Những kết luận mới của luận án: 1. Luận án cho thấy tình trạng tuân thủ một số quy trình kiểm soát nhiễm khuẩn như vệ sinh tay, thay băng vết thương và đặt catheter tĩnh mạch ngoại vi của nhân viên y tế tại bệnh viện Thanh Nhàn còn chưa đồng bộ. 2. Luận án cho thấy một số yếu tố liên quan đến nhiễm khuẩn bệnh viện như tuổi, giới tính, khoa lâm sàng, tình trạng phẫu thuật và thời gian nằm viện. 3. Can thiệp đa phương thức cho thấy có tính hiệu quả cao khi cải thiện tuân thủ thực hành các quy trình kiểm soát của điều dưỡng và cải thiện tình trạng nhiễm khuẩn bệnh viện.
Trang 1HAI PHONG UNIVERSITY OF MEDICINE AND PHARMACY
TRAN THANH TU
COMPLIANCE WITH INFECTION CONTROL
PROCEDURES AND EFFECTIVENESS OF INTERVENTIONS
AT THANH NHAN HOSPITAL IN 2018 - 2020
Major: Public Health No: 9720701
SUMMARY OF DOCTORAL THESIS
HA NOI – 2022
Trang 2MEDICINE AND PHARMACY
Supervisors:
1 Assoc Prof Dr Pham Minh Khue
2 Assoc Prof Dr Doan Ngoc Hai
Trang 3Nosocomial infections are one of the leading public healthproblems worldwide Nosocomial infections occur after the patient isadmitted to the hospital and are considered an important indicator ofhospital quality, the ability to organize management and the ability toensure patient safety of the medical facility Nosocomial infections arespread by multiple routes through surfaces (especially hands), water,air, the gastrointestinal tract, and surgery In particular, the role ofhealth workers in the transmission of NCDs is significant Manynosocomial infections are caused by transmission from one patient toanother through health care workers, especially nurses
Thanh Nhan Hospital is a class I general hospital of Hanoi withinvested treatment equipment, but the treatment area is notsynchronized, the number of patients is overloaded, as well as theposition to perform well the hospital's infection control work is notappropriate In addition, through internal assessment, the hospital'sinfection control system has not been systematically and regularlyimplemented The compliance status of hospital-acquired infectioncontrol procedures among health workers in general and nurses inparticular is still low According to the monitoring report of ThanhHospital's Infection Control Department, it is necessary to find out thestatus of compliance with the basic infection control procedures andimplement appropriate interventions to improve the level ofcompliance with the infection control measures of the staff healthworkers, especially nurses The study: "Compliance with infectioncontrol procedures and effectiveness of interventions at Thanh NhanHospital in 2018-2020" was conducted with the following objectives:
1 Describe the compliance with some hospital infection preventionand control procedures and related factors at Hanoi Thanh NhanHospital in 2018-2019
2 Identify some factors related to nosocomial infections at hospitals
Trang 41 The thesis showed that the compliance with some infectioncontrol procedures such as hand hygiene, wound dressing change andperipheral venous catheterization of medical staff at Thanh Nhanhospital was insufficient.
2 The thesis showed a number of factors related to nosocomialinfections such as age, gender, clinical department, surgical status andlength of hospital stay
3 Multimodal interventions were shown to be highly effectivewhen improving nursing compliance with infection control proceduresand improving nosocomial infections, enabling infection controlpractices to be integrated into hospital regulations
STRUCTURE OF THE THESIS
The thesis has 136 pages, including: Proposal 02 pages; Chapter 1.Overview: 31 pages; Chapter 2 Research subjects and methods: 26pages; Chapter 3 Research results: 42 pages; Chapter 4 Discussion:
31 pages; Conclusion: 02 pages, Recommendation: 01 page Theresults of the thesis are presented in 31 tables and 11 tables The thesisuses 165 references, including 28 Vietnamese and 137 Englishliterature
Chapter 1 OVERVIEW 1.1 The concept of hospital infection
Hospital-acquired infections: or healthcare-associated infections(HAIs) are infections that occur in healthcare facilities at least 48hours after a patient's admission, but not was either incubating orsymptomatic at the time of admission Nosocomial infections includeboth hospital-acquired infections and occupational infections inhealth-care workers
1.2 Status of compliance with some hospital infection control procedures among medical staff's
Enhancing compliance with infection control procedures, especiallyhand hygiene procedures, safe injection procedures, sterilization-sterilization procedures, wound dressing changes and peripheralvenous catheterization procedures, closure role as the focus ofintervention programs to improve infection control capacity inhospital departments and units
Trang 51.3 Epidemiological characteristics of nosocomial infections and related factors
Pathogens that cause HAIs can come from many different sources,causing different types of HAIs, including common types such as:
- Respiratory tract infections (including ventilator-associatedpneumonia)
- Ssurgical site infection
- blood infection related Central-line catheterization
- Urinary tract infections during catheterization
