Nghiên cứu thực trạng nhiễm khuẩn bệnh viện do acinetobacter baumannii và hiệu quả áp dụng một số biện pháp dự phòng tại bệnh viện bệnh nhiệt đới trung ương, 2011 2013 tt tiếng anh
MINISTRY OF EDUCATION AND TRAINING
DEPARTMENT OF DEFENSE
MILITARY MEDICAL UNIVERSITY
DOAN QUANG HA
RESEARCH SITUATION OF HOSPITAL NOSOCOMIAL INFECTIONS BY ACINETOBACTER BAUMANNII AND EFFICIENCY APPLICATION OF SOME PREVENTION MEASURES AT THE CENTRAL HOSPITAL OF TROPICAL DISEASES, 2011 - 2013 Majors: Preventive medicine Code: 9720163
UMMARY OF MEDICAL DOCTORAL THESIS
HA NOI - 2019
THE DISSERTATION WAS MADE IN VIETNAM MILITARY MEDICAL UNIVERSITY
Science instructor: 1. Prof.PhD. Nguyen Van Kinh 2. Assoc.Prof.PhD. Nguyen Vu Trung
Reviewer 1: Assoc.Prof.PhD. Le Thi Anh Thu - Cho Ray Hospital Reviewer 2: Assoc.Prof.PhD. Tran Viet Tien - Vietnam Military Medical Academy. Reviewer 3: Assoc.Prof.PhD. Dinh Van Trung - 108 Military Cental Hospital.
The dissertation is protected before the school's thesis dissertation council at Military Medical University at: …
Can learn the dissertation at 1. National Library 2. VMMU Library 3. …………………………...
1 ABSTRACT Hospital nosocomial Infections (HNI) are infections that patients suffer during hospitalization are one of the main causes of high morbidity and mortality rates for patients in hospitals around the world. HNI is often caused by multi-antibiotic resistant bacteria. When bacteria are resistant to an antibiotic, the treatment will face many difficulties, prolong the time of disease, the risk of death increases, new generation antibiotics have higher costs causing great economic losses. Hospital nosocomial Infections occur in the Emergency Department at a higher rate than other departments in the hospital, usually 2-3 times. In Vietnam, there is no research on the situation of HNI, in the Emergency Department of infectious diseases hospitals, so it is difficult to compare and assess the quality of implementing preventive measures. HNI, as well as insufficient analysis of risk factors associated with HNI, to take appropriate and timely measures
to reduce the risk of HNI. 1. Objectives of the study: 1. Describe the current situation and factors related to HNI caused by Acinetobacter baumannii at the Emergency Department, Central Hospital of Tropical Diseases, 2011. 2. Evaluation of results of application of some measures and techniques to improve HNI control activities at the Central Hospital for Tropical Diseases. 2. Summary of new main scinetific contributions of the thesis - Assessing the status of HNI at the emergency care department, Hospital for Tropical Diseases, discovering bacteria Acinetobacter baumannii is the most common pathogenic bacteria. - Find some risk factors for HNI by Acinetobacter baumannii at emergency resuscitation department, Tropical Diseases Hospital. This is the basis for making preventive measures. - The study has shown that the basic interventions are the organization of infection control network, improving the knowledge and skills of HNI control for medical staff and closely monitoring the hygiene compliance. Hand and surface cleaning, this is the core key to minimize the risk of HNI.
