Original Article
Compliance Towards Infection Prevention and Control Practices in Orthopedic Department of a Tertiary Care Hospital.
Authors:
Latha T, Assistant Professor, MCON Manipal, Manipal Academy of Higher Education, Manipal,
Anil K Bhat, Professor and Head, Department of Orthopedics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal,
Manjunatha Hande, Professor and Head, Department of Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal,
Chiranjay Mukhopadhyay, Professor, Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education Manipal,
Elsa Sanatombi Devi, Professor, MCON Manipal, Manipal Academy of Higher Education Manipal,
Baby S Nayak, Professor, MCON Manipal, Manipal Academy of Higher Education, Manipal,
Anice George, Professor, MCON Manipal, Manipal Academy of Higher Education, Manipal.
Address for Correspondence
Anil K Bhat,
Professor and Head,
Department of Orthopedics,
Kasturba Medical College,
Manipal Academy of Higher Education,
Manipal.
E-mail: anilkbhat@yahoo.com.
Citation
Latha T, Bhat AK, Hande M, Mukhopadhyay C, Devi ES, Nayak BS, George A. Compliance Towards Infection Prevention and Control Practices in Orthopedic Department of a Tertiary Care Hospital. Online J Health Allied Scs.
2019;18(3):11. Available at URL:
https://www.ojhas.org/issue71/2019-3-11.html
Submitted: Sep 10,
2019; Accepted: Oct 16, 2019; Published: Oct 30, 2019 |
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Introduction:
Hospital associated infection is one of the indicators of quality care and patient safety. Though the risk of infection is present everywhere, the hospital is considered as a high risk area. For every 100 admitted patients in the hospital, seven in developed and ten in developing countries are at a threat of being affected by hospital related infection (1). Infection control is the responsibility of all the employees of the hospital. The knowledge and practice of infection control practices are the key element in breaking the chain of infection. Simple measures such as hand washing can reduce infection in the hospital to a great extent (2). The additional measures such as adherence to the use of Personal Protective Equipment (PPE) and following aseptic techniques during the invasive procedures are found to be useful in protecting the patient as well as Healthcare Professionals (HCPs) from infection (3). Non-compliance to adhere to the infection control guidelines has resulted in various out-breaks (4).
Though hand hygiene is considered very important in preventing infection, the global adherence to it among healthcare workers is poor and the overall compliance rate is less than fifty percent (5-7). The prevention and control of hospital associated infection is given little importance due to a lack of qualified human resources, lack of organization and observation systems, poor staff – patient ratio, deprived cleanliness, dearth of hygienic water, absence of legislation mandating hospital accreditation, and poor attitudes and compliance to elementary infection control procedures amongst hospital employees (8).
The risk of serious infection are likely to be more among Orthopedic patients due to the nature of problems such as repeated surgical procedures, frequent hospitalization, traumatic and contaminated wounds, insertions and removal of implants, etc. Therefore, the healthcare professionals working in the orthopedic department must have sound knowledge on infection prevention strategies. However, having merely knowledge on infection control measures will not to reduce the rate of infection (9) unless it is practiced during the patient-care activities (11). Therefore, this study was conducted with the aim of analyzing the situation of infection control practices in the Orthopedic department.
Methods
A quantitative approach with cross sectional descriptive survey design with quantitative approach was adopted. The study was carried out in the Orthopedic units of a selected hospital which has more than 2000 beds with all the super-specialties catering to the health needs of a large population. It also meets the teaching needs of medical, nursing and other allied health courses. The hospital is certified by International Organization for Standardization (ISO) 9001 and ISO 14000 and accredited by National Accreditation Board for Hospitals & Healthcare Providers (NABH). Orthopedic department has five wards with a total of 185 beds. The bed occupancy rate was more than 80% during the study period. It has a well-established trauma center to meet the orthopedic emergencies, separate operation theaters (with 5 operation rooms) for orthopedic patients and one orthopedic ICU with 16 beds. Doctor to patient ratio and hospital facilities were maintained as per the description of the Medical Association of India (MCI). Nurse to patient ratio was as per NABH requirement in orthopedic wards, operation rooms, and Orthopedic ICU and trauma centers.
