ISSUES: INCREASING RATE OF NOSOCOMIAL INFECTION IN

SURGICAL WARD

INTRODUCTION
Definition OF NOSOCOMIAL INFECTION

A hospital-acquired infection is usually one that first appears three days after a patient is admitted to
a hospital or other health care facility. Infections acquired in a hospital are also called nosocomial
infections

Causes and symptoms

All hospitalized patients are susceptible to contracting a nosocomial infection. Some patients are at
greater risk than others—young children, the elderly, and persons with compromised immune
systems are more likely to get an infection. Other risk factors for getting a hospital-acquired infection
are a long hospital stay, the use of indwelling catheters, failure of healthcare workers to wash their
hands, and overuse of antibiotics

Prevention
Hospitals and other healthcare facilities have developed extensive infection control programs to
prevent nosocomial infections. These programs focus on identifying high risk procedures and other
possible sources of infection. High risk procedures such as urinary catheterization should be
performed only when necessary and catheters should be left in for as little time as possible. Medical
instruments and equipment must be properly sterilized to ensure they are not contaminated. Frequent
handwashing by healthcare workers and visitors is necessary to avoid passing infectious
microorganisms to hospitalized patients.

o Statistic by infection control survey show nosocomial infection had increased in surgical
ward.Due to few factors listed as below.The main factors which cause nosocomial was due to
poor infection control.The causes were listed ot in this Ishihara chart.
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 MAN
POWER

MONEY NOSOCOMIAL

INFECTION

METHODS

Fish bone shows the cause factors of nosocomial infection.

FACTORS CAUSING NOSOCOMIAL INFECTION.

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1.Man power.
 Staff lack of knowledge about infection control.
 Patients with low immune system.
 Patient those transfer from other hospital.(risk of MRSA and MDRO)

2.Methods.
 Sinks that located at certain areas only.
 Sinks located far away from the door of the room, which may discourage handwashing by
personnel leaving the room.
 Solution for hand rub which cause dermatitis to staff.

3.Money
 Charges to do dressing in treatment room consider as minor O/T cause patients bill increasing
 Hand rubs for each nurses need high budget for management .

GANTT CHART

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PROPOSED MAY JUNE JULY AUGUST SEPT OCTOBER
PLAN
MEETING * * * * * * * * * * *
-find out cause
-set standard

TEACHING * * * *
SESION
IMPLEMENTATIO * * * *
N
FEED BACK(3 * *
MONTH REVIEW)
COMPETENCY * *
EVALUATION *
POST MORTEM *
COMPETENCY
AUDITING * * * * * * * * * * * *
STATISTIC(6 * * * *
MONTH)
POST MORTEM
SATISTIC AND
ABNA

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OBJECTIVE OF QUALITY ASSURANCE
 To identify infection rate and cause of infection in surgical ward.
 To asses knowledge and educate nurses regarding factors that influenze to nosocomial
infection.
 To prevent staff from exposed to infection.

Purpose of implementing changes.

 To give a good and quality care to patients and to shorten patients hospitalization.
 To prepare hospital as a standard for ISO.
 To reduce the MRSA,MDRO and Nosocomial infection .
 To improve wound healing process.
 To get a good image for the hospital .

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Key performance indicator
 Infection rate less than 1% within 6 months time.
 All health care staff and patients aware about prevention of nosocomial infection.

POLICY:

1.Provide septi gel to all patients , make sure its kept in patients locker and teach patients the
purpose of using it.

2.Make sure septi gel always kept in dressing trolley , enterance of each ward,doctor’s round
trolley’s, and nurses counter.

3.Dressing should be done only in treatment room.

4.All nursing staff should pass theory and practical infection control competency with 80% of passing
mark .

5.Auditing with staff and environmental should done every 6 month.

6.Hand washing poster which is updated and latest should be at each sinki.

7.All nurses should carry mini pocket septi gel .

8.Make sure staff nail is not too long and should do nail swab as screening test.

9.All dressing should be done under aseptic technique.

10.Patient those transfer in from other hospital with wound should screen for MRSA first.

