A

PROJECT REPORT

ON

“A STUDY ON HOSPITAL ACQUIRED INFECTION AND

PREVENTION IN CCU AT APPLLO HOSPITALS”
SUBMITTED

To

CENTRE FOR ONLINE LEARNING

Dr. D.Y .PATIL VIDYAPEETH, PUNE

IN PARTIAL FULFILMENT OF DEGREEOF

MASTER OF BUSINESS ADMISTRATION

BY

STUDENT NAME: SRIDEVI

PRN:2105023660

2021-2023

i
 Dr. D.Y. Patil Vidyapeeth’s
CENTRE FOR ONLINE LEARNING,
Sant TukaramNagar,Pune.

CERTIFICATE

This is to certify that Mrs. SRIDEVI, PRN – 2105023660 has completed his/her internship at
APPOLLO HOSPITALS starting from 03-04-2023 to 10-06-2023. Her project work was a
part of the MBA (ONLINE LEARNING), The project is on “A STUDY ON HOSPITAL
ACQUIRED INFECTION AND PREVENTION IN CCU AT APPLLO HOSPITALS”
Which includes research as well as industry practices. She was very sincere and committed in
all tasks.

Course Coordinator Director

_________________ ___________________

Date -

ii
iii
 DECLARATION

This is to declare that I have carried out this project work myself in part fulfillment of
the M.B.A Program of Centre for Online Learning of Dr.D.Y.Patil Vidyapeeth’s, Pune –
411018. The work is original, has not been copied from anywhere else, and has not been
submitted to any other University / Institute for an award of any degree / diploma.

Date: - Signature: -

Place: Name:

iv
 ACKNOWLEDGEMENT

I express my sincere gratitude to Ms. Mamta Chavan(Mentor) and Mrs. NIRMALA KURIS

my project guide and lecturer in the department of management of Dr. D.Y .PATIL

VIDYAPEETH, PUNE for her valuable suggestions and guidance for my project work.

I feel privileged in extending my earnest obligation to our college Director DR. SAFIA
FAROOQUI for providing us this opportunity.

I am also grateful to the respondents who have given their valuable time to respond to the
questionnaire.

I express my sincere thanks to my parents, friends who have been a strong source of energy
and guidance.

(SRIDEVI)
H.T.NO : 2105023660

v
 TABLE OF CONTENT

Sr. Item Page No

No.
1 Executive Summary 1

2 Chapter 1: Introduction (Company Profile & 2-7

General Introduction of Topic)

& Objective, Scope and Purpose of Study

3 Chapter 2: Literature Review 8-65

4 Chapter 3: Research methodology 66-69

5 Chapter 4: Data Analysis 70-77

6 Chapter 5: Findings, suggestions, 78-81

recommendation and Conclusion

7 Bibliography ( Books, Journals, research 82-86

work)

8 Annexure 87

vi
 ABSTRACT
A hospital-acquired infection (HAI), also referred to as a nosocomial infection, is an infection
acquired in a hospital or other health care setting. Infections acquired in hospitals are
significant complications in all hospital units, especially the intensive care unit. Hospital
acquired infections are a societal burden. This increased morbidity, mortality, treatment costs,
and hospitalization duration. The nosocomial infection typically infects patients, their family
members, and healthcare workers.
The primary objectives of this study were to evaluate the prevalence of hospital-acquired
infections (HAI), length of stay, and antibiotic use in the Intensive Care Unit (ICU), as well
as the cleanliness practices of physicians and personnel in the ICU.
A two-month observational investigation was conducted in the CCU department of the
College of Medicine and the JNM hospital. The data was collected by visiting the CCU daily
at 10 a.m. to record the category of patients, signs, symptoms, demographics, vital signs, etc.
of nosocomial infection in accordance with the guidelines of the Centers for Disease Control
and Prevention (CDC). The absence or presence of nosocomial infection was determined
through the use of admitted patients' medical records and communication with clinical staff.
Statistical method employed for additional evaluation analysis.
During the research period, 84 patients who were admitted to the CCU of College of
Medicine and JNM Hospital for more than 48 hours were included. 28 (33.33%) of 84
admitted patients were verified and documented as having a nosocomial infection. The rates
of urinary tract infection, respiratory tract infection, surgical site infection, intravascular
infection, and other infections in 28 nosocomially infected patients were 53.57 percent, 32.14
percent, 21.42 percent, 28.57 percent, and 17.85 percent, respectively.

1
 CHAPTER-I
INTRODUCTION

2
 I. INTRODUCTION
A hospital-acquired infection (HAI), also referred to as a nosocomial infection, is an
infection acquired in a hospital or other tertiary health care facility. Sometimes referred to
as a healthcare-associated infection. Infections of this type can be contracted in hospitals,
nursing homes, rehabilitation facilities, clinics, and other clinical settings. In the clinical
context, the Infection is transmitted to susceptible patients through a variety of modes of
transmission. In addition to contaminated medical equipment, bed linens, air droplets, etc.,
the health care personnel can transmit infection to susceptible patients. In some cases, the
source of the infection cannot be determined. The infection may have originated from the
outside environment, another infected patient, or staff members who may be infected. In
some instances, the microorganism originates from the patient's own skin microbiot,
becoming opportunistic following surgery or other procedures that compromise the skin's
protective barrier.

Background
Although the quality of health services has been improved and infection prevention and
control methods have been developed, the occurrence of nosocomial infections remains a
health threat to patients and hospital staff. Due to the biological characteristics of
nosocomial infection pathogens, such as antibiotic resistance and high pathogenicity, as
well as the sensitivity and frailty of hospitalized patients, there is a strong relationship
between nosocomial infection and mortality.

Nosocomial infections affect many patients around the world. Roughly, 15% of
hospitalized patients suffer from these infections. The economic losses from these
infections are increasing. The incidence rate in developed countries is about 3.5 to 12%.
The prevalence of these infections in underdeveloped countries is about three times higher
than in developed countries.. In these countries, this rate varies between 5.7–19.1%]. In
Iran, most of these infections occur in intensive care units and surgical wards. Giving the
role and duties of clinical staff in hospitals, they can be a factor in the transmission of
nosocomial infections. Adherence to infection control instructions such as the use of masks
and cleaning and disinfection of hands and equipment after contact with patients and their
contaminated equipment is the most important duties of these employees. Therefore,
adherence to these behaviors can reduce nosocomial infections.

3
 To prevent and control nosocomial infections, it is essential to determine the predictors of
preventive behaviors of nosocomial infection. For this end, effective models are needed to
improve patient safety and reduce nosocomial infections. Social cognitive theory is a
comprehensive theory. According to this theory, behavior is formed from the interaction of
environmental, personal and behavioral factors. Self-regulation, self-efficacy, outcome
expectation, and environment are important constructs of social cognitive theory. These
constructs can be used as a guide for developing procedures and implementing of
interventions to change healthy behaviors. Bandura emphasized that self-regulation
strategies (i.e., ability to self-monitor and evaluate their behavior) must be used to set goals
and plan to adopt and maintain a behavior [8]. Self-monitoring is a guide to evaluating
one’s progress toward goals, which leads one to a behavior [10]. The results of the study
indicated that self-regulation is one of the determinants of behavior related to standard
precautions such as hand hygiene.

A study showed that nurses in the intensive care unit need to strengthen self-efficacy as one
of the internal factors in order to carry out infection control-related behaviors. Another
study also showed that self-efficacy is related to nursing care.

In previous studies, the effect of social cognitive factors on hand hygiene as one of the
measures in the control and prevention of nosocomial infections has been investigated, but
the effect of social cognitive factors on compliance with standard precautions for
nosocomial infection control is not well understood. In a study that was conducted to
identify social cognitive factors affecting on hand hygiene in hospital nurses, subjective
norms, attitudes, perceived behavioral control, risk perception and intention were identified
as important predictors of hand hygiene [14]. Structural equation modeling helps
researchers determine how the theory works to influence the outcome because it
approaches the model through predictor variables, the mediation, and the consequence of
the variables’ relationships with each other. It is used for testing several theoretical models,
which define the structure of constructs and their relationship with each other.

This study aimed to provide Structural equation model to predict social cognitive theory on
behaviors related to prevent and control of nosocomial infections in nursing staff.

4
Figure 1 Nosocomial infection prevention and control framework based on clinical best
practices. CDAD, Clostridium difficile- associated diarrhoea; CRGNB, carbapenem-
resistant Gram-negative bacilli; MRSA, methicillin-resistant Staphylococcus aureus;
NIPC, nosocomial infection prevention and control; VRE, vancomycin-resistant
enterococci.

5
6
 OBJECTIVES
 Assess the extent of various hospital-acquired infections (HAI) and the length of CCU stays.
 Assess the hygiene practices of CCU physicians, medical technologists, nurses, and non-
medical personnel.

Need for the study

To study the awareness of hospital acquired infections amongst undergraduate medical
students and to determine the underlying common causative factors.

7
CHAPTER-II
REVIEW OF
LITERATURE

8
REVIEW OF LITERATURE
Robert Weinstein et al.8 in their comparative study on nosocomial infections at present and in
the past showed that there had been a reduction in number of cases of nosocomial infections;
however the numbers of death were still high. According to them poor hygiene standards in
most health centers have contributed to this. Cases of medical practitioners overlooking basic
hygienic measures such as a proper hand washing when attending to patients was one of the
common causes. They observed some medical services like injections were not administered
in a proper manner. This is due to unqualified medical expertise especially in small health
care centers which lead to infections.
Tony rizzo et al. in their research observed respiratory procedures, intravenous (IV)
procedures, surgery and wound and urinary bladder catheterization as the common types of
infections acquired in hospital. They said that most hospital-acquired UTIs happen after
urinary catheterization. A catheter picks up bacteria that may be in or around the urethra and
take them up into the bladder hence infecting it.
Jessica Lietz et al. in their research on nosocomial infections with emphasis on the causes and
preventive measures for the infections observed that, there were higher rates of infections in
public hospitals as compared to private health centers. They showed lack of adequate public
education on the infections was a key factor in the spread of infections. For instance one may
visit a patient suffering from an air borne disease and contact the disease without knowing.
Similarly patients may share personal items such as towels, not knowing that they are
subjecting themselves to harmful infections. They thought enlightening the public in general
on the dangers of these infections and the basic control measures like maintaining a high
personal hygiene can go a greater mile in trying to control these infections.
Sheetal Sharma In their research on health system infection control measure in developing
countries ,highlighted three overarching lessons related to infection control and maternal
mortality Dreduction. despite limited evidence on effective infection control measures during
labour and delivery and from low resource settings, it appears that education, surveillance,
organisational change and quality improvement interventions should be introduced,
confirming the need for a health systems approach to reduce maternal mortality, especially in
relation to sepsis. There is the need to improve our understanding of organisational and
behavioural change to effectively implement infection control measures. Finally, globalized,
targeted health policies or initiatives have the potential to bring attention to, and catalyse
action for what is currently a neglected, but important cause of maternal death worldwide.

9
Savanthe AM et al observed that knowledge of the medical students regarding infection
source is adequate but infection prevention practices was relatively less particularly needle
stick injury prevention, hand hygiene techniques, blood borne infection control. Hospitals
should reinforce the knowledge of universal precaution continually and recommended
performing infection control education programs at the college level before starting the
clinical practice years along with seminars and feedback, highlighting importance of IPC
guidelines to increase safety of our graduates and patients. Education should be enhanced by
peers, seniors, and HCWs by acting as role models of infection control.

Nosocomial infection or hospital-acquired infection (HAI) is a localized or systemic

condition caused by the presence of infectious agents. No nosocomial infections are present
or incubating at the time of a patient's admission to the Intensive Care Unit. They are caused
by pathogens that spread readily within the body. Numerous CCU patients have
compromised immune systems and are therefore less able to fend off infections. These
infections occur in both developing and developed nations.

countries. They are a significant burden for patients and the public health of the community.
They are a leading cause of mortality and morbidity among hospitalized patients, which is a
matter of grave concern today(2).