Data collection tool
Infection control practices were observed during the patient care activities using observational checklist. There was no standardized tool available to measure the infection control practices. Hence, observation checklist was prepared after an extensive review of World Health Organization (WHO) and Center for Disease Control (CDC) infection control guidelines (11,12), infection control manual of selected hospital, discussion with microbiologists, infection control nurses and Hospital Infection Control Committee (HICC) members of other reputed hospitals. The checklist had a total of 38 items and four subsections: 1) Hand hygiene with soap and water and/or alcohol based hand sanitizer (13 items), 2) Use of personal protective clothing (5 items), 3) Personal factors (12 items), and 4) Procedure related factors (8 items). This was an observational check list with ‘yes’ or ‘no’ options. There were no negative items.
The content validity of the tool was established by seven experts. Minor corrections were done as per the suggestions of experts. Infection control practices during patient care activities were observed.
Inter-rater reliability technique is used to find the reliability. The calculated reliability co-efficient was r = .985. Altman Bland plot (figure 1) showed an excellent agreement between the raters (1.95 to -2.05).
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Figure 1: Altman Bland Plot showing the reliability of observational checklist on infection control measures |
Sample size
The infection control measures were observed and the proportionate sample size was calculated. However, additional observations were made to check for better compliance.
Individual specific infection control measures |
Required numbers of observations |
Observations made |
Hand Hygiene with Hand- sanitizers
Hand Hygiene with soap and water |
164 (water + hand sanitizers) |
200 (121 water + 79 hand sanitizers) |
Use of personal protective clothing |
115 |
131 |
Personal factors |
42 |
89 |
Removal of jewellery |
29 |
44 |
Infection control practices during various procedures |
67 |
71 |
Total |
417 |
535 |
Sample size was not calculated for unit specific (orthopedic wards, OTs, ICU and trauma triage) infection control measures and all seven areas were observed.
Ethical Consideration
Administrative permission was taken from the Medical Superintendent and Chief Operating Officer, Head of the orthopedic department and Chairperson of Hospital Infection Control Committee. Institutional Ethics Committee (IEC) clearance was obtained. The project was registered in Clinical Trail Registry – India (CTRI/2018/01/011510). Informed consent was taken from the study subjects after explaining the study details. HCPs were explained that patient care activities will be observed. But they were not aware of the specific events that will be observed. This was kept confidential to reduce the observer bias.
Data collection and analysis
The principal investigator has participated in patient care activities along with other HCPs and observed the activities carried out by different categories of HCPs using observational checklist. Since the majority of the activities were carried out in the morning, less in the afternoon and least at night, the number of observations also matched this. The data were coded and entered in SPSS 16.0 version. The analysis was done using frequency and percentage.
Results
A total of 535 observations were made on different infection control practices. Table 1 describes the observation on hand hygiene using alcohol based hand sanitizer, and soap and water.