11.Protocol and Policy of infection control file should be kept in every ward .

METHODS OF MONITORING AND CONTROL

1.Meeting at every week intensively till the committee reach their key performance indicator.
2.Auditing will be done for all staff on handwashing and dressing.Enviroment auditing will be carried
out every month.

3.Post mortem of auditing will be reviewed.

4.Circular memo on post mortem will be distributed to the wards.

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5.Charts, poster and screen saver on handwashing technique will be displayed at appropriate places
such as handwashing station,Treatment room and computers.

6.Staff will designated for auditing.

7.All audit and fed back will be written as a report and submitted to the head of organization(matron )

IMPLEMENT

 Set up Organisation team of infection control which consist of clinical head and link nurses to
all wards.
 Auditing should be done intensively every 2 weeks till the committee achieve our key
performance indicator.
 Update all hand washing chart .
 Trained all staff and teach proper hand washing technique.
 Set up a committee consists of incharge nurse,staff nurse and assistants.
 All nurses should audit by commitee members.
 Audit every sift by observation, questioanire chart to staff and evaluation from statistic by
infection control.
 Take wall swab in treatment room to make sure its not contaminated.
 Infection control talk as awareness for patients and nurses.
 meeting with infection control and ward sister to achieve the goal.
 Treatment room settings will be reset according to policy of infection control.

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Infection control committee.

Objective infection control committee.

o To prevent and control infection in the hospital as to ensure that is. safe to all those use it.

Organization chart of Infection control unit

DOCTOR
INCHARGE

Matron

Sister
incharge

Infection
control
nurse

staff staff staff staff staff staff

Policy:
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o The committee has the following specific function :
 to develop written policies and procedure for continuing review and evaluation of all aseptic
, isolation and sanitation technique.
 to amend exisiting policy and procedure periodically as an when the need arises.
o The policy and procedures related to sterilization and disinfection,cross-infection and
isolation.,waste-disposal.,laundry.infectious diseases and notification
procedures.environmental control.
o The infection control committee meets 3 times a year and meets with Hospital management
yearly.The Infection Control Sister and Nurse meet with the Link Nurses 3 times a year to
discuss Nursing Issues.
o Environmental audits are conducted yearly throughout the hospital to audit On Infection
Control activity and conformances within each department. Environmental audit forms are
complied and documented by the Infection Control Nurse.
o The Infection Control Committee review reports on :
 incidence of hospital acquired infection
 Implementation of Infection Control policies .
 prevalence studies.
o The committee ensures that there are adequate policies and procedures for dealing with
infectious patients and those requiring isolation, including the following:
 accommodation for isolated patients with care of the same quality as is provided
elsewhere.
 Facilities for hand-washing and for implementing effective isolation techniques are
available.
 Isolation facilities are available for all clinical services including reverse isolation for
immunocompromised patients.
o The committee also has a role in staff health and may advise on the following:
 pre- employment screening
 needlestick injury.
 tracking of emerging infectious diseases.
 staff health vaccination
o The committee also advice management an infection control aspects:
 related to building/ renovation projects in the hospital.
 related to equipments purchase.

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 CONCLUSION.

The following performance indicators are recommended for measuring improvements in infection
control.

 Periodically monitor and record adherence as the number infection, by ward or by

service.
 When outbreaks of infection occur, assess the adequacy of health-care worker hand
hygiene and method of dressing technique..
 Nurses play a crucial role in the management of wounds so they need to have good
current knowledge and be more aware of their own wound care practices so to bring
about more effective wound management .
 It has helped the nurses to be more observant of their patients ; increased their
knowledge and skills ; assisted them in acquiring more experience and skills ; and set
up an on-going framework for improvements in infection control.

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  Heather Marr and Hannie Giebing.Quality Assurance In
Nursing,Concepts Methods and Case Studies.Campion press2004
 www.MOH Policies and Procedures on Infection Control
2010.com.my
 www.medicine .ox.com.

Aseptic wound dressing technique.

Objective:

 To ensure nurses perform wound dressing using aseptic technique and exhibit caring
component during dressing.