2 3. Thesis layout: The thesis consists of 137 pages, including sections and 4 chapters: Problem: 02 pages Chapter 1. Document overview: 34 pages Chapter 2. Subjects and research methods: 20 pages Chapter 3. Research results: 42 pages Chapter 4. Discussion: 36 pages Conclusion: 02 pages Recommend: 01 page Reference 1267 documents (44 Vietnamese documents, 82 English documents). CHAPTER 1 OVERVIEW DOCUMENT 1.1. Current situation of HNI Developed countries: General HNI 8.7%. HNI at ICU 30%. Developing countries: 1 out of 10 patients admitted to hospital is patients with HNI. At the Faculty of Active Treatment, there were 35.2% (4.4% - 88.9%) patients with HNI. 1.2. Risk of HNI caused by Acinetobacter baumannii Factors related to the patient's condition: Chronic disease, immunodeficiency caused by HIV / AIDS, the use of immunosuppressive drugs or anti-mitotic drugs, ... Patients over 60 years old, or newborns. Factors related to invasive techniques: Mechanical ventilation, pacemaker, central vascular catheter placement or other invasive procedures, ... are risk factors for A.baumannii infection. Factors related to the emergence of antibiotic resistant A.baumannii strains: Located in the department of high-risk infection such as positive resuscitation, Neonatology, Burns, ... are at risk of infection potential A.baumannii and are favorable conditions for the emergence of resistant A.baumannii strains. 1.3. Solution to control HNI Research indicates that at least 20% of all HNI can be prevented through a number of interventions. Some basic measures in HNI prevention: Hand hygiene, sterility, patient isolation, policy solutions, training and supervision. The role of hand hygiene in HNI prevention: WHO recommends hand washing is the cheapest and most effective measure to prevent
3 HNI. Many studies show that good hand hygiene reduces the incidence of HNI. Infection rate can be reduced from 33% to 12% and from 33% to 10% immediately after two times of intervention to promote routine hand washing. The role of surface sanitation in HNI prevention: Many studies show that contaminated surface environment is an important cause of the spread of pathogens causing hospital outbreaks. Proper sanitation and disinfection of surface environments contribute to reducing HNI and controlling outbreaks that may occur in medical facilities. CHAPTER 2 STUDY SUBJECT AND METHODOLOGY 2.1. Subjects, locations, study time 2.1.1. Research subjects * Descriptive study - The patient was treated at the Emergency Department of the Central Hospital of Tropical Diseases from January 1, 2011 to December 31, 2011. * Intervention study - Patients who are treated at the Emergency Department from January 1, 2012 - December 31, 2013. - Medical staff: Doctors, nurses, infection control staff working at the departments of the Central Hospital of Tropical Diseases. - Organizational system, infrastructure related to HNI prevention of Central Hospital of Tropical Diseases. 2.1.2. Study location: Central Hospital of Tropical Diseases. 2.1.3. Research time: - The study describes: January 1, 2011 to December 31, 2011. - Intervention study: January 1, 2012 to December 31, 2013. 2.2. Research methods 2.2.1. research design Research design includes 2 studies: - Research to assess the status of HNI and factors related to HNI in the Department of Emergency Medicine. - Intervention study: Develop, implement and evaluate the effectiveness of a number of measures and techniques to improve infection control activities at the Central Hospital for Tropical Diseases. 2.2.2. Sample size and sampling method * Descriptive study
4 - Sample size: All patients with HNI in the Emergency Department are from January 1, 2011 to December 31, 2012. - Sampling: Choose samples without probability, successively. All patients qualify for research into the Emergency Department. - Criteria to select patients: The patient is in the Emergency Department for 48 hours or more. - Exclusion criteria: The patient had a HNI before entering the Emergency Department; The patient showed signs of HNI within the first 48 hours after entering the Emergency Department; The patient died within 48 hours after entering the Emergency Department. * Intervention study - Patients with HNI at the Emergency Department: All patients with HNI in the Department of Emergency Medicine from January 1, 2012 to December 31, 2013. - Sample size of medical staff: All doctors, nurses, sanitation workers, infection control staff working in the departments of the Hospital. 