Robert Weinstein et al.8 in their comparative study on nosocomial infections at present and in
the past, showed that there had been a reduction in number of cases of nosocomial infections,
however the numbers of death were still high. According to them poor hygiene standards in
most health centers have contributed to this. Cases of medical practitioners overlooking basic
hygienic measures such as a proper hand washing when attending to patients was one of the
common cause. They observed some medical services like injections were not administered
in a proper manner. This is due to unqualified medical expertise especially in small health
care centers which lead to infections.
Tony rizzo et al. in their research observed respiratory procedures, intravenous (IV)
procedures, surgery and wound and urinary bladder catheterization as the common types of
infections acquired in hospital. They said that most hospital-acquired UTIs happen after

10
urinary catheterization. A catheter picks up bacteria that may be in or around the urethra and
take them up into the bladder hence infecting it.
Jessica Lietz et al. in their research on nosocomial infections with emphasis on the causes and
preventive measures for the infections observed that, there were higher rates of infections in
public hospitals as compared to private health centers. They showed lack of adequate public
education on the infections was a key factor in the spread of infections. For instance one may
visit a patient suffering from an air borne disease and contact the disease without knowing.
Similarly patients may share personal items such as towels, not knowing that they are
subjecting themselves to harmful infections. They thought enlightening the public in general
on the dangers of these infections and the basic control measures like maintaining a high
personal hygiene can go a greater mile in trying to control these infections.
Sheetal Sharma et al.9 In their research on health system infection control measure in
developing countries ,highlighted three overarching lessons related to infection control and
maternal mortality Dreduction. despite limited evidence on effective infection control
measures during labour and delivery and from low resource settings, it appears that
education, surveillance, organisational change and quality improvement interventions should
be introduced, confirming the need for a health systems approach to reduce maternal
mortality, especially in relation to sepsis. There is the need to improve our understanding of
organisational and behavioural change to effectively implement infection control measures.
Finally, globalized, targeted health policies or initiatives have the potential to bring attention
to, and catalyse action for what is currently a neglected, but important cause of maternal
death worldwide.
Savanthe AM et al 10 observed that knowledge of the medical students regarding infection
source is adequate but infection prevention practices was relatively less particularly needle
stick injury prevention, hand hygiene techniques, blood borne infection control. Hospitals
should reinforce the knowledge of universal precaution continually and recommended
performing infection control education programs at the college level before starting the
clinical practice years along with seminars and feedback, highlighting importance of IPC
guidelines to increase safety of our graduates and patients. Education should be enhanced by
peers, seniors, and HCWs by acting as role models of infection control.

The origin of hospital-acquired infections;

Infectious agents that cause healthcare-associated infections (HCAI) may originate either

11
endogenously or exogenously.
• Endogenous source:
Infection is acquired endogenously from the body's flora. Bacteria are present on the
epidermis as well as in the nose, mouth, throat, digestive tract, and female genital tract.
Whenever there is a decrease in tissue resistance, these organisms invade. In susceptible
individuals, it is difficult to prevent and control such opportunistic infections. A protracted
hospital stay and the administration of antibiotics modify the normal flora, both in terms of
the types of organisms and their susceptibility to antibiotics. Hospitalized individuals have a
higher incidence of faecal carriage of Pseudomonas aeruginosa than the general population,
and intestinal carriage of resistant strains of Gram-negative bacteria frequently precedes self-
infection and cross infection, according to studies.
• Exogenous source:
Exogenous origins of infection can be either living or nonliving organisms. During sneezing,
talking, and other body movements, both patients and hospital personnel release a large
number of bacteria into the environment from their skin and oral and nasal secretions. Studies
on staphylococcal carriage in hospitals have revealed that certain individuals shed significant
numbers of organisms from their body surface, particularly the perineum, and are referred to
as 'dispersers' These individuals may also contaminate their hands, clothing, and other
inanimate objects. Environmental contamination is caused by human activity. Food, fluids,
disinfectants, instruments, equipment, and wound dressings are all infectious agents due to
contamination with human organic waste, sputum, blood, and blood products (Table 3).
Rarely, free-living bacteria and saprophytic fungi derived from the environment are capable
of infecting susceptible individuals.
Major prevalent infection:

a urinary tract infection is characterized by:

Urinary tract infection (UTI) is a significant health risk. Due to numerous physiologic
changes of the urinary tract caused by the activity of microorganisms, this condition is given
its name. Additionally, urinary tract infections have been a significant cause of hospital-
acquired infections. According to a review article by Nicolle et al., 70 to 80 percent of
catheter-associated urinary tract infections are attributable to the overuse of indwelling
urethral catheters. Urinary tract infection (UTI) is the most prevalent infection in developing
countries. A recent survey reveals that 17.6% of patients in Europe and 23.6% of patients in

12
the United States have urinary catheter-related infections. According to a 2011 surveillance
report by the National Health Service (NHS), 45-79 percent of patients in the intensive care
unit are catheterized (4,5).
The increasing incidence of urinary tract infections (UTIs) in intensive care units (ICUs) is
influenced by the high rate of urinary catheterization, frequent contact with health care
personnel, and an increase in resistant pathogens.
Female genital anatomy, sexual activity, diabetes, obesity, lack of education, malnutrition,
and family history are risk factors.

Each year, approximately 150 million individuals in India developed urinary tract infections.
It has been observed that women are more susceptible to urinary tract infections than males.
The infection incidence was greater among female patients than male patients. Up to 10% of
women develop a urinary tract infection in a given year, with 50% developing at least one
infection in their lifetimes.

Operative site infections; -

Definition of surgical site infection (according to the Center for Disease Control)
1. The incision is superficial, influencing the skin and subcutaneous tissue. Localized (Celtic)
signs such as redness, pain, heat, or edema at the incision site, or pus drainage, may indicate
these infections.
2. Deep incisions that affect the muscle and fascia layers. Indicators of these infections
include the presence of pus or an abscess, fever with tenderness of the wound, or a separation
of the incision's margins exposing deeper tissues.
3. Infection of an organ or space, involving any part of the anatomy other than the incision
that is opened or manipulated during surgery, such as the joint or peritoneum. These
infections may be indicated by fluid drainage or the formation of an abscess detected by
histopathology, radiology, or during reoperation.
According to Atul Jain, SSIs are separated into incisional SSIs and organ-space SSIs. Only 33
to 67% of infected lesions are cultured; of these, 15 to 20% of SSI are caused by
Staphylococcus aureus, Enterococcus(15%), and the rest are caused by gram-negative
organisms and yeast(30).
Surgical site infection results in increased pain, suffering, delayed wound healing, increased
use of antibiotics and antibiotic resistance, increased duration of hospital stay, mortality,

13
morbidity, and increased healthcare costs. Depending on the type of surgery and the severity
of the infection, additional costs attributable to SSI have been reported to range between £814
and £6,626, with the majority of costs related to re-opening, additional investigations, nursing
care and interventions, and medication treatment. SSIs have also been linked to the
emergence of multidrug-resistant microorganisms. The incidence of SSIs in India has not
been studied systematically.
Implementing an effective surveillance approach can reduce the incidence of HAIs by as
much as 30 percent and SSIs by as much as 55 percent, according to numerous studies
conducted in high-income countries, including the United States (6,35).

Nosocomial pneumonia:
Nosocomial pneumonia (NP) is an infection of the lung parenchyma that was neither present
nor incubating at the time of hospital admission and develops after 48 hours.
According to data from the United States' National Nosocomial Infections Surveillance
system (NNIS), nosocomial pneumonia is the second most prevalent nosocomial infection in
intensive care units. In addition, pneumonia is associated with the highest mortality rate
among nosocomial infections and a substantial increase in healthcare costs. The ubiquitous
use of tracheal intubation and mechanical ventilation to support critically ill patients increases
the risk of developing NP in patients who are already at high risk. Despite advancements in
diagnosis and treatment, our knowledge of the NP is still insufficient. The incidence of NP in
the ICU ranges from 9 to 24%, depending on the intensity of intensive care and the diagnostic
procedures employed (7).

In various hospitals in India, the incidence of postoperative infections ranges from 10 to 25%
(8).
The mortality rates of patients with NP are higher than those of patients without NP, but it is
uncertain whether this reflects a cause-and-effect relationship. Patients who develop
nosocomial infections are likely already members of a high-risk group of critically ill patients
with greater mortality rates than the general population. It is difficult to determine the precise
role of nosocomial infections in worsening the prognosis of intensive care unit (ICU) patients
because these patients are so critically ill that they require ICU care and may die without it.
Consequently, although rates of NP and mortality are high, it is challenging to assess the
contribution of several other risk factors that confound this relationship (37).

14
Bloodstream catheter-related nosocomial infection:
Catheter-related bloodstream infection (CRBSI) is the prevalence of bacteraemia originating
from an intravenous catheter at the time of the patient's admission to the CCU. It is one of the
most common, deadly, and expensive complications associated with central venous
catheterization. In critically ill patients, intravascular catheters are inserted to administer
fluids, blood products, medications, nutritional solutions, and for hemodynamic monitoring.
Central venous catheters (CVCs) pose a greater risk of device-related infections than any
other type of medical device and are among the leading causes of morbidity and mortality
(39).
In hospitals, the central vascular catheter (CVC) was introduced in the 1940s and has since
become an integral part of modern medicine. Intravenous catheters were the most common
devices for administering fluids directly into the circulation. Although the incidence of local
or BSIs associated with these devices is typically low, frequent use of these catheters results
in a significant number of deaths annually due to severe infectious complications (9,39).
In the CCU, central venous catheterization is the primary risk factor for bloodstream
infections.
The mortality rate attributable to its use ranges from 12 to 25 percent, extending
hospitalization by an additional 10 to 40 days and increasing treatment expenditures by
$33,000 to $35,000 per patient (10,11).
The incidence of CRBSI is a reliable indicator of product quality.
The incidence of catheter-associated bloodstream infections varies significantly by catheter
type, frequency of catheter manipulation, insertion site, and patient-specific factors, such as
underlying disease and severity of illness.
The vast majority of CRBSIs are associated with central venous catheters, and prospective
studies indicate that the relative risk of CRBSI is up to 64 times higher with CVCs than with
peripheral venous catheters. The most essential preventive systems for short-term CVCs (10
days), which are commonly colonized by cutaneous organisms along the external surface of
the catheter, are those that reduce extra-luminal contamination. in contrast to short-

Endoluminal dissemination from the hub appears to be the primary mechanism of infection in
long-term CVCs (>10 days). In addition to reducing extra-luminal catheter invasion,

15
technologies that reduce endoluminal colonization should provide additional protection
against CRBSI. It is reported that the incidence of dialysis-related CRBSI is between 2.5 and
F5.5 cases per 1,000 catheter days, or between 0.9 and 2.0 episodes per patient per year(39).
Among the risk factors for CVC-associated bloodstream infections are the presence of a
multi-luminal catheter, hemodialysis catheter, catheter-related thrombosis, anatomical site of
insertion, duration of catheterization, difficulty of catheter insertion, and length of hospital
stay prior to insertion(12).

Infections of the Skin and Soft Tissues (SSTI)

Skin and soft tissue infections (SSTIs), also known as severe microbial invasion of skin and
skin structure, are a heterogeneous group of infections with a range of clinical manifestations
and degrees of severity. Purulent infections (such as furuncles, carbuncles, and abscesses)
and non-purulent infections (such as erysipelas, cellulitis, and necrotizing fasciitis) are the
two categories.

Stevens DL, Bisno A L, Chambers HF, et al. classified as mild, moderate, and severe. Mild
skin and soft tissue infections exhibit only local symptoms (inflammatory symptoms),
whereas moderate to severe infections are accompanied by systemic signs of infection, such
as a temperature greater than 38oC, a heart rate greater than 90 beats/minute, a respiratory
rate greater than 24 breaths/minute, or a white blood cell count greater than 12 x 10cel l s/m
m3. And Patients with immunocompromising conditions, inflammatory conditions (redness
of skin, pain or tenderness, swelling,blister).a red streak (swollen lymph node, fever or chills,
fatigue, irritability, loss of appetite, nausea and vomiting)clinical signs of deeper infection, or
infection that does not improve with incision and drainage (I&D) plus oral antibiotics are also
considered to be severe cases. (41). Antibiotics are necessary for purulent and nonpurulent
infection control.
Soft-tissue infections are frequent, typically mild to moderate in severity, and treatable with a
variety of agents. The majority of superficial infections, including impetigo, erysipelas,
cellulites, and subcutaneous bursitis, are simple to treat. In contrast, diffuse necrotizing
infections may disguise themselves under numerous guises, delaying diagnosis and treatment.
Such necrotizing infections are characterized by edema out of proportion to erythema,
subcutaneous gas, and skin vesicles(40).
In patients with diabetes mellitus, diabetic foot ulcers (DFU) and concomitant infections are

16
one of the most common complications. Chronic foot ulcers in diabetics can be limb- or life-
threatening. Chronic DFU is one of the most common reasons diabetics are hospitalized, and
nearly half of all non-traumatic amputations are performed on diabetic patients.

Sonja Marie demonstrates that among hospital-acquired SSTI, burn lesions are particularly
challenging to treat and control. 50%–75% of patients present with abscesses, while 25%–
50% present with cellulitis (14)

The following are the causes of nosocomial infections:

There are three documented main causes of nosocomial infection. First is the use of
antimicrobials; long-term and international use of antimicrobials results in the evolution of
resistant pathogen strains. Second, the hospital staff's and infection control committee's
leniency in maintaining strict conditions. In addition, the patient is susceptible to nosocomial
infections due to low immunity and unsanitary surroundings. In addition to these main
precipitating factors, additional precipitating factors may also contribute to the cause of
nosocomial infections.
Influencing factors of nosocomial infection development:

The microorganism:
The patient is exposed to a diversity of microorganisms during hospitalization. Other factors
influence the nature and frequency of nosocomial infections in addition to patient-to-patient
and provider-to-provider contact, which leads to the development of clinical disease. The
likelihood that an exposure will result in an infection depends in part on the characteristics of
the microorganisms, including antimicrobial resistance, intrinsic virulence, and the quantity
of infective material.
Numerous bacteria, viruses, fungi, and parasites are responsible for nosocomial infections.
Infections may be caused by the patient's own flora (endogenous infection), a microorganism
acquired from another person in the hospital (cross-infection), or some particles acquired
from an inanimate object or recently contaminated substances.
Prior to the introduction of basic hygienic practices and antibiotics into medical practice, the
majority of hospital infections were spread by pathogens of external origin (foodborne and
airborne diseases, gas gangrene, tetanus, etc.) or were caused by microorganisms not present
in the patients' normal flora (diphtheria, tuberculosis, etc.). Antibiotic treatment

17
advancements have reduced mortality from many bacterial infections

There are infectious diseases. Staphylococcus aureus, coagulase-negative staphylococci,

enterococci, and Enterobacteriaceae are the microorganisms responsible for the majority of
hospital-acquired infections today. In the general population, these microorganisms cause no
or milder disease than in hospital patients.

