FACTORS CONTRIBUTING TOWARDS POST SURGICAL INFECTIONS IN KENYATTA NATIONAL HOSPITAL, NAIROBI KENYA.

Transcription

1 A RESEARCH PROPOSAL PRESENTED IN PARTIAL FULFILLMENT FOR THE AWARD OF A DEGREE IN BACHELOR OF SCIENCE IN NURSING OF THE UNIVERSITY OF NAIROBI. FACTORS CONTRIBUTING TOWARDS POST SURGICAL INFECTIONS IN KENYATTA NATIONAL HOSPITAL, NAIROBI KENYA. By WACHIRA ALEX KAMAU BSC (N) IV H32/6694/2001 SUPERVISOR MR. WAITHAKA PETER MUCHINA Bse N, MPH (UON) LECTURER SCHOOL OF NURSING SCIENCE UNIVERSITY OF NAIROBI. DATE (AUGUST 2006 )

2 TABLE OF CONTENTS TABLE OF CONTENTS,. 11 DECLARATION IV CERTIFICATE OF APPROVAL V ACKNOWLEDGEMENT DEDiCATION ABBREVIATION VI VII VIII OPERATION DEFINITIONS IX EXECUTIVE SUMMARY,. X CHAPTER ONE INTRODUCTION [ 1.1 PROBLEM STATEMENT JUSTIFiCATION OBJECTiVES MAIN OBJECT/VE SPECIFIC OBJECT/VE RESEARCH QUESTIONS HyPOTHESiS EXPECTED BENEFIT 8 CHAPTER TWO LITERATURE REVIEW INTRODUCTION KNOWLEDGE ATTITUDE AND PRACTICE [0 2.3 FACTORS AFFECTING POST SURGICAL INFECTIONS [ [ 2.4 EFFECTS OF POST SURGICAL INFECTION [2 CHAPTER THREE, METHODOLOGY, STUDY DESIGN [4 3.1 STUDY AREA [4 3.2 STUDY POPULATION [4 3.3 SAMPLING [ Sampling criteria Inclusion Criteria Exclusion Criteria SAMPLE SIZE DETERMINATION SAMPLING METHOD [7 3.6 STUDY INSTRUMENTS [7 3.7 STUDY INSTRUMENT PRE TESTING 17 ii

3 3.8 DATA RECORDING AND PROCESSiNG DATA ANALYSIS AND PRESENTATION RECRUITMENT AND TRAINING OF RESEARCH ASSISTANTS STUDY limitations ETHICAL CONSIDERATION 19 TIME FRAME 20 GHANT CHART 21 STUDY BUDGET 22 REFERENCES ; 23 APPENDiCES 25 ApPENDIX I: OBSERVATION CHECKLIST FOR PATIENTS 25 APPENDIX II: QUESTIONNAIRE FOR HEALTH CARE WORKERS 28 ApPENDIX III: OBSERVATION CHECKLIST 31 ApPENDIX IV: RESEARCH PARTICIPANTS CONSENT FORM 33 ApPENDIX V: LETTER TO THE ETHICAL AND RESEARCH COMMITTEE.. 34 ApPENDIX VI: LETTER TO THE DIRECTOR KENYATTA NATIONAL HOSPiTAL 35 ApPENDIXVII: LETTER TO THE MINISTER MINISTRY OF EDUCATION 36 ApPENDIX VII: MAP SHOWING KENYATTA NATIONAL HOSPITAL 37. III

4 DECLARATION I Wachira Alex Kamau do hereby declare that this research proposal is my original work and has not been submitted for an award of degree or Diploma in any University. s;9natudx---- d Date: Sf'$''''''=D,( 'l--0-o to,. / ~ IV

5 CERTIFICATE OF APPROVAL This research proposal has been submitted for examination for the award of the degree of Bachelor 0 cience in Nursing with my approval as a university supervisor. Mr. Waithaka P. Muchina. Ssc N, MPH (UON) Lecturer, School of Nursing Sciences. University of Nairobi. v

