Prevention Is Better Than Cure
6. BRIEF RESUME OF INTENDED WORK.
6. 0. INTRODUCTION :
“Prevention is better than cure”
Nursing is a call (vocation) to service. Nursing is a service which includes ministration to the sick, care of whole patient, the care of the patients environment, health education, health services to the individual, family, and society for the prevention of disease and promotion of health.
Hospitals are the organized institutions for the care of the sick and injured. The word hospital is comes from the word ‘hospes’ which means host. The function of which is to provide for the population the complete health care, both curative and preventive and whose outpatient services reach out to the family and its home environment.1
Infections which arise in hospitals are termed "hospital associated infections" (HAI). Such infections have also been called "noscomial infections" and sometimes "hospital acquired infections".1
But after a century of sometimes spectacular medical progress, nosocomial infections continue to be major surgical and medical problems. Nosocomial infections 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.2
A report released by Britain’s National Audit Office revealed that infections in hospitals affect 100,000 people each year, costing the National Health Service (NHS) approximately £1 billion to treat.4 More importantly, hospital-acquired infections are primarily responsible for killing 5000 patients per year and are a substantial factor in 3% or 15,000 deaths per year. Additionally, the report found that approximately one-third of hospital-acquired infections may be preventable and concluded that infection control expenditures play an important role in improving patient care and reducing costs. 3
Medical asepsis is a clean technique used to reduce and prevent the spread of microorganisms. Surgical asepsis is a sterile technique that requires nurses to use different precautions than they do for medical asepsis. It includes procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area. Surgical asepsis procedures are followed when performing an invasive procedure into a body cavity normally free of microorganisms. Medical aspesis means clean; surgical asepsis means sterile. These medical and surgical sepsis includes many practices that help to protect the patient from these Nosocomial infections like, hand washing, cleaning of articles, gown technique, face masks, gloving, disinfection and sterilization of articles etc. 2
6. 1.NEED FOR THE STUDY:
Hospital-associated infections are considered as major causes of mortality, emotional stress and enhanced morbidity in hospitalized patients. These also account for significant economic loss and additional burden on health care institutions. In a study conducted by WHO, the highest frequencies of HAI were reported from hospitals in the Eastern Mediterranean Region (11.8%) followed by South-East Asia, where it was 10%. It has also been estimated that at any time over 1.4 million people worldwide suffer from infectious complications acquired in hospital. The infections acquired in the hospitals may be due to resistant organisms that further accentuate the problem. It has also been estimated that these infections cost more than US$ 40 million every year in Thailand alone.4
The Centers for Disease Control and Prevention (CDC) of united states estimates that roughly 1.7 million hospital-associated infections, from all types of bacteria combined, cause or contribute to 99,000 deaths each year.[1] Other estimates indicate that 10%, or 2 million, patients a year become infected, with the annual cost ranging from $4.5 billion to $11 billion.2
One study estimates that bloodstream nosocomial infections are the eighth leading cause of death, assuming a nosocomial infection rate of 5%, of which 10% are bloodstream infections, and an attributable mortality rate of 15%. In absolute numbers, if the overall attack rate was 5%, and 25 million patients were admitted each year, 1.75 million people would acquire nosocomial infections each year. If 10% of these were bloodstream infections, 175,000 would get these serious infections each year. If the attributable mortality rate of nosocomial infections is 20% and the infection rate is 5%, an estimated 350,000 life years would be lost annually.[24] Another source reports an incidence of 2 million new cases of nosocomial infections per year, leading to an estimated 20,000 deaths per year.3
Currently several organizations are involved in the setting of guidelines for infection control practices in the United States. The major non-governmental regulation agency is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which act to survey and accredit hospital infection control programs across the country.3
Besides the committees and other leaders in infection control, much of infection control lies in the hands of the personnel in direct contact with the sick patient. These healthcare employees must understand specific guidelines in prevention of infection transmission through isolation and other good healthcare habits. Much of this information in disseminated through training and educational programs given by the infection control departments.4
Hands are among the principal vehicles for transfer of nosocomial pathogens in hospitals. Often, outbreaks of infection are thought to be caused by a lack of compliance with hand washing guidelines, rather than due to the inadequacy of the hand washing agents used. One of the study proved that when hands heavily contaminated, an ordinary hand washing followed by disinfectants is not enough to eradicate potentially pathogenic bacteria from the hands.3
In a multidisciplinary setting, one role of the nurse or other allied health professional is to assist the doctor in caring for the patient while maintaining asepsis, i.e., by supplying equipment to the surgeon in a sterile fashion. Nursing staff independently practice aseptic techniques in many day-to-day procedures, such as urinary catheter insertion, dressing changes, and respiratory suction. Even personnel experienced with aseptic technique must constantly monitor their own movements and practices, those of others, and the status of the overall field to prevent inadvertent breaks in sterile or clean technique. It is expected that personnel will alert other staff when the field or objects are potentially contaminated. Health care workers can also promote asepsis by evaluating, creating, and periodically updating policies and procedures that relate to this principle.4
6. 2.REVIEW OF LITERATURE
The review of literature is a summary of current knowledge about a particular practice problem and includes what is known and not known about the problem. The literature is reviewed to summarize knowledge for use in practices or to provide a basis for conducting a study.