Patient sensitivity:
Age, immune status, underlying disease, nutritional status, and diagnostic and therapeutic
interventions are important patient factors that influence infection acquisition. The resistance
of infants and elderly patients to infections decreases over time.
Patients with chronic diseases such as malignant tumors, leukemia, diabetes, renal failure, or
acquired immunodeficiency syndrome (AIDS) are more susceptible to infection. Infections
caused by organisms that are ordinarily harmless and part of the human's normal bacterial
flora, but can become pathogenic when the body's immune defenses are compromised.
Immunosuppressive drugs or irradiation may reduce infection resistance. Injuries to the skin
or mucous membranes can circumvent the body's natural defenses. Malnutrition is a risk
factor as well. Biopsies, endoscopic examinations, catheterization, intubation, ventilation,
insertion of a central line during dialysis, vacuum, and surgical procedures all increase the
risk of infection. It is possible to introduce contaminated objects or substances directly into
tissues or normally pristine sites such as the urinary tract and lower respiratory tract(15).

Environmental factors:
Patients with infections or carriers of pathogenic microorganisms admitted to the hospital are
potential sources of infection for other hospitalized patients, their family members, and the
health care provider. Patients who become infected while hospitalized are an additional
common source of infection. Congested hospital conditions, frequent patient transfers
between departments, and the concentration of highly susceptible patients in one area
(newborn infants unit, burn unit, intensive care unit,operation,dialysis unit) all contribute to
the development of nosocomial infections. Objects, medical devices, and materials that
contact susceptible patient body sites may be contaminated with microbes. Moreover, new
infections associated with bacteria such as waterborne bacteria (atypical mycobacteria) and/or

18
 viruses and parasites continue to be identified.

Bacterial resistance:
Numerous patients receive antimicrobial medications. Antibiotics promote the emergence of
multidrug-resistant strains of bacteria through the selection and exchange of genetic
resistance elements of microorganisms; sensitive microorganisms in the normal human flora
are suppressed when resistant strains persist and may become endemic in hospitals. The
indiscriminate use of antimicrobial agents for therapy or prophylaxis (including topical) is the
most important factor in determining resistance. In some instances, antimicrobial agents are
losing efficacy due to resistance. As the use of an antimicrobial agent increases, drug-
resistant bacteria may develop and proliferate within the healthcare setting(15).

Prevention of nosocomial infection:

Prevention of nosocomial infection two types
1. standard precaution
2. transmission based precaution

Standard Precaution
Basic infection prevention and control strategies applied routinely for care of all patients in
hospital to minimize risk to both patients and healthcare workers.
Cardinal rules of Standard precautions:
I. Standard precautions are to be followed in all patient care situations.
II. Standard precautions are to be used for contact with blood, all body fluids, secretions
and excretions regardless of whether contaminated grossly with blood or not; non-intact
skin; and mucous membrane.

Procedure for standard precautions for infection control:

Hand Washing:
Hand washing is the most essential method of infection prevention. The microbial flora of the
epidermis prevents hospital-acquired microorganisms from colonizing the skin. There are
both resident and transient microorganisms in the skin's flora. Hand washing is required
routinely before and after contact with a patient, before and after performing invasive
procedures, before touching wounds, and after contact with potentially contaminated

19
 inanimate sources, such as patient urine bag handling, could prevent many nosocomial
infections. Microorganisms can be removed mechanically, by washing hands with soap or
liquid hand washing solution and rinsing; or chemically, by washing hands with antimicrobial
products that can inhibit the growth or kill the microorganisms.
Effective hand cleansing with antimicrobial agents (containing chlorhexidine, cetrimide, and
providone iodine solution) has been shown to reduce nosocomial infections in intensive care
units compared to washing with soap and water.
Mechanically removing transient microorganisms in contact with resident flora is
straightforward. Antimicrobial cleansers should be used in nurseries, neonatal units, intensive
care units (ICUs), and pediatric intensive care units (PICUs), as well as when dealing with
patients with immune deficiencies or who are at risk of developing infections caused by
resistant organisms. Lack of education of health care providers, poor hygienic practices,
perceived lack of importance, lack of time, dry skin, skin irritation or dermatitis, absence of a
suitable cleansing agent, and inadequate hand washing facilities contribute to poor hand
washing compliance (30).

Different Levels of Hand Hygiene

(A) There are three recommended levels of Hand Hygiene to ensure that the level of hand
hygiene conducted is appropriate for the task at hand. The efficacy of hand hygiene will
depend on the application of an adequate amount of a suitable hand hygiene agent with
proper technique for the appropriate amount of time, followed by a thorough drying of the
hands.
(B) Social Hand Hygiene- Routine Hand Washing
The purpose of social (routine) hand washing with detergent and warm running water is to
remove debris, organic material, dead skin, and the majority of transient organisms. On
hands that are visibly clean, an alcohol-based hand massage can be used to eliminate
transient organisms.
(C) Antiseptic Hand Hygiene
Antiseptic hand hygiene is achieved with an antiseptic hand washing agent i.e. providione
iodine solution, chorohexidine solution is generally carried out for aseptic procedures on the
ward and for areas of Isolation. Hygienic hand disinfection helps to remove and kill most
transient micro- organisms- indications of antiseptic hand hygiene
 During outbreaks of infection where contact with blood/body fluids or situations
where microbial contamination is likely to occurs in ―high‖ risk areas ( isolation, ICU

20
 etc),before/after performing an invasive procedure and before/after wound care, urethral or
IV catheters etc.
(D) Surgical Hand Hygiene
Surgical hand washing helps to remove and kill the transient micro-organisms and
substantial reduce and suppuration of the resident flora of the surgical team for the duration
of the operation, in case of surgical glove is punctured/torn. Ensure of all staffs fingernails
are kept short and clean. Wrist watch and jewellery must be removed before surgical hand
washing.

Use of Alcohol Based Handrub

Definition according according to
CDC
An alcohol-containing preparation designed for application to the hands for reducing the
infection. In India, such preparations usually contain 60%--95% ethanol or isopropanol.
Steps of hand hygiene using alcohol based hand rub (according to national infection control
guidelines)
Duration of the entire procedure: 20-30 seconds
Step 1 -Apply a palm full of the product in a cupped hand, covering
all surfaces. Step 2 -Rub hands palm to palm.
Step 3 -Right palm over left dorsum with interlaced fingers and
vice versa. Step 4 -Palm to palm with fingers interlaced.
Step 5 -Backs of fingers to opposing palms with fingers interlocked.
Step 6 -Rotational rubbing of left thumb clasped in right palm and vice versa.
Step 7 -Rotational rubbing, backwards and forwards with clasped fingers of right hand in
left palm and vice versa. Once dry, hands are safe.

Advantages of alcohol-based handrubs

It is easily accessible at point of care.
Alcohol based solution is a good antimicrobial activity against Gram-positive and Gram-
negative vegetative bacteria, Mycobacterium tuberculosis and a wide range of fungi.
However, the disadvantages of alcohol based hand rubs are no activity against the bacterial
spore.

21
 Use of gloves
The wearing of protective gloves is a sensible precaution in various clinical
situations in order to prevent cross contamination of nosocomial infection. It break down
the chain of infection more effectively than hand-washing or hand disinfection. A
prospective, controlled intervention study showed that a training session and the
availability of gloves directly at the bedside can significantly reduce the
incidence of Clostridium difficile–associated diarrhoea (CDAD). All ways, the hands
should be disinfected when protective gloves are used, because in contrast to surgical
gloves, ordinary protective gloves are often permeable to pathogens even before use. In the
case of vancomycin-resistant enterococci (VRE), a study showed that despite the use of
gloves the same pathogen could be found on the hands of staff involved in treatment in
30% of cases (18)
Use of Fluid Resistant Gown / Apron
 Wear a fluid resistant gown to prevent soiling of clothing and skin during the invasive
procedures that are likely to generate splashes of blood, body fluids, secretions or
excretions.
 The sterile gown is required only for aseptic procedures that prevent the nosocomial
infection
 Remove the soiled gown as soon as possible, that prevent the cross contamination.

Room sterilization :
According to protocol of department of CCU of college of medicine & JNM hospital
I. Cleaning :
Floor wash with available antiseptic (certimide and cholorohexidine solution, Phenyl) in
the morning and evening , if not once per shift.
II. Fumigation :
 fumigation can be done using silver nitrate and hydrogen peroxide or formal
dehydrate solution. The room must be closed for 4 hours after fumigation.

Isolation room:
Definition :-
Isolation is a process of separation of a person or a group of person infected or believed
to be infected with contagious disease to prevent spread of infection in hospital setting.
Types of Isolation :

22
• Source Isolation :AIIR ( Airborne Infection Isolation Room) or negative pressure room.
• Protective Isolation : Positive Pressure Room Source Isolation (Most frequent Type
;Negative Pressure Room)
– This type of isolation facility is used to prevent spread of infection from the patient
to other patient and hospital Staffs .
• Patients with communicable disease who can pass infections to others patients,
healthcare provider and patients relative via airborne droplets are isolated in this type of
room. eg.TB.SARS,H1N1 etc.
Protective Isolation: (positive Pressure Room)-These type of isolation facility are meant to
isolate profoundly immune -compromised patients, such as
patient undergoing organ transplant, or oncology patient receiving chemotherapy, HIV, etc.

Requirement of Isolation Facility

Influenced by the pattern of clinical work and type of specialist units
• 2.5% of total beds ,
• 10-20% of Total ICU beds in ICU (1 per 5 bed)
• Area required for Isolation Room – 22 Sq. m
Device Related Protocol :
Daily check list is to be maintained according to CCU department protocol
• Peripheral venous catheter:− Change after every 3 days. If patient comes with Peripheral
venous Catheter – in case coming from Emergency OPD – change immediately and if from
the ward – 1st. change after 24 hrs. allways avoid insertion in legs.
• Central venous catheter:− Not to be changed routinely. Fresh replacement is done in
case of strongly suspected / documented CV catheter related infection by C/s test or
mechanical problems like blockage / kinking. When indicated fresh insertion is done on the
opposite side. Always avoid insertion in femoral site
• IV Drip set: − Needs to be changed daily.
• Ryle's tube:− In case of malfunction or after every 5 – 7 days to avoid formation of
biofilm and thereby preventing pneumonia. Every day changed Ryle’s tube dressing

• Tracheostomy tube: − 1st change 48 hrs. of insertion and every after 24 hrs thereafter.
Every day dressing changed of tracheostomy tube.
• Foley's catheter :− Not to be changed routinely. Bladder wash is also abandoned except
in selected urosurgical conditions. In case of catheter block by sediment, controlled catheter

23
 wash may be cautiously tried avoiding bladder wash. These are to avoid vesico ureteral
reflux and UTI – sepsis. − Change is indicated in case of malfunctioning catheter or
infection strongly suspected / documented by culture. − Closed system with two bags -
Storage & collecting is preferred.
• Arterial Catheter and Pulmonary Arterial Catheter: − These catheters need not to be
changed routinely. Every day changed the dressing.

IV care practices:
• Clean injection ports/caps with alcohol based solution or providion iodine solution
before accessing the system.
• Cap all stopcocks when not in use.
• Use aseptic technique including a cap, mask, sterile gown, sterile gloves and a large
sterile sheet for the insertion of central venous catheters (including Peripherally Inserted
Central Catheter or PICCs) or guide-wire exchange.
• Do not routinely replace central venous catheters, haemodialysis catheters, or pulmonary
artery catheters.
• Do not remove central line or peripheral line on the basis of fever alone. Remove the
catheter if infection is evidenced • Do not routinely replace peripheral arterial catheters.

Respiratory care - Patient-Based Interventions:

• If there is no medical contraindication, elevate the head of the bed of a patients who are
at high risk for aspiration pneumonia, e.g., a person receiving mechanically assisted
ventilation and/or who has an enteral tube in place, at an angle of 30 degree.
• Periodically drain and discard any collection in the tubing of a mechanical ventilator,
taking precautions not to allow condensate to drain toward the patient. Decontaminate hands
with soap and water or chlorohexidine or providone iodine based antiseptic agent after
performing the procedure or after handling the fluid.
If available, use an endotracheal tube with a dorsal lumen above the endotracheal cuff to
allow drainage (by continuous suctioning) of tracheal secretions that accumulate in the
patient's subglottic area.
• Use sucralfate, H2-blockers, PPIs and/or antacids interchangeably for stress-bleeding
prophylaxis in a patient receiving mechanically assisted ventilation (H2-blockers alone
decrease gastric acidity and increase gastric colonization and increases the susceptibility to
respiratory infections).