6 ACKNOWLEDGEMENT I wish to express my sincere gratitude and appreciation to all those people who helped me in one way or the other in the development of this proposal. I wish to thank Mr. P.M. Waithaka who is my lecturer and my supervisor in all his efforts to see me through. I would like to thank the several institutions and librarians who have helped me to obtain the necessary data. Your kindness is highly appreciated. God bless you all. VI

7 DEDICATION I dedicate this proposal to my parents Mr and Mrs. William Wachira for their continued support and for having educated me up to this level I say thank you and God bless you. And to my late Grandfather Joseph Muriuki Mathenge who loved to see me graduate. Rest in Peace. VII

8 ABBREVIATION AIDS BSC (N) CDC CSSD OMS HAl HCW HIV I.C.P K.A.P KNH MOH NNIS SPSS SSI U.O.N Acquired Autoimmune Deficiency Syndrome Bachelor of Science Nursing Centre for disease control and prevention Central Sterilizing Services Department. Director of Medical Services Hospital acquired infections Health care workers Human Immunodeficiency Syndrome Infection control and prevention practice. Knowledge attitude and practice Kenyatta National Hospital Ministry of Health National Nosocomial infection surveillance Statistical Package for Social Sciences Surgical site infection University of Nairobi WHO World Health Organization viii

9 OPERATION DEFINITIONS Clean Contaminated wound: clean contaminated wounds are from clean operations in which the gastrointestinal or respiratory track was entered but no significant spillage occurred. Clean wound: They are wounds from operations in which the gastrointestinal, genitals urinary or respiratory tract is not entered, no apparent information is encountered and no break in aseptic technique occurs, however the following operations are excluded from this category cholecystectomy, appendicectomy in passing and hysterectonomy are excluded if no acts inflammation occurs. Contaminated wound: Contaminated wounds are from operations in which acute inflammation without pus formation is encountered or in which gross spillage from a hollow viscous occurs, fresh traumatic wounds and operation wounds in which a major break in aseptic technique occurs are included in this category. Dirty wound: They are created by operation in which pus is encountered or a perforated viscous is found, traumatic wounds more than fours hours old are included in this group. Infected wound: All wounds and clinical evidence of infection such as pus discharge, abscess formation or indurations, including wound rupture (or wound gaping) or oozing of the main wound (whether serous or bloody). Possible infected wound: if it develop the signs of inflammation or a serous discharge wound classification Uninfected wound: if it heals per primes without discharge. IX

10 EXECUTIVE SUMMARY This is a cross sectional survey focusing on the infection control and prevention practices by the health care workers in Kenyatta National Hospital Nairobi and how these practices contribute to post surgical infections. The main objective of the study is to assess the ICP practices by HCW in KNH surgicar units and to establish the causes of post surgical infections in patients who have had their surgery done in KNH. The study will involve observation of patients who have had surgery done in theatres of KNH.A sample size of a total of 276 patients will be observed and a follow up done in the wards and clinics to see the outcome of the operation. The study tools will include a questionnaire for HCW, whose main items include CME attendance by HCW, their ICP practices and activities of the Hospital's ICP committee. There will be an observation check list which will focus on among others ICP practices by HCW in theatre this includes gloving, scrubbing, gowning. An observation check list for the patients will be filled separately and will focus on the patient condition pre and postoperatively. Bsc. N Interns will be recruited and trained on study tools implementation. Before commencing on the study authority will be sought from the research and ethical committee of KNH as well as from the OMS in MOH. The findings are expected to generate useful information on any existing "gaps" if any in the practice of ICP among the HCW and secondarily offer suggestions on the way forward with regard to this issue. The study is expected to take a total of 27 weeks at a cost of Kshs 292,000 x

