Summary Of Nosocomial Infection

Statement of Problem and Significance

A total of 1.7 million nosocomial infections occurred in 2007. Almost 99,000 deaths resulted from, or were associated with, a nosocomial infection, making these infections the sixth leading cause of death in the United States (Peleg, Hooper). Nosocomial infections, also known as “hospital-acquired infections”, are infections acquired during hospital care that were not present before admission. Infections occurring within 48 hours of hospital admission, 3 days of discharge or 30 days of an operation can also be classified as nosocomial (Inweregbu, Dave, Pittard). These infections are most commonly found in intensive care units. A study known as “The European Prevalence of Infection in Intensive Care Study”

(EPIC) found that, of the studies 4,500 patients, 20.6% acquired a nosocomial infection (Inweregbu, Dave, Pittard). Of these infections, Methicillin-resistant Staphylococcus aureus (MRSA) was the most common infectious agent, accounting for 60% of infections (Inweregbu, Dave, Pittard).
Overall, nosocomial infections are split into three categories according to their source or resulting condition: urinary, surgical site and nosocomial pneumonia. Urinary infections are the most common type, with 80% of infection attributed to the use of an indwelling bladder catheter (Ducel, Fabry, Nicolle). Although common, these infections have a rather low morbidity rate in comparison. All other infections can be lumped into an “Other” category, including skin and soft tissue infections, gastroenteritis, and sinusitis. All of these infections can have exogenous causes (e.g. from the air, medical equipment, surgeons and other staff) or be acquired endogenously from the bacteria on the skin or in the operative site (Ducel, Fabry, Nicolle).
A majority of infections can be attributed to a hospital's environment. From contaminated equipment to employee hygiene upon arrival, a patient is exposed to hundreds of easily preventable infections. Several surveys of hospital directors report 91% consider overcrowding to be a major problem within their representative hospitals (Olshaker, S., Rathlev). An issue that, according to Dr. Archie Clements from the School of Population Health, leads to an increased rate of infections such as MRSA, which can then lead to extended inpatient stays, overcrowding, and more MRSA infections. Overcrowding causes these infections through its impact on hand hygiene, the number of contacts between healthcare workers and different patients, overburdening of screening and isolation programs and by causing staff burnout (Clements). Even in the case of overcrowding, however, hand washing remains a common root cause. Often a lesson learned before kindergarten, poor hand hygiene is responsible for 40% of infections transmitted in hospitals. Several studies have shown that doctors wash their hands less frequently than nurses, with the backs of hands, tips of fingers, web spaces and thumb being commonly missed areas (Inweregbu, Dave, Pittard). These areas can transfer infectious agents to many surfaces, including wounds and medical devices that will be entering the patient's body during exams or surgeries.
Beyond a patient’s direct surroundings, a patient can also receive an infection through the equipment used to save their life. A 2002 survey highlighted the fact that two-thirds of bacteremia cases were associated with intravascular devices, with central intravenous catheters being the most common source of hospital-acquired bacteremia (Inweregbu, Dave, Pittard). Contaminated ventilators in intensive care units are responsible for 3% of infections each day in the form of pneumonia (Ducel, Fabry, Nicolle). These causes are easily preventable sources of the deaths of 4.5 out of every 100 admissions.
Nosocomial infections is often a common cause of death for patients, even those who came in with simple ailments. Studies show that of the 1.7 million hospital patients that become infected each year, 100,000 people succumb to their infections (IHI). These statistics put nosocomial infection in the top ten causes of death in the United States, right up there with heart disease and strokes. Even if the patients survive, the cost in the United States for ventilator-associated pneumonia sits at $4,888 per person, on top of whatever the patient entered the hospital for in the first place (Hôpitaux Universitaires De Genève). The increased length of stay is the greatest contributor to cost. One study showed that the overall increase in the duration of hospitalization for patients with surgical wound infections was 8.2 days, ranging from 3 days for gynecology to 9.9 for general surgery and 19.8 for orthopedic surgery (Ducel, Fabry, Nicolle). Prolonged stay also increases direct costs to hospitals by taking up beds that could have been used by patients that they must now turn away. The hospital loses even more money through the increased use of drugs, need for isolation, and use of additional laboratory and other diagnostic studies. The estimated costs to the U.S. health care budget are $5 billion to $10 billion annually. Approximately one third or more of hospital-acquired infections are preventable (Peleg, Hooper).

Proposed Solution (Thesis)
In order to reduce the rate of nosocomial or hospital-acquired infections, hospital administrators must improve employee compliance with current infection control procedures.

Administrators will do so through the regular review of procedures, surveillance of compliance and accountability. All hospital staff will need to attend yearly training on procedures. Employees will be required to report violations, and administrators will receive a report at the end of each week with documentation of any possible nosocomial infections. Not only will this system keep all employees knowledgeable on procedures and allow hospitals to sense its weak points with precision, but accountability will also keep the acceptable number of infections at zero, and maintain infection control at the forefront of everyone’s

minds.