2.3. Content, research variables and data collection methods 2.3.1. Descriptive study 22.214.171.124. Research variables * The main variable - Determination of HNI: Based on WHO 2002 standards. Time is counted as a case from 48 hours after admission to the Emergency Department to 48 hours after leaving the Emergency Department. - Date of onset of HNI: The time of determining the case according to WHO standards. For patients with multiple HNI, the time of onset is calculated from the first HNI. If bacterial isolation is performed, the time is calculated at the time of sampling. * The secondary variable + Duration of treatment in the Department of Emergency Medicine: Calculated from the time of arrival to the exit of the Emergency Department. + Full treatment period: The time the patient is in the hospital. + Treatment costs: The entire cost of treatment for the patient during the hospital stay. + Pathogen: Is an isolated agent from a patient's sample corresponding to a specific HNI. * Independent variable - Epidemiological factors: Age, gender - Factors: (1) Background disease: Select the main disease type for this admission; (2) Comorbidities: The disease is accompanied by
5 the main disease and affects the current medical condition at many levels. - Intervention factor + Invasive intervention: Intubation, peripheral intravenous clearance, central venous catheterization, catheterization, gastric emptying, pleural drainage, peritoneal membrane ... + Drug treatment: Antibiotic treatment: When antibiotics are used in patients with evidence of infection. Other drugs: Corticosteroids, H2 inhibitors, vasomotor, muscle relaxants, sedation are calculated when appointing patients for at least 24 hours. + Blood transfusion: patients receive blood transfusions and blood products. + Intravenous feeding: When the patient is nourished by infusing a solution containing protein or fat for at least 24 hours. - Time to put the device: Calculated from the time of intervention to the detection of HNI. If the patient does not have a HNI, it will be calculated from the time of placing the device to the end of the intervention or when leaving the Emergency Department.. 126.96.36.199. The method of data collection * Initial assessment of patients Patients who meet the criteria for study will be examined, perform diagnostic tests and record information filled in the collection form. * Monitor and evaluate patients All patients are cared for, monitored and treated according to the regimen appropriate to the condition and have the same conditions for HNI control. Interventions on patients and treatments are recorded on the date of implementation and duration of use. Monitor and evaluate signs of HNI of each location. + Urinary catheterization: Urine testing every 72 hours until urination is withdrawn, urine urine + (+) and leukocytes (+) will be considered suspected urinary infection. + Intubation: When clinically there is a fever or changes in sputum or hearing of the lungs with a new burst will appear for chest X-ray. + Intravenous catheter placement: When there is a change in place of the injection site, or the presence of an infection syndrome for carrying out infection determination tests. - The test identifies the case: + Blood culture: Conducted when the patient has the symptoms of infection syndrome:
6 1) There are 2 of the following 4 criteria: fever> 38.50C; Rapid pulse; Fast breathing; white blood cells increase or decrease compared to Band neutrophil age> 10%. 2) Evidence of infection or suspicion through examination and examination. Blood was taken from the periphery, inserted into Bactec Peds plus / F blood culture bottle and implanted with an automatic implant. + Implant urine on the third day after catheterization and repeat when there are signs of: Urine pain, dysuria, pain on the pubic bone when pressed, or opaque urine; If no urinary catheterization is available, a urine culture will be performed when there are symptoms on or with leukocytes or nitrites (+) in the total urine analysis. The inoculum is considered to be positive when there is at least 105 cfu/mm3. + Transplant from the wounds and secretions of the drainage pipes to find the pathogen. The specimen will be inoculated with bacteria on aerobic environment and fungal environment if it is suspected to be fungus. Interpretation of transplanting results: If there is an isolated agent, it will be considered as the cause of the disease. In the case of a specimen that has two or more agents, the predominant agent is considered to be the cause of infection. In cases where the microbiological result is negative but suspicion can still be replanted. - Determination of case: the patient was followed up 48 hours after leaving the Emergency Department, if there was a HNI during this period, it was also considered a HNI associated with the Emergency Department. The end result of the patient is calculated until discharge, the time in the Emergency Department, the length of hospital stay and the patient's treatment cost are recorded.. 2.3.2. Intervention study 188.8.131.52. Intervention content Building a HNI control system, establishing an Infection Control Council, an infection control network, developing rules and operation mechanism of the council and a network of HNI monitoring. Develop training programs and contents for ongoing HNI Develop programs, content and implement training on knowledge and skills to practice HNI control for health workers. 184.108.40.206. Research variables HNI control system. Reality of hand hygiene before and after intervention.
