Nosocomial Infections and Hand Hygiene Protocols in Acute Care Settings: An Evidence-Based Review

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Table of Contents

Introduction
Nosocomial infections
Review of Literature
Integrated summary of the literature reviewed
Implications for nursing (patient care)
Remaining gaps in the literature identified
Conclusion
References

Introduction

Nosocomial infections (NCI) are the leading cause of sepsis in the acute care setting. According to the Centers for Disease Control and Prevention (CDC), the highest rates of infection occurred in the Burn Intensive Care Unit (ICU), neonatal ICU, and pediatric ICU. The CDC strives to understand how healthcare-associated infections happen and develop appropriate interventions.

A new report from CDC updates previous estimates of healthcare-associated infections. In American hospitals alone, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. The most reportable NCI in the acute care setting are related to; urinary tract infections (32%), 22 % are from surgical site infections, 15 % are pneumonia (lung infections) and, 14 % are from bloodstream infections (CDC, 2002). The purpose of this literature review is to collect data on evidence-based practice (EBP) protocols that have been used or are in a testing phase to determine successful parameters that will help decrease nosocomial infections in the acute care setting.

Nosocomial infections

In order to understand the significance of evidence-based parameters to decrease the incidence of NCI in the acute care setting, the author would elaborate on an important aspect of the pathophysiology of NCI. Nosocomial infections result due to improper interventions or procedures in a hospital (acute care facility) or a healthcare service unit. The microbial flora especially bacteria of patients tend to attain the unique features of the bacterial pool in the vicinity. Infections are better regarded as hospital-acquired if clinical signs manifest early or after 48 hours of hospitalization.

Infections are better regarded to have a nosocomial origin if organisms invade the body during the hospital stay and cause infections after the patient’s discharge from the hospital.

NCI can be classified as iatrogenic, organizational, and patient-related based on risk factors.

Pathogenic agents on the hands of medical personnel, invasive procedures (eg, intubation and extended ventilation, indwelling vascular lines, urine catheterization), antibiotic use, and prophylaxis are iatrogenic risk factors (Mayoclinic, 2008). Contaminated air-conditioning systems, contaminated water systems, and staffing and physical layout of the facility (eg, nurse-to-patient ratio, open beds closed together) are organizational risk factors include (Mayoclinic, 2008). The severity of illness, underlying immunocompromised state, and length of stay are patient risk factors include the (Mayoclinic,2008).

The incidence of Nosocomial infections has increased at an alarming rate in the 21st century. The main reasons could be; mass admitting of sick people when their body loses the potential to mount an immune attack, proliferation of pathogens when medical staff members move frequently between the patients, escaping of the body’s natural protective barriers by the medical procedures. Another significant and the most important reason is the sanitation protocol regarding uniforms, equipment sterilization, washing, and other preventative measures that may be either overlooked by the hospital staff or too lax to sufficiently isolate patients from the infectious agents.

Review of Literature

There is a growing body of evidence on the spectrum of risk contributing agents. There may be a further need to gain insights on the development and better management of nosocomial infections. Earlier it was found that Candida albicans has potential for possible cross-transmission (Bischoff et al., 2000). This was revealed when a large study on 194 patients was undertaken to determine the colonization and possible transmission of yeasts among patients and healthcare workers in adult intensive care units. The overall contribution of Yeats was 67% where 19 % of Candida albicans was found in the oropharynx and 8% Candida parapsilosis was recovered from hands (Hedderwick et al., 2000).

This has strengthened an earlier report on the role of yeasts with regard to their frequency and distribution on the hands of hospital personnel working in an intensive care units (ICUs). Here, the techniques used for isolating C. parapsilosis were genotyping by electrophoretic karyotyping using contour-clamped homogenous electric-field gel electrophoresis (Huang et al., 1998). Hence, these reports may indicate the pathogenic role of Candida SPS. during the episode des of nosocomial infections. In addition, there are reports on outbreaks of hepatitis A in the burn treatment center of a referral hospital.

This was attributed to poor hand-washing and oral contamination accompanied by frequent eating on the wards on the hospital wards (Doebbeling, Li & Wenzel, 1993). These reports may indicate an urgent need to prevent the colonization and spread of multidrug-resistant bacteria. The intervention of hand hygiene strategies/protocols has revolutionized the management of nosocomial infections to a maximum amount. Over the years there has been much interest in the good practice of handwashing. Many learning programs were proposed to NHS for ward-based –learning. This has become a more adaptable strategy for nurses to take responsibility, a process known as Post-registration education and practice (PREP) (Gould, 1996).

Pittet (2001) described that hand hygiene that involves alcohol-based hand rubs rather than traditional hand washing could easily reduce hospital-acquired cross-infection in hospitals, provided there is a good adherence to guidelines by the healthcare workers’. This could facilitate great skin protection and improve overall hygienic behavior (Pittet, 2001).Further, nosocomial infections are reported to pass through blood stream which could lead to morbidity and mortality (Gura, 2004). This has caused nearly 8% of all nosocomial infections in the United States (Gura, 2004). The suspected reason was the administration of contaminated infusate through a central venous catheter without properly following asceptic techniques and poor hand washing (Gura, 2004). Therefore, there is a need for educational awareness regarding the nosocomial bloodstream infections (Gura, 2004).