A study was conducted on an evaluation of Hospital Emergency Department (HED) adherence to universal precautions. A total of 1,541 procedures were observed on 56 randomly selected 8-h work shifts. Shifts were distributed: 34% day shift; 34% evening shift; and 32% on the night shift. Observations on the evening shift were oversampled to capture an adequate number of trauma patients. Observations were distributed: 33% day shift; 39% evening shift; and 28% on the night shift. Conclusion is evaluation of the database revealed that glove compliance increased over the period of the study and adverse exposure decreased. Conducting ongoing or periodic observational studies of this kind are important and necessary in order to gauge Hospital Emergency Department response to the epidemiologic challenges of urban society. 5
A study was conducted with an objective to clarify whether external factors (e.g. ward capacity, level of nursing intensity) had an influence on nursing staff compliance with hand hygiene guidelines. The study was conducted at a German hospital (450 beds),ten hospital departments: four surgical wards, four internal medicine departments, and two interdisciplinary intensive care units. In six participant observation trials, nursing staff were monitored for the disinfection of hands. Narrative interviews were conducted immediately after the observation with those who did not disinfect their hands in accordance with national guidelines. The statistical relevance of staff compliance to the rate of used ward capacity could be proved using a multifactorial regression model (P=0.011). The conclusion is workload factors (e.g. maximum ward capacity, severity of patient cases) have an impact on staff compliance with hand hygiene guidelines, even where non-compliance contradicts the personal level of professional training.6
A study was conducted onBacterial contamination of stethoscopes used by health workers: public health implications. A structured questionnaire was administered to health workers and the surface of the diaphragm of their stethoscopes swabbed for bacteriological analysis using standard techniques. In this study 107 stethoscopes surveyed, the result of that is84 (79%) were contaminated with bacteria; 59 (81%) of the contaminated stethoscopes belonged to physicians and 25 (74%) were from other health workers. Isolates included Staphylococcus aureus (54%), Pseudomonas aeruginosa (19%), Enterococcus faecalis (14%), and Escherichia coli (13%). All stethoscopes that had never been cleaned were contaminated while lower levels of contamination were found on those cleaned one week or less before the survey. Contamination was significantly higher on stethoscopes cleaned with only water (100%) compared to those cleaned with alcohol (49%).Finally in conclusion there is Significantly fewer (9%) stethoscopes from health workers who washed their hands after seeing each patient were contaminated when compared with the instruments (86%) of those who did not practice hand washing. E. coli showed the highest antibiotic resistance, while S. aureus showed the highest antibiotic susceptibility. Strict adherence to stethoscope disinfection practices by health workers can minimize cross-contamination and ensure improved patient safety in hospital environments.7
A study was conducted with an objectiveto compare alcohol-based hand rubbing with hand washing using antimicrobial soap regarding antimicrobial efficacy and compliance with routine practice in hospital and intensive care units. In samples 35 nurses were randomly selected from a nursing staff of 141 and divided into two groups: hand rubbing and hand washing groups. A total of 368 routine patient care activities were observed during the study period. The result is hand rubbing with alcohol-based solutions significantly reduced the bacterial contamination of the hands of the nurses more than hand washing with an antimicrobial soap (54 and 27%). Compliance was also better in the hand rubbing group than in the hand washing group (72.5 and 15.4%, respectively). Compliance with hand rubbing was markedly lower among the nurses who had experience of more than 3 years in hospital practice. Both hand rubbing and hand washing compliance were poorer among nurses working in intensive care units than among nurses working in the other hospital wards. These data conclude that alcohol-based hand rubbing reduces mean bacterial counts on the hands of nurses more effectively than hand washing with antimicrobial soaps, and compliance rates with hand rubbing were also higher than with hand washing. Nevertheless, the compliance with hand rubbing was markedly lower in more experienced nurses.8
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A study was conducted on use of gloves and hand washing behavior among health care workers in intensive care units. The study included a total of 1632 patient procedures performed by 325 persons. Results showed that health care workers washed their hands more often after glove use (57%) than when gloves had not been used (40%). This significant difference in HW frequency was also noted when similar procedures were carried out by HCW with or without gloves. This might be a matter of personal discomfort after wearing gloves, but could also be due to differences in awareness of hygienic aspects of patient care. In the two countries gloves were used on average at 17% of the procedures, but were not used appropriately for dirty procedures. The conclusion is more effective methods for the implementation of appropriate glove use and HW should be emphasized.9