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  To provide guideline on aseptic technique for nurses to follow so as to reduce
nosocomial infection and promote wound healing with effective wound dressing
technique.

Policy:

 To ensure that nurses perform wound dressing using aseptic technique and document codition
of wound in the appropriate patients record .

Introduction

This article will describe how a to improve and maintain the standard of wound care in a surgical
ward. It outlines how the project was established; describes the issues the project addressed from
junior nurses up to the surgeons; discusses the problems encountered in carrying out such a project;
and what strategies were used to overcome some of these problems .

The Planning.

(i) A wound survey chart was devised that documented the process of observations to assess the
effectiveness of wound care procedures and dressings for all the different wounds.

(iI) To provide us with a knowledge base for our decision making it was decided that the members of
staff who were on relevant hospital committees, such as, infection control, product review, wound
care, quality assurance, research and professional practice, would carry out literature reviews
pertaining to their specific committee subject and our research project.

Implementation.

After the trial implementation, discussion was held regarding the survey chart during a ward meeting
to obtain feedback from the nurses. Obtaining feedback from all the nurses was difficult because of

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their shift work making it impossible for some to attend. To overcome this problem it was decided to
produce a fairly simple questionnaire for all nurses to answer.

This questionnaire was very successful as it showed that the survey chart was useful in making
nearly all nurses more observant of their patients’ wounds, but unfortunately only half showed any
interest in wanting to learn more about wound care.As the previous questionnaire proved to be a very
efficient, fast and confidential method of obtaining information and comments, future questionnaires
would be used to help obtain information from nurses that could not attend meetings.

Conclusion

Nurses play a crucial role in the management of wounds so they need to have good current
knowledge and be more aware of their own wound care practices so to bring about more effective
wound management .

It has helped the nurses to be more observant of their patients wounds; increased their knowledge
and skills on wound care; assisted them in acquiring more experience and skills ; and set up an on-
going framework for improvements in wound management.

Aseptic Dressing Technique1

Introduction

Maintain asepsis

Expose the wound for the minimum time.

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 Explain the procedure, to gain consent and
co-operation.Draw screens around the bed
and ensure adequate light. Clear the bed
area, close windows, turn off fans,
etc.Adjust bedclothes to permit easy
access to the wound but maintain warmth
and dignity.Assess the wound
dressing.Check
Consult the care planpatient comfort,the
to determine e.g.
type of
position, convenience, need for
dressing required, frequency of change,toilet,etc.
Administer
etc.Make analgesics
sure hair as appropriate
is tied back securely.Washand allow time to
take effect .
and dry hands thoroughly.
An apron should be worn. Additional protective clothing
may be necessary if indicated by the patient’s condition

Wash hand with follow the

hygienic hand wash technique.

Preparation of Equipment.

 Dressing trolley or other suitable surface

 Dressing pack, syringe (for irrigating the wound), cleansing solution and new dressing according to
the care plan/local policy
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 Alcohol hand-rub or hand washing facilities

Disinfect hands. Ensure your

hands are completely dry before
proceeding

Clean the trolley or other appropriate

surface according to local policy

Open the yellow waste bag and put your

hand inside so that the bag acts as a
glove. Use this to remove the soiled
dressing. DressingInspect the dressing
to determine the type and amount of
exudates
Gather the equipment, check the sterility
and expiry date of all equipment and
solutions. Place these on the bottom of
the trolley or somewhere convenient

Disinfect hands. Ensure your hands are

completely dry before proceeding
•Remove the yellow waste bag and place it to
one side.
•Touching only the wrist part of the gloves (or
edge of glove pack) move them to the edge of
the sterile field.
•Taking care not to contaminate the sterile
field, carefully pour the cleansing solution into
the tray.
•Open the dressing, syringe, etc., onto the
sterile field.

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Use a gauze swab dipped in
cleansing solution to clean
aroundthe wound to remove
blood, etc.
wound

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Peel off the backing paper and
apply the new dressing

Wrap all used disposable items in

the sterile field and place in the
waste bag.

