Nursing Role For Common Nosocomial Infections
Nosocomial Infections and Surveillance Data,Common Nosocomial Infections, Nosocomial Infection and Mortality Rate,Hygiene Maintenance and Outcomes ,Nursing Role to Prevent or Minimize Nosocomial Infection.
Nosocomial Infections and Surveillance Data
Approximately two million nosocomial (hospital associated)
infections occur annually in the United States, resulting in increased
morbidity, mortality, and cost (US Department of Health & Human Services,
2000).
Despite a decrease in the average length of hospital stay in the United
States from 7.9 days in 1975 to 5.3 days in 1995, the rate of nosocomial
infections rose from 7.2 per 1,000 patient days to 9.8 per 1,000 patient days,
respectively; an increase of 36%.
Category of Infection and Stay Time
Hospital surveillance data indicate a 5% nosocomial
infection rate, or an incidence of 5 infections per 1,000 patient days;
however, the infection rate may be closer to 10% in larger institutions (Wenzel
& Edmond, 2001).
The length of hospital stays due to nosocomial infection can increase up to 4 days for a urinary tract infection (UTI), 8 days for a surgical-site infection (SSI), 21 days for a bloodstream infection, and up to 30 days for pneumonia .
Common Nosocomial Infections
The overall mortality rates associated with nosocomial bloodstream infections and pneumonia can be as high as 50% and 71%, respectively. In addition, these infections have attributable mortality rates of 16% to 35% (Jarvis, 1996).
Serious nosocomial bloodstream infections are associated with central venous catheters (CVCs) placed in patients in intensive care units (ICUs), and it has been estimated that approximately 80,000 CVC-associated bloodstream infections occur in ICUs each year in the United States (O’Grady et al., 2002).
Pneumonia is the second most common nosocomial infection in the
United States, following UTIs, which can add 7 to 30 days to a hospital stay at
an average cost of $4,947 (Jarvis, 1996). Nosocomial pneumonias are mostly
bacterial, with gram-negative bacilli generally the predominant organisms.
How
ever, Staphylococcus aureus (especially methicillin-resistant S. aureus, MRSA)
and Streptococcus pneumoniae have emerged as significant pneumonia pathogens.
Also, outbreaks of Aspergillus pneumonia have been reported in granulocytopenia
bone marrow transplant patients.
Although patients with mechanical ventilation
are not a major proportion of patients with nosocomial pneumonia, they have the
highest risk of developing an infection ( Tablan et al., 1994).
Surgical site infections rank third among reported nosocomial
infections, accounting for 14% to 16% of all infections ( Mangram , Horan,
Pearson, Silver, & Jarvis, 1999). According to Jarvis (1996), hospital
stays increased 7 to 8 days for each SSI, at a cost of $2,734.
The main
criterion for an SSI is that it occurs within 30 days after surgery (or within
1 year with an implant). Studies show that most SSIs occur within 21 days of
surgery, and 12% to 84% of all SSIs are diagnosed after patients are discharged
from the hospital.
Declines in average length of hospital stays and increasing
numbers of outpatient surgical procedures place limitations on surveillance to
identify SSIS ( Mangram et al.). Avato and Lai (2002) found that 72% of
post-coronary artery bypass graft SSIs were identified after discharge,
compared to 28% before patients were discharged.
Without post discharge data,
including surveillance data for SSIs by nurses and other health care providers
in clinics and ambulatory care settings, meaningful comparisons cannot be made,
making it difficult to identify best practices to improve patient safety
(Goldrick, 2003).
Nosocomial Infection and Mortality Rate
The total cost of nosocomial infections to society is unclear;
however, it is estimated that they are the fifth leading cause of death in the
United States, with approximately 90,000 deaths attributed to such infections annually
(Haley, Culver, White, Morgan, & Emori , 1985).
