14^th Surgical Nursing & Nurse Education Conference

Biography

Biography: PARAM HANS Mishra

Abstract

Management of Hospital Acquired infection is a very important aspect of health care management.

A Nosocomial infection affects approximately 2 million patients annually in acute care facilities in our country and their annual patient care costs several millions of rupees.

Studies shows that nearly one-third of nosocomial infections can be prevented by a well organized infection control program. But only less than 10% are actually prevented.

Health-care waste is an important source of HAI and should be considered as a reservoir of pathogenic microorganisms, which can cause contamination and give rise to infection. If waste is inadequately managed, these microorganisms can be transmitted by direct contact, air or by a variety of vectors. Infectious waste contributes in this way to the risk of nosocomial infections, putting the health of hospital personnel, and patients, at risk.

The aim of the Hospital Infection Control Program is dissemination of information, surveillance activities, investigation, prevention and control of nosocomial infections in the hospitals.

Introduction

This study describes the measure taken in a tertiary care hospital to control infection and its effect. There are big human and economic burdens of health care associated infections (HAIs). The appropriate resources and activities required for an effective Infection Prevention and Control Program (IPCP) are very important to minimize the incidence and adverse outcomes of these infections. The goals of IPCPs are to minimize these and other negative effects by contributing to patient safety through protecting patients from infections; protecting health care workers and visitors to health care facilities from infections; and accomplishing these goals in the most cost effective manner whenever possible, thus reducing the economic impacts of HAIs on individual health facilities, health systems and the national health care industry.

Health care associated infections occur in relation to health care interventions including invasive, diagnostic, surgical, and medical procedures. Examples of HAIs include bloodstream, surgical site, urinary tract, pulmonary, and skin and soft tissue infections. Transmission of infectious diseases, such as SARS, tuberculosis, influenza, Clostridium difficile (C. difficile), Norovirus, and antibiotic resistant organisms (e.g., MRSA [methicillin-resistant Staphylococcus aureus] and VRE [Vancomycin-resistant Enterococci]) to patients within the health care delivery system are also considered HAIs.

Infection Prevention and Control Programs were first introduced in the1950s. Initially referred to as Infection Control Programs, these hospital-based programs focused on the control of hospital-acquired infections, which were referred to as nosocomial infections. As health care increased in complexity and sophistication and expanded beyond acute care, the mandate of IPCPs should have expanded to encompass infections in all settings across the health care continuum. Contrary to expectations, however, IPCPs have seen their resources either decrease or remain static, and consequently have failed to achieve the needs of the expanding mandate.

Health care associated infections contribute to significant morbidity, mortality, and economic costs and the risk of hospital acquired infections is increasing. These infections are the most common complication affecting hospitalized patients. Effective IPCPs reduce nosocomial infections by at least 30% (10) and have repeatedly been shown to be effective in controlling infection outbreaks in the health care setting. Appropriate resources, both in quantity and in quality, are required to support effective IPCPs.

AIM of the Study

The aim of the study is to see the effect of Hospital Infection Control program in a tertiary care hospital ICU.

Materials and methods:

This study was conducted in the ICU of a tertiary care super specialty hospital (Indian Spinal Injuries Centre) by observing and monitoring the effect of implementing Hospital Infection control program in post operative cases over a period of 7 days from the date of surgery.

Indian Spinal Injuries Centre is a tertiary care specialized centre for Spinal Injury patient, Orthopedics and Joint Replacement. 

Infection control Program

Hospital control Program team consists of two Infection Control Nurses & One Infection Control Officer (microbiologist) who are responsible for infection control work.

There is a multidisciplinary Hospital Infection Control Committee chaired by Medical superintendent and Microbiologist is the member secretary and other members are from different clinical & nonclinical specialties, nursing and housekeeping.

Review of Literature

A nosocomial infection (derived from the Greek words nosos [disease] and komein [to care for], and later the Latin word for hospital nosocomium) is defined as an

"Infection that is not present or incubating when the patient is admitted to hospital or other health-care facility¹". The time frame for diagnosis of a nosocomial infection will thus clearly be dependent on the incubation period of the specific infection; 48–72 h after admission is generally deemed indicative of nosocomial, rather than community acquired, infection. Although generally associated with hospital admission (hence the term hospital-acquired infection), nosocomial infections can arise after admission to any health-care facility, and the term health-care associated infection is increasingly being used. Such infections are common and associated with great morbidity and mortality. Indeed, one provocative headline stated “Hospital acquired infections kill 5000 patients a year in England²”. The information for this news piece was taken from a government report on hospital-acquired infection in England, which suggested that there are at least 100 000 cases of hospital-acquired infection every year in England, costing the UK National Health Service some £1 billion each year³. In addition to their association with increased morbidity and mortality, nosocomial infections are frequently associated with drug-resistant micro-organisms, including Methicillin-resistant Staphylococcus aureus and extended spectrum lactamase (ESBL)-producing gram-negative bacteria, which can pose considerable therapeutic problems. Medico legal issues can also arise, since patients or their families sometimes blame the hospital or staff for the infection, and demand compensation.3 Nosocomial infections can affect any part of the body, but respiratory tract infections are most frequent, followed by central line infections, urinary tract infections, and wound infections.