7 Reality of surface hygiene before and after intervention. Knowledge and practice of HNI control by medical staff. Efficacy index for HNI control capacity. 2.3.3. Data processing Data are statistically processed by SPSS 22.0 software. CHAPTER 3 RESEARCH RESULTS 3.1. Current situation, factors related to HNI caused by Acinetobacter baumannii at the Emergency Department, Central Hospital of Tropical Diseases, 2011 3.1.1. Situation and factors related to HNI caused by Acinetobacter baumannii at the Emergency Department
Figure 3.1. The cause of HNI in the Emergency Department The cause of HNI at the Department of Emergency is the highest due to Acinetobacter baumannii (34.1%). Other causes of other HNI are P.aeruginosa (18.2%), K.pneumoniae (11.4%) and Providencia spp (9.1%). Table 3.1. Distribution of HNI by A.baumannii according to accompanying diseases HNI Total Diseases p Yes No n = 682 n = 102 (%) n = 580 (%) Alcoholism 13(12.75) 67(11.55) 80(11.73) > 0.05 COPD 9(8.82) 53(9.14) 62(9.09) > 0.05 Diabetes 7(6.86) 478.10) 54(7.92) > 0.05
8 immunodeficiency 7(6.86) 17(2.93) 24(3.52) < 0.05 Cancer 4(3.92) 21(3.62) 25(3.67) > 0.05 Hepatitis progresses 2(1.96) 15(2.59) 17(2.49) > 0.05 HIV 1(0.98) 10(1.72) 11(1.61) >0.05 TNMMN 1(0.98) 5(0.86) 6(0.88) >0.05 renal impairment 33(32.35) 174(30.00) 207(30.35) > 0.05 Heart disease 25(24.51) 171(29.48) 196(28.74) > 0.05 The rate of HNI by A.baumannii in patients with renal impairment is highest (32.35%), followed by heart disease (24.51%), alcoholism (12.75%), COPD (8.82%), diabetes (6.86%), immunodeficiency (6.86%). Table 3.2. Time of HNI by A.baumannii appearance Time appears Type of HNI by A.baumannii Averaged ± SD (day) General HNI by A.baumannii 6.25 ± 2.26 Hospital pneumonia by A.baumannii 7.12 ±1.65 Sepsis by A.baumannii 6.20 ± 2.23 Urinary tract infections by 4.56 ± 1.12 A.baumannii The onset of HNI averaged 6.25 ± 2.26 days. Urinary tract infections have the earliest time of occurrence 4.56 ± 1.12, the longest is hospital pneumonia is 7.12 ±1.65. Table 3.3. Rate of HNI by A.baumannii to location (n = 102) Type of HNI Number of cases Rate (%) Hospital pneumonia 46 45.10 Sepsis 26 25.49 Bacterial infection of vascular catheter placement 22 21.57 Urinary tract infections 6 5.88 Other infections 5 4.90 Hospital pneumonia was highest (45.10%), septicemia (25.49%), infection of vascular catheter placement (21.57%) and urinary tract infection (5.88%). Table 3.4. The duration of treatment in the Emergency Department and the hospital stay of HNI locations by A.baumannii Type of HNI by HNI by A.baumannii Difference p
9 A.baumannii Yes No HNI Time for Resuscitation 10,2 ± 3,5 4,6 ± 1,6 5,6 (3,5 – 10,7) <0,01 Time in hospital 12,8 ± 2,8 7,2 ± 2,5 5,6 (3,3 – 10,9) <0,01 Hospital pneumonia Time for Resuscitation 11,7 ± 3,2 5,5 ± 3,0 6,2 (4,0 – 12,4) <0,01 Time in hospital 14,5 ± 3,5 8,2 ± 3,2 6,3 (4,4 – 13,0) <0,01 Septicemia Time for Resuscitation 11,5 ± 3,6 6,8 ± 3,2 4,7 (3,1 – 11,5) <0,01 Time in hospital 15,4 ± 3,4 8,8 ± 4,2 6,6 (4,0 – 14,2) <0,01 Urinary tract infections Time for Resuscitation 10,7 ± 3,2 6,5 ± 3,2 4,2 (2,2 – 11,5) <0,05 Time in hospital 13,4 ± 3,2 9,3 ± 4,4 4,1 (2,5 – 11,7) <0,05 Bacterial infection of vascular catheter placement Time for Resuscitation 9,6 ± 3,5 6,9 ± 3,5 2,7 (1,3 – 9,7) <0,05 Time in hospital 12,4 ± 3,5 9,4 ± 4,5 3,0 (1,0 – 11,0) <0,05 The duration of treatment in the Emergency Department and the hospital stay of hospital-acquired cases are longer than 5.6 days. Hospital pneumonia has a longer duration of treatment and hospital stay than 6.2 and 6.3 days. Table 3.5. Treatment cost of group with and without HNI by A.baumannii (million VND) HNI by A.baumannii Type of HNI by Difference p A.baumannii Yes No HNI by A.baumannii 23.5 ± 6.5 16.5 ± 4.6 7.0 (5.1 – 22.1) <0.01 Hospital pneumonia 25.6 ± 6.7 15.7 ± 6.7 9.9 (3.5 – 23.3) <0.01 Septicemia 24.8 ± 6.2 16.5 ± 6.9 8.3 (4.8 – 21.4) <0.01 Urinary tract 22.3 ± 4.9 16.5 ± 7.2 infections Bacterial infection of vascular catheter 22.5 ± 5.5 16.7 ± 7.5 placement
5.8 (6.3 – 17.9)
5.8 (7.2 –18.8)
The total cost of treatment for cases of HNI increased by more than 7.0 million VND. The cost of treatment increased for the case of hospital pneumonia more than 9.9 million VND, the cost of treatment increased for sepsis more than 8.3 million VND.
10 3.1.2. Factors related to HNI by A.baumannii in the Emergency Department Table 3.6. The relationship between intervention techniques and HNI by A.baumannii No Yes (n = 580) (n = 102) Intervention p n % n % Gastric catheterization 241 41.55 50 49.02 0.057 Intubation - Breathing 0.000 machine 68 11.72 54 52.94 Put the central venous 0.000 catheter 18 3.10 41 40.20 Reveal veins 0 0.00 26 25.49 0.000 Put arterial catheter 9 1.55 21 20.59 0.000 Put urine catheter 168 28.97 36 35.29 0.015 Pleural drainage 80 13.79 11 10.78 0.219 Peritoneal drainage 47 8.10 5 4.90 0.075 Invasive interventions were associated with HNI, including: gastric catheterization, intubation-mechanical ventilation, central venous catheterization, venous disclosure, arterial catheterization and put arterial catheter. Table 3.7. Compare the index of instrument use between 2 groups with and without HNI by type of intervention
Intervention Gastric catheterization Intubation Put the central venous catheter venous disclosure Put arterial catheter Put urine catheter Pleural drainage
Not HNI by A.baumannii (n = 580) Time set Index (n = 2843) SDDC
HNI by A.baumannii (n = 102) Time set Index (n = 3384) SDDC
11 Peritoneal drainage 70 0.025 45 0.012 < 0.001 Medium 185.3 0.065 664.8 0.171 < 0.001 Index of instrument use = Time of tooling/ Treatment time
Chart 3.2. Correlation between the time at which the device was placed and the use index of the instrument in the group with HNI by A.baumannii
Chart 3.3. Correlation between the time to place the device and the index using the device of the group without the HNI by A.baumannii
The average use index in patients with HNI by A.baumannii was higher than for patients without HNI (p <0.001). The index of instrument use is used to assess the exogenous risk and the patient's risk of endogenous infection. When patients have a high index of instrument use, the risk of HNI is higher. There is a correlation between the time to put the tool and the index to use the tool. The length of time to place the device increases the index of instrument use and increases the risk of HNI. Time and index of instrument use of endotracheal procedure, central venous catheterization and catheterization were markedly different between the group with HNI and no HNI by A.baumannii.
Chart 3.4. Correlation between the number of HNI by A.baumannii and the number of days treated at the Emergency Department The number of HNI increased gradually in patients treated after 5 days. The number of HNI is highest in patients with 10-15 days of treatment. The number of HNI decreased gradually in the treatment group after 15 days. Thus, the group of patients hospitalized for 10-15 days has the highest risk of HNI by A.baumannii. Table 3.8. Relationship between some risk factors with hospital pneumonia by A.baumannii Hospital pneumonia by A.baumannii Research OR Total p information (95% CI) Yes No (n = 46) (n = 636) 203 3.0 Intubation 30(14.78) 173 (85.22) 0.001 (29.8) (2.5 –3.6) Intubation > 5 181 3.9 46(25.41) 135 (74.59) 0.001 day (26.5) (3.1 – 5.1) H2 receptor 216 1.3 29(13.43) 187(86.57) 0.215 inhibition (31.7) (0.9 – 1.9) Gastric 305 25 (8.20) 280 (91.80) 1.2 0.386
For multivariate analysis, the risk factors for hospital pneumonia were intubation with OR: 3.0 (2.5 - 3.6), intubation time with OR: 3.9 (3.1 - 5.1). Using sedative, H2 receptor inhibition, muscle relaxation and gastric catheterization are not risk factors in multivariate analysis (p> 0.05).
14 Table 3.9. Multivariate analysis of risk factors for sepsis by A.baumannii Sepsis by A.baumannii Research OR Total p information (95% CI) Yes No n = 26 (%) n = 625 (%) Central venous 2.3 133 (19.5) 25 (18.80) 108 (81.20) 0.001 catheter (1.9 – 2.8) Central venous 2.3 132 (19.4) 25 (18.94) 107(81.06) 0.001 catheter > 3 day (1.9 – 2.8) Number of 1.8 intravenous 70 (10.3) 12 (17.14) 58 (82.86) 0.104 (0.9 – 3.5) lines ≥ 3 Feeding by 75 (11.0) 25 (33.33) 50 (66.67) 0.001 intravenous Blood 1.0 155 (22.7) 17 (10.97) 138 (89.03) 1.00 transfusion (0.6 – 1.8) By multivariate analysis showed that the risk factors for sepsis were: Place the central venous catheter with OR: 2,3 (1,9 - 2,8); The venous catheter is centered over 3 days with OR: 2,3 (1,9 - 2,8). Table 3.10. Single analysis of risk factors for urinary tract infections by A.baumannii Urinary tract infections by A.baumannii Research OR p information (95% CI) Yes No n = 6 (%) n = 676 (%) 1.08 Put urine catheter 6 (2.83) 206 (97.17) 0.001 (1.04 – 1.12) Put urine catheter > 3 1.08 6 (2.83) 206 (97.17) 0.001 day (1.04 – 1.12) Univariate analysis showed that the risk factors of urinary tract infection were: Set catheterization with OR: 1.08 (1.04 - 1.12) and time to urinate> 3 days with OR: 1, 08 (1.04 - 1.12).
