1.1 Introduction
Nosocomial infections also known as health-acquired conditions (HACs) are complications that originate from a stay in a clinical or hospital facility (Lobdell et al., 2012). Hospital-acquired infection is an infection contracted by the patient while receiving care in a health facility but not seen at the time of admission (Nejad et al., 2011). Hospital-acquired infections are the main challenge for low and middle-income countries with inadequate health-care resources (Shahida et al., 2016). Nosocomial infection is a major worldwide safety concern for both patients and health-care professionals (Nejad et al., 2011). Risk factors include lack of proper health care facilities such as isolation units, sinks, bed space; appropriate waste management, decontamination of equipment and hand hygiene facilities (Shahida et al., 2016).
This chapter will address the background information that motivated this study, the challenges that prompted it, its aim, and its objectives as a preface to subsequent sections of the study. Additional factors include the study's significance, scope, limitations, research questions and hypotheses, and the definition of technical terms.
1.2 Background of Study
Nosocomial or hospital acquired infections (HAIs) is a serious global public health issue, causing the suffering of about 1.4 million people across the world at any given time (WHO 2007). Susceptibility to these infections has been associated with use of invasive devices, extremes of age, immune status and infection control practices (Haley et al 1985, Emori and Gayness 1995, Vincent et al 1995).They often increase costs of health care both for patients and health services alike (Coello et al 1993, McCuckin et al 1999, Kim et al 2001). The World Health Organization offers several definitions of a nosocomial infection/ hospital − acquired infection:
An infection acquired in hospital by a patient who was admitted for a reason other than that infection. An infection occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility.
As a general timeline, infections occurring more than 48 hours after admission are usually considered nosocomial. Nosocomial infections are also divided into two classes, endemic or epidemic. Most are endemic, meaning that they are at the level of usual occurrence within the setting. Epidemic infections occur when there is an unusual increase in infection above baseline for a specific infection or organism. Epidemiological studies report that nosocomial infections are caused by ubiquitous. pathogens such as bacteria (Lepelletier et aI., 2005), viruses (de-Oliveira et aI., 2005) and fungi (Trick et aI., 2002) present in air, surfaces or equipment. Nosocomial infections occur worldwide, both in the developed and developing world. They are significant burden to patients and public health. They are a major cause of death and increased morbidity in hospitalized patients. They may cause increased functional disability and emotional stress and may lead to conditions that reduce quality of life. Not only do they affect the general health of patients, but they are also a huge burden financially.
The greatest contributors to these costs are the increased stays that patients with nosocomial infections require. The increased length of stay varies from 3 days for gynecological procedures to 19.8 days for orthopedic procedures. Other costs include additional drugs, the need for isolation, and the use of additional studies. There are also indirect costs due to loss of work.
Nosocomial infections are most frequently infections of the urinary tract, surgical wounds, and the lower respiratory tract. A World Health Organization prevalence study and other studies have shown that these infections most commonly occur in intensive care units and in acute surgical and orthopedic wards. Infection rates are also higher in patients with increased susceptibility due to old age, underlying disease, or chemotherapy. Patients are exposed to a variety of microorganisms during a hospital stay, but contact between a patient and an organism does not necessarily guarantee infection. Other factors influence the nature and frequency of infections. Organisms vary in resistance to antimicrobials and in intrinsic virulence. Bacteria, viruses, fungi, and parasites can all cause nosocomial infections. There are multiple ways of acquiring such an organism. The organisms can be transferred from one patient to another (cross-infection). They can be part of a patient’s own flora (endogenous infection). They can be transferred from an inanimate object or from a substance recently contaminated by another human source (environmental transfer).
The organisms that cause most hospital acquired infections are common in the general population, in which setting they are relatively harmless. They may cause no disease or a milder form of disease than in hospitalized patients. This group includes Staphylococcus aureus, coagulase-negative staphylococci, enterococci, and Enterobacteria. Factors that increase a patient’s susceptibility to nosocomial infections include young or old age, decreased immune resistance, underlying disease, and therapeutic and diagnostic interventions.
