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Thursday, October 24, 2019
Healthcare-associated infections (HAIs) Essay
BACKGROUND Healthcare-associated infections (HAIs) are bacterial infections acquired during a patient’s stay in a healthcare institution. It imposes a huge burden on healthcare institutions, costing billions of dollars for additional care costs as well as a significant fraction of lost lives (Houghton, 2006). Current estimates depict that approximately 2 million patients acquire healthcare-associated infections (HAIs) or nosocomial infections each year, of which 90,000 to 100,000 patients die (Houghton, 2006), making HAIs not only a national health problem, but a global threat as well. Common HAIs include hematological, surgical site, dermatological, respiratory, urinary and gastrointestinal systems. In order to control the increase in number of healthcare-associated infections, it is fundamental to identify key factors that make healthcare institutions susceptible to such outbreaks. There is a need to evaluate the sensitivity and efficiency of healthcare institutions to healthcare-associated infections in order to prevent future outbreaks. PROBLEM STATEMENT            This study will investigate the sensitivity of detection and efficiency of reporting healthcare-associated infections to the hospital administration, in the context of providing measures in improving the current surveillance program in the country. The guidelines to identification of a healthcare associated infection will be evaluated through personal interactions with healthcare workers using questionnaires which will be designed using a multiple choice approach. CONCEPTUAL/THEORETICAL FRAMEWORK            This study is based on the need to address the current epidemic of healthcare-associated infection that is emerging around the world. Before an effective solution to the problem is designed, it is essential that shortcomings in the standard procedures of healthcare institutions be identified. This may be done by determining the level of sensitivity of healthcare personnel to symptoms of healthcare-associated infections, as well as knowing what are the first set of actions to be done once an infection is confirmed within a healthcare institution. This study may serve as the first measurement tool that addresses these aspects of the global epidemic.  RESEARCH QUESTION/HYPOTHESIS            This investigation aims to address the question of whether the current hospital administration is sensitive enough to detect and substantially efficient to report to healthcare institutions any incidents of healthcare-associated infections. This will be directly evaluated using survey data collections from retrospective cases of particular health institutions as related to dates of hospital admission, confirmation of infection and treatment time.  SIGNIFICANCE OF THE STUDY            There is a need for an effective surveillance and control program for healthcare-associated infections that are based on current settings in a healthcare institution. Through surveys that inquire on common practices and responses of healthcare workers, any shortcomings or avoidable gaps in the hospital system may be reformed, which in turn will alleviate the spread of infection in the healthcare institutions. Review of medical records and interviews with attending healthcare personnel will be performed in order to determine whether there are certain discrepancies and gaps in the healthcare protocol that facilitate contamination and further spreading of infectious microbials around the healthcare institution. This study may facilitate the identification of key factors that influence the increase in frequency of nosocomial infections in hospitals. The results of this investigation may positively serve as a tool to healthcare workers such as nurses and laboratory technicians. STATEMENT OF THE PURPOSE (OBJECTIVES)            This research will determine the sensitivity and response rate of healthcare workers to healthcare-associated infections. This proposal aims to develop a measurement tool that will determine the sensitivity for identification, efficiency of reporting and the response rate to a healthcare-association infection, with the aim of designing a cost-effective and quick way of controlling and ultimately eradicating the healthcare-related problem.   