15 Table 3.11. Multivariate analysis of infectious risk factors where vascular catheters are placed by A.baumannii Bacterial infection where blood vessels are placed by Research OR p A.baumannii information (95% CI) Yes No n = 22 (%) n = 660 (%) Place the central 7.2 22 (16.54) 111 (83.46) 0.001 venous catheter (4.2 – 12.4) Intravenous infusion 0.9 21 (30.0) 49 (70.0) 0.692 ≥2 (0.5 – 1.5) Use vasomotor 0.8 13 (7.8) 153 (92.17) 0.540 medicine (0.4 – 1.5) Risk factors for vascular infection are: Place the central venous catheter with OR: 7.2 (4.2 - 12.4). The number of intravenous lines and the use of vasomotor drugs is not a risk factor for infection due to vasculature. 3.2. Results of applying some measures and techniques to improve HNI control activities at the Central Hospital for Tropical Diseases 3.2.1. Results of building HNI control model Intervention to establish an infection control system consists of three levels: the control committee for infection of infection and infection control network in each department. Infection Control Council The council consists of the CHNIrman, 01 Vice CHNIrman, 01 permanent member and members. CHNIrman of the Infection Control Council is the Deputy Director of the Hospital. Vice CHNIrman of the Council is Head of infection control department. Commissioner of the Infection Control Council is representative of clinical and subclinical departments. The task of the Infection Control Council + Proposing and advising the Director of the hospital to develop, amend and supplement professional technical regulations on infection control in accordance with the actual hospital. + Advise the Director about the plan to develop infection control related to medical care; Consultation on repair, design and
16 construction of new medical facilities in hospitals in accordance with the principles of infection control. + Organize training, scientific research on infection control. Infection control network Infection control network includes hospital level, department level. Infection control network organization: Each department at least one doctor with a nurse participating in the infection control network operates under the specialized guidance of the infection control department. Members are often trained to update their expertise on infection control. The mission of infection control network + Coordinate to organize the implementation of infection control in hospitals. + Check, supervise and urge hospital staff to implement professional regulations and procedures related to infection control. 3.2.2. Evaluate the effectiveness of improving HNI in the intervening aspects * Effective for hand hygiene Table 3.12. Effective intervention for hand hygiene conditions Maximum PreScore after interventio Evaluation criteria point ∆ intervention n points (WHO) The infrastructure
∆: Points difference before - after intervention. Assessment of infrastructure for hand hygiene: Increase 60 points after intervention. The hospital has a separate budget for hand hygiene, plans to improve the infrastructure for hand hygiene, fully equipped with hand sanitizing solutions in departments and rooms. Training on hand hygiene: Increased by 65 points after intervention. The hospital has built a training system and has teaching
17 staff on hand hygiene; Strengthen training, hand hygiene training and regulations on hand hygiene training for medical staff. Monitoring of hand hygiene compliance: Increasing 42.5 points after intervention. The hospital has strengthened most of the activities of supervising hand hygiene in departments and rooms and informed hand hygiene status to all employees in the hospital.. Hand hygiene communication activities: Increase 20 points compared to before intervention. The hospital has strengthened posters to guide the use of hand sanitizing solutions at departments and rooms. Degree of improvement of safe environment on hand hygiene: Increased by 35 points compared to before intervention. The hospital has established an official program for patients to participate in hand hygiene programs and has organized monitoring and evaluation of personal responsibility in implementing hand hygiene at departments. Table 3.13. Knowledge of research subjects, on hand hygiene, before after intervention Before After intervention intervention Efficiency Level p (n = 259) (n = 259) index (%) n % n % Achieved 82 31,7 223 86,1 < 0,001 171,6 Not 36 13,9 achieved 177 68,3 Total 259 100 259 100 Overall assessment of hand hygiene knowledge of the subjects showed that the proportion of subjects with knowledge gained after the intervention increased from 31.7% to 86.1%. Performance index 171.6%. The difference is statistically significant with p <0.001. Table 3.14. The rate of compliance with hand hygiene by time of day, before - after intervention Time Before intervention After intervention PV
18 Opportunitie Number of Rate Opportunities Number of Rate s need hand opportunitie % need hand opportunities % hygiene s with hand hygiene with hand hygiene hygiene
3.072 1.831 59,6 3.083 2.820 91,5 53,5 2.654 1.479 55,7 2.769 2.511 90,7 62,8 5726 3310 57,81 5852 5331 91,10 57,59 The table above shows that the health workers' hand hygiene compliance rate over time is similar. However, the number of opportunities needed to clean the hands of the morning is much more than in the afternoon. After the intervention, the rate of hand hygiene compliance of health workers increased markedly, the preventive value reached 53.5% and 62.8%. * Effective for surface disinfection at hospital Table 3.15. Effective interventions for hygienic surface disinfection conditions
Means and chemicals for hygiene and surface 100 55 100 45 disinfection Training and guidance on surface disinfection at 100 50 90 40 hospitals Frequency of disinfection by surface position, 100 55 85 30 according to the time of day at the hospital After the intervention, the hospital has facilities, chemicals for disinfection hygiene and personal protective equipment. Score increased 45 points. The hospital has its own budget and has a plan to improve adequate sanitation and disinfection. Training and guidance on hygiene and surface disinfection at hospitals increased by 40 points after intervention. The hospital has full training materials and regular training and guidance for medical staff. However, the training plan only reached 30/40 points. The frequency of cleaning and disinfecting surfaces at the hospital increased by 30 points after the intervention. The hospital has planned and implemented strict monitoring of surface disinfection and evaluation of 85/100 points. Evaluating the effectiveness in compliance with hygiene practices of surface disinfection after intervention increased by 23 points. Table 3.16. Evaluate knowledge of research subjects
19 on hygiene and surface disinfection, before-after intervention Level
Before intervention (n = 259)
p (n = 259) index (%) n % n % Achieved 130 50,2 224 86,5 <0,001 Not achieved 129 49,8 35 13,5 72,3 Total 259 100 259 100 The percentage of research subjects who gained knowledge about surface hygiene and sanitation increased from 50.2% to 86.5% after intervention. Efficiency index after intervention reached 72.3%. The difference is statistically significant with p <0.001. * Effect of minimizing HNI Table 3.17. Effect of minimizing infection Type of HNI Hospital pneumonia Sepsis Bacterial infection of vascular catheter placement Urinary tract infections Other infections Number of HNI patients
(n = 682) n %
(n = 2480) n %
16 14 299
2,3 2,1 43,8
32 30 555
1,3 1,2 22,4
45,0 41,1 49,0
The reserve value of HNI is 49.0%. In particular, the highest preventive value of hospital pneumonia was 52.5%, the lowest was the other measures of infection prevention (41.1%). CHAPTER 4 DISCUSSION 4.1. Current situation and factors related to HNI caused by Acinetobacter baumannii at the Emergency Department, Central Hospital of Tropical Diseases 4.1.1. Situation of HNI caused by Acinetobacter baumannii at the Emergency Department, Central Hospital of Tropical Diseases
20 The rate of HNI in the Department of Emergency Medicine, Central Hospital of Tropical Diseases is relatively high (43.8%), 34,1% HNI by A. baumannii. The consequences of HNI by A. baumannii are quite severe, increasing treatment time 5.6 days and increasing treatment costs by 7.0 million VND. Compared with other research results, the rate of HNI in the Department of Emergency Medicine, Central Hospital of Tropical Diseases is higher than that of other domestic research results. The study of Huynh Van Hue at the Department of Positive and AntiPoisoning at Sa Dec General Hospital in 2012 showed that the rate of HNI was 14.48%. Ha Manh Tuan's study at the Emergency Department, Children's Hospital in 2006 was 24.4%. Like some other research results, the incidence of HNI in the Emergency Department is higher than that of other departments. Regarding the position of HNI, the rate of pneumonia accounts for the highest rate (45.10%), followed by septicemia (25.49%), infection of blood vessels (21.57%) and the lowest is urinary tract infections (5.88%). This result is consistent with the research results of Huynh Van Hue (hospital pneumonia 49.33%) and Ha Manh Tuan (hospital pneumonia accounts for 49.3%). The cause of the rate of HNI in the Department of Emergency Medicine, Central Hospital of Tropical Diseases is higher than that of other domestic research results, possibly due to one of the following reasons: High patient density At the Emergency Department of the Central Hospital of Tropical Diseases currently 5m2 / 1 patient, compared with the standard of infection of 7.4 - 9m2 / patient; The ratio of nursing to patients at the time of the survey was 1/4 lower than the standard of 1/1 of the Emergency Department. The lack of nursing makes compliance with HNI control measures inadequate. From the above analysis to reduce the risk of HNI in the Emergency Department in addition to implementing routine HNI prevention measures, attention should be paid to: Reducing patient density and strengthening direct care nursing patients.