| Table 1: Frequency and percentage of observation on hand hygiene using hand sanitizer (N=121) |
| Observations |
With soap and water (N=79) |
With hand sanitizer (121) |
f |
% |
F |
% |
Wash hands before the procedure |
36 |
45.6 |
41 |
33.9 |
Wash hands after the procedure |
60 |
75.9 |
84 |
69.4 |
Wets hands with water before using soap |
63 |
79.7 |
NA |
NA |
Palm-to-palm rubbing |
68 |
86.1 |
110 |
90.9 |
Right palm over left dorsum and vice-versa |
67 |
84.8 |
108 |
89.3 |
Palm-to-palm with fingers interlaced |
62 |
78.5 |
97 |
80.2 |
Back of fingers to opposing palms |
59 |
74.7 |
86 |
71.1 |
Rotational rubbing of each thumb |
59 |
74.7 |
62 |
51.2 |
Rub tips of finger in opposite palm |
63 |
62 |
67 |
55.4 |
Rub each hand with opposite hand |
49 |
79.7 |
87 |
71.9 |
Rinse hand with water |
58 |
73.4 |
NA |
NA |
Dry the hand |
52 |
65.8 |
NA |
NA |
Dispose the towel |
53 |
67.1 |
NA |
NA |
Palm to palm rubbing was done more frequently (90.9%) in hand disinfection using hand sanitizers. Hand disinfection after the procedure (69.4%) was twice more than before performing the procedure (33.9%). Though, in more than 90% of the event, hand washing was done, all the steps of hand washing were not performed. In more than half (54.4%) of events, hands were not disinfected before the procedures, but in 75.5% of the events, hands were washed after the procedure. Performing hand washing techniques was better with soap and water than hand disinfection with hand sanitizer.
The personal protective equipment usage during patient care activities.
Among 131 observations, disposal of gloves was in 101 (75%) events, gloves were appropriately disposed in 99 (76.7%) events and four (1.6%) events HCPs carried gloves in their pockets.
Personal factors such as personal hygiene, grooming and handling of the soiled linen and waste observed (n=89) and are given along with removal of jewellery in Table 2.
| Table 2: Personal factors of infection control measures followed in the orthopedic wards in frequency and percentage (N=89) |
| Personal factors |
Frequency |
Percentage |
Personnel wearing clean clothing |
87 |
97.8 |
Good personal hygiene, including hair and body cleanliness, is practiced |
88 |
98.9 |
Fingernails clean and trimmed |
79 |
88.8 |
Hair is neat and off the collar |
86 |
96.6 |
Personnel follow strict clothing and linen handling procedures to avoid contaminating their clothes |
81 |
91.0 |
Disposable gloves are worn when handling contaminated equipment |
79 |
88.8 |
Removal of jewellery(N=44) |
Frequency |
Percentage |
Remove jewellery when going from a dirty to a clean area |
36 |
81.8 |
Remove jewellery when hands are soiled |
41 |
93.2 |
Wash hands before and after feeding the patients. |
42 |
95.5 |
Wash hands after combing hair of the patient |
40 |
90.9 |
Wash hands after using a handkerchief or tissue |
26 |
59.1 |
Wash hands before and after handling soiled linen |
39 |
88.6 |
Personal factors of HCP's regarding infection prevention and control were very good. However, wearing gloves, and clean and trimmed finger nails were 88.8% only. Disinfecting hands and removal of jewellery such as finger rings and watch were good (>80%) except for hand disinfection after using hand kerchief/tissue (59.1%).
The procedural specific infection control practices during wound care (wound dressing, wound inspection, suture removal, etc.) and other procedures (medicine administrations: oral, intravenous, intramuscular, subcutaneous and local application; Limited Access Dressing – LAD care, nasogastric tube feeding, position change, application or removal of skin or skeletal traction, passive exercises, etc.) were observed. The data is given in the following Figure 2.
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Figure 2: Infection control measures followed during patient care activities |
Infection control measures followed correctly during wound care was 92.9%, during the dressing was 97.7.% and during different procedures such as medication administration, collection of samples, feeding, change of positions, pre and post-operative care, etc. was 74.6%.