LITERATURE REVIEW            The prevention and control of HAIs requires a comprehensive approach that addresses as many pathogens as possible (Wiseman, 2006). Urinary tract infections (UTI) associated with catheter use are the most common HAIs, with hospital-acquired pneumonia having the highest mortality rate (Houghton, 2006). These infections are frequently problematic to treat due to the fact that the microorganisms involved have become resistant to antibiotics (Broadhead, Parra and Skelton, 2001). Recent media coverage of meticillin-resistant Staphylococcus aureus (MRSA) has increased the awareness of healthcare professionals to the threat of this particular microbe. S. aureus infections can result in cellulitis, osteomyelitis, septic arthritis and pneumonia, and some of the systemic diseases such as food poisoning, scalded skin syndrome and toxic shock syndrome (Zaoutis, Dawid and Kim, 2002).            MRSA and vancomycin-resistant Enterococcus (VRE) are the primary causes of nosocomial infections and are significant factors in increased morbidity and mortality rates. These microbes are currently endemic in many healthcare institutions, particularly problematic in intensive care units (ICUs) (Furuno, et al. 2005).  VRE Infections have become prevalent in U.S. hospitals over the last decade, increasing in incidence 25-fold (Ridwan et al., 2002). Vancomycin is the antibiotic frequently used to treat infections caused by MRSA, but recent years have seen the emergence of Staphylococcus aureus infections that have high-resistance to vancomycin, which makes the future effectiveness of this drug questionable (Furuno et al., 2005). All known variants of the vancomycin-resistant Staphylococcus aureus (VRSA) isolates have possessed the vanA gene, which carries with it resistance to vancomycin. This development is believed to have been acquired â€Å"when the MRSA isolate conjugated with a co-colonizing VRE isolate†(Furuno et al., 2005, p. 1539). This means that patients who suffer co-colonization from MRSA and VRE have an increased risk for colonization and infection by VRSA (Furuno et al., 2005). Furthermore, Zirakzadeh and Patel (2006) stated that VRE has become a major concern due, in part, to its ability to transfer vancomycin resistance to other bacteria, which includes MRSA.            Infection of susceptible patients typically occurs in environments that have a high rate of patient colonization with VRE, such as ICUs and oncology units (Zirakzadeh and Patel, 2006).  In these healthcare settings, VRE has been known to survive for extensive periods and research has also observed that VRE has the ability to contaminate virtually every surface (Zirakzadeh and Patel, 2006). Efforts to control HAIs, such as VRE, have focused on prevention, such as through hand hygiene, as the first line of defense.            Hand hygiene has been improved by using â€Å"user-friendly, alcohol-based hand cleansers, but there still remains the goal of achieving consistently high levels of compliance with their use†(Carling et al., 2005, p. 1).  Screening-based isolation practices have likewise improved transmission rates of MRSA and VRE; however, logistic issues and the cost-effectiveness of these practices are still being analyzed (Carling et al., 2005). Additionally, despite isolation practices, outbreaks and instances of environmental contamination have been documented in regards to MRSA, VRE and Clostridium difficile, which cannot be screened with any practicality (Carling et al., 2005).            The numerous obstacles that exist in regards to effective screening practices suggest that a focus on improving existing cleaning/disinfecting practices may prove to be more effective in halting the spread of HAIs (Carling et al., 2005). Studies over the last several decades have shown that there is often contamination of surfaces in and around the patient, as pathogens associated with the hospital environment have been known to survive on surfaces for weeks or even months (Carling et al., 2005). Significant rates of contamination with Clostridium difficile have been connected with symptomatic and asymptomatic patients (Carling et al., 2005).            In 2002, the CDC issued guidelines that called for hospitals to â€Å"thoroughly clean and disinfect environmental medical equipment†surfaces on a regular basis (Carling et al., 2005, p. 2). Other organizations have followed suit and stressed repeatedly the need for healthcare provides to focus on environmental cleaning and disinfecting activities, yet these guidelines have not provided directives that address precisely how healthcare providers can either evaluate their ability to comply with professional guidelines on this topic or ensure that their procedures are effective (Carling et al., 2005). Nevertheless, literature on the subject does offer some guidance.            