In addition, some other hospital-acquired infections such as ventilator-acquired pneumonia, gastrointestinal infections, otherprimary bacteremia unrelated to catheter use, and other urinary tractinfections unrelated to catheter use HAIs can also be groupedaccording to the organ system affected such as ear, eye, nose, andthroat infections, lower respiratory tract infections (includingbronchitis, tracheitis, bronchiolitis, lung abscesses or edema withoutevidence of pneumonia), skin and soft tissue infections, cardiovascularinfections, bone and joint infections, nervous system infections, andreproductive tract infections
non-1.4 Multimodal intervention model in enhancing compliance with infection control procedures among healthcare workers
1.4.1 Multimodal strategies in infection control
The development of health worker training activities is thecentral intervention for the improvement of KS, however, thesustainable implementation and maintenance of the HCWimprovement interventions requires a systematic approach with manyinvolved parties Current evidence supports a multimodal strategy inthe development of infection control programs A “Multimodal”strategy is defined as a strategy consisting of several elements orcomponents (three or more; usually five) implemented in an integratedmanner with the aim of improving outcomes and changing behavior.Because In 2009, WHO published guidelines for the implementationand evaluation of hand hygiene programs in health facilities [20] Thisguide identifies five components that need to be implementedspecifically: alcohol-based hand sanitizer at the point of care orperformed by health workers, training and education, observationalfeedback and performance outcomes, and recommendations.reminders (e.g posters) and administrative/environmental/institutional
Trang 6support WHO guidelines have been widely disseminated around theworld and are reported to have had a major impact on bacteriologicalcontrol in hospitals Later, the multimodal strategy was alsodisseminated by WHO and applied to other activities in improving theinfection control processes of health workers.
The five most common components include: (i) system change(the availability of appropriate infrastructure and supplies to enablegood practice of infection prevention and control); (ii) education andtraining of health care workers and key players (eg, managers); (iii)monitor infrastructure, practices, processes, results and provide datafeedback; (iv) workplace reminders/contact information; and (v)change the culture within the facility or enhance the safe environment
In infection control, a multimodal strategy typically includes atrio or more components (e.g improving governance, leadership andaccountability; educating and training service providers; examining,monitoring and evaluation; and effective communication) are donecollectively and continuously to maximize outcomes and changebehavior The ultimate goal is to create an organizational culture andpatient-safe environment that supports overall quality improvement
1.4.2 In Viet Nam
In nosocomial infection prevention programs, hand hygiene (handhygiene) is always an indispensable component, playing an importantrole in infection control Hand hygiene is a part of body hygiene that
is included in the general hygiene of the hygiene industry, it isconsidered that hand washing along with body, eye and mouthhygiene is a great achievement of mankind Body biology is included
in the common curriculum of citizenship education of countriesaround the world In addition, other processes are also implementedsuch as enhanced sterilization - sterilization or safe injection
1.4.3 Effectiveness of multimodal interventions in improving compliance with infection control procedures
The factors involved in infection control are: Encouraging healthcareworkers to perform procedures; strengthen facilities; supervise theimplementation of the HCW procedures It can be confirmed thatnosocomial infections occur related to many factors including: people,hospital environment and patients Therefore, an implementation of aninfection control program also includes multimodal activities, withmulti-sectoral mobilization and participation of all
Trang 7Chapter 2 SUBJECTS AND RESEARCH METHODS
2.1 Research subject, place and time
2.1.1 Research subjects
2.1.1.1 Patient
- Criteria for patient selection include:
+) The patient is in inpatient treatment
+) Have a hospital stay >48 hours
+) Present at the time of investigation
Exclusion criteria include:
+) Patients with a hospital stay of less than 48 hours, patients treated
on an outpatient basis
+) The patient is incubating an infectious disease when admitted to thehospital, detection of this patient is mainly based on abnormalparaclinical signs such as X-ray, blood tests, etc., and clinicalexamination showing signs of the disease infection
2.1.1.2 Medical staff for goals 1 and 2
Selection criteria include:
+) Directly examine, treat and care for patients
+) Present at the time of study
+) Agree to participate in the study
- Exclusion criteria
+) Those who are in school, on maternity leave, sick or refuse toparticipate
2.1.1.3 Nurses for the goal 3
Selection criteria include:
+) Directly taking care of the patient
+) Present at the time of study
+) Agree to participate in the study
+) Participating in phase study
- Exclusion criteria
+) Those who are in school, on maternity leave, sick or refuse toparticipate
2.1.2 Place and time of study
The study was conducted at the clinical departments of Thanh NhanHospital, Hanoi
2.1.3 Research time
Trang 8The study was conducted from January 2018 to September 2020.