24
 • Instruct preoperative patients, especially those at high risk of contracting pneumonia,
regarding taking deep breaths and ambulating as soon as medically indicated in the
postoperative period and high-risk patients include those who will have an abdominal,
thoracic, head or neck operation or who have substantial pulmonary dysfunction.
• Follow manufacturers' instructions for use and maintenance of central oxygen line
&humidifiers.
• Between patients, change the tubing, any nasal prongs or oxygen mask or nebulizer
mask used to deliver oxygen from a wall outlet.
• Small-volume medication nebulizers: "in-line" and hand-held nebulizers: Between
treatments on the same patient, disinfect; rinse with sterile or pasteurized water; and air-dry
small-volume in-line or hand-held medication nebulizers.
• Use only sterile water for nebulisation and dispense the fluid into the nebulizer aseptically.
• If multidoses medication vials are used, then handle, dispense, and store them according
to instructions using sterile techniques.
• Total Parenteral Nutrition to be infused through central line and not beyond 12 hours at a
time.

Suction & drainage bottles:

These are usually disposable, with a self-sealing inner container held in a outer
container. Non-disposable bottles:
• Must be changed every 24 hourly .
• The contents may be emptied .
• Must be rinsed with water and autoclaved.
• Do not leave fluids present in suction bottles

Antibiotic prophylaxis:
Appropriate use of antibiotics is essential. Up to 30 percent of pneumonias
associated with mechanical ventilation are inadequately treated. There is accumulating
evidence that early and appropriate antibiotic administration improves outcomes.
Mortality and morbidity rates. Appropriate antibiotic use requires a thorough
comprehension of their mode of action, antibiotic history, local bacterial resistance profile,
and local pathogen prevalence. Antibiotics should be administered at the correct dosage and
for the correct duration. The local antibiotic formulary and consulting microbiologists are
valuable assets.

25
 Antibiotic-resistant bacteria prolong hospital stays, increase mortality risk, and
necessitate the use of toxic and expensive antibiotics for treatment. Because laboratory
results are frequently not available until 48 hours after samples have been sent to the
laboratory for culture, it is frequently necessary to use antibiotics empirically. Acceptable
specimens include blood, urine, sputum, bronchoalveolar lavage, pus, and lesion samples.
Pathogens are only detected in one-third of blood cultures.(29)
When the documented benefits outweigh the risks, chemoprophylaxis is
administered. Among the indications are specific surgical procedures, individuals at risk of
infective endocarditis (patients with mechanical heart valves), and immunocompromised
patients with a higher risk of infection. There are contradictory findings regarding VAP and
antibiotic prophylaxis administration. There are few clinical indications that aerosolized
antibiotics might be able to prevent VAP. Concerns about the high cost, resistant bacteria,
and other potential risk factors of aerosolized antibiotics have prompted several evidence-
based groups to advise against the routine use of antibiotic prophylaxis.(24)

Needle stick injury (NSI) is a puncture wound, cut, or abrasion caused by medical
instruments designed for cutting or puncturing (intra venous or arterial cannula, lancets,
scalpels, etc.) during an invasive procedure that may be contaminated with blood or other
body fluids. As more than 70 percent of sharps-related injuries are caused by needles, the
term (NSI) is sometimes used in lieu of or in conjunction with sharp injuries (SI). A secure
injection does not injure the recipient, does not expose the provider to any avoidable risks,
and does not generate hazardous waste for the patient, the patient's family, the healthcare
provider, or the community. Consequently, the risk of infection of health care workers
(HCWs) from contaminated sharps and needle jabs should be viewed as part of a larger
group of risk factors known as "Unsafe injections."According to the National Health
Service (NHS), needlestick injuries (NSI) are the second most common cause of
occupational injuries.(22)
Inadequate waste collection, transportation, treatment, and disposal in India result in
serious environmental issues.
An estimated 83 percent of the roughly 3 billion injections administered annually in
India were for therapeutic purposes, whereas 63 percent were administered in a potentially
dangerous manner.
Self-care for diabetes is accorded a great deal of importance. Insulin self-
administration and/or blood glucose self-monitoring (SMBG) are required. Patients with

26
 diabetes use insulin injectors, needles, syringes, lancets, etc. at home as part of their self-
care regimen. These items are either pointed or made of plastic. Sharps instruments are
defined by the World Health Organization (WHO) as "items that can cause cuts or puncture
wounds, such as needles, hypodermic needles, scalpels and other blades, knives, infusion
sets, saws, broken glass, and nails."(42).

IV. Practical Guidance On Giving Medications

(According to guideline of NATIONAL CENTRE FOR DISEASE CONTROL, government
of India) Injection safety protocol
 Use a new device for each invasive procedure in ccu, including for the reconstitution of a
unit of medication or vaccine.
 Inspect the package of the syringe to ensure that the protective barrier has not been breached.
 Discard the syringe if the package has been punctured, torn or damaged by exposure to
moisture, or if the expiry date has been passed

Single vial use

Always use a single dose vial for each patient in CCU, to reduce the cross contamination
between patients
Multidose vials uses protocol
 Use multi doses vial only if there is no alternative route of option.
 Open only one vial of a particular medication at a time in each patient care area.
 If possible, keep one multi dose vial for each patient, and store it with the patient’s name on
the vial in a separate treatment or medication room.
 Don’t store multi dose vials in the open ward, where they could be inadvertently
contaminated with spray or spatter.
 Discard a multi doses vial: if sterility or content is compromised;
 if the expiry date or time has passed (even if the vial contains antimicrobial preservatives);

 if it has not been properly stored after opening; within 24 hours of opening, or after the
time recommended by the manufacturer, if the vial does not contain antimicrobial
preservatives;
 if found to be undated, improperly stored, inadvertently contaminated or perceived to be
contaminated, regardless of expiration date.
 Pop open ampoules whenever possible, use pop open ampoules rather than ampoules that

27
 require use of a metal file to open.

Practical guidance on preparing injections

Following step must be followed when preparing injections in CCU.
1) Before starting the injection session, and whenever there is contamination with blood or
body fluids, clean the preparation surfaces with 70% alcohol (isopropyl alcohol or ethanol)
and allow to dry.
2) Assemble all equipment needed for the injection: sterile single use needles and syringes;
reconstitution solution such as sterile water or specific diluents; alcohol swab or cotton
wool; sharps container.

Biomedical waste management:

Biomedical waste is defined as waste generated during the diagnosis, treatment, or
immunization of a patient, or in research activities pertaining thereto, or in the production or
testing of biological, including categories listed in schedule one of the biomedical waste rules
2000 issued by the Ministry of the Environment and Forests (19).
To prevent nosocomial or hospital acquired infections, it is crucial that hospital waste such as
body parts, organs, tissues, blood, and body fluids as well as solid linens, cotton bandages,
used disposables, and plaster from infected and contaminated areas be collected, separated,
stored, transported, treated, and disposed of in a safe manner.
The range of medical waste production per bed per day in India is between 0.5 and 2.0 kg.
The annual medical waste estimate in India was approximately 0.33 million tons. Food,
bandages, soiled linen, and other infectious debris account for 70 to 80 percent of hospital
waste, while plastics, disposable syringes, and glass account for 7 to 10 percent, 0.3 to 0.5
percent, and 3 to 5 percent, respectively. This waste is collected, transported, and disposed of
in conjunction with municipal solid wastes (43).
The types of biomedical waste is
 General waste includes kitchen waste, packing materials, paper, patient used food and plastic
material.
 Pathological waste includes human tissue organ, body parts, human fetus, blood and body
fluids(20).
 Infectious waste like pathogens in sufficient concentration that are culture media and
slocks of infectious agents from laboratory
 Sharps instrument includes needles, blades, scalpels etc..

28
 Pharmaceuticals waste includes drugs and chemicals that have been return from wards,
out dated and contaminated items
 Chemical wasted includes housekeeping, floor cleaning and infectious materials.
 Radioactive waste includes solid, liquid and gaseous wastes produce from radiology
department

TRANSMISSION BASED PRECAUTIONS

Formerly known as additional precautions: Effectively managing infectious agents where
standard precautions may not be adequate on their own. These specific interventions for
patients known or suspected to be infected or colonized with epidemiologically significant
pathogens that can be transmitted by airborne, droplet, or contact with dry skin or
contaminated surfaces should be applied to control infection by interrupting the mode of
transmission.

ISOLATION POLICIES AND PROCEDURES

Isolation procedures are means to prevent or interrupt transmission of pathogenic
microorganisms within the CCU. Selected patients may be require specific precautions to
control cross transmission of potential infecting organisms to other patients.

Recommended Isolation Precautions: Routes of Transmission

Microorganisms are transmitted by three main routes:
• Contact

• Air

• Droplet

In nosocomial infections, transmission by contact, droplet, and air plays a major role in
CCUs.
Nosocomial Infection by direct or indirect contact: Nosocomial infection occurs through
direct contact between the source of infection and the recipient or indirectly through
contaminated objects.

Air-borne infection: Infection usually occurs by the respiratory route, with the agent
present in aerosols (infectious particles less than 5 μm in diameter).
Droplet infection: Large droplets transmit the infectious agent (greater than 5 µm in
diameter).

29
 Contact Isolation Precautions
(According to HOSPITAL EPIDEMOLOGY AND INFECTION CONTROL: of UCSF
MEDICAL CENTER)
Contact, or touch, is the most common mode of transmission of infectious agents.
Contact transmission can occur by directly touching the patient, through contact with the
patient’s environment, or by using contaminated gloves or equipment, patient used linen.
Patients in CCU Contact Isolation Precautions include those with confirmed or suspected
Clostridium difficile infection (CDI) rotavirus, or other organisms deemed significant by
Infection Control. Contact Isolation Precautions requires:
1. Private Room
2. Dedicated, disposable equipment (e.g., stethoscope, blood pressure cuff, thermometer,
mask etc.). If shared equipment is used, it must be cleaned with hospital disinfectant and
sterilised after each use.
3. Children under 2 years who was in Droplet Precautions and also placed in Contact
Precautions.
4. Show in appropriate door signage (green)
5. Education for the all patient/representative: ―Contact Isolation Precautions Patient
Information Sheet‖

Healthcare workers caring isolated patients in CCU for Contact Isolation

Precautions must: 1.Allways Clean hands before putting on gloves.
2. Put on gloves and gown prior to entering the patient’s isolation room.
3. Remove and discard gloves and gown and clean hands before leaving the patient’s
room or, in semiprivate room or multi-bed bay situation, before leaving the patient’s
immediate vicinity.
4. For CCU patients in Contact Isolation Precautions for diarrhea (suspect or confirmed ),
use soap and water to clean hands upon exiting unless CDI is ruled out.
5. Patients on Contact Isolation Precautions are not allowed in communal spaces (play
room, school room), but may ambulate in hospital always wearing a clean and disposal
gown and after washing hands with soap and water.
6. Always place a clean patient gown and bed cover on the patient prior to transporting
patient off unit for test/procedure.
Patient Transport: Gown and gloves must be wear during the transportation of a patient on

30
 Contact Isolation Precautions. Personal protective equipment must be discards and hand
hygiene performed when the transfer is complete. Visitors must be choose to wear
indicated personal protective equipment.

Droplet Isolation Precautions require:

According to HOSPITAL EPIDEMOLOGY AND INFECTION CONTROL: of UCSF
MEDICAL CENTER
1. Private room, except when directed otherwise by Infection Control.
2. Patients to remain in their room except for essential purposes (surgery, tests, treatments,
therapy services). The patient may ambulate in the hallway, however not allowed in
communal spaces (playroom, school rooms, solarium, cafeteria, etc.).
3. When patients on droplet precautions are out of their room they must wear a regular
mask (without the eye shield), clean gown, and must complete hand hygiene (hand gel
and/or wash with soap and water) before leaving their room. If the patient is unable or
unwilling to wear a mask the patient must remain in their room.
4. Children under the age of 2 years who require Droplet Precautions also require Contact
Precaution
5. Appropriate door signage (yellow).
6. Education for the patient/representative: ―Droplet Isolation Precautions Patient
Information Sheet‖. Healthcare workers caring for patients in Droplet Isolation Precautions
will: 1. Hand hygiene with alcohol based hand rub or soap and water should be performed
prior to entering room. Put on a mask that covers the mouth and nose (regular surgical or
paper mask), and eye protection (safety goggles, fluid shield) upon entering the room of a
patient in precautions.
2. Wear eye protection and respiratory protection at least as effective as an N-95
respirator when performing high hazard procedures (bronchoscopy, sputum induction,
elective intubation and extubation, autopsies, open suctioning of airways. and when feasible
during emergent situations such as cardiopulmonary resuscitation, emergent intubation) for
patients with suspected or confirmed diseases requiring Droplet Isolation Precautions.
3. Remove and discard mask/respirator and clean hands before leaving the patient’s room
or, in semiprivate room or multi-bed bay situation, before leaving the patient’s immediate
vicinity. Goggles may be reused; they should be cleaned with a disinfectant wipe between
uses by different healthcare workers.