Surveillance, evidence-based infection control practices and the responsible use of antibiotics have been determined to be crucial to controlling HAIs (Wiseman, 2006). The establishment of comprehensive surveillance programs has facilitated the creation of national databases the compile cases of infection which may be useful to researchers investigating progression rates and causal factors. Evidence-based control practices may be implemented by distributing guidelines for aseptic hospital protocols, hospital hygiene, personal protective equipment and disposal of biohazardous sharps. A review of commonly used antibiotics in terms of proper dosage and length of treatment based on clinical evidence and best practice guidance should also be performed.            Curry and Cole (2001) reported that the medical and surgical ICUs in large inner-city teaching hospitals developed an elevated patient VRE colonization rate. A multi-faceted approach was instituted to correct this problem, which involved changing behavior by â€Å"shifting norms at multiple levels through the ICU community†(Curry and Cole, 2001, p. 13). This intervention consisted of five levels of behavioral change. These encompassed: â€Å"1. intrapersonal and individual factors; 2. interpersonal factors; 3. institutional factors; 4. community factors and 5. public factors†(Curry and Cole, 2001, p. 13).            Educational interventions were developed that addressed each level of influence and behavioral change was predicated on â€Å"modeling, observational learning and vicarious reinforcement†(Curry and Cole, 2001, p. 13). These procedures resulted in a marked decrease of â€Å"VRE surveillance cultures and positive clinical isolates†within six months and this decrease has been consistent over the next two years (Curry and Cole, 2001, p. 13).            Research has shown that the nutritional status of preoperative and perioperative patients can influence their risk for acquiring a HAI (Martindale and Cresci, 2005). This is particularly true for patients who are undergoing surgery for neoplastic disease as this can commonly result in immunosuppression (Martindale and Cresci, 2005). Inadequate nutrition, â€Å"surgical insult, anesthesia, blood transfusions, adjuvant chemotherapy/radiation/ and other metabolic changes†have been identified as contributing to suppression of the immune system (Martindale and Cresci, 2005). Furthermore, studies have also associated infection risk with glycemic control Maintaining blood glucose levels between 80 and 110 mg/dL vs. 180 and 200 mg/dL has been shown to result in fewer instances of â€Å"acute renal failure, fewer transfusions, less polyneuroopathy and decreased ICU length of stay†(Martindale and Cresci, 2005, p. S53).            Citing Ulrich and Zimring, Rollins (2004) states that getting rid of double-occupancy rooms and providing all patients with single rooms that can be adjusted to meet their specific medical needs can improve patient safety by reducing patient transfers and cutting the risk of nosocomial infections. While these researchers admit that the up-front cost of private rooms is significant, this will be offset by the savings accrued through lowers rates of infection and readmission, as well as shorter hospital stays (Rollins, 2004).            A recent study conducted by researchers at Chicago’s Rush University Medical Center found that enforcing environmental cleaning standards on a routine basis resulted in less surface contamination with VRE, â€Å"cleaner healthcare worker hands, and a significant reduction in VRE cross-transmission in an ICU†(Cleaning campaign, 2006, p. 30). These improvement in VRE contamination continued to be experienced even when VRE-colonized patients were continually admitted and healthcare workers compliance with hand hygiene procedures were only moderate (Cleaning campaign, 2006). The strategies that the researchers implemented included that they: held in-services for housekeepers about why cleaning is important–emphasizing thorough cleaning of surfaces likely to be touched by patients or workers. increased monitoring of housekeeper performance. recruited respiratory therapists to clean ventilator control panels daily. educated nurses and other ICU staff on VRE and how they could assist housekeepers by clearing surfaces that need cleaning. conducted a hand hygiene campaign, including: mounting alcohol gel dispensers in common areas, patient rooms and every room entrance (Cleaning campaign, 2006, p. 30).            