Pathophysiology

The development of nosocomial infection is dependent on two key patho physiological factors: decreased host defences and colonization by pathogenic, or potentially pathogenic, bacteria. Although these two factors can arise independently, for infection to result both must be present to some degree.

Direct contact can include spread from the hands of health-care workers or visitors⁴, but also from contaminated equipment and infusions^5,6.

Underlying health impairment

Certain conditions predispose to bacterial colonization, and hence nosocomial infection, by impairing host-defense mechanisms. Patients with chronic lung disease are at an increased risk of developing nosocomial infection^7,8.

Poor nutrition and chronic debilitation are associated with reduced immune defense, explaining the increased risk of nosocomial infections in such patients¹⁰.

The acute disease process

The underlying disease process as well as the severity of disease can affect the risk of developing nosocomial infection. Patients with a primary diagnosis of trauma or burns are at an increased risk^11-14.

Trauma patients too have altered immune responses¹⁵, making  them more likely to develop infection. Perhaps unsurprisingly, severity of illness as assessed by severity scores has also been associated with the development of nosocomial infection^16,17,but rather associated with other risk factors for infection, such as prolonged length of stay¹⁸.

Invasive devices

In a report from the National Nosocomial Infection Surveillance (NNIS) system¹⁹, involving data from 498 998 patients, 83% of episodes of nosocomial pneumonia were associated with mechanical ventilation, 97% of urinary tract infections arose in patients with a urinary catheter in place, and 87% of primary bloodstream infections were in patients with a central line.

Treatment methods

Various therapeutic strategies are associated with a raised risk of nosocomial infection. Cook and colleagues12 noted that the administration of paralytic agents was an independent predictor of nosocomial pneumonia in their study of 1014 mechanically ventilated patients. Sedative drugs²⁰,corticotherapy²¹, antacids^22,23, stress-ulcer prophylaxis^11,214, previous antibiotic therapy⁹, and multiple blood transfusions 25 have all been identified as risk factors.

Epidemiology

The quoted incidence of nosocomial infection varies, according to the setting—ie, the type of hospital or intensive-care unit—the population of patients, and the precise definition used (hospital-acquired, intensive-care unit-acquired, nosocomial pneumonia). One of the largest databases related to nosocomial infection in intensive care . In this 1-day point  prevalence study, information was obtained on all patients who occupied a bed in an intensive-care unit over 24 h in 1992: 10 038 patients were recruited from 1417 western European intensive care units. Of these patients, 4501 were infected, and of those 2064 (21% of the total number) had an intensive-care-unit-acquired infection. There was a relation between the prevalence of nosocomial infection and mortality according to country¹¹, with greater incidence of infection and higher mortality rates in the southern European countries of Portugal and Greece than in Scandinavia and Switzerland (figure 1).

Other studies25,26-28 have quoted incidence rates of between 9% and 37%, dependent largely on the populations studied and the definitions used. Differences in surveillance techniques can also affect detection of nosocomial infection and, hence, rates²⁹.

However, we are becoming less invasive in our treatment techniques (less aggressive surgical procedure are used, fewer Swan-Ganz catheters are being placed, non-invasive mechanical ventilation is being applied when possible and appropriate), and are more aware of techniques that could prevent nosocomial infection (antibiotic-coated catheters, avoidance of naso tracheal intubation thus limiting sinusitis), which could result in a reduced incidence of infections. In a study on one intensive-care unit, comparing data over 25 years, the incidence of bacteraemia  increased from 1·8% in 1971–75 to 5·5% in 1991–95, with the largest increase seen between 1986–90 and 1991–95⁴⁶.Dagan and co-workers²⁸,however, reported a fall in the nosocomial infection ratio from 25·2 in 1987 to 20 in 1992.

Effect of nosocomial infection

The effect of nosocomial infection in terms of morbidity, mortality, and increased resource use is substantial. Nosocomial infection is associated with an increased length of stay^30-33,which results in an additional cost of about US$3·5 billion per year³⁴, without taking into account antibiotic or other therapeutic costs

Crude mortality rates associated with nosocomial infection vary from 12% to 80%, dependent on the population studied and the definitions used.

Organisms

Any organism can be implicated in nosocomial infection, and many infections are polymicrobial¹¹.Recent years have seen a swing in the pattern of infecting organisms towards gram-positive infections³⁵.The surveillance and control of pathogens of epidemiologic importance project (SCOPE) data³⁶ revealed that gram-positive cocci were isolated in 64% of 10617 episodes of nosocomial bacteraemia, whereas gram-negative bacilli were isolated in only 27% of cases. The EPIC study¹¹ identified the following as the most commonly reported nosocomial pathogens: Staphylococcus aureus (30%), Pseudomonas aeruginosa (29%), coagulase-negative staphylococci (19%), yeasts (17%), Escherichia coli (13%), enterococci (12%), Acinetobacter spp (9%), and Klebsiella spp (8%)³⁷. Other studies have noted similar patterns of causative microorganisms^19,26