Remove gloves and discard into

waste bag

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 When the dressing is secure,
make the patient comfortable and
assist the patient as necessary
into a comfortable
position.Readjust the bed to a
safe height. Replace bed rails if
necessary

Dispose of the waste bag in

clinical waste

Remove apron and wash hands. Return any unused items to the
stock cupboard and clean the trolley according to local policy.
Document the care given and the condition of the wound. Report
any changes or abnormalities

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HAND WASHING TO PREVENT INFECTION.
INTRODUCTION
The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers
with a review of data regarding handwashing and hand antisepsis in health-care
settings. In addition, it provides specific recommendations to promote improved hand-
hygiene practices and reduce transmission of pathogenic microorganisms to patients
and personnel in health-care settings.

New studies of the efficacy of alcohol-based hand rubs and the low incidence of
dermatitis associated with their use are reviewed. Recent studies demonstrating the
value of multidisciplinary hand-hygiene promotion programs and the potential role of
alcohol-based hand rubs in improving hand-hygiene practices are summarized.
Recommendations concerning related issues (e.g., the use of surgical hand antiseptics,
hand lotions or creams, and wearing of artificial fingernails) are also included washing.

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Purpose Of Hand Wash And Evidence of Transmission of Pathogens on Hands

Transmission of health-care--associated pathogens from one patient to another via the

hands of Health Care Workers requires the following sequence of events:

 Organisms present on the patient's skin, or that have been shed onto inanimate
objects in close proximity to the patient, must be transferred to the hands of
HCWs.
 These organisms must then be capable of surviving for at least several minutes
on the hands of personnel.
 Next, handwashing or hand antisepsis by the worker must be inadequate or
omitted entirely, or the agent used for hand hygiene must be inappropriate.
 Finally, the contaminated hands of the caregiver must come in direct contact with
another patient, or with an inanimate object that will come into direct contact with
the patient.

Plain (Non-Antimicrobial) Soap

Soaps are detergent-based products that contain esterified fatty acids and sodium or
potassium hydroxide.. Their cleaning activity can be attributed to their detergent
properties, which result in removal of dirt, soil, and various organic substances from the
hands. Plain soaps have minimal, if any, antimicrobial activity

Alcohols

The majority of alcohol-based hand antiseptics contain either isopropanol, ethanol, n-

propanol, or a combination of two of these products. The majority of studies of alcohols
have evaluated individual alcohols in varying concentrations.

Alcohols have excellent in vitro germicidal activity against gram-positive and gram-
negative vegetative bacteria, including multidrug-resistant pathogens (e.g., MRSA ,
Mycobacterium tuberculosis, and various fungi . Despite its effectiveness against these
organisms, alcohols have very poor activity against bacterial spores, protozoan oocysts,
and certain viruses.

Chlorhexidine

Chlorhexidine base is only minimally soluble in water, but the digluconate form is water-
soluble. The antimicrobial activity of chlorhexidine is likely attributable to attachment to,
and subsequent disruption of, cytoplasmic membranes, resulting in precipitation of
cellular contents . Chlorhexidine's immediate antimicrobial activity occurs more slowly
than that of alcohols.

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WHY SHOULD PROVIDE ANTISEPTIC?

In certain health-care facilities, only one sink is available in rooms housing several
patients, or sinks are located far away from the door of the room, which may discourage
handwashing by personnel leaving the room. In intensive-care units, access to sinks
may be blocked by bedside equipment (e.g., ventilators or intravenous infusion pumps).

In contrast to sinks used for handwashing or antiseptic handwash, dispensers for

alcohol-based hand rubs do not require plumbing and can be made available adjacent
to each patient's bed and at many other locations in patient-care areas. Pocket carriage
of alcohol-based hand-rub solutions, combined with availability of bedside dispensers,
has been associated with substantial improvement in adherence to hand-hygiene
protocols .

To avoid any confusion between soap and alcohol hand rubs, alcohol hand-rub
dispensers should not be placed adjacent to sinks. Health care workers should be
informed that washing hands with soap and water after each use of an alcohol hand rub
is not necessary and is not recommended, because it may lead to dermatitis. However,
because personnel feel a "build-up" of emollients on their hands after repeated use of
alcohol hand gels, washing hands with soap and water after 5--10 applications of a gel
has been recommended by certain manufacturers.

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Recommendations

1. Indications for handwashing and hand antisepsis

 When hands are visibly dirty or contaminated with proteinaceous material

or are visibly soiled with blood or other body fluids, wash hands with an
antimicrobial soap and water .
 Before having direct contact with patients .

 Before wear sterile gloves when inserting a central intravascular

catheter ,before inserting indwelling urinary catheters, peripheral vascular
catheters, or other invasive devices that do not require a surgical
procedure .
 After contact with a patient's intact skin (e.g., when taking a pulse or blood
pressure, and lifting a patient) .
 After contact with body fluids or excretions, mucous membranes, and
wound dressings .
 After contact with inanimate objects (including medical equipment) in the
immediate vicinity of the patient .
 After removing gloves .
 Before eating and after using a restroom, wash hands with a non-
antimicrobial soap and water or with an antimicrobial soap and water .

2. Hand-hygiene technique .

A. When wash hands with an alcohol-based hand rub, apply product to palm of one
hand and rub hands together, covering all surfaces of hands and fingers, until
hands are dry .
B. When washing hands with soap and water, wet hands first with water, apply an
amount of product, and rub hands together vigorously for at least 15 seconds,
covering all surfaces of the hands and fingers. Rinse hands with water and dry
thoroughly with a disposable towel.

Multiple-use cloth towels of the hanging or roll type are not recommended for use in
health-care settings .

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3. Surgical hand antisepsis .

A. Remove rings, watches, and bracelets before beginning the surgical hand scrub .
B. When performing surgical hand antisepsis using an antimicrobial soap, scrub
hands and forearms .
C. When using an alcohol-based surgical hand-scrub product with persistent
activity, follow the manufacturer's instructions. Before applying the alcohol
solution, prewash hands and forearms with a non-antimicrobial soap and dry
hands and forearms completely. After application of the alcohol-based product as
recommended, allow hands and forearms to dry thoroughly before donning
sterile gloves .

4. Skin care .

A. Provide Health Care Workers with hand lotions or creams to minimize the
occurrence of irritant contact dermatitis associated with hand antisepsis or
handwashing .
B. Solicit information from manufacturers regarding any effects that hand lotions,
creams, or alcohol-based hand antiseptics may have on the persistent effects of
antimicrobial soaps being used in the institution

5. Other Aspects of Hand Hygiene .

A. Do not wear artificial fingernails or extenders when having direct contact with
patients at high risk .
B. Keep natural nails tips less than 1/4-inch long .
C. Wear gloves when contact with blood or other potentially infectious materials,
mucous membranes, and nonintact skin could occur .
D. Remove gloves after caring for a patient. Do not wear the same pair of gloves for
the care of more than one patient, and do not wash gloves between uses with
different patients .

6. Health-care worker educational and motivational programs .

A. As part of an overall program to improve hand-hygiene practices of HCWs,

educate personnel regarding the types of patient-care activities that can result in
hand contamination and the advantages and disadvantages of various methods
used to clean their hands .
B. Monitor HCWs' adherence with recommended hand-hygiene practices and
provide personnel with information regarding their performance.
C. Encourage patients and their families to remind HCWs to decontaminate their
hands .

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8. Administrative measures

A. Make improved hand-hygiene adherence an institutional priority and provide

appropriate administrative support and financial resources .
B. Implement a multidisciplinary program designed to improve adherence of health
personnel to recommended hand-hygiene practices .
C. As part of a multidisciplinary program to improve hand-hygiene adherence,
provide HCWs with a readily accessible alcohol-based hand-rub product.
D. To improve hand-hygiene adherence among personnel who work in areas in
which high workloads and high intensity of patient care are anticipated, make an
alcohol-based hand rub available at the entrance to the patient's room or at the
bedside, in other convenient locations, and in individual pocket-sized containers
to be carried by health care workers.

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