2.2 Research Methods
2.2.1 Research design
- Phase 1: A cross-sectional descriptive study is applied, combiningquantitative and qualitative data collection through in-depthinterviews and group discussions
- Phase 2: A before-after comparative trial study without a controlgroup
- Stage 3: Post-intervention assessment, combining quantitative andqualitative data collection through in-depth interviews and groupdiscussions
2.2.2 Study sample size
2.2.2.1 Sample size for objective 1
- The required sample size for the study is 229 medical staff Plus 10%
of the preventive health workers who did not agree to participate inthe study or gave up, the total sample size was 252
- 03 focus group discussions were conducted with 15 health workers
in clinical departments (5 health workers/call) Health workers wererandomly selected from among the health workers invited toparticipate in the study
- 02 in-depth interviews with) 1 representative of the head of theinfectious disease department and) 1 representative of the hospitalleadership The convenient sampling method is applied
2.2.2.2 Sample size and sample selection for objective 2
For objective 2, the study was conducted on all inpatients in clinicaldepartments and met the inclusion and exclusion criteria A total of
712 patients in 2018 (assessment August 29, 2018) and 751 patients in
2019 (assessment July 27, 2019)
2.2.2.3 Sample size and sample selection for objective 3
* Sample size and sample selection for patients
The study was conducted on all inpatients in clinical departments andmet the inclusion and exclusion criteria A total of 647 inpatients wereevaluated for hospital-acquired status in 2020 (assessment September
30, 2020)
* Sample size and sample selection for nurses
The total sample was 190 nurses, corresponding to the actual number
of nurses selected in phase 1 Thus, all nurses in phase 1 were selectedfor the research phase 2 and 3
Trang 9* Sample size and sampling method for in-depth interviews and focusgroup discussions
- 03 focus group discussions were conducted with 15 health workers
in clinical departments (5 health workers/call) Health workers wererandomly selected from among the health workers invited toparticipate in the study
- 02 in-depth interviews with 1) 1 representative of the head of theinfectious disease department and 2) 1 representative of hospitalleadership The intentional sampling method is applied
* Variables and indicators of hospital infection
2.2.3.3 Research variables and indicators for objective 3
* Quantitative variables and indicators before and after intervention innurses
* Qualitative information
2.3 Research implementation
2.3.1 Group organization and research implementation process
2.3.1.1 Organization of the study group
2.3.1.2 Intervention content
In this study, a multimodal approach was applied to improvecompliance of three basic ER procedures including: hand hygiene,dressing change, and peripheral venous catheterization The core ofthe intervention includes 4 activities:
- Supplementing, completing and promulgating regulations on theprocess
- Equip necessary means and materials
- Training for supervisors and nurses
- Strengthen and improve the quality of process compliancemonitoring activities
2.3.2 Techniques and tools for collecting information
2.3.2.1 Observation practice
2.3.2.2 Evaluation of nosocomial infections
Trang 102.3.2.3 In-depth interviews and group discussions
2.4 Evaluation criteria used in the study
2.4.1 Determining research indicators on hospital-acquired infections
2.4.1.1 Investigation, clinical examination, detection of patients with UTIs
2.4.1.2 Microbiological testing, isolation and identification of bacteria
2.4.2 Determination of variables and indexes of hand hygiene research
2.5 Data management and analysis
The data was entered into Epidata software and analyzed using Stata16.0 software Qualitative information collected through in-depthinterviews and group discussions was recorded and de-tape,synthesized through Microsoft Excel software The contents are citedand aggregated according to the identified topics
Chapter 3 RESEARCH RESULTS 3.1 Status of compliance with some infection control procedures
at Thanh Nhan Hospital in 2018-2019
3.1.1 General information of medical staff
3.1.2 Actual situation of hand hygiene compliance of healthcare workers and some related factors
In this study, there were a total of 6 handwashing opportunities forhealthcare workers, divided into two time points:
- Before contact with the sick person (including the period beforecontact with the sick person, before performing a clean, sterile, glovedprocedure or procedure) A total of 13,258 observations prior topatient contact
- After contact with a patient (including after examining/caring for apatient, after contact with body fluids, after a procedure, after being incontact with the patient's surroundings) A total of 3286 observationswere made after contact with the sick person
Table 3.2 Hand hygiene compliance status
No of
observati
on
No of complian ce
Percenta ge
Correct complian ce
Percenta ge
Trang 11When assessing the causes of non-compliance with handhygiene, the most common cause was “complicated procedures”(24.6%), followed by “too many opportunities for hand hygiene”.hands” (21.4%) and not enough chemicals for hand hygiene (17.5%).