31
 4. Notify receiving department of patient isolation status when patient transportation
(e.g., off-unit testing/procedure) is required.
Visitors precautions policy
1. Visitors will be educated regarding the transmission of diseases requiring Droplet Isolation
Precautions:
a. Hand hygiene with alcohol based hand rub or soap and water should be performed
regularly and always upon leaving the patient’s room.
b. Risk of acquisition of diseases requiring Droplet Isolation Precautions is reduced
through the use of personal protective equipment (i.e. surgical mask with eye shield or
goggles). This equipment will be available for visitors upon request.
2. Visitors with upper respiratory symptoms are asked to refrain from visiting. Special
consideration may be given to close family members. Those family members will be
required to wear a surgical mask while visiting.
3. Nursing staff will instruct family/visitors to clean hands after contact with patient
secretions or contact with immediate patient environment.
4. Visitors may choose to wear the indicated PPE.
5. Patients on Droplet Precautions (and their paediatric siblings) are not allowed in
communal spaces (play room, school room, solarium, etc.)

Airborne Isolation Precautions Require:

According to GUIDELINES FOR ISOLATION PRECAUTIONS of MONTANA STATE
HOSPITAL POLICY AND PROCEDURE
1. Applies to patients known or suspected to be infected with a pathogen that can be
transmitted by the droplet route: these include, but are not limited to: a. Respiratory viruses
(influenza), pertussis, and Neisseria meningitides (group A streptococcus) for the first 24
hours.
2. Place the patient in a private room. When a private room is not available , place the
patient in a room with patient(s) who has present same infection and the same
microorganism . When a private room is not available maintain spatial separation of at least
3 feet between the infected patient and other patients and visitors.

Personal Protective equipment use For Airborne Isolated Patients

a. Wear a face mask when working within 3 feet of the patient. The face mask should be
donned upon entering the patient’s room.

32
 b. If substantial spraying of respiratory fluids with microorganism is anticipated, gloves
and gown as well as goggles (or face shield in place of goggles) must be wear.
c. Perform hand hygiene before and after toughing the patient and after contact with
respiratory secretions and contaminated objects/materials; note: use soap and water when
hands are visibly soiled.
d. Instruct patient to wear a facemask when exiting the patient room, avoid coming into
close contact with other patients, and practice respiratory hygiene and cough etiquette.
e. Clean and disinfect the patient room accordingly.

Patient Transport Policy:

Limit the movement and transport of the isolated patient from the room to essential
purposes only. Face mask required during the transportation or movement.
Visitor's Policy When Patient is in Isolation (According to NABH Standard)
The ward sisters doctors and security guard concerned have the responsibility of
informing the patient’s and their relatives of the measures to be taken and the importance of
restriction of visitors.
1. The patient and the relatives must be given health education about the cause, spread, and
prevention of the infection in detail. The need for isolation and restriction of visitors of
isolated patients should be discussed with them.
2. Hand washing after all contact with the patient has to be stressed.
3. Visitors need to wear a respiratory protective device. Be aware of restrictions on visitation
of relatives of patient due to outbreak or other hazardous conditions within the facility.
4. No more than two adult visitors should be allowed at a time during the hospital visiting
hours and the length of stay should be governed by the needs of the patient.
5. Children below 12 years of age should not be allowed into isolation areas.
6. Visitors’ footwear, bags, and other belongings should be left outside of the isolated room.
7. Visitors should not be allowed to sit down on the patient’s bed.
8. Visitors should wash their hands well with soap and water and hand rub apply before
entering and when leaving the room.

9. Any prophylactic medication or active immunization for attendants should be conducted

by the attending medical officer and sister.

Use specific strategies focused on prevention of specific nosocomial infection:-

33
 In addition to the standard and transmission-based precautions, there are several
strategies focused on prevention of specific hospital acquired infections in critically ill
patients. Of these, ventilator-associated pneumonia (VAP), catheter-related bloodstream
infection (CRBSI) and urinary tract infection (UTI) are the most important. Hospital
acquired infection.

Strategy for reduce ventilator-associated pneumonia (VAP):- According to guideline of

reference no (32, 7)
□ Thorough hands washing is the simplest and most effective means of limiting
spread of infection but is frequently inadequate or/ not performed at all.
□ Heat and moisture exchanges may decrease the incidence of NP. However, not all studies
confirm this.
□ Noninvasive ventilation has been associated with reduced rates of infection and should
be considered in appropriate patients.
□ Nursing patients in the supine position may increase the risks of pulmonary aspiration of
gastric contents. Several studies have confirmed reduced rates of NP in patients nursed in
semi recumbent rather than supine and this should be encouraged although it is not always
practically possible.
□ Avoiding excessive sedation – sedation should be titrated to minimal level required to
keep patient comfortable.
□ Several authors have suggested an increased incidence of pneumonia with antacids and
H 2 blockers. Routine use of antacid strategies should be avoided.
□ Selective digestive decontamination (SDD): Consists of non-absorbable tropical
antibiotics (Polymycin, tobramycin and amphotericin B) plus the use of systemic
antibiotics (cefotaxime). Many studies have shown that SDD reduces NP. However,
concern has been raised about risks of encouraging antimicrobial resistance and this has not
gained wide acceptance.
□ Kinetic beds and continuous subglottic suctioning of secretions that pool above
endotracheal different cuff both are expensive and not widely used.
□ Simple techniques such as had washing, placing the patient in semi recumbent position
and avoiding excess sedation must become a routine part of ICU care.

Strategy for reduce Catheter related blood stream infection

(According to operational guideline CCU and HDU WB health & family welfare)

34
1. Prefer the upper extremity for catheter insertion. Avoid femoral route for central venous
cannulation (CVC)
2. If the intravenous or arterial catheter is inserted in a lower extremity site, replace to an
upper extremity site as soon as possible.
3. Use maximal sterile barrier precautions (cap, mask, sterile gown and sterile gloves) and a
sterile full-body drape while inserting CVCs, peripherally inserted central catheters, or
guide wire exchange.
4. Clean skin with more than chlorhexidine preparation with alcohol (usually 0.5%
chlorhexidine with 70% w/v ethanol) before CVC, arterial catheter insertion, etc.,
5. Use ultrasound-guided insertion if technology and expertise medical persons are available.
6. Use either sterile gauze or sterile, transparent, semi permeable dressing to cover the
catheter site. Replace the catheter site dressing only when the dressing becomes damp,
loosened, blood content or visibly soiled.
7. Evaluate the catheter insertion site daily check if a transparent dressing is present and
palpate through the dressing for any tenderness.
8. Insertion date ,time should be put on all vascular access devices
9. Use chlorhexidine based solution wash daily for skin cleansing to reduce catheter related
blood stream infection.
10. Clean injection ports with an appropriate antiseptic solution (chlorhexidine,
povidone-iodine, an iodophor, or alcohol), accessing the port only with sterile devices. Cap
stopcocks when not in use
11. Assess the need for the intravascular catheter daily and remove when it is not required.
12. Peripheral lines should not be replaced more frequently than 72-96 h. Routine
replacement of CVCs is not required
13. Replace administration sets, including secondary sets and add-on devices, every day in
patients receiving blood, blood products, or fat emulsions
14. If other intravenous fluids are used, change not <96-h intervals and at least every 7 days
15. Needleless connectors should be changed frequently (every 72 h)
16. Replace disposable or reusable transducers at 96-h intervals.

Strategy for reduce urinary tract infection (UTI)

1.Personnel
a. Only medically trained persons (e.g., hospital personnel, family members, or
patients themselves) who know the correct technique of aseptic insertion and maintenance

35
 of the catheter should handle catheters
b. Health care provider and others trained person who take care of catheters should
be given periodic in- service training stressing the correct techniques and potential
complications of urinary catheterization.

2.Catheter Use
a. Urinary catheters should be inserted only when required appropriate medical cause.
b. Others useful methods f urinary drainage system such as condom catheter
drainage, supra pubic catheterization, and intermittent urethral catheterization can be useful
alternatives to indwelling urethral catheterization.
3. Hand washing

Hand washing should be done immediately before and after any touches of the catheter
site , catheter bag and apparatus.
4.Catheter Insertion
i. Catheters should be inserted using aseptic technique and sterile equipment.
ii. Gloves, drape, sponges, an appropriate antiseptic solution for periurethral cleaning, and a
single-use packet of lubricant jelly should be used for insertion.
iii. As small a catheter as possible, consistent with good drainage, should be used to minimize
urethral trauma
.
iv. Indwelling catheters should be properly secured after insertion to prevent movement and
urethral traction .

5.Closed Sterile Drainage

i. A sterile, continuously closed circuit drainage system should be maintained .
ii. The catheter and drainage system should not be disconnected unless the catheter must be
irrigated
iii. If breaks the aseptic technique, disconnection, or leakage occur, the collecting
system should be replaced using aseptic technique after disinfecting the catheter-tubing
junction.

6. Irrigation

36
 I. Irrigation should be avoided unless obstruction is anticipated (e.g., as might occur with
bleeding after prostatic or bladder surgery);closed continuous irrigation may be used to
prevent obstruction. To relieve obstruction of urinary drainage system due to blood clots,
mucus, or other causes, an intermittent method of bladder wash irrigation may be used.
Don’t collected urine sample of routine urine examination and culture sensitivity during the
continuous bladder wash irrigation.
II. Always urinary catheter-tubing junction must be disinfected( povidone iodine
solution)before disconnection.
III. A large-volume sterile syringe and sterile irrigant should be used and then discarded. The
person performing irrigation should use aseptic technique.
IV. If the catheter becomes obstructed and can be kept open only by frequent irrigation,
the catheter should be changed if it is likely that the catheter itself is contributing to the
obstruction (e.g. Formation of concretions).

7.Urinary Flow
1. Unobstructed flow should be required . (Occasionally, it is necessary to
temporarily obstruct the catheter for urine specimen collection or other medical purposes.)
2. To achieve free flow of urine
a) the catheter and collecting tube should be kept from kinking; the collecting bag should
be emptied regularly using a separate collecting container for each patient (the urometer and
uro bags collecting container should never come in contact ) ;
b) Poorly functioning or obstructed catheters must be irrigated.
c) Or if necessary, replaced; and sent the catheter tip for culture sensitivity.
d) Collecting bags must be kept below the level of the bladder.

8. Catheter Change Interval

Indwelling catheters should not be changed at arbitrary fixed intervals.

11. Spatial Separation of Catheterized Patients

To minimize the chances of cross-infection, infected and uninfected patients with
indwelling catheters should not share the same room or adjacent beds.

12. Bacteriologic Monitoring

37
 The value of regular bacteriologic monitoring of catheterized patients as an infection
control measure has not been established and is not recommended.

Architecture and layout, especially while designing a new ICU According to guideline of
reference no(32)
□ The CCU may be situated close to the operating theater and emergency department for
easy accessibility, but should be away from the main ward areas.
□ Central air-conditioning systems are designed in such a way that recirculated air must pass
through appropriate filters and maintain the temperature.
□ Suitable and safe air quality must be maintained at CCU all times.
□ It is recommended to CCU a minimum of six air circulation per room per hour,
□ Adequate space required around beds is ideally 2.5-3 m
□ Electricity, oxygen connection ,air, vacuum outlets/connections should not hamper access
around the bed
□ Adequate no of washbasins should be installed in CCU.
□ Alcohol gel dispensers are required at the CCU entry, exits, every bed space and every
workstation
□ There should be separate medication preparation area
□ There should be separate areas for clean storage, soiled waste storage, a disposal and
storage for cleaning instruments.
□ Adequate toilet facilities should be provided for CCU staff.