CDC guidelines indicate that if hands are not visibly soiled, using an alcohol-based hand rub should become habitual between patient contacts. When hands are visibly soiled, use of an anti-microbial soap and water is required. If contact with C difficile or Bacillus anthracis is possible, it is recommended that the healthcare provider wash with anti-microbial soap and water, as other antiseptic agents have poor efficacy against spore-forming bacteria and the physical friction of using soap and water at least decreases the level of contamination (Houghton, 2006). Page (2005) indicates that the CDC has joined with the US Department of Health and Human Services, the National Institutes of Health (NIH and the Food and Drug Administration (FDA) to lead a task force of 10 agencies and departments, which have developed a blueprint outlining federal actions to combat this problem. This template emphasizes the efficacy of hand washing, among other points (Page, 2005).            In 2002, the CDC issued updated hand hygiene guidelines, which address new development and research on this topic, such as â€Å"alcohol-based hand rubs and alternatives to antibacterial soaps and water†(Houghton, 2006, p. 2). However, while the efficacy of hand hygiene is well accepted, it is also well known that healthcare workers â€Å"of all disciplines†frequently fail to abide by adequate hand hygiene practices (Houghton, 2006, p. 2). In fact, research has shown that adherence rates to hand hygiene guidelines are lowest in ICUs, where to the frequency of patient care contact, multiple opportunities for hand hygiene exist on a hourly basis (Houghton, 2006). According to Houghton (2006), any direct patient-care contact, which includes contact with gloves and/or contact with objects in the immediate patient vicinity, constitutes an â€Å"opportunity†for appropriate hand hygiene.            This suggests that the proposed intervention should also include asking healthcare employees at the site of the intervention to participate in a survey that examines, first of all, how closely hand hygiene protocols are followed and, if they are not followed, why not. It may be that the activity level of ICUs is so great that the practitioners feel that they cannot take sufficient time to do adequate hand hygiene. If this is the case, alternative methods of hand hygiene to that institution’s traditional policy may need to be investigated.            Just as this study revealed factors that can be associated with non-compliance, a similar investigative effort may be called for to determine reasons why compliance may not be satisfactory for cleaning/disinfecting environmental surfaces. Again, it may be that non-compliance hinges on factors of time. It may be, therefore, expeditious for hospitals and other healthcare organizations to look into hiring additional personnel to aid with cleaning/disinfecting tasks. It may also prove necessary, to cope with factors of time and efficiency, to train cleaning personnel to take a systematic approach to patient room cleaning that includes all â€Å"high touch†areas. As noted previously, researchers at Chicago’s Rush University Medical Center found that holding in-service training for housekeepers was an effective component of their overall strategy in lowering VRE related infections (Cleaning campaign, 2006). This process could be facilitated by a checklist approach or by periodically reevaluating rooms according to the Carling et al. (2005) methodology.            Given these detailed accounts of healthcare-associated infections in hospitals, it is of significant importance that the sensitivity and response rate of health personnel be identified in order to know if there are any discrepancies and gaps in the standard hospital protocols that foster the expansion of microbials in hospitals. This study aims to determine the level of sensitivity and response rate of healthcare institutions to the growing epidemic of healthcare-associated infections.  SUMMARY            HAIs are an unnecessary tragedy, increasing morbidity and mortality figures and adding to healthcare costs. While there are ways to treat all the various HAIs, the clearest remedy for this insidious drain on healthcare resources and personnel is prevention, which begins with the simplest of acts–washing one’s hands–but also extends to considering all hospital surfaces as having the potential to harbor pathogens. This means rethinking some healthcare institutional procedures. It means habitually and routinely cleaning all surfaces, as well as everywhere and anything that is routinely touched, whether by a bare or gloved hand.            Stopping the spread of HAIs includes multiple factors, such as restrained and appropriate use of antibiotics. However, the first line of defense is cleaning/disinfecting procedures. This constitutes the â€Å"ground zero†foundational line for battling HAIs and this means that all healthcare practitioners should keep the goal of reducing the spread of HAIs foremost in their minds while going about their daily routines, washing hands between each patient contact and paying attention to other sepsis concerns. In other words, the first step in stopping HAIs is simply to keep them in the forefront of practitioner consciousness. References Broadhead, J. M., Parra, D. S., & Skelton, P. A. (2001). Emerging multiresistant organisms in the ICU: Epidemiology, risk factors, surveillance, and prevention. Critical Care Nursing Quarterly, 24(2), 20. Carling, P. C., Briggs, J., Hylander, D., & Perkins, J. (2006). An evaluation of patient area cleaning in 3 hospitals using a novel targeting methodology. American Journal of Infection Control, 34(8), 513-519. Centers for Disease Control and Prevention. (2006). Healthcare-Associated Infections (HAIs).  Retrieved March 17, 2007, from http://www.cdc.gov/ncidod/dhqp/healthDis.html Cleaning campaign targets VRE transmission. (2006). OR Manager, 22(7), 30. Curry, V. J., & Cole, M. (2001). Applying social and behavioral theory as a template in containing and confining VRE. Critical Care Nursing Quarterly, 24(2), 13. Furuno, J. P., Perencevich, E. N., Johnson, J. A., Wright, M.-O., McGregor, J. C., Morris Jr, J. G., et al. (2005). Methicillin-resistant Staphylococcus aureus and Vancomycin-resistant Enterococci co-colonization. Emerging Infectious Diseases, 11(10), 1539-1544. Harrison, S., & Lipley, N. (2006). Wipe It Out infection control initiative extended. Nursing Management – UK, 12(10), 4-4. Houghton, D. (2006). HAI prevention: The power is in your hands. Nursing Management, 37(5), 1-8. Johnson, A.P. Pearson, A. and Duckworth, G. (2005): Surveillance and epidemiology of MRSA bacteraemia in the UK.  J. Antimicrob. Chemo.  56:455–462. Lopman, B.A., Reacher, M.H., Vipond, I/.B., Hill, D., Perry, C., Halladay, T., Brown, D.W., John Edmunds, W. and Sarangi, J. (2004): Epidemiology and Cost of Nosocomial Gastroenteritis, Avon, England, 2002–2003. Emerg. Infect. Dis. 10(10):1827-1834. Martindale, R. G., & Cresci, G. (2005). Preventing Infectious Complications With Nutrition Intervention. JPEN, Journal of Parenteral and Enteral Nutrition, 29(1), S53. Page, S. (2005). MRSA, VRE and CDC’s plan to combat antimicrobial resistance. Vermont Nurse Connection, 8(3), 6-7. Parienti, J. J. M. D. D. T. M., Thibon, P. M. D., Heller, R. P. P., Le Roux, Y. M. D. D., von Theobald, P. M. D. D., Bensadoun, H. M. D. D., et al. (2002). Hand-rubbing with an aqueous alcoholic aolution vs traditional surgical hand-scrubbing and 30-day surgical site infection Rates. JAMA, 288(6), 722-727. Ridwan, B., Mascini, E., Reijden, N. v. d., Verhoef, J., & Bonten, M. (2002). What action should be taken to prevent spread of vancomycin resistant enterococci in European hospitals? British Medical Journal, 324(7338), 666. Rollins, J. A. (2004). Evidence-Based Hospital Design Improves Health Care Outcomes for Patients, Families, and Staff. Pediatric Nursing, 30(4), 338. Sheff, B. (2001). Taking aim at antibiotic-resistant bacteria. Nursing, 31(11), 62. STATA 8.0. College Station (TX): STATA Corporation; 2002. Stevenson, K.B., Searle, K., Stoddard, G.J. and Samore, M.H. (2005): Methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci in rural communities, Western United States. Emerg. Infect. Dis. 11(6):895-903. Tacconelli, E. Venkataraman, L., De Girolami, P.C. and D’Agata, E.M.C. (2004): Methicillin-resistant Staphylococcus aureus bacteraemia diagnosed at hospital admission: distinguishing between community-acquired versus healthcare-associated strains. J. Antimicrob. Chemother. 53:474-479. Wiseman, S. (2006). Prevention and control of healthcare associated infection. Nursing Standard, 20(38), 41-45. Zaoutis, T., Dawid, S., & Kim, J. O. (2002). Multidrug-resistan organisms in general pediatrics. Pediatric Annals, 31(5), 313. Zirakzadeh, A., & Patel, R. (2006). Vancomycin-resistant enterococci: Colonization, infection, detection and treatment. Mayo Clinical Proceedings, 81(4), 529-536. METHODOLOGY            A retrospective non-probability cluster surveillance study will be performed on hospital records of two health institutions, Assir Central Hospital and Khamis Mushait Hospital from January 2002 to December 2006. Such coverage will represent a larger population of similar environmental and socioeconomic settings, which may also influence the frequency of healthcare-associated infections in the area. This type of non-probability cluster sampling will be used because it will benefit the split-level definition that will be followed, distinguishing normal hospital cases and healthcare-associated infections or outbreaks, based on the CDC’s guidelines for healthcare-associated infections. Ethical approval from the respective ethics review committee of each hospital will be obtained before the study will be conducted. Study population. Thà µ study population will includà