21 4.1.2. Factors related to HNI by Acinetobacter baumannii at the Emergency Department, Central Hospital of Tropical Diseases Results of analysis of each type of HNI by A. baumannii: The risk factor for hospital pneumonia is intubation, prolonged intubation time> 5 days; Risk factors for hospital sepsis are central venous catheterization, central venous catheterization for more than 3 days and intravenous manifestations; Risk factors for urinary tract infection are urinary catheterization and time for catheterization> 3 days. The research results of a number of domestic and foreign authors have shared the same view. Research by Nguyen Viet Hung et al. (2012), there is an association between HNI and catheterization (OR = 3.5, p <0.01), mechanical ventilation (OR = 2.9). , p <0.05). This result is also consistent with results from HNI monitoring statistics at US hospitals: 83% of lung infections related to artificial ventilation, 97% of urinary infections occur in patients. Catheterization and 87% of septicemia occur in patients with central venous catheters. This result shows that it is necessary to focus a lot of resources on the control of regional infections Emergency care of the hospital, especially the need to strengthen the sterile practice in caring for patients with roadrelated procedures breathing, blood vessels and urinary tract.
22 4.2. Effective intervention measures In this intervention, we propose and test some of the following interventions: Building HNI control management system: Establishing HNI control network, developing rules and operation mechanism of the Council and HNI control network. Develop programs, contents, documents and organize HNI control training for nursing such as HNI monitoring procedures and epidemic management; Preventive isolation measures; Hand washing process; Instructions for using protective equipment; Process of cleaning, disinfecting and sterilizing tools; Practical procedure for prevention of hospital pneumonia; Procedure for practicing hospital sepsis prevention; Procedures for prevention of primary HNI; Procedures for prevention of skin and soft tissue infections; Regulating architecture, organization and environmental standards in clinical departments; Hospital hygiene process; Hospital solid waste management process The study results showed that, both before and after the intervention, the health workers adhere to good hand hygiene at the time before touching the patient. This can be said that health workers are conscious of protecting patients from the risks of HNI. After the intervention, hand hygiene rate increased in all target groups. The preventive value is highest in the nurse group, reaching 86.3%, followed by the nursing group 53.4% and the lowest being the doctor 49.7%. This result shows that the implementation of the training program at the Central Hospital of Tropical Diseases is effective. The program contributes to improving the infection control capacity of medical staff. For other infectious disease hospitals, this training program can be used to strengthen HNI control capabilities for medical staff.
23 CONCLUSION 1. Situation, factors related to HNI caused by A.baumannii at the Emergency Department, Central Hospital of Tropical Diseases, 2011 1.1. Situation and factors related to HNI caused by A.baumannii at the Emergency Department The rate of HNI in the Emergency Department is 43.8%. In particular, infection caused by A.baumannii is the highest (34.1%). Hospital pneumonia by A.baumannii accounted for the highest proportion (45.10%), septicemia (25.49%), infection of vascular catheter placement (21.57%), urinary tract infection (5.88% ). The average onset of HNI was 6.25 ± 2.26 days. Consequences of HNI by A.baumannii: The duration of treatment and the length of hospital stay in the Emergency Department of the HNI cases are longer than 5.6 days. Treatment costs increased by more than 7.0 million VND. 1.2. Factors related to HNI by A.baumannii in the Emergency Department Invasive intervention is associated with HNI by A.baumannii, including: Gastric catheterization, intubation - mechanical ventilation, central venous catheterization, venous disclosure, angioplasty and catheter placement vein. There is a correlation between the duration of treatment with the risk of HNI by A.baumannii. The group of patients hospitalized for 10-15 days has the highest risk of HNI by A.baumannii. Risk factors for hospital pneumonia by A.baumannii: Intubation, endotracheal time >5 days; Risk factors for hospital sepsis are central venous catheterization, central venous circulation > 3 days, revealing veins; Risk factors for urinary tract infection are urinary catheterization, time of catheterization > 3 days. 2. Results of applying some measures and techniques to improve HNI control activities at the Central Hospital for Tropical Diseases