Organizational and administrative measures

 Hospital administration to maintain ratio of patient nurse
 Hospital administration to implement the policies for controlling traffic flow to and from
the unit to reduce sources of contamination from visitors, staff and medical equipment .
 To maintain the biomedical waste and sharp disposal policy
 Education and training for all CCU staff about prevention of nosocomial infections
 ICU protocols making for prevention of nosocomial infections
 To maintain Antibiotic uses policy
 Provide vaccination of all health care personnel

38
Types of Sterilization:

There are many methods for sterilizations ,it goes further than just sanitizing. It kills all
microorganisms on equipment and surfaces via exposure to chemicals, ionizing
radiation, dry heat, besides to steam under pressure. Lately, steam sterilization of single-
use implants have been questioned via US researchers who discovered contaminants
with bacteria on single-use implants that have been repeated reprocessed in bulk before
surgery. They suggested use of gamma-sterilization of implants, and providing implants
in a single ready-to-use package to avoid repeated reprocessing of bulk implants for each
surgery.
The same concern was raised via Scottish Health Department more than a decade ago,
also as a result Scottish hospitals underwent transition from steam sterilization of bulk
implants to gamma sterilization of individually packaged implants. A petition has been
filed via the reputable health science authors Aakash Agarwal to ban steam
sterilization of implants in US, requesting FDA to transition into a one-time gamma
sterilization of single use implants.
Environmental factors:
Ecological factors Health care settings are a location where both diseased persons
besides to persons at improved risk of infection congregate. Patients with
contaminations or carriers of pathogenic microorganisms admitted to hospital are
potential sources of pollution for patients with staff. Patients who become infected in the
hospital are a further source of infection.
Bacterial resistance :
Numerous patients take antimicrobial drugs. Through selection besides to exchange of
genetic resistance elements, antibiotics promote the emergence of multi-drug resistant
strains of bacteria; microorganisms in the normal human flora sensitive to the given
treatment are suppressed, while resistant strains persist and may become endemic in the
hospital.
Methicillin treatment was the first broadly applied penicillinase resistant antibiotic also
was therefore used in susceptibility screening in the laboratory as a marker of beta-
lactam creating (Staphylococcus aureus).

Prevention of hospital-acquired infections:

The main preventive effort must be fixated in hospitals besides to other health care

39
 facilities. Risk prevention for patients and staff is a concern of anyone in the facility,
also should be supported at the level of senior administration. Patient care is provided in
facilities which range from highly equipped clinics and technologically advanced
university hospitals to front-line units with only basic facilities. Despite progress in
public health and hospital care, infections continue to develop in hospitalized patients,
and may affect hospital staff
Treatment of Contamination:
Controlling of hospital-acquired pollutions follows standard goal-directed therapy if
sepsis, antibiotics, fluid resuscitation, also close monitoring for organ dysfunction. Fluid
resuscitation should be followed by serial assessments of the clinical and hemodynamic
responses. The selection and timing of initiation of antibiotics are critical. Empiric
antibiotics should be selected based on risk factors for MDR pathogens and clinical
stability of the patient. Antibiotics should be started early within an hour if possible., In
addition to the device-associated pollutions, wounds and surgery sites are also locations
of HAIs. In fact, 22% of hospital-acquired infections effect surgical incision sites and
may include the skin or deeper tissue and/or organs. Infections may also involve an
implanted device or material.

Hand washing:

Hand washing frequently is called the single most important measure to reduce the risks
of transmitting skin microorganisms from one person to another or from one site to
another on the same patient. Washing hands as promptly and thoroughly as possible
between patient contacts and after contact with blood, body fluids, secretions,
excretions, and equipment or articles contaminated by them is an important component
of infection control and isolation precautions. The spread of nosocomial infections,
among immune compromised patients is connected with health care workers' hand
contamination in almost 40% of cases, and is a challenging problem in the modern
hospitals. The best way for workers to overcome this problem is conducting correct

40
 hand-hygiene procedures; this is why the WHO launched in 2005 the GLOBAL Patient
Safety Challenge.[24] Two categories of micro- organisms can be present on health care
workers' hands: transient flora and resident flora. The first is represented by the micro-
organisms taken by workers from the environment, and the bacteria in it are capable of
surviving on the human skin and sometimes to grow.
Gloves:

In addition to hand washing, gloves play an important role in reducing the risks of
transmission of microorganisms. Gloves are worn for three important reasons in
hospitals. First, they are worn to provide a protective barrier for personnel, preventing
large scale contamination of the hands when touching blood, body fluids, secretions,
excretions, mucous membranes, and non-intact skin. In the United States, the
Occupational Safety and Health Administration has mandated wearing gloves to reduce
the risk of blood-borne pathogen infections. Second, gloves are worn to reduce the
likelihood that microorganisms present on the hands of personnel will be transmitted to
patients during invasive or other patient-care procedures that involve touching a patient's
mucous membranes and nonintact skin.

Antimicrobial surfaces:

Micro-organisms are known to survive on inanimate ‘touch’ surfaces for extended

periods of time. This can be especially troublesome in hospital environments where
patients with immuno-deficiencies are at enhanced risk for contracting nosocomial
infections.

Touch surfaces commonly found in hospital rooms, such as bed rails, call buttons, touch
plates, chairs, door handles, light switches, grab rails, intravenous poles, dispensers
(alcohol gel, paper towel, soap), dressing trolleys, and counter and table tops
are known to be contaminated with Staphylococcus, MRSA (one of the most
virulent strains of antibiotic-resistant bacteria) and vancomycin-resistant
Enterococcus

Reducing person-to-person transmission :

Hand decontamination The importance of hands in the transmission of hospital
infections has been well demonstrated , and can be minimized with appropriate hand
hygiene . Compliance with hand-washing, however, is frequently suboptimal. This is
due to a variety of reasons, including: lack of appropriate accessible equipment, high

41
 staff-to-patient ratios,

Surgical care:

surgical hand also forearm washing with antiseptic soap and sufficient time and duration
of contact (3– 5 minutes) ,or surgical hand and forearm disinfection: simple hand-wash
and drying followed by two applications of hand disinfectant, then rub to dry for the
duration of contact defined by the product.

42
 THEORETICAL REVIEW

Table I
Non-pharmacological hospital infection control strategies which have either been proven
effective or some level of evidence suggests may be effective
Class of intervention Interventions used
I. Increased hand-washing rates
II. Alcohol-based and/or antiseptic hand-washing solutions
1. Hand washing, gowning III. Disposable gowns, gloves
and personal items
IV. Avoiding, regular cleaning or one-patient use of such
items as artificial fingernails, rings, stethoscopes, blood
pressure cuffs and electrodes
I. Better training and feedback for hospital cleaning staff
2. Cleaning II. Bleach may be more effective than other cleaners for
such pathogens as C. difficile
I. Malnutrition common in hospitalised patients and
increases risk of nosocomial infection
II. ‘Immunonutrition’ enteral and parenteral formulas may
3. Nutrition
reduce infection risk in acutely ill
III. Probiotics may reduce risk of some infections such
as C. difficile
I. Housing patients in separate rooms may reduce
nosocomial infection risk
II. Admission screening or ‘search and destroy’ protocols
for MRSA and other pathogens
4. Administration controls and
III. Molecular biology methods to detect pathogens on
surveillance
patient, staff and environmental surfaces
IV. Need for adequate numbers of nurses
V. Public reporting of nosocomial infections has been
proposed as possible method to reduce infections
5. Preventing urinary tract I. Proper catheter cleaning and management
infection II. Silver- or nitrofurazone-coated catheters
6. Preventing central venous I. Barrier precautions and antiseptic site cleaning when
line and haemodialysis inserting catheters
infections II. Subclavian site of insertion: less infection risk than
femoral site
III. Chlorhexidiene- or silver sulfadiazene-coated catheters
may reduce infection risk
IV. Higher rates of infection in temporary catheters vs

43
Class of intervention Interventions used
PTFE grafts or AV fistulas
V. Dedicated machines for HCV+ and HCV– patients
I. Use positive pressure ventilation instead of intubation
whenever possible
II. Place patient in semi-erect position
7. Avoiding ventilator- III. Use enteral instead of parenteral feeding when possible
associated pneumonia IV. Kinetic bed therapy
V. Subglottic secretion drainage
VI. Use heat and moisture exchangers vs heated humidifiers
VII. Oral decontamination with chlorhexidine
I. Avoiding long or contaminated surgical procedures
whenever possible
II. Clipping rather than shaving surgical sites
8. Avoiding surgical infection III. Warming surgical patients
IV. Laparoscopic rather than open abdominal surgery
whenever possible
V. Proper cleaning of surgical instruments
I. Sterile water for drinking, bathing and procedures
II. Cleaning shower areas and sinks
III. Heating water to 50 °C may reduce some pathogens
such as Legionella
IV. UV water treatment may reduce Legionella
concentrations
9. Preventing waterborne
hospital infections V. Copper–silver water ionisation systems may reduce
pathogen levels
VI. Regular monitoring of Legionella may or may not be
helpful
VII. Repair water leaks within 24 h
VIII. Avoid installation of large indoor decorative pools
and fountains
I. HEPA filtration reduces airborne levels of many
pathogens
10. Air filtration and treatment II. Adequate outdoor air infiltration rates
III. UV-light treatment reduces levels of some, but not all
pathogens
11. Preventing spread of I. Proper mask use when in contact with patients with
tuberculosis infectious TB
II. UV lights and adequate outdoor air infiltration
III. Negative pressure rooms

44
Class of intervention Interventions used
IV. Testing and surveillance of patients and staff

45
 Table II
Kampf's six ‘golden rules’ for hand washing (abridged)50

1. Select an alcohol-based hand-cleaning solution that has good skin tolerance.

2. Hand rubs should be easily available. Wall dispensers near the patient may help.

3. Implement teaching and promotion of hand hygiene.

4. Create a hospital budget which covers all costs involved with preventable nosocomial
infections. Even a small number of nosocomial infections prevented will outweigh the cost of
effective hand hygiene products.

5. Encourage senior staff to set a good example to motivate junior staff.

6. Have adequate staff:patient ratios.

46
 The emergence of HAIs dates back centuries ago; however, wide-scale

recognition of the problem did not come about until the 1950s when penicillin-

resistant Staphylococcus aureus infections caught the public’s attention.

Unfortunately, this issue was taken lightly until it became an epidemic. Ten years

later, hospitals in the United States began hospital-based infection control, and later in

the 1990s, HAI control programs were established in virtually all hospitals across the

nation.

Although the emergence of HAIs are unknown, there are many explanations to

how they came about and are still thriving to this day. The first problem is that

hospitalized patients tend to be more susceptible to infections due to their weakened

immune systems. Second, because they are usually grouped together in confined areas of

the hospital, the exchange of infections can occur more frequently between individuals.

Third, staff members must move quickly from one patient to another, allowing cross

contamination to occur if standard regulations are not met. Other explanations for the

emergence of HAIs include the use of medical procedures that bypass the body’s natural

protective barriers, improper sterilization of equipment, routine use of antimicrobials

allowing for the emergence of resistant strains, and inadequate sanitation protocols

regarding washing of hands and self. Despite these reasons, the rise of these infections

can be easily reduced if healthcare providers and patients put in the extra effort. If done

correctly, hand hygiene can help decrease the spread of HAIs by a significant amount.

Because the hands are the main pathway for contact transmission of pathogens in

healthcare, proper hand hygiene is an important measure to help avoid and prevent the

spread of HAIs. Some factors that contribute to poor

47
compliance of hand hygiene include lack of knowledge, understaffing, overcrowding of

patients, poor access to hand washing or sanitizing facilities, irritant contact dermatitis of

clinicians’ hands, and lack of organizational commitment to appropriate hand hygiene.

STATEMENT OF THE PROBLEM

Despite efforts, no institution or country has been able to solve this issue. Current

data shows that on any given day, 1 in

25 hospitalized patients will acquire at least one HAI and 1 in

9 patients with an HAI will die during their hospitalization. 5 Because hospitals are an

ideal breeding ground for pathogens, these surroundings make it even more difficult to

solve this issue. Therefore, it is significant for physicians to follow the recommended

procedures to help reduce the occurrence of HAIs.

SIGNIFICANCE OF THE STUDY

Stated earlier, HAIs are the most frequent adverse event in healthcare worldwide

and create numerous problems and risks to patients affected. The impact of HAIs include

additional suffering to the individual, expensive treatments leading to high medical costs,

expensive surveillance, prolonged hospital stays, long-term disability, increased

resistance to antibiotics, and unnecessary deaths. The most recent study from the CDC in

2011 shows than an estimated 722,000 individuals were affected by HAIs in acute care

hospitals in the United States.5 Of these cases, 99,000 resulted in death. 4 In 2009, the

annual direct medical cost of HAIs in the U.S. ranged from 28-45 billion dollars.4

48
 The HAI type that causes the highest morbidity and mortality is ventilator

associated pneumonia, or VAP.2 This infection is one of the top three concerns of

clinicians today and can account for up to 60% of all deaths from HAIs in the

U.S.2 If death does not occur, VAP can increase patient time in the intensive care unit by

four to six days and is estimated to generate increased medical costs of 20,000 to 40,000

dollars.2 VAP is an increasing concern world-wide, as there is evidence of an increase of

transmission in ICU patients in Germany, France, and the United Kingdom.2 Because

there is a great risk of pneumonia in patients receiving continuous ventilation, most of the

research on HAIs have been focused on VAP.