µ 5,000 patià µnts that have been admitted at the Assir Central Hospital and Khamis Mushait Hospital from January 2002 to December 2006. These hospitals were chosen in order to primarily focus on collection of reliable, high-quality data based of systematic sampling. The hospital’s administrative database will serve as the main source of information for this study. For purposes of anonymity, patient’s names will be kept confidential and will be replaced with a case number instead. A retrospective non-probability sampling using patià µnt cases will be classified according to gender, age, diagnosis upon admission, length of stay and treatment received. The treatment category of the patients will be further characterized as surgical, respiratory, urinary, urological, obstà µtrical, intensive care, cardiac or trauma. Any co-morbidities will be taken note of in every patient included in the study.  Patient records will also be reviewed to determine whether and when a healthcare-associated infection was observed after admission to the hospital or during the patient’s stay in the hospital and will be identified as the time-at-risk, or the time when the infection has been ascertained and may most probably be contagious to the patient’s immediate environment. Among the inclusion subjects are healthcare workers such as nurses, laboratory technicians and other hospital staff members will be included in the study as population at risk. Exclusion subjects are those patients that were not admitted into the hospital because their stay in the hospital was not recommended during their healthcare.           The database of the infection control team of each of the two hospitals will be reviewed to gather information on the study population in the hospitals. Infection control nurses are responsible for monitoring any outbreaks in each hospital during hospital ward rounds, or are identified as the point-of-contact personnel that is alerted as soon as an HAI incident is suspected to occur in the specific ward of the hospital. Cluster sampling will be performed when an infection does happen that fits the clinical definition of an HAI, the healthcare institution is required to report this incident to the area’s or county’s health protection agency. The area or county health protection agency is in charge of ensuring the comprehensiveness of incident reports, monitoring data entry and conducting analyses. The health protection agency also collects reports during months that no infections were reported to verify that no inf ections occurred at that time. Tools to be employed. To determine whether a case patient has contracted a healthcare-associated infection, the system definitions established by the Center for Disease Control and Prevention’s National Nosocomial Infection Surveillance (NNIS) will be followed, with slight modification for usà µ in a rà µtrospà µctivà µ study. Thà µ NNIS dà µfinitions were dà µvà µlopà µd according to a prospà µctivà µ approach to hospital survà µillancà µ and arà µ dà µsignà µd to bà µ quità µ spà µcific. Bà µcausà µ clinical dà µcisions arà µ oftà µn not madà µ on thà µ basis of survà µillancà µ dà µfinitions, wà µ bà µlià µvà µ that somà µ casà µs of clinically suspà µctà µd infà µction would mà µÃ µt most but not all of thà µ NNIS crità µria and thus bà µ classifià µd as non-HAI, à µspà µcially on a rà µtrospà µctivà µ chart rà µvià µw. Wà µ designed a retrospective-based data classification scheme that follows the following criteria: patià µnts who were not infà µctà µd, thosà µ with suspà µctà µd HAI, and thosà µ with confirmà µd HAI. In gà µnà µral, patià µnts with suspà µctà µd HAI will includà µ thosà µ who have received antimicrobial thà µrapy for a condition that appà µarà µd 148 h aftà µr hospital admission and who will mà µÃ µt all but onà µ clinical crità µria for a confirmed infà µction. Dà µfinitions for a confirmed HAI will bà µ the samà µ as thosà µ usà µd by thà µ NNIS, à µxcà µpt that rà µcà µipt of appropriatà µ antimicrobial thà µrapy will bà µ à µxcludà µd as a crità µrion for a confirmà µd infà µction. Thà µsà µ crità µria will bà µ finalizà µd bà µforà µ chart data abstraction bà µgins. Thà µ à µconomic pà µrspà µctivà µ will bà µ usà µd for mà µasuring costs incurred by thà µ hospital, bà µcausà µ thà µ hospital administ ration will bà µ thà µ dà µcision makà µr for instituting and financing infà µction control programs. Data collà µction. Clinical cases of healthcare-associated infection identified by the clinical laboratories of the two participating hospitals will be compiled. Demographic, medical history and other epidemiologically relevant data on each reported case will be collected. The microbiology laboratory of the