In 1992, the total cost of
nosocomial infections in the United States was estimated to exceed $4.5 billion
(CDC, 1992), which converted to $5.7 billion in 2001 dollars (Stone, PW,
Larson, & Kawar, 2002).
In prospective payment systems based on diagnosis
related groups, Jarvis (1996) estimated that the average cost to the health
care system for nosocomial infections in 1996 ranged from $576 for each UTI to
$22,000 for each bloodstream infection.
In an audit of 72 distinct results in published studies, PW Stone
and colleagues. (2002) found that 40% of the infection control interventions
studied were cost saving interventions.
For example, Papia and colleagues
(1999) found screening high-risk patients for MRSA colonization on admission
prevented nosocomial transmission and was cost-effective. Kotilainen and
Keroack (1997) found that extending ventilator circuit changes from 72 hours to
7 days was cost effective and did not increase rates of nosocomial pneumonia in
ICU patients.
Hygiene Maintenance and Outcomes
Handwashing is considered to be the most important infection
control practice to prevent the transmission of pathogenic microorganisms, and
studies demonstrate a relationship between improved hand hygiene and reduced
infection rates (CDC, 2002c; F. Pittet , 2001).
However, observational studies
indicate that adherence to recommended hand-hygiene procedures among health
care providers had an overall average of 40%, with rates ranging from 5% to 81%
(CDC).
Pittet reports that alcohol based hand rubs may be better than
traditional handwashing because they require less time, contribute to sustained
improvement in compliance, and are associated with decreased infection rates.
A
study comparing the efficacy of an alcohol-based hand rub versus conventional
hand-washing using an antiseptic soap found that the alcohol-based hand rub was
significantly more efficient in reducing hand contamination ( Girou , Loyeau ,
Legrand, Oppein , & Brun-Buisson , 2002).
Another study found that the
introduction of easily accessible dispensers with a waterless alcohol-based
antiseptic led to significantly higher handwashing rates among health care
providers (Bischoff, Reynolds, Sessler, Edmond, & Wenzel, 2000).
The CDC’s
revised hand hygiene guidelines strongly recommend an alcohol-based hand rub
for routine decontamination of hands in certain clinical situations; however,
the CDC also emphasizes that hands must still be washed with soap or an
antimicrobial product and water when visibly soiled or contaminated with blood
or other body fluids.
Nursing Role to Prevent or Minimize Nosocomial Infection
Nurses play an important role in the prevention of nosocomial
infections, and represent the first line of defense for such adverse outcomes.
In a study, the American Nurses Association (2000b) identified five adverse
outcomes related to nurse staffing: length of stay, pneumonia, postoperative
infections, pressure ulcers, and UTIs. Multiple regression analyzes found
statistically significant inverse relationships between nurse staffing and all
five outcome measures.
A recent study reported that a higher proportion of
hours of care provided by registered nurses (RNs) was associated with lower
rates of nosocomial infections (Needleman, Buerhaus, Mattke , Stewart, &
Zelevinsky , 2002).
Other studies have shown that health care facilities with
appropriate levels of nursing staff can prevent infections.
For example, Cho,
Ketefian , Barkauskas , and Smith (2003) showed that a 10% increase in RN
staffing decreased the odds of a patient acquiring nosocomial pneumonia by
9.5%. Kovner, Jones, Zhan, Gergen, and Basu (2002) found an inverse
relationship between RN staffing and post-surgical adverse events.
A study of
the effect of nurses’ educational level on surgical patient mortality found,
after controlling for all other risk factors, that surgical patients who were
cared for in hospitals where a higher proportion of direct care RNs held
bachelor’s degrees had a better survival rate over those treated in hospitals
where a lower proportion of staff nurses held bachelor’s degrees (Aiken, Clarke,
Cheung, Sloane, & Silber, 2003).
Although these studies do not imply
causation, nurses who incorporate evidence based infection prevention and
control recommendations into their practice can decrease infectious adverse
events and the odds of failure to rescue while reducing health care costs.