A study was conducted with an objective of whether nursing students could learn and retain the theory and skill of hand washingmore effectively when taught using computer-assisted learning compared with conventional face-to-face methods. Two-hundred and forty-two first year nursing students of mixed gender; age; educational background and first language studying at one British university were recruited to the study. The result is knowledge scores increased significantly from baseline in both groups and no significant differences were detected between the scores of the two groups. Skill performance scores were similar in both groups at the 2-week follow-up with significant differences emerging at the 8-week follow-up in favour of the intervention group; however, this finding must be interpreted with caution in light of sample size and attrition rates. The conclusion is the computer-assisted learning module was an effective strategy for teaching both the theory and practice of hand washingto nursing students and in this study was found to be at least as effective as conventional face-to-face teaching methods.10
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A study was conducted to evaluate the effectiveness of the authors' infection control programme in relation to hand washing compliance of healthcare workers. Ten nursing students observed 300 uninformed staff members and recorded their hand washing practices throughout the working day. The observations were categorized by profession, gender, age, hospital unit and type of delivered care. In 1035 opportunities that required hand washing the overall compliance was 76%. Healthcare workers washed hands before (68%) and after patient care (80%). Females complied more than males (69 vs. 80%) and nurses more than physicians (81 vs. 69%). In intensive care units, overall compliance exceeded 97%, while in other wards and in the emergency departments, it approximated 61%. More hand washingwas observed during the evening shift compared with the morning shift. Despite the high compliance, only 30% washed their hands for the required 10–20s. In conclusion, compliance with hand washingin the authors' institution is the highest reported to date, and reflects the intensive and incessant educational infection control programme.11
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A study was conducted with an objective to determine whether a hygiene program can promote hand washing and thereby reduce illness absenteeism. The samples included 40 Jerusalem preschools with 1029 children for 6 baseline days and 66 study days, yielding 73,779 child days.This multi-site intervention program produced sustained behavioral and environmental changes over a 6-month period. An approximately threefold increase in hand washing with soap was observed among preschool children exposed to the intervention. Neither the preschool nor the home intervention program reduced illness absenteeism or overall absenteeism. At last this study concludes that the potential of the preschool as a promising venue for health promotion activities leading to sustained behavioral change, yet suggests the need for enhanced approaches for reducing illness absenteeism.12
A study was conducted on quantity of ethanol absorption after excessive hand disinfection using three commercially available hand rubs is minimal and below toxic levels for humans. Twelve volunteers applied three hand-rubs containing 95% (hand-rub A), 85% (hand-rub B) and 55% ethanol (hand-rub C; all w/w). For hygienic hand disinfection, 4 ml were applied 20 times for 30 s, with 1 minute break between applications. For surgical hand disinfection, 20 ml of each hand rub was applied to hands and arms up to the level of the elbow 10 times for 3 minutes, with a break of 5 minutes between applications. Blood concentrations of ethanol and acetaldehyde were determined immediately prior and up to 90 minutes after application using head space gas chromatography. The result is the median of absorbed ethanol after hygienic hand disinfection was 1365 mg (A), 630 mg (B), and 358 mg (C). The proportion of absorbed ethanol was 2.3% (A), 1.1% (B), and 0.9% (C). After surgical hand disinfection, the median of absorbed ethanol was 1067 mg (A), 1542 mg (B), and 477 mg (C). The proportion of absorbed ethanol was 0.7% (A), 1.1% (B), and 0.5% (C). The highest median acetaldehyde concentration after 20 hygienic hand disinfections was 0.57 mg/L (hand-rub C, after 30 min), after 10 surgical hand disinfections 3.99 mg/L (hand-rub A, after 20 minutes). The overall dermal and pulmonary absorption of ethanol was below toxic levels in humans and allows the conclusion that the use of the evaluated ethanol-based hand-rubs is safe. 13
A study was conducted to evaluate the microbiocidal activity of superoxidized water (SOW) on common clinical isolates, ATCC strains, vegetative cells and spores of Bacillus subtilis. Bacterial suspensions were treated with superoxidized water (SOW) and deionized water (control). All the tubes were incubated at 37°C for 0.5, 2.5 and 5.0 min. The number of viable cells was counted. The result is all the clinical isolates and ATCC strains were killed within 0.5 min of exposure to the SOW. Vegetative cells and spores of B. subtilis were killed after 5.0 min. Final conclusion superoxidized water (SOW) is an effective microbiocidal agent for routine hospital use.14
6. 2.1. STATEMENT OF THE PROBLEM:
“A Study to assess the knowledge and practiceregardingmedical and surgical asepsis among staff nurses in selected hospitals, Davanagere”
6. 3. OBJECTIVES OF THE STUDY:
1. To assess the knowledge on medical and surgical asepsisamong staff nurses in selected hospitals, Davanagere.
2. To assess the practice on medical and surgical asepsisamong staff nurses in selected hospitals, Davanagere.