia. In patients with acute lymphocytic leukemia, treatment with vancomycin and/or imipenem appears to be an independent risk factor for candidemia; colonization of stool by Candida species may be another important predisposing factor in these patients. Rapid detection of invasive candidemia in these high-risk patients is particularly important to the improvement of rates of survival. Methods for rapid detection, such as the measurement of manna (the major cell-wall polysaccharide of Candida), may be useful for diagnosing invasive candidacies and for monitoring the response of this infection to antifungal therapy. Further studies of risk factors and the development of new methods for rapid diagnosis and monitoring should help decrease the morbidity and mortality associated with nosocomial fungal infections.
A study was conducted to find the incidence of hospital-acquired pneumonia in 1886 consecutive admissions to an 1800 bed hospital in Bombay; 991 of them to general medical wards and 895 to a 17-bed medical intensive care unit (ICU). The average bed occupancy in the general wards was 56 patients in a ward with 40 beds. Staffing in the general ward was two nurses for 56 patients, and in the ICU three nurses for 17 beds. One hundred and sixty-eight patients developed nosocomial pneumonia: 18 (1·8%) in general wards and 150 (16·7%) in the ICU. Common isolates included Pseudomonas spp (44%) and Klebsiella spp (34%). The most frequently used antibiotics were cefotaxime (34%), amikacin (25%), gentamicin (23%) and ofloxacin (13%). Crude mortality in general ward patients was 88·9 vs. 14·6% in patients without pneumonia. The corresponding figures for ICU patients were 67·4 vs 37·1%; 40% of the crude mortality in ICU patients with pneumonia was attributable to the infection. Infected patients stayed an additional 5·8 days in the ICU and 6·7 days in the general ward. Costs of additional stay and antibiotics accounted for 18·6% of the ICU budget. The incidence of nosocomial pneumonia was lower than expected, despite occupancy exceeding bed capacity, low nurse:patient ratios, and extensive reuse of disposable respiratory therapy equipment. Nevertheless, nosocomial pneumonia imposes a significant financial burden on the already scarce resources available for intensive care in developing countries like India.
A study included 201 patients (1285 patient days) admitted to RICU over a period of one-and-a-half years. A total of 77 infections were identified in 67 patients (33.5%). The infections included pneumonia (23%), sepsis of unknown origin (10.5%), bacteremia (7.5%), urinary tract infections (1.5%), catheter related blood stream infections (1%) and Clostridium difficile colitis (1%). The most commonly identified organisms were the Acinetobacter species (34.8%), Pseudomonas aeruginosa (23.9%) and Escherichia coli (15.2%). The median length of stay in patients with and without infection was 13 days (interquartile range, IQR, 28) and 4 days (interquartile range, IQR, 3), respectively (p<0.0001). Multivariate analysis showed the following risk factors for ICU-acquired infection: the admitting diagnosis of infection (odds ratio [OR] 3.3; 95% confidence intervals [CI] 1.06–10.1), length of stay in the RICU (OR, 1.2; 95% confidence intervals [CI] 1.1–1.33); renal failure (OR, 4.7; 95% CI, 1.52–14.41) and institution of parenteral nutrition (OR, 16.9; 95% CI, 1.07–269.03). Multivariate analysis showed the following risk factors for death in ICU: APACHE II scores (OR, 1.06; 95% CI, 1.01–1.11), and endotracheal intubation (OR, 5.07; 95% CI, 1.24–20.65).
The Norwegian Institute of Public Health initiated a national surveillance system for nosocomial infections in 2002. The system is based on two annual one-day prevalence surveys recording the four most common types of nosocomial infection: urinary tract infections; lower respiratory tract infections; surgical site infections and septicaemia. All acute care hospitals in Norway (N=76) were invited to participate in the four surveys in 2002 and 2003. The total prevalence of the four recorded nosocomial infections varied between 5.1% and 5.4% in the four surveys. In all surveys, nosocomial infections were located most frequently in the urinary tract (34%), followed by the lower respiratory tract (29%), surgical sites (28%) and septicaemia (8%). The prevalence surveys give a brief overview of the burden and distribution of nosocomial infections. The results can be used to prioritize further infection control measures and more detailed incidence surveillance of nosocomial infections.
A one-day survey was carried out in 88 out of 113 public hospitals in Lombardy to obtain prevalence rates of hospital-acquired infections (HAIs) by hospital departments and to identify the pathogens more frequently involved. In total 18 667 patients were surveyed, representing 72% of the average daily total of occupied beds in public hospitals in Lombardy. The overall prevalence of HAI was 4.9%. The highest prevalence was observed in intensive care units and in spinal units. The prevalence of bloodstream infections was 0.6%; pneumonia 1.1%; urinary tract infections 1.6% and gastrointestinal infections 0.4%. In surgical patients the prevalence of surgical site infections was 2.7%. The most frequently isolated pathogen from all sites of infections was Escherichia coli (16.8%), followed by Staphylococcus aureus (15.0%), Pseudomonas aeruginosa (13.2%) and Candida spp. (8.7%). Methicillin-resistant S. aureus accounted for 23% of all isolated S. aureus. The results provide baseline data for rational priorities in allocation of resources, for further studies and for infection control activities.
A retrospective study was undertaken to compare the nosocomial infection rate in obese and normal weight surgical patients. All patients undergoing general, urologic, vascular, thoracic, or gynecologic surgical procedures between October 1 and December 31, 1991, were reviewed. Nosocomial infection data were obtained from the Department of Hospital Epidemiology. A total of 849 patients were evaluated, of which 536 (63%) were normal weight (BMI < 27 kg/m2), 175 (21%) were obese (BMI 27-31 kg/m2), and 138 (16%) were severely obese (BMI > 31 kg/m2). Age, mortality, and American Society of Anesthesia (ASA) risk scores did not differ among the three groups. There were significant increases in the number and percent of nosocomial infections in the obese populations, with rates of 0.05 per cent in normal weight, compared to 2.8 per cent and 4.0 per cent in obese and severely obese groups (P < 0.01). Infections consisted of seven wound infections, five C. difficile infections, one pneumonia, and three bacteraemia. No differences in distribution between groups were evident. Mortality was similar among the groups. These data support the hypothesis that obesity is a significant risk factor for clinically relevant nosocomial infections in surgical patients.
6.1 NEED FOR THE STUDY
Hospital-acquired pneumonia is a growing concern that all nurses need to be aware of because hospital-acquired infections are a major challenge to patient safety. It is also estimated that in 2002, a total of 1.7 million hospital-acquired infections occurred (4.5 per 100 admissions), and almost 99,000 deaths resulted from or were associated with a hospital-acquired infection, making hospital-acquired infections the sixth leading cause of death. At the same time it is also estimated that approximately one third or more of hospital-acquired infections are preventable.1
A case-control study was conducted intending to evaluate the influences of severity of illness and evolution of therapeutic activity on the development of nosocomial infections, and to estimate the attributable consequences of these infections on ICU patients. The study concluded that a persistent high level of therapeutic activity and persistently depressed consciousness on the third day after ICU admission are associated with the acquisition of nosocomial infection by critically ill patients hospitalized in a medical ICU. Such nosocomial infections are responsible for excess mortality, prolonged stay, and increased therapeutic activity independently of the initial severity of illness. Thus, nosocomial infections exact a heavy toll on all concernedthe patient, the medical staff, and economic resourcesespecially in cases of multiple infections.2
A prospective study was conducted to know the incidence of hospital-acquired pneumonia in 1886 consecutive admissions to an 1800 bed hospital in Bombay; 991 of them to general medical wards and 895 to a 17-bed medical intensive care unit (ICU). The average bed occupancy in the general wards was 56 patients in a ward with 40 beds. Staffing in the general ward was two nurses for 56 patients, and in the ICU three nurses for 17 beds. One hundred and sixty-eight patients developed nosocomial pneumonia: 18 (1·8%) in general wards and 150 (16·7%) in the ICU. Common isolates included Pseudomonas spp (44%) and Klebsiella spp (34%). The most frequently used antibiotics were cefotaxime (34%), amikacin (25%), gentamicin (23%) and ofloxacin (13%). Crude mortality in general ward patients was 88·9 vs 14·6% in patients without pneumonia. The corresponding figures for ICU patients were 67·4 vs 37·1%; 40% of the crude mortality in ICU patients with pneumonia was attributable to the infection. Infected patients stayed an additional 5·8 days in the ICU and 6·7 days in the general ward. Costs of additional stay and antibiotics accounted for 18·6% of the ICU budget. The incidence of nosocomial pneumonia was lower than expected, despite occupancy exceeding bed capacity, low nurse: patient ratios, and extensive reuse of disposable respiratory therapy equipment. Nevertheless, nosocomial pneumonia imposes a significant financial burden on the already scarce resources available for intensive care in developing countries like India.3
According to the most recent statistics from the CDC, hospital-acquired pneumonia accounts for nearly 15% of all hospital-acquired infections and is associated with the highest mortality rates (20% to 33%). It's second only to urinary tract infections as the most common Hospital acquired infections.4
Throughout the world, including Asia, Nosocomial infection is an important public health problem, often with pneumonia as a significant consequence. Hospital-acquired pneumonia is associated with significant morbidity and mortality and increased costs of treatment. Hospital acquired pneumonia is associated with crude mortality rates of up to 70% and attributable mortality rates as high as 33% to 50%. A study conducted in India showed that the Mortality rates relating to nosocomial pneumonia was 37% to 47.3% and the Incidence of ventilator associated pneumonia was 8.95 per 1000 ventilator days and the incidence of hospital acquired pneumonia was 53.9%.5
A study was conducted to identify knowledge deficits concerning nosocomial pneumonia prevention among critical care nurses. A survey design using a mailed self-administered questionnaire was used. A sample of 134 critical care nurses was included in the study. The results showed that nurse practioners knowledge score ranged from 21% to 92%. The mean (and median) was 48%. Items related to knowledge about nosocomial risks had the highest mean score (67%) compared to items addressing nosocomial pneumonia prevention (43%) or the role of devices in the transmission of NP (45%). No nurse demographic or workplace characteristic was associated with nosocomial pneumonia knowledge. The study concluded that nurse practioners knowledge score ranged from 21% to 92%. The mean (and median) was 48%. Items related to knowledge about nurse practioners risks had the highest mean score (67%) compared to items addressing nurse practioner prevention (43%) or the role of devices in the transmission of nurse practioner (45%). No nurse demographic or workplace characteristic was associated with nurse practioner knowledge.6