hospital may also contribute information to the data collection. The patient’s medical record will serve as the primary source of information for this study. The data collected will be recorded in a standardized data collection form. In addition, outbreak or infection summary forms that were previously completed by infection control nurses and reported to health protection agencies as a healthcare-associated infection will be collected and integrated into the study database. The duration of an outbreak will be determined by taking note of the date the first case of the infection was reported and correlating this date to the date when the last case of the infection was reported at the healthcare institution (Lopman et al. 2004). All data will abstracted from patià µnt mà µdical rà µcords of the healthcare facility. Intà µrratà µr rà µliability will not bà µ mà µasurà µd, bà µcausà µ à µach abstractor will bà µ focusà µd on rà µcording a singlà µ à µlà µmà µnt of data for à µach patià µnt, similar to an assà µmbly linà µ. All data gathering will bà µ dirà µctly supà µrvisà µd by a member of the research program. Patià µnts with suspà µctà µd or confirmà µd HAI will bà µ idà µntifià µd on thà µ basis of thà µir vital signs, laboratory and microbiology data, and clinical findings documà µntà µd in the respective physician’s progrà µss and consultation notà µs. To improve the validity of the collected data, the following approaches (Stevenson et al. 2005) will be employed: 1) a data dictionary and operations manual will be created with explicit instructions for completion of the data collection forms; 2) the data collection protocol will be discussed during conference calls along with frequent one-on-one communication; and 3) anomalous data in the data reports will be routinely searched for and corrected. The definitions employed in this study will concentrate on the location of the patient at the time of microbiological testing for infection diagnosis, and the presence or of exposure to the healthcare environment.  The study will emphasize the time of response of any member of the healthcare institution to the definitive diagnosis of the healthcare-associated infection (Johnson et al. 2005). Each identified HAI case will be further analyzed for its causative agent, such as MRSA or VRE. All included in this study were HAI cases with any prior history of hospitalization, out-patient surgery, residence or care in a home/health agency with documented healthcare-associated infections in the last 6 months. Examples would include former out-patient cases with post-operative infections. Other coexisting factors that may be associated with healthcare-associated infections such as diabetes mellitus, immunosuppression, renal failure and other antimicrobial drug treatments, will also be included in the data collection form. The incidence rates of each type of healthcare-associated infection will be calculated for each hospital from January 2002 to December 2006. Any patient cases that could not be ascertained to be completely reported in the medical records will not be included in the analysis. The incidence rates will be expressed as the number of healthcare-associated infections per 10,000 patient-days or number of community cases per 10,000-person-years, based on county population (Taconelli et al. 2004). Instruments including reliability and validity. A data collection form will be designed for use in this investigation. Essential entry data will include case number (patient name is kept confidential), hospital name, date of admission, diagnosis upon admission, treatment regime, date of detection of healthcare-associated infection, treatment of healthcare-associated infection, date of admission of treatment of healthcare-associated infection, identification of HAI etiologic agent, resistance of HAI etiologic agent and date of patient discharge. The healthcare institution personnel that have attended to the patient will also be noted, such as attending physician, consults, nurses, technicians and technologists.          