The organisms that cause nosocomial infections are often drug-resistant. The regular use of antimicrobials for treatment therapy or prophylaxis promotes the development of resistance. Through antimicrobial-driven selection and the exchange of genetic resistance elements, multi-drug resistant strains of bacteria emerge. Antimicrobial-sensitive microorganisms that are part of the endogenous flora are suppressed, while the resistant strains survive. Many strains of pneumococci, staphylococci, enterococci, and tuberculosis are currently resistant to most or all antimicrobials which were once effective. Health care workers (HCWs) are at a high risk of needle stick injuries and blood-borne pathogens as they perform their clinical activities in a hospital.3 They are exposed to blood borne pathogens, such as human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) viruses, from sharp injuries and contacts with blood and other body fluids. Consequently, it is important to note that approximately one-third of hospital-acquired infections may be preventable (Comptroller and Auditor General 2000). Therefore, in Nigeria where the research was carried out, the activities that was conducted is to know the Knowledge and Perception of Nosocomial Infection Among Health Workers and Resident.
1.3 Statement of Problems
Investigation revealed that healthcare workers (HCWs) are at menace of occupational hazards as they carry out their clinical activities in the hospital. Nosocomial infections have been acknowledged as a problem disturbing the quality of health care and a principal source of adverse healthcare outcomes. It has been recognized in the literature that within the realm of patient safety, these infections have serious impact. Increased hospital stay days, increased costs of healthcare, economic destitution to patients and their families and even deaths, are among the many negative outcomes (Emori et aI., 1991; Starfield et aI., 2000; Angus et aI., 2001; Zhan &Miller, 2003; CDC, 2005; Engemann et aI., 2005; Elward, et aL, 2005: Klevens et aL, 2007; Kaye et aL, 2009; Edwards et aI., 2009; Scott II, 2009; Anderson et al., 2009). These findings are indicative of the enormous economic burden associated with nosocomial infections. Epidemiological studies report that nosocomial infections are caused by ubiquitous pathogens transmitted, at least in part, by healthcare workers through direct and indirect contact.
The resident microbiota, commonly referred to as normal flora consists of bacteria mostly found in the superficial cells of the skin and mucous membranes; and in linings of the orifices of digestive, respiratory and reproductive systems (Black, 2012). It has been demonstrated in several immunological studies that resident microbiota exhibits protective functions against invasion, or outgrowth, of pathogenic microorganisms and its depletion or aberration may lead to opportunistic infections (Fujimura et al., 2010). However, these bacteria may cause infections in non-intact skin.
The most overriding species of resident microbiota is Staphylococcus epidermidis. Transient microbiota is microorganisms present, under definite conditions, in any of the locations where resident microbiota are found. Some of these microorganisms take possession of the superficial layers of the skin. They are more amenable to removal by routine hand hygiene and such microorganisms are often acquired by healthcare workers during direct contact with patients or contaminated environmental surfaces, within the patient’s surroundings. The most common types of transient bacteria are the Staphylococcus aureus, Escherichia coli, Serratia mercescens, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterobacter species, Candida albicans and Clostridium difficile (Black, 2012). These are the organisms frequently implicated in nosocomial infections (Monarca et aI., 2000; CDC 2002; Lepelletier, 2005; Ribby et aI., 2005 &Hayden et al., 2006) and some of the strains are resistant to antibiotics (Lodise et aI., 2002; Conly et aI., 2004; Abba et al., 2005).
Epidemiological studies have demonstrated that transient bacteria are often acquired by healthcare workers during direct contact with patients, or contaminated environmental surfaces, within the patient’s surroundings (Monarca et aI., 2000; Lepelletier, 2005; Ribby et aI., 2005 & Hayden et aI., 2006). Epidemiological studies suggest that nosocomial infections can be transmitted through direct person-to- person contact between infected patient., healthcare workers, non-infected patients and by indirect contact through equipment, supplies, medical procedures, or air (CDC, 2000; WHO 2002). The affected body systems depend on the virulence of the pathogens, accessibility of the pathogen to the patient and susceptibility of the patient to the pathogen (CDC, 2000). The most common types of nosocomial infections affect the urinary tract, surgical wounds, respiratory system and blood stream (WHO, 2002).