Discussion
Hospitals have numerous disease causing pathogens. Infection control practices play an important role in preventing infection among patients. A total of 535 observations were made during different activities of patients care. Hand hygiene using hand sanitizer before performing the procedure (33.9%) was comparatively lesser and hand wash after the procedure (69.4%) was good. Nevertheless, hand disinfection using soap and water was better, showing 45.6% compliance before procedure and 75.9% compliance after procedure. Hand hygiene is one of the essential components of infection control practice. It must be performed by all healthcare professionals. A few of the healthcare professionals expressed different opinions regarding poor compliance of hand disinfection. The first one is skipping the hand wash during heavy hours is acceptable when the hands are not visibly dirty. The second excuse is that frequent hand washing is time consuming and delays the patient care activities. Numerous use of soap or hand sanitizer hardens the skin and loses its texture is the third belief. Fourth opinion expressed by them was that gloves cannot be worn immediately after hand wash as wearing gloves on dry hand is easier. A few of the technical staff articulated that they were not sure of killing pathogens when they washed their hands is the fifth judgment. However, they agreed that hand disinfection must be practiced strictly before sterile procedures such as performing surgery, dressing and while handling central lines. Similar reporting is available in the previous studies. Infection control is the responsibility of all HCP's in the hospital. On the other hand, there are many factors influencing the proper practice. Known barriers against following standard precautions are discomfort, lack of time and absence of role model to use PPE (13).
Infection control measures such as availability of hand sanitizers, isolation of MRSA infected patients, use of barrier precautions, routine use of nasal mupirocin and antiseptic body differs from country to country (14). In the present study, use of personal protective equipment was good. Infection control measures followed correctly during wound care was 92.9%, during the dressing was 97.7% and during different procedures was 74.6%.
There are studies available regarding perceived practices of infection control measures followed, but there were no studies available on observing the infection control practices in the hospital. Kotwal and Taneja (13) from New Delhi reported that the knowledge on standard precautions was 100% for interns and 84% for nurses (total of 92, 95% CI, 84.4-96.5, p=0.006). The practice of standard precautions was not similar among healthcare professionals in the same hospital. Usage of gloves was higher at 90%among the interns whereas it was only 80% among nurses (p=0.161). Hand washing was good among nurses (64%) compared with interns (40%) (p=0.011).
A study from South India showed positive results for nursing students in practicing universal precautions (use of gloves – 96%, washing hands – 92%, use of masks – 98%) than medical students (use of gloves – 78%, washing hands - 66%, use of masks - 50%) (15). Another study with regard to the use of PPE showed the use of hand sanitizers among doctors was 71.5% and nurses was 81.1%. Also, 82.6% doctors and 90.6% nurses were using gloves wherever needed. Use of masks (doctors – 34.8%, nurses – 67.9%), eye protector (doctors – 19.2%, nurses – 28.3%) and use of gowns (doctors – 33%, nurses 18.85) was poor (16).
Hospital attire is important in preventing transmission of infection (17). Most of the hospitals in India have no specific attires for HCP's except for OT. Nurses have specific dress code in majority of the hospitals and for other healthcare professional dress code is not mandatory. Around 12% of hospitals in America motivated short sleeves and 7% observed that the HCPs follow this practice. Around 20% of the hospitals were encouraging removal of watches and jewellery. Nearly 8% felt that use of neckties should be stopped and 63% of hospitals felt that all HCPs should wear a specific type of footwear (17). Nevertheless, no such report is available from Indian hospitals. The most of the HCP's in the current setting followed a clean and hygienic attire.
Improving the nurse patient ratio would help the nurses to practice infection control in a better way. Similarly, behavior changing strategies such as frequent motivation and reinforcement will certainly help in improving the infection control practices of doctors. Doctors and nurses have mandatory professional development (such as CME/CNE) program in which infection control measures can be stressed. Such programs can be extended to other healthcare professionals (physiotherapists, orthopedic and anesthesia technicians and housekeeping staffs) in order to improve infection control practices in the hospital.
All the standard policies and periodic in-service education were strictly followed in the orthopedic wards. The only infection control measure not followed in the hospital was screening of HCP's at the time of recruitment. However, HCP's are screened when suspected for infectious diseases or any outbreaks in the hospital. The specimen collection and transportation procedure were also very good.
Conclusion
International agencies such as WHO, CDC and international and national infection control societies have developed useful guidelines to reduce infection in the hospital. Compliance towards such infection control practices in the hospital is mandatory. All the infection control practices in the study setting were good except hand hygiene. Further studies can be conducted to explore the barriers to good compliance towards infection control practices through qualitative studies.
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