Support
If hospitals wish to solve their issues of nosocomial infections, the first step is education. In 2014, the National Nurses Union conducted a survey of 2,200 nurses. Of these 85% reported that their hospitals had not provided education on the latest viruses or infection control (Canon). This lack of instruction played a major role in the outbreaks of the West African Ebola virus on American soil. In order to prevent similar cases hospitals should implement annual recertification for their employees. This policy should not only extend to doctors and nurses, but to all employees within the hospitals. Each employee should receive a review on old procedures and education on new practices. In five intensive care units in Barnes-Jewish Hospital, an urban teaching hospital, a similar education program was instituted focusing on the prevention of ventilator-associated pneumonia. The program consisted of a ten-page self-study module on risk factors and practice modifications involved in ventilator-associated pneumonia, in-services at staff meetings, and formal didactic lectures. Each participant was required to take a pre-intervention test before the study module, and an identical post-intervention test following completion of the study module. In the twelve months before the program, 191 episodes of ventilator-associated pneumonia occurred. Following implementation of the program, the rate of ventilator-associated pneumonia decreased by 57.6% to 81 episodes. The estimated cost savings for the 12 months following the intervention were up to $4.05 million (Zack, E., Garrison, Trovillion). Education is the best way to keep lifesaving infection procedures at the forefront of everyone's mind, however, this does nothing if hospitals are unable to spot issues and improve compliance.
The next step to a hospital free of nosocomial infection is meticulous surveillance. The underlying problem with preventable infections lies in non-compliance with procedures and inadequate procedures. Hospitals should not only encourage, but also require, the report of failures to follow procedures. Any reports of infection must be reported to those in charge, and made known to all staff. The infection should then be heavily investigated to find the cause of the issue. Mercy Hospital in Coon Rapids, Minnesota, was able to reduce their rate of ventilator-associated pneumonia by implementing suggestions from staff. Staff suggestions created the Ventilator Bundle procedures, which includes elevating the head of the patient’s bed by 30 to 45 degrees to avoid pooling of secretions in the patient’s lungs, which may increase the potential for infection. Mercy Hospital followed up these changes in procedure with the clinical nurse specialist and two nurse champions, monitoring compliance for a few months until the change solidified (McCannon). This use of surveillance, and continuous problem solution method, should be used in response to every nosocomial infection.
To promote the sharing of these issues and possible solutions, hospital administrators should set up an Infection Control Committee in every hospital. This committee will provide a forum for multidisciplinary input, information sharing and cooperation. This committee should include representation from all relevant positions: management, physicians, other health care workers, clinical microbiology and pathology, pharmacy, central supply, maintenance, housekeeping, and training services. The committee would review each case of infection, analyze the contributing factors and propose solutions. The ultimate goal is to create an environment completely dedicated to the eradication of nosocomial infections. This committee would serve as a public embodiment of cooperation toward this goal. Zero tolerance for infection through this committee, and all other changes, must become part of the culture of every hospital.

Limitations/Obstacles
Even with education and surveillance nosocomial infections still present further issues, such as how to track these infections. If hospitals are to determine issues within their current procedures and the practice of those procedures, they must first be able to identify the infection. Unfortunately, shrinking post-operative hospital stays are stopping identification of these infections in their path. The average post-operative stay, now approximately 5 days, is usually shorter than the 5- to 7-day incubation period for S. aureus surgical wound infections (Weinstein). Hospitals may never know the true extent of their issues, or even that they exist, severely limiting their ability to respond to the problems.
Another issue emerges in a hospital's ability to respond to the multiple factors of each case. In the fast-paced environment of a hospital intensive care unit, documenting each possible cause becomes a daunting task. An infection can be contracted from patients with infections or carriers of pathogenic microorganisms admitted to hospital. Patients who become infected in the hospital are a further source of infection. Crowded conditions, frequent transfers of patients between units, and high concentrations of patients highly susceptible to infection in one area: newborn infants, burn patients, intensive care--all contribute to the development of nosocomial infections. Hospitals, overwhelmed by patients, and stuck in a culture of compliance, will have to overcome many hurdles in the path to zero infections
In order to produce real change in procedure and see an improvement in nosocomial infection rates, the first thing to go must be the compliant culture, which will be a major hurdle for any hospital. For years, hospitals have forsaken patients in exchange for averages. Hospitals measure their performance against national averages, such as three infections per 1,000 patient days (McCannon). If infections are maintained under the national average, no changes are made, and administrators are satisfied. The only way for the re-education and surveillance to work is if the only acceptable number of infections is zero. Employees must be completely dedicated to the prevention of every infection. If not, employees will continue to forget to wash their hands and make mistakes in protocols. Observing health care providers performing hand-hygiene procedures 17.8% of the time must be not only appalling, but completely unacceptable (Dou, Han,Zhang). Administrators must create a culture in which every employee, from administrator, to doctor, to janitor, must be dedicated to the eradication of nosocomial infections.

Conclusion
When a patient walks into a hospital, they’re seeking help for a condition or injury.

They want to be healed, not to contract a separate infection. Unfortunately, with rising nosocomial infection rates, 1.7 people are going into a hospital and staying there because of another ailment. These infections are costing the healthcare system billions of dollars for the increased use of drugs, need for isolation, and use of additional laboratory and other diagnostic studies. The infections are also costing lives. As the seventh leading cause of death in the United States, nosocomial infection lead to the deaths of 100,000 people per year. These deaths can be avoided by an improved adherence to current infection protocols and rigorous identification of weaknesses. Hospital administrators will require all hospital personnel to attend annual procedure recertification, and institute an infection control committee to investigate every infection. For years, hospitals have evaluated their performance by comparing themselves to the national average. It did not matter as long as they were below the national average, but as the infection rates climb, the only acceptable benchmark can be

zero.