Recent reports have emphasized that most cases of morbidity and mortality result from healthcare-associated infections. However, hand hygiene was better considered as the reliable and cost effective method for minimizing the incidence. Although there are certain indifferences shown by the health care workers (HCW) in following this method, a well planned study to investigate the effectiveness of interventions to improve hand hygiene practices were recommended like focusing on the inclusion criteria employed by the Cochrane Effective Practice and Organisation of Care Group (Gould et al., 2008).

As the incidence of yeast carriage on the HCWs’ hands is increasing, there is a need for the usage of gloves for minimizing the hand grown pathogenic yeast.(Brunetti et al., 2008) To this end a study was conducted in three departments like Surgery, Intensive Care Unit, Obstetrics and Gynaecology (Brunetti et al., 2008).It was revealed that the carriage of yeast and Candida species in the Surgery department was 50% and 49%, Intensive Care Unit was 61% and 57% and Obstetrics and Gynaecology was 65% and 59%.Hence, there is a need to monitor the colonization of these pathogenic strains in the recent developing hospital atmospheres.(Brunetti et al., 2008).

Integrated summary of the literature reviewed

From the above scientific documentation, it can be summarized that nosocomial infections have emerged as the major hospital acquired infections. Yeasts especially Candida sps. have become primary concern in the episodes of NI due to increased chances of cross transmission and invasion. The timely interference of prevention strategies especially, hand hygiene methodologies have provided immense relief to the health care professionals as they are easy accessible and cost effective. Aqueous alcoholic solution could offer great protection during hand-rubbing. Hence, approaching for risky chemicals or solutions could be avoided.

Apart from ICU’s, surgery and obstetrics departments may also carry great risk. Hence, a thorough clinical evaluation of aseptic techniques and hand hygiene strategies/protocols was suggested for these departments. Health care workers like nurses have shown an increased affinity in the maintenance of hand hygiene protocols. This could be widely appreciated and needs a consistent implementation.

Implications for nursing (patient care)

Nosocomial infections have become problematic in the major departments of Hospitals. There is a need to monitor the growth or colonization of yeasts. The implementation of molecular Biology techniques to investigate the colonization of microbial pathogens could be better considered as evidence based approach and has bright future implications. Maintaining the registry of morbidity and mortality may help to assess the rising prevalence rates of nosocomial infections. The utility of infectious or inflammatory markers like Adenosine deaminase (ADA) and C-reactive protein (CRP) could help in assessing the health status of severely ill patients.

Nosocomial infections may be more thoroughly controlled by the modifications of existing hand hygiene protocols with safer and cost effective agents,. Routine educational intervention programs for all the healthcare workers may have good implications for the rapid eradication of hospital acquired infections. There is a great need of proper implementation of guidelines recommended for the management of nosocomial infections by the medical professionals.

Remaining gaps in the literature identified

The literature cited here is more probably confined to few microbial populations like yeasts. There is also a need of understanding the role of other infectious agents like mycoplasma. Technical aspects involving molecular biology were not well covered. Much information would help to understand the pathways of bacterial colonization as there may be an emergence of good number of drug resistant bacteria. Apart from the prior mentioned departments, respiratory, cardiovascular, nephrology may also serve as hosts for transmitting infections. An upto date information on the methods of assessing the efficacy of hand hygiene strategies/protocols was more suggestive.

Conclusion

The management of all kinds of nosocomial infections could be possible with the collaboration of medical professional and researchers. As, the incidence rates may contribute to the mortality, hand hygiene protocols are the safest approaches to control. Educational awareness and intervention strategies like DNA typing may greatly influence prevalence indices registered across various hospitals.

Maintenance of databases regarding the history of incidence and therapy provided through hand hygiene protocols could help to streamline the evidence based approach.This could probably eliminate all possible chances of hospital acquired or other opportunistic infections. Therefore, nosocomial infections could be totally eradiated in the society.

References

National Nosocomial Infections Surveillance System. (NNIS). 2006. Web.
National Nosocomial Infections Surveillance (NNIS) System Report. (2002).Am J Infect Control, 30,458-75.
Quoc V Nguyen. (2009). Hospital Acquired Infections. Web.
Mayo Clinic. Hand washing: An easy way to prevent infection. Web.
FAQ. Web.
Hedderwick, S., Lyon, M., Liu, M., Vazquez, J., Kauffman, C. (2000). Epidemiology of yeast colonization in the intensive care unit. European Journal of Clinical Microbiology & Infectious Diseases, 19, 663-70.
Huang, J., Lin, T., Leu, S., Wu, H. (1998).Yeast carriage on hands of hospital personnel working in intensive care units. Journal of Hospital Infection, 39(1), 47-51.
Doebbeling, B., Li. N, Wenzel, R., (1993). An outbreak of hepatitis A among healthcare workers: risk factors for transmission. American Journal of Public Health, 83(12), 1679-84.
Gould, D. (1996). Hand-washing: Can Ward-based learning improve infection control? Nursing Times, 92(24), 42-3.
Gura, K. (2004). Incidence and nature of epidemic nosocomial infections. Journal of Infusion Nursing, 27(3), 175-80.
Gould, J., Drey, N.S., Moralejo, D., Grimshaw, J., Chudleigh, J. (2008).Interventions to improve hand hygiene compliance in patient care. Journal of Hospital Infection, 68(3), 193-202.
Brunetti, L., De Caro, F., Boccia, G., Cavallo, P., Capunzo, M. (2008). Surveillance of nosocomial infections: a preliminary study on yeast carriage on hands of healthcare workers. Journal of Preventive Medicine Hygiene, 49(2), 63-8.

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