Common Nosocomial Infections Their Causes and Nursing Role

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.