Another major site of infection that affects around 158,000 out of 722,000 HAI

infected patients are surgical site infections.5 Any breach of skin can lead to a surgical

site infection. These invasive procedures can then lead to additional or extended

treatment, resulting in up to 10 billion dollars in treatment costs every year in the U.S.

alone.2

In addition to these concerns, there are many factors that put patients at risk for

HAIs. First, distinct settings create specific patient populations. The risk of acquiring

HAIs in developing countries is 2 to 20 times higher than in developed countries.2

Therefore, factors that place patients at greater risk for HAIs in settings with limited

resources can include poor environmental hygienic conditions and waste disposal, poor

infrastructure, insufficient equipment, understaffing, overcrowding of patients, poor

knowledge and application of basic infection control measures, lack of procedure, lack of

49
knowledge of injection and blood transfusion safety, and absence of local and national

guidelines and policies.3 In developed countries, the factors that put patients at greater

risk consist of prolonged or inappropriate use of invasive devices and antibiotics, high

risk procedures, weakened immune systems, and inappropriate application of standard

isolation precautions.3 When looking at overall circumstances that place a patient at risk,

one could examine patient characteristics (age and/or underlying conditions that

compromise the immune system), presence of invasive medical devices (catheters,

breathing tubes), complications from surgical procedures, and antibiotic use.3

Another factor contributing to HAIs are antibiotic resistant microorganisms,

particularly bacteria. Overuse of medication can promote the emergence of antibiotic

resistant organisms that cause these infections and limit treatment options. Studies

show that up to 50% of antimicrobial use in hospitals is unnecessary, inappropriate,

and contribute to the overgrowth of resistant Clostridium difficile infections. 5 C.

difficile infections are currently at historically high levels and can cause severe

diarrhea, fever, and abdominal pain.

50
REVIEW OF RELATED LITERATURE AND STUDIES

PREVENTION

Research shows that HAIs are often preventable and can be reduced by up to

70%.5 However, this requires training and discipline by all health care providers.

Several organizations have examined ways to prevent HAIs, including through the

creation of recommendation lists for clinicians to follow. The organizations examined

include the National Centers for Biotechnology Information, Centers for Disease

Control and Prevention and the Healthcare Infection Control Practices Advisory

Committee.

According to the NCBI, six steps are recommended to reduce HAIs by 30%.4

First, it is necessary to maintain improvement in national surveillance of HAIs so there is

accurate representative data for studies. In order to do this, researchers must assess the

sensitivity and specificity of the surveillance, and they also need to create systems for

surveillance of HAIs that occur outside of hospitals. Second, surveillance uses need to be

valid, and followed by increased outpatient surveillance. Third, invasive designs must be

improved, as it is easier to change than human behavior in regard to proper hand

washing for example. Fourth, creation of aggressive antibiotic control programs which

can be used to limit and prevent antibiotic resistance are needed. Fifth, emphasis is

needed of the importance of new microbiologic methods, which will help to provide a

better understanding of the factors that lead to the emergence of resistant strains. And

last, control of tuberculosis in hospitals, which exemplifies the successful collaboration

of the infection control community, CDC and regulatory agencies, is mandatory.

51
 The CDC follows similar steps when observing the problem as a whole; however,

Director Julie Gerberding stresses the importance of preventative steps maintained by all

health professionals. These preventative solutions include the topics of hand hygiene,

cross contamination, methicillin-resistant Staphylococcus aureus, ventilator associated

pneumonia, and surgical site infections. In regard to hand hygiene, the focus is better

knowledge and understanding of proper hand washing and sanitizing. When hand

washing, soap and water must be used when hands are visibly soiled or have bodily fluid

contamination.

This will help to physically remove germs and to rinse them down the drain, out of

patient contact. When hands are not visibly soiled, sanitization can be used for

decontamination through the use of alcohol-based hand rubs. The next precaution is to

avoid cross contamination, which is stated by the CDC as the number one source of

HAIs. Dr. Gerberding asserts, “Clean hands are the single most important factor in

preventing the spread of dangerous germs and antibiotic resistance in healthcare

settings.2” In order to prevent this cross contamination, personal protective equipment

must be available during patient contact; however, the use of PPE does not eliminate the

need for hand hygiene. Gloves are able to reduce hand contamination by

70-80%.2 These, when used along with other PPE and hand hygiene, can create the first

line of defense in preventing the spread of

52
infection from person to person within healthcare settings. Consequently, PPE can be used

adversely as a source of contamination, commonly through methicillin-resistant

Staphylococcus aureus. MRSA is a member of the common Staphylococcus family of

infections. Infections caused by this bacterium were treated successfully in the 1940s by

penicillin; however, the pathogen has become increasingly resistant to treatment. In the

span of 30 years, MRSA infections increased from 2% to 63% of the total number of

Staphylococcus infections.2 In 2005, 85% of life threatening MRSA infections were

associated with healthcare settings.2 The reason for such a high percentage is because of

the easy transmission between individuals, equipment, and environmental surfaces. In

addition, MRSA is able to survive and divide on virtually all surfaces. For these reasons,

the CDC emphasizes the factors that must be taken into consideration when wearing

gloves and/or gowns (Table 1).2

Table 1: Guidelines for Use of Personal Protective Equipment

Worn when in contact with mucous

membranes and non- intact skin (blood,
bodily fluids, secretions and excretions).
Gloves should be…

53
 Selected with appropriate durability for
the task at hand.

Changed between patients, tasks, and

procedures on the same patient after
contact with possibly infected material.

Removed promptly after use and before

touching non- contaminated items or surfaces
(followed by hand hygiene).

Worn for all contact with patients known or

suspected to be infected with MRSA.

Worn to protect skin and prevent soiling of

clothing during procedures and patient care
activities when exposed with blood, bodily
Gowns should be… fluids, secretions, and excretions.

Selected accordingly to the patient care

activity, removed promptly if soiled and hands
cleansed thoroughly after removal.

Worn for all contact with patients known or

suspected to be infected by MRSA.

The next approach mentioned by the CDC is to challenge the problem of ventilator

associated pneumonia. Because VAP is a

54
global issue and is known to be the highest source of morbidity and mortality of all

HAIs, prevention requires collaboration between the CDC and the American Thoracic

Society to develop the following guidelines (Table 2).7 This table explains guidelines

adapted from both organizations in regard to management of adults with hospital

acquired, ventilated-associated, and healthcare-associated pneumonia.

Table 2: Recommendations for Prevention of Ventilator Associated Pneumonia via the

Centers for Disease Control and Prevention and the American Thoracic Society

1) Perform hand hygiene before patient contact or aseptic procedure, after patient contact,
contact with the care environment or bodily fluids (regardless of glove use).

2) Wear gloves, gowns, and face protection following standard and transmission-based
precautions as clinically indicated.

3) Make comprehensive patient oral hygiene standard practice.

4) Keep patient head of bed elevated above 30 ° unless against the advisability of treatment.

5) Use a closed-suction system or sterile single-use suction catheter.

6) Minimize saline lavage.

7) Prevent patient contamination from ventilator circuit condensate.

8) Perform oral and subglottic suctioning when necessary.

9) Avoid nasal placement of endotracheal (ET) or gastric tubes and consider non-invasive
breathing support methods whenever possible.

55
 10) Maintain optimal pressure in ET tube cuff while patient is intubated.

11) Avoid unnecessary manipulation of ET tube.

12) Remove ET tube as early as possible, but avoid inadvertent extubation or re-intubation.

13) Prevent cross-contamination with reusable devices and common-use patient

equipment.

14) Vaccinate staff and patients against influenza.

15) Utilize methods for early diagnosis of VAP.

16) Write patient care policies, educate staff and monitor compliance.

Doctors and organizations have also looked at how to limit surgical site

infections (SSI). Any breach of skin can lead to an SSI. Out of 30 million surgical

procedures performed in the U.S., 80,000 result in SSIs.2 In relation to healthcare-

associated infections in surgical patients, about 38% of them are SSIs.2 The common

causes of these infections include complications from surgical hypothermia,

contamination of the incision area by skin flora, bacteria cross-contamination, and

surgical instrument contamination. Without prevention, SSIs can increase the patient’s

length of stay by an average of 7.5 days and result in up to 10 billion dollars in medical

costs every year in the U.S.2 Below in Table 3,2 the CDC explains methods that

patients and health professionals should follow to stay a step ahead of SSIs. For more

details on SSI prevention,

56
additional recommendations can be found on the Centers for Disease Control and

Prevention webpage under SSI Prevention Guidelines in Category IA.

Table 3: Recommendations for Prevention of Surgical Site Infections via the Centers for
Disease Control and Prevention

1) Use antibiotics appropriately.

2) Maintain normal body temperature.

3) Maintain normal blood glucose levels.

4) Control blood glucose in all diabetics and maintain postoperative glucose control
for major cardiac surgery patients.

5) Avoid shaving surgical site. Use clippers is necessary.

6) Have an informed surgical team working in a safety culture.

7) Identify and treat any pre-existing infections

8) Encourage patients to stop smoking as soon as surgery is anticipated.

9) Maintain perioperative normal body temperature for colorectal surgery patients.

10) Educate patients on proper incision care and prompt reporting of signs indicating possible
SSI.

57
 TREATMENT CONSEQUENT TO INFECTION

The treatment of HAIs varies depending on the type of infection, the pathogen

involved and the medical history of the patient. Generally, treatment consists of

administering antibiotics at the right dosage and duration. Evidence shows that early

antibiotic treatment leads to better outcomes in regard to morbidity and mortality.4

Empirical use of antibiotics is usually necessary, as most laboratory results take a minimum

of 48 hours. After results are in, a narrow-spectrum antibiotic can be used. Indicators for an

effective treatment are often measured by the patient’s temperature, leukocyte count, C-

reactive protein and procalcitonin.

POSSIBLE SOLUTIONS

Today, solutions are being viewed through many perspectives. One point of view

focuses on the responsibility of healthcare providers and their role in preventative care.

Standardized regulations have been made to ensure proper hand hygiene, disinfection

of equipment and environment, and correct application during all procedures. Another

aspect focuses on research at the national level. The Centers for Disease Control and

Prevention and the World Health Organization play a huge role in this, as the CDC

publishes yearly progress reports to better target the issue and WHO helps to reduce

HAIs globally through their “Clean Care is Safer Care” program.

58
 ROLE OF CENTERS FOR DISEASE CONTROL AND PREVENTION

In order to publish reports on the prevalence of HAIs, the CDC asks all health

care facilities to collect and submit data related to HAIs and prevention. Since 2008, the

CDC has been using a combination of data systems, public health-healthcare programs,

evidence-based recommendations and partnerships.3 Because there is no solution for

preventing HAIs, the CDC focuses its efforts on major device-and procedure-related

HAIs, along with controlling the spread of infections. When creating yearly progress

reports (Figure 1)6, data is pooled from two sources: The National Healthcare Safety

Network (NHSN) and the Emerging Infections Program Healthcare-Associated

Infections Community-Interface (EIP HAIC). The NHSN is the nation’s most used

system to track HAIs, helping to better target the concerns of these infections. After

results are produced, gaps are identified where more interventions are needed. In 2012,

this method was able to identify the emerging threats of C. difficile and Carbapenem-

resistant Enterobacteriaceae. When developing approaches to HAI prevention, the CDC

collaborates with research partners to identify and test new strategies for prevention,

control, and clinical practice. When prevention measures work, results are

communicated and promoted to all public health communities to show hospital CEOs

and medical officers ways to

59
improve antibiotic use and protection of patients in their facilities. In order to report

accurate findings, the CDC constantly looks for ways to expand their collaborations.

When working with diverse public health and healthcare partners, they are able to align

prevention goals, promote the use of CDC guidelines and data, and combatively work to

prevent HAIS across the spectrum of care.

Figure 1: National Progress Report of Acute and Long-term Care Hospitals in 2015

60
 INFECTION CONTROL AND PREVENTION IN PHYSICIAN
OFFICES

Because billions of visits are made to hospitals each year, it is significant for

infection control and prevention to begin at the source. Some general infection control

recommendation by the CDC for physicians include the following: protocol within

physician offices and clinics should mirror the same standards as a hospital,

administration should include equipment and supplies to maintain proper infection

prevention, the practice should have at least one individual on staff trained in infection

prevention, and infection prevention policies should be reassessed on a regular basis.1 If

these recommendations are not taken into consideration, the least that should occur in all

patient care are standard infection precautions, or the minimum infection prevention

practices. Standard precautions created by the CDC include hand hygiene, use of

personal protective equipment, safe injection practices, safe handling of potentially

contaminated equipment or surfaces, and respiratory hygiene. Explanations of proper

hand hygiene and PPE protocols are noted in my thesis.8 In regard to injection safety,

many steps need to be taken into consideration to ensure safe practice. The following

recommendations for safe injection practices are noted below in Table 4.1

61
 Table 4: Recommendations for Safe Injection Practices

1) Use aseptic technique when preparing and administering.

2) Cleanse the access diaphragms of medication vials with

alcohol before inserting a device into the vial.
3) Never administer medications from the same syringe to multiple patients, even if the
needle is changed.

4) Do not reuse a syringe to enter a medication vial or container.

5) Do not administer medications from single dose or single use vials, ampoules or bags or
bottles of IV solution to more than one patient.

6) Do not use fluid infusion or administrations sets for more than one patient.

7) Dedicate multidose vials to a single patient whenever possible.

8) Dispose used sharps at the point of use in a sharps container that is closable, puncture-
resistant, and leak- proof.

9) Wear a facemask when placing a catheter or injecting material into the epidural or
subdural space.