3.1.3 Actual status of medical staff's compliance with the wound dressing change procedure and some related factors
A total of 391 observation opportunities across 66 medical staffacross the Departments of Surgery, ICU, Obstetrics and Oncology.For the wound dressing process, the step with the lowestpercentage of medical staff performing is removing gloves, cleaning
Trang 12hands (29.2%), preparing gauze and antiseptic solution (30.4%) andhand hygiene, wearing gloves (32.0%) Steps such as informing thepatient have the highest failure rate The rate of correct and completecompliance with the 16-step wound dressing change procedure amongmedical staff was 28.6% There were no differences in compliancerates by gender, professional level, years of service and training status.Medical staff in Orthopedic Department had the highest rate ofcorrect and complete compliance with wound dressing procedures(31.8%), followed by Obstetrics (30.3%) and Neurosurgery(30.3%) ,2%) The difference between departments was notstatistically significant with p>0.05.
Complex processes (28.8%), forgetting steps (21.2%) andinsufficient tools and equipment (19.7%) are the 3 most commonfactors related to non-compliance wound dressing change
3.1.4 Status of medical staff's compliance with peripheral venous catheterization procedures and some related factors
With the procedure of peripheral venous catheterization, thisprocedure is mainly performed in the Departments of InternalMedicine, Pediatrics and Internal Resuscitation Therefore, the studyconducted to evaluate the compliance level of the peripheral venouscatheterization procedure in these departments A total of 388observation opportunities per 93 healthcare workers
For the peripheral venous catheterization procedure, the stepwith the lowest percentage of medical staff is informing the patient(66.8%), instructing the patient (67.0%) and providing information(69.1%) Overall, the compliance rate for a full 16-step peripheralvenous catheterization procedure among healthcare professionals was65.7% There was no difference in compliance rates by gender,qualification, and years of service Health workers trained on KSadhere better than health workers who are not trained (p<0.05).Medical staff in the Pediatric Department had the highest rate ofcorrect and complete compliance with the procedure (72.3%),followed by Internal Resuscitation (69.8%) and Stroke (66.7%) Thedifference between departments was not statistically significant withp>0.05 The most common cause of non-compliance with peripheralvenous catheterization was forgetting steps (32.3%), complicatedprocedures (22.6%), and finding it unnecessary to complete theprocedure (21.5%)
Trang 133.2 Some factors related to nosocomial infections at hospitals in 2018-2019
3.2.1 General information of the patient
3.2.2 Situation of hospital infections
5.9%
6.1%
6.0%
Figure 3.7 The incidence of hospital-acquired infections
The evaluation results showed that in 2018, there were 5.9% ofinpatients with HAIs, increasing to 6.1% in 2019 Overall, there were88/1463 patients with HAIs in 2 years (6.0%) )
All patients with NKBV had only 1 type of NKBV The mostcommon nosocomial infections were BV (31.0% in 2018 and 43.5%
in 2019), followed by upper respiratory tract infections (26.2% in
2018 and 21.7% in 2019), hospital-acquired pneumonia (includingventilator-associated pneumonia) (19.1% in 2018 and 8.7% in 2019).Skin and soft tissue infections accounted for the lowest rate with 4.8%
in 2018 and 6.5% in 2019
The density of hospital admissions/1000 days of hospital staywas 5.11 The density of 4 common bacterial infections includingsepsis was 7.02; urinary tract infection is 6.61; wound infection was10.26 and respiratory infection was 8.76
Out of 88 cases of HAI, 36 were microbiologically tested,mainly blood cultures (29/36 cases) and sputum (5/29 cases) Therewere 2 cases of urine culture Of which, 18 cases (50%) testednegative The positive rate in blood cultures was 55.2%; Sputumculture was 20.0% and urine culture was 100% Among the positivesamples, Pseudomonas aeruginosa accounted for the majority (41.7%
in 2018 and 20.8% in 2019), followed by Klebsiella pneumoniae(0.0% in 2018 and 20.8% in 2019)
3.2.3 Some factors related to nosocomial infections
Patients aged 18-29 had a lower risk of UTI compared withpatients < 18 years old (OR=0.17, 95%CI=0.03-0.99) Females,