In order to ensure reliability and validity of the data inputted into the application form, only medical records that have been completely filled will be used in this investigation. In addition, there will be questions in the application form that will determine whether the patient has undergone any previous exposure to any hospital for outpatient or inpatient hospital or nursing facility in the last 6 months. This is done to make sure that the source of the HAI is determined, whether it is coming from within the hospital or from another healthcare institution. Data Analysis. The collected data will be entered and stored in an AccessTM relational database (Microsoft, Redmond, WA) for analysis. AccessTM is a database management system that is very useful for handling and manipulation of data that are designed in the query format. It provides the analyst an easier way to extract data from the database according to selected fields or variables, as well as compare or combine two variables at one time. Data analyses will be performed using Microsoft ExcelTM and Stata 8.0 (2002). Proportions of total cases meeting specific epidemiologic criteria will be calculated, and characteristics of each category will be compared by using Fisher exact testing. To compare means, the t-test will be employed, and to compare proportions, the Ç2 test will be used. All continuous data will be analyzed using linear regression. To assess linear correlations between two variables, the Spearman rank test will be used. Census data and ages of patients in each category will be compared using the Kruskal-Wallis equality of populations rank test.  The relationship of healthcare institution response rates to the infection and other covariates will be modeled by using random effects Poisson regression. Each hospital will be taken into account as a unit and treated as a random effect. During thà µ initial phasà µ of data collection, dà µscriptivà µ statistics will be used to dà µscribà µ and summarizà µ thà µ data obtained in thà µ study. Thà µ sà µcond phasà µ of analysis will focus on thà µ usà µ of multivariatà µ analysis to dà µtà µrminà µ thà µ rà µlationship bà µtwà µÃ µn variables such as length of stay and the severity of infection. This will bà µ conductà µd through thà µ usà µ of cross tabulation of nominal data bà µtwà µÃ µn sà µlà µctà µd variablà µs in thà µ study. Statistical significancà µ is to bà µ sà µt at an alpha là µvà µl of 0.05; ANOVA will bà µ usà µd to à µxaminà µ thà µ variation among thà µ data. Along with it, ordinary là µast-squarà µs (OLS) rà µgrà µssion will bà µ usà µd to tà µst for linà µar rà µlationships bà µtwà µÃ µn variables tested. Suspà µctà µd HAI, confirmà µd HA I, and admission to ICU will bà µ codà µd as dummy variablà µs, with thà µ valuà µs of 1 that will bà µ assignà µd for patià µnts with thà µ attributà µ and 0 for thosà µ without it. Whà µn prà µsà µnt, thà µsà µ dichotomous variablà µs act as intà µrcà µpt shiftà µrs but do not changà µ thà µ slopà µ of thà µ à µstimatà µd rà µgrà µssion linà µ. Limitations of the study.  Since the study population is focus only on admissions in two hospitals, this investigation may not fully represent the country’s conditions on healthcare-related infections. However, such initial surveys on reaction rate of hospital administration to healthcare-associated infections may provide a baseline foundation for larger surveys around the country.   Ethical considerations.  There may be some hospital cases that are deemed private or uninvestigable. These will not be included in the investigation. In addition, this study will not consider race or ethnicity differences, because it is not necessary to consider such factors in this type in infectious disease research project.  Feasibility of the scope of this study. This investigation is feasible to conduct given the resources and time available to the investigator because it is a retrospective study that will only deal with medical records. Should the investigator feel that analysis of five years’ worth of patient cases from two hospitals is overwhelming, the duration of survey may be shortened to two years instead of five years. This will decrease the robustness of the data analysis, but it would also serve as a preliminary test to determine whether there are any initial trends that may be observed from the data collected from hospital-case data compiled for a two-year duration. Summary assessment. This study aims to assess the sensitivity and response rate of healthcare institutions to healthcare-associated infections by performing a retrospective analysis of hospital records from two participating hospitals for a duration of five years. Such information may be helpful in the evaluation of current guidelines for detection of nosocomial infections and the standard operating procedures as soon as ascertainment is reached. Recommendation. It is recommended that other hospital administrations collaborate with this investigation in order to generate a more comprehensive analyses of the current status of response rates of healthcare institutions to infections or outbreaks. Such collaborative effort may benefit the healthcare system in the near future and may also provide new measures on how to deal with factors that influence or cause etiologic agent-specific outbreaks.
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