Studies that have examined the impact of nosocomial infections caused by antibiotic resistant pathogens at a single center in Egor L.G.A and some laboratories that served hospitals in Edo state, showed that infections caused by antibiotic challenging pathogens were associated with amplified mortality rates, increased lengths of hospital stay and higher healthcare costs compared to the nosocomial infections caused by pathogens susceptible to antibiotics. These findings sustain the notion that nosocomial infections present massive economic encumber to the public and the healthcare system. In response to the realization of the degree of the problem, various agencies including federal and state governments, and professional societies − both nationally and internationally, have devised measures aimed at reducing the incidence of nosocomial infections. For example, Center for Infection Control and Epidemiology developed guidelines for hand-hygiene in healthcare settings and made recommendations for infection control practices which were based upon the obtainable evidence surrounding the best practices for patient care (Boyce at al., 2002).
Furthermore, the Centers for Disease Control and Prevention (CDC), in cooperation with government and non-government organizations throughout the world, has synchronized efforts and resources to help minimize the occurrence of nosocomial infections; and recommend activities that increase quality of patient care. In this regard, healthcare workers have been fostered to implement strategies that would call attention to measures aimed at prevention of the transmission of nosocomial infections. For that reason, healthcare professionals have been encouraged to participate in in-service continuing education on topics related to measures deemed necessary to reduce the transmission of nosocomial infections.
The World Health Organization (WHO), in conjunction with CDC, set prevention of nosocomial infections as main concern by developing a practical guide (manual) for the prevention of nosocomial infections globally (WHO, 2002). The centers for Medicare and Medicaid Services instituted a “payment reform” program where the eventual reimbursement system will not cover costs for preventable infections (nosocomial infections) acquired in the course of treatment (Johnson, 2009). Moreover, the federal government requires that healthcare institutions’ statistics on nosocomial infections be made available to the public and hospitals with highest rates of nosocomial infections will be penalized (DHHS, 2009). Furthermore, the Healthcare Reform Law has instituted measures that incentivize hospitals and other healthcare facilities to improve their programs for reducing nosocomial infections. Findings from several epidemiological studies divulge that healthcare workers such as physicians, dentists and nurses are implicated in the transmission of nosocomial infections.
Besides, their expertise with regards to knowledge, attitudes and practice to control the spread of infection is also well evidenced by their success in licensure exams and other significant assessments, which test their knowledge of infection control practices and the application of skilled safe patient care activities, over the course of their academic journey (Sherwood et aI., 2007; Smith, 2007). hence, the continued presence of nosocomial infections raises an enigma which may only be explained by other factors. fascinatingly, studies that investigated the responsibility of institutional support and the spread of nosocomial infections showed that low staffing levels lead to high workload and increased healthcare workers’ non-compliance with recommended hand hygiene practices (Huggonet et aI., 2007).
Furthermore, existing studies show that the lack of proper equipment and surveillance systems for the monitoring of infections further increased the episodes of nosocomial infections (Monarca et aI., 2000; Chen et aI., 2003, Garretson et aI., 2004; Lo et aI., 2008 & Saint et aI., 2008). Thus, it is plausible that this paradox could be explained through a thorough examination of socio-cognitive perspectives with regards to knowledge; or behavioral aspects such as attitude that could affect the healthcare workers’ on-the- job practice; or ecological factors that include organizational support or architectural design of healthcare facility.
1.4 Aim and Objectives of Study
The aim of the study is to examine the Knowledge and Perception of Nosocomial Infection Among Health Workers and Resident. In achieving this aim, the following specific objectives were laid out as follows:
- To investigate the level of knowledge, attitudes and perception of health workers with regards to the spread of nosocomial infections in Egor, Edo State;
- To ascertain the attitude, knowledge and perception of health care workers in Egor, Edo towards standard precautions;
- To compare the knowledge and perception in novice and experienced healthcare workers with regards to the spread of nosocomial infections;
- To determine the level of practice of standard precautions among health care workers in Egor, Edo State;
- To determine the level of immunization of the health care workers against infectious diseases such as HBV;
- To describe the action taken by the health care workers when they are exposed to occupational hazards and injuries;
- To investigate the level of organizational support as reported by the health workers; and
- To examine if a relationship exists between organizational factors or support and the level of health workers’ knowledge, and understanding with regards to the spread of nosocomial infections.
1.5 Research Questions
The study came up with research questions so as to be able to ascertain the above stated objectives. The specific research questions for the study are stated below as follows:
- Is there significant difference in the level of knowledge between novice and experienced healthcare workers with regards to the spread of nosocomial infections?
- Is there significant difference in attitude between novice and experienced healthcare workers with regards to the spread of nosocomial infections?
- Is there significant difference in practice of safe patient care between novice and experienced healthcare workers with regards to the spread of nosocomial infections?
- What is the level of organizational support as reported by healthcare workers?
- What is the level of immunization of the health care workers against infectious diseases?
- What is the overall level of knowledge, attitudes and perception among healthcare workers with regards to the spread of nosocomial infections?
1.6 Significance of Study
It has been recognized in several epidemiological studies that healthcare workers such as physicians, dentists and nurses are caught up in the transmission of nosocomial infections. Literature that has explored the knowledge, perception and practices of nurses and other health workers is limited.
As a result, it is vital to further investigate the impact of knowledge, understanding and practices of novice and experienced graduate nurses with regard to the level of the spread of nosocomial infections. The findings from this study will add to the existing literature and may be used in developing interventions to reduce the spread of nosocomial infections.
1.7 Implications of the Study
The findings in this study suggest that the strong educational standards, set in place, should be continued and enforced. Furthermore, monitoring of adherence to and compliance with established guidelines set by the Centers for Disease Control and Prevention (CDC) by healthcare workers should be sustained. Additionally, the fundamental role of healthcare institutions to provide support in the form of adequate staffing and equipment should be intensified.
1.8 Scope of Study
The scope of the research is focused on the Knowledge and Perception of Nosocomial Infection Among Health Workers and Resident. The study utilizes Edo State in Sixty three health care facilities, including all tertiary and secondary care facilities and selected Primary Health Centres and Private Clinics were sampled from 8 Local Government Areas from the three senatorial districts in Edo State.
Three pre-tested tools were adapted to the local setting and used to interview key informants in the health facilities and to observe for practices and records relating to infection control and past experiences of puerperal sepsis. These included four LGAs in Edo South (Egor, Oredo, Ovia north-east and Ikpoba-okha), three in Edo Central (Esan Central, Esan North and Esan South-west), and one in Edo north (Etsako).
1.9 Limitations of the Study
During the course of this study, there were some problems encountered which stood as limitations to the research work. Some of the limitations include:
- Time Constraint: The time frame given to accomplish this project was very short due to school academic calendar and it was carried out under pressure which made the researcher not to implement some necessary features.
- Financial Constraint: Insufficient fund tends to impede the efficiency of the researcher in sourcing for the relevant materials, literature or information and in the process of data collection (internet, questionnaire and interview).
- Initial Cooperation Delay from Respondents: A particular limitation of this work came as a result of the respondent refusal to offer their cooperation at the initial time they were contacted. This contributed in making the success of this research study difficult.
1.10 Definition of Terms
NLS:
It is acronym for Nosocomial infections.
Nosocomial Infection:
It is also known as hospital-acquired infections is one of the leading causes of death and has much economic cost due to increased hospitalization and prognosis (WHO, 2015).