11 CHAPTER ONE 1.0 INTRODUCTION Post operative and hospital acquired infections have been a problem for as long as there have been hospitals, attempts to prevent their occurrence and spread began hundreds of years ago when separate hospitals were built for patients with communicable diseases fever hospitals, small pox hospitals, tuberculosis sanitoria and "pest houses" were established in efforts to separate the infected patients from other patients and from the community [America College of surgeons, 1998]. The ideal surgical operation results in primary healing an uneventful recovery and cure of the disease. When an operation fails to achieve these objectives because of complications it becomes expensive. The price tag includes human suffering, hospitals utilization as we as the patients loss of income and productivity. (Ponce-de- Leon, 1991) In spite of the advances of the twentieth and twenty first century surgical infection remains the principal course of prolonged and debilitating complications of surgery (infection in surgical practice, [Erick W. Taylor 1992]. Hospital acquired sepsis is unacceptable given that patients entrust their lives to the confidence and skills of health care workers, it would be sad to note that those who should be taking care of the patients are at the fore front of endangering their lives. [Erick W. Taylor 1992]. The practice of infection control and preventions (ICP) is quite significant in the prevention of post surgical infections and maintenance of quality of care in health care facilities. In these facilities some areas are more sensitive to compromised practice of ICP owing to the nature of procedures performed and clients involved such as theatre when surgical operations are done.

12 Apart from reluctance, lack of knowledge, lack of policies and protocols of infection control in facilities. Lack of resources would also contribute to poor infection control practices. Lack of administrative and financial has led to inadequate key ICP personnel training thus time or no standard guidelines on practice (international federation of infection control, 1997). The purpose of this study is to assess the factors that contribute to post surgical infections in Kenyatta National Hospital and secondarily offer suggestions that would assist in bridging the gaps that may exist on knowledge, attitudes and practice of ICP among HCW. This is with the hope of reducing maternal morbidity and mortality 2

13 1.1 PROBLEM STATEMENT Hospital acquired infections are one of the main causes of morbidity and mortality in hospitalized patients at the present time globally (CDC, 2001). The surgical site infection SSI rate reported from countries with more resources is often below 5%. In Brazil and Mexico the SSI rates are usually between 10% and 15% \Santos KRN 1997). Reported rates from African countries range from 19% to 38.7% (Kofiso B 1998). There's little knowledge on the magnitude, consequences and the related risk factors of SSI in countries with fewer resources. In countries where there have been studies, the SSI rates frequently are reported higher than 10% in the USA it is estimated at 3 %( Nicholos 1990). In a study done in Ethiopia it was estimated that each patient with postoperative infection did cost at least 100 US Dollars extra and that 14 of 18 deaths among surgical patients were attributed to Nosocomial infections (Haste-Gabr E1988). The infection rate in hospitals in Tanzania is not known. The economic impact of Nosocomial infections in countries with fewer resources is far greater than in developed countries due to the larger number of infections and small health budget (pounce-de -Leons1991). Nosocomial infections are an important health problem world wide but the efforts to control them has been initiated only in some developing countries. Lack of administrative and financial support has led to inadequate key ICP personnel training thus little or no standard guidelines on ICP practice [International federation of infection control 1997). Post operative wounds infections can be disastrous to the patient. It involves suffering of the patients, a risk to other patients, extra cost because of the need for more operations, blood, antibiotics nursing and prolonged hospitalization. (Erickson M, 2001) Nosocomial infections are too expensive to be tolerated in terms of prolonged hospital stay, time for treatment, increased use of staff time for treatment, Increased cost of supplies for would care, loss of man hours may be the largest but hardest to measure. The informed medical consumer is unlikely to return to a 3

14 hospital or recommend a hospital where they became more ill while they were inpatients than they were before being admitted (CDC, 2001). Some of the effects of hospital acquired infections include loss of life, incapacitation which leads to less production by the person and to the family at large psychological trauma, long periods of hospitalization and in other cases change of lifestyle e.t. c. Infection control committees should be formed in health care facilities and may include a simple team of a doctor, infection control nurse and a lab technician where applicable a record officer: (WHO, 2003) In other facilities the team may be bigger depending on the size of the facility and staff availability. In Kenyatta National Hospital the ICP committee has designated an infection control nurse in each of its department. The hospital developed a guideline in 1999 titled "handling infectious diseases" on the guideline they have highlighted precautions on patients' placement, patient teaching and instructions, visitors' teachings & instruction. 4