When examining respiratory hygiene, the CDC was able to create several

recommendations for outpatient settings. The two main points were to implement

measures to contain patients who have signs and symptoms of a respiratory infection

and to educate health professionals on the importance of infection prevention measures

to reduce the spread of respiratory pathogens. When determining the appropriate

measures to contain patients of interest, ideas included providing tissues, masks, and a

separate space to encourage individuals with symptoms of infection to sit as far away

from others as possible.7 In addition, it was recommended to post signs at entrances

62
with instructions to patients with likely respiratory infections to: inform health

professional of symptoms, cover their mouth when coughing, use and dispose of tissue,

and perform hand hygiene after hands have been in contact with respiratory secretions.

63
 CHAPTER III
RESEARCH
METHODOLOGY

64
 RESEARCH METHODOLOGY

1. Study area:- in patient department in the department of critical care unit, the college
medicine &jnm hospital
2. Study population:- Indore patient who admitted in ccu at the Appllo Hospitals
3. Period of study:-2 months
4. Sample size:- 130 admitted patients in ccu
5. Study design:-It is a observational study
6. Study tools:-The CDC for disease control and prevention define hospital associated
infection as those that occur after 48 hours staying in CCU admission or within 48 hour
after transfer from an CCU. In the present study patients who had developed infection after
48 hour of admission to the CCU or clinically suspected of having acquired any infection
were included in the study. Patient showing clinical signs of infection on or prior to
admission or transfer to CCU were not included

Predesigned proforma was developed to assess the incidence of nosocomial infection in

CCU. The proforma was designed in two parts.
Part A: The proforma enlisted demographic details of the patient including age, sex,
geographic details and diagnosis.
Part B: It was used to establish presence or absence of nosocomial infection in the study
subject. Criteria for establishment of nosocomial infection were adopted in accordance with
the simplified definition derived from the Centre for disease control, USA. The selected
criteria to establish the presence or absence of nosocomial infection was as under

1. Surgical site infection: Any purulent discharge, abscess or spreading cellulitis at the
surgical site during the month after the operation.
2. Urinary tract infection: Positive urine culture (1 or 2 species) with at least 105 bacteria/
ml, with or without clinical symptoms.
3. Respiratory tract infection: Respiratory symptoms with at least two of the following
signs appearing during hospitalization.
 Cough
 Purulent sputum
 New infiltrates on chest radiograph consistent with infection
4. Septicaemia: Fever or rigors and at least one positive blood culture.
65
5. Vascular catheter associated infection: Inflammation, lymphangitis or purulent discharge at
the insertion site of catheter.
6. Plan for analysis:- approximate statistical technique will be applied to establish the analysis
and evaluate the study.

Statistical analyses

The collected data were analyzed using IBM SPSS Statistics 21.0 (IBM Corp., Armonk, NY)
for evaluating the normality of variables and descripting of statistics. In this study, the
principles of social cognitive theory were used to structural equation modeling. The basic
conceptual model of behavior predictors based on social cognitive theory [20], which
provides a theoretical framework for our study, is illustrated in Fig. 1. The fit of the
constructs of social cognitive theory for behaviors related to the control of nosocomial
infections in hospital nursing staff was examined using the latent variable structural equation
model (SEM) with AMOS software version 24.
Fig. 1

Theoretical model of Social cognitive theory

66
Structural equation modeling is a detailed statistical method for testing models that contain
both causal relationship and correlations between observed variable and latent variables.
SEM is used in social and behavioral sciences, education, biology, economy, marketing and
medicine, which is based on substantial or suggested theories that describe and explain
phenomena under investigation. We used R2 and the path coefficients to test the fit of the
model. Before carrying out the SEM analysis, the normality of variables was examined [21].
All the indicators in the model were treated as reflective indicators of their respective
constructs. We developed the model (theoretically driven) with eight latent factors. The
modification index suggested correlation of several error terms. After covering the errors, we
obtained the acceptable model fit. The goodness-of-fit of the model was confirmed using the
χ2 statistic, RMSEA (Root-Mean-Square Error of Approximation), CFI (Comparative Fit
index), IFI (Incremental Fit Index), PNFI (Parsimonious Normal Fit Index), and PGFI
(Parsimonious Good Fit Index) [15]. Parameter estimation and effect analysis were
performed using the bootstrapping method. Statistical significance was set at P < 0.05.

67
 CHAPTER IV
DATA ANLYSIS
AND
INTERPRETATION

68
 DATA ANLYSIS AND INTERPRETATION

Table 1: Total number of observed patients in CCU during the study period (2 months)
No of No of patient No of male patient No of female patient
stay
(day)
0 10 7 3
1 19 13 6
2 15 7 8
3 16 8 8
4 16 10 6
5 17 10 7
6 9 5 4
7 5 4 1
8 7 5 2
9 4 3 1
10 3 3 0
12 3 2 1
13 1 0 1
16 1 0 1
20 2 1 1
Total 128 78 50

69
Table 2: Distribution of Sex and Admitted in CCU more than 48 hr
Duration of staying No of total patient No of male patient No of female
patient
3 16 8 8
4 16 10 6
5 17 10 7
6 9 5 4
7 5 4 1
8 7 5 2
9 4 3 1
10 3 3 0
12 3 2 1
13 1 0 1
16 1 0 1
20 2 1 1
Total 84 51 33

During the study period for more than 48hours staying, 84 patients were nosocomial
infected and out of total 84 patients 51 male and 33 female. Most of the patient stays for 3
to 5 days.

Figure 1: Showing Sex Distribution

70
Figure 1 shows that out of total 84 patients , male patient were 51 and female patients
were 33. According to percentage calculation male patients were 61% and female patients
were 39 %

Table 3 : Average Duration of ICU stay

Patient group No of days
Nosocomial infection 9.71
Without nosocomial infection 6.1O

Figure 2: Showing No. of Total Patient, Sex and No of Day Staying

Table 2 shows that non nosocomial infected patients’ average staying days were 6.10 days
when patients were nosocomial infected , their average staying days were
increasing(9.71days).

71
72
TABLE 4 DISTRIBUTION OF SOCIO ECONOMIC STATUS
Socio economic status Nosocomial infection
Yes No
Lower class 16 35
Middle class 9 51
Upper class 3 14
Total 28 100

Table 3 shows that among 28 nosocomial infected patients, belonging in lower class 16,
middle class 9 and upper class 3

Figure 3: Socioeconomic Status of Nosocomial Infected Patients

Figure 3 shows that among 28 nosocomial infected patients ,16 patient were in lower
class ,9 were in middle class and 3 were in upper class. According to percentage calculation
lower class were 57% ,middle class were 32% and upper class were 11%.

73
Table 5 : Outcome Result Due To Nosocomial Infection And Without Nosocomial Infection
Types of Total no. expired Discharge Transf Transfer Percentage
infection of d er out
patient to general of mortality
ward
Nosocomial 28 12 7 3 6 42.85%
infection
Non 56 15 20 4 17 26.78%

nosocomial
infection

Table 5 shows that among 28 nosocomial infected patient, 12( 43%)

expired,7(25%) discharged,3(10.71%)transferred out and 6(21%) transferred to general
ward. Percentage of mortality was 42.85% among 56 non nosocomial infected patient,
15(27%) expired, 20 (36%) discharged , 4(7%) transferred out and 17(30%) transfer to
general ward. Percentage of mortality rate was 26.78%.

74
75
Table 6: Distribution Of Nosocomial Infection Among Nosocomial Positive Patients.
Nosocomial infection Number of patient
Urinary tract infection 15
Respiratory tract infection 9
Surgical site infection 6
Intravascular infection 8
Other 5

Table 6 shows that among the positive nosocomial infected patient ,15 patient were urinary
tract infection ,9 patient were respiratory tract infection, 6 patient were surgical site
infection 8 patient were intravascular infection and 5 patient were other nosocomial
infection.

Figure 6: Distribution of Nosocomial Infection Among The Nosocomial Positive Patients

Figure 6 shows that among the positive nosocomial infected patient ,15 patient were urinary
tract infection ,9 patient were respiratory tract infection, 6 patient were surgical site
infection 8 patient were intravascular infection and 5 patient were other nosocomial
infection.

76
Table 7 Distribution Of Sex In Urinary Tract Infection
Urinary tract infection
Male Female
6 9

Table 7 shows that out of 15 urinary tract infection , 6 male patient were urinary tract
infected and 9 female patient were urinary tract infected.

Figure 7: Distribution Of Sex In Urinary Tract Infection

Figure 7 shows that out of 15 urinary tract infection , 6 male patient were urinary tract
infected and 9 female patient were urinary tract infected. According to percentage male
urinary tract infected patient were 40% and female urinary tract infected patient were 60%.

77
 CHAPTER-V
RECOMMENDATIONS
AND
CONCLUSION

78
 RECOMMENDATION
1. During entering in CCU wear apron and uses caps and mask.
2. Proper hand washing and use of hand rub solution before touching patient.
3. Used of disposal shoe cover before entering in CCU.
4. Fumigation to be processed in the regular interval.

79
 CONCLUSION
During the study period, the hospital acquired infection rate was 33.33% .In India
nosocomial infections rate is alarming and is estimated at about 30-50% of all hospital
infections according to world health organisation.

A study from Appollo Hospitals, Hyderabad, India, it has been observed that
infection rate was 24.3% (2).
A Appollo Hospitals, Hyderabad, India, shows their infection rate of 12 bedded
surgical ICU was 11.98%(46).
The observed study indicated high prevalence rate .However, in developing
countries, due to lack of formal surveillance the rate of health-care-associated infections is
high and compliance with hand hygiene is low.
Healthcare-associated infections (HAIs) are additional burdens on individual
hospitals and healthcare systems. They can increase the costs of patient care from several
economic perspectives, including those of hospital administrators, third-party payers and
patients. In healthcare systems relying on fixed per diem accounting systems, the presence
of an HAI does not necessarily decrease reimbursement revenue for hospitals, as added bed-
days can be charged to third-party payers (e.g. health insurance companies). Excess costs of
HAI are related to additional diagnostic tests and treatment, additional hospital days, and
post discharge complications, among others. Quantifying the exact economic burden
attributable to HAI still remains a challenging issue. (25)
In table 2 the observed study shows that average duration of stay of non infected
nosocomial infection and nosocomial infected patient’s was 6.10 days and 9.71 day
respectively where as mortality of two group was 28.1% and 31.2% respectively. (Table3,
4)
In other study it has been found that the average ICU stay of patients with and
without nosocomial infection was 15.7days (4-40days) and 5.2 days (3-21days) accordingly
(2) t Appollo Hospitals, Hyderabad.
Table 3 shows that out of 28 nosocomial infected patients , the socio economic
status of nosocomial infected patients presents socioecomically lower class was 16 , middle
class was presented 9 and upper class presented in 3 .
Nosocomial infection rate was inversely proportional to the socio-economic status of
the patient. At the same time some underlying diseases in the patients influenced the rate of
infection to a great extent, eg infection rates in patients with anaemia , diabetes mellitus ,
80
hypertension and obesity were much more than in patients with no such underlying disease.
In table 5presents, non-nosocomial infected patients are 56,among them 15
expired,20 discharged 4 transferred out and 17 transfer to general ward and it has been
observed mortality rate 26.78% .
In table 5 presents nosocomial infected patients are 28,among them 12 expired, 7
discharged, 3 transferred out,6 transfer to general ward and it has been observed mortality
42.85%
In table 4 & table 5 present ,in case of nosocomial infection mortality rate is
increasing and survival rate is decreasing.
In our observed study shows that rate of urinary tract infection ,respiratory tract
infection ,surgical site infection, intravascular infection and other was
15(53.57%) ,9( 32.14%), 6(21.42%) ,8(28.57%) and5(17.85%) respectively.
most common nosocomial infection is urinary tract infection. Infection rate of male
and female was 40% and 60% respectively.
Women are particularly more vulnerable to develop UTI because of their short
urethra and certain factors like delay in micturition, sexual activity and use of diaphragms
and spermicides which promote colonization of coliform bacteria in the periurethral region.
Infection in most women occurs when the bacteria present in the perineal or per urethral
region enter the urethra and ascend into the bladder(2).
second most common nosocomial infection respiratory tract infection.
It is the most common nosocomial infection encountered in the intensive care unit
(ICU), with 9-28% of all intubated patients developing VAP(50)

81
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86
 ANNEXURE PROFORMA
Name of patient:………………………………………………………….
RegNo…………………….Age……………..Sex……………………………
Duration of stay ……………………………...................................................
Outcome………………………........................................................................
Economic status………………….....................................................................
A. Patient exposure

1. Surgical procedure (during the last month) ■ Yes ■ No

2. Urinary catheter Yes ■ No
3. Mechanical Yes ■ No
ventilation
4. Intravascular catheter Yes ■ No
B. Nosocomial infection

Yes ■ No
If yes, fill the
following items
1. Surgical site infection ■ Yes ■ No
2. Urinary tract infection ■ Yes ■ No
3. Respiratory tract infection ■ Yes ■ No
4. Intravenous catheter related infection ■ Yes ■ No
5. Other nosocomial infection ■ Yes ■ No

87