RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

SYNOPSIS PROFORMAFOR REGISTRATION OF SUBJECT FOR

DISSERTATION1. NAME OF THE CANDIDATE AND

ADDRESS MERIN MARY MATHEW. M.Sc NURSING I YEAR,PRAGATHI COLLEGE OF NURSING, #33 BYRATHI (EXT), NEAR EBENEZAR HOSPITAL, HENNUR BEGALUR MAIN ROAD, KOTHANUR POST, BANGALORE-77

2. NAME OF THE INSTITUTION PRAGATHI COLLEGE OF NURSING, #33 BYRATHI(EXT),NEAR EBENEZAR HOSPITAL,HENNUR BEGALUR MAIN ROAD ,KOTHANUR POST, BANGALORE-77

3. COURSE OF

STUDYAND SUBJECTDEGREE OF MASTERS IN NURSING

CHILD HEALTH NURSING.

4. DATE OF ADMISSON TO THE

COURSE

15/11/2010

5. TITTLE OF THE TOPIC “EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME REGARDING

KNOWLEDGE ON MANAGEMENT AND

PREVENTION OF NOSOCOMIAL

PNEUMONIA AMONG STAFF NURSES

WORKING IN PEDIARIC WARD IN

SELECTED HOSPITALS, BANGALORE.”

BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

Nosocomial infections are infections that are a result of treatment in a hospital or a

healthcare service unit. Infections are considered nosocomial if they first appear 72 hours

or more after hospital admission or within 30 days after discharge.

Nosocomial infections are commonly transmitted when hospital officials become

complacent and personnel do not practice correct hygiene regularly. Also, increased use of

outpatient treatment means that people who are hospitalized are more ill and have more

weakened immune systems than may have been true in the past. Moreover, some medical

procedures bypass the body's natural protective barriers. Since medical staff moves from

patient to patient, the staff themselves serves as a means for spreading pathogens.

Hospitals have sanitation protocols regarding uniforms, equipment sterilization, washing,

and other preventative measures. Thorough hand washing and/or use of alcohol rubs by all

medical personnel before and after each patient contact is one of the most effective ways

to combat nosocomial infections. More careful use of antimicrobial agents, such as

antibiotics, is also considered vital

In the United States, the Centers for Disease Control and Prevention estimates that

roughly 1.7 million hospital-associated infections, from all types of bacteria combined,

cause or contribute to 99,000 deaths each year. In Europe, where hospital surveys have

been conducted, the category of Gram-negative infections are estimated to account for

two-thirds of the 25,000 deaths each year. Nosocomial infections can cause severe

pneumonia and infections of the urinary tract, bloodstream and other parts of the body.

Many types are difficult to attack with antibiotics, and antibiotic resistance is spreading to

Gram-negative bacteria that can infect people outside the hospital.

In a representative sample of US general hospitals, the authors found that the

establishment of intensive infection surveillance and control programs was strongly

associated with reductions in rates of nosocomial urinary tract infection, surgical wound

infection, pneumonia, and bacteremia between 2000 and 2005–2006, after controlling for

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other characteristics of the hospitals and their patients. Essential components of effective

programs included conducting organized surveillance and control activities and having a

trained, effectual infection control physician, an infection control nurse per 250 beds, and

a system for reporting infection rates to practicing surgeons. Programs with these

components reduced their hospitals' infection rates by 32%. Since relatively few hospitals

had very effective programs, however, only 6% of the nation's approximately 2 million

nosocomial infections were being prevented in the mid-2000s, leaving another 26% to be

prevented by universal adoption of these programs. Among hospitals without effective

programs, the overall infection rate increased by 18% from 1990 to 2006.

Currently, about 180 hospitals participate in the National Nosocomial Infections

Surveillance (NNIS) system. From January 1980 through April 1998, 127,200 fungal

isolates causing nosocomial infections were reported from these hospitals; Candida

species accounted for 19,621 (72.1%) of these isolates. Immunocompromised patients are

at particularly high risk for candidemia. In patients with acute lymphocytic leukemia,

treatment with vancomycin and/or imipenem appears to be an independent risk factor for

candidemia; colonization of stool by Candida species may be another important

predisposing factor in these patients. Rapid detection of invasive candidemia in these

high-risk patients is particularly important to the improvement of rates of survival.

Methods for rapid detection, such as the measurement of manna (the major cell-wall

polysaccharide of Candida), may be useful for diagnosing invasive candidacies and for

monitoring the response of this infection to antifungal therapy. Further studies of risk

factors and the development of new methods for rapid diagnosis and monitoring should

help decrease the morbidity and mortality associated with nosocomial fungal infections.

A study was conducted to find the incidence of hospital-acquired pneumonia in 1886

consecutive admissions to an 1800 bed hospital in Bombay; 991 of them to general

medical wards and 895 to a 17-bed medical intensive care unit (ICU). The average bed

occupancy in the general wards was 56 patients in a ward with 40 beds. Staffing in the

general ward was two nurses for 56 patients, and in the ICU three nurses for 17 beds. One

hundred and sixty-eight patients developed nosocomial pneumonia: 18 (1·8%) in general

wards and 150 (16·7%) in the ICU. Common isolates included Pseudomonas spp (44%)

and Klebsiella spp (34%). The most frequently used antibiotics were cefotaxime (34%),

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amikacin (25%), gentamicin (23%) and ofloxacin (13%). Crude mortality in general ward

patients was 88·9 vs. 14·6% in patients without pneumonia. The corresponding figures for

ICU patients were 67·4 vs 37·1%; 40% of the crude mortality in ICU patients with

pneumonia was attributable to the infection. Infected patients stayed an additional 5·8

days in the ICU and 6·7 days in the general ward. Costs of additional stay and antibiotics

accounted for 18·6% of the ICU budget. The incidence of nosocomial pneumonia was

lower than expected, despite occupancy exceeding bed capacity, low nurse:patient ratios,

and extensive reuse of disposable respiratory therapy equipment. Nevertheless,

nosocomial pneumonia imposes a significant financial burden on the already scarce

resources available for intensive care in developing countries like India.

A study included 201 patients (1285 patient days) admitted to RICU over a period of one-

and-a-half years. A total of 77 infections were identified in 67 patients (33.5%). The

infections included pneumonia (23%), sepsis of unknown origin (10.5%), bacteremia

(7.5%), urinary tract infections (1.5%), catheter related blood stream infections (1%) and

Clostridium difficile colitis (1%). The most commonly identified organisms were the

Acinetobacter species (34.8%), Pseudomonas aeruginosa (23.9%) and Escherichia coli

(15.2%). The median length of stay in patients with and without infection was 13 days

(interquartile range, IQR, 28) and 4 days (interquartile range, IQR, 3), respectively

(p<0.0001). Multivariate analysis showed the following risk factors for ICU-acquired

infection: the admitting diagnosis of infection (odds ratio [OR] 3.3; 95% confidence

intervals [CI] 1.06–10.1), length of stay in the RICU (OR, 1.2; 95% confidence intervals

[CI] 1.1–1.33); renal failure (OR, 4.7; 95% CI, 1.52–14.41) and institution of parenteral

nutrition (OR, 16.9; 95% CI, 1.07–269.03). Multivariate analysis showed the following

risk factors for death in ICU: APACHE II scores (OR, 1.06; 95% CI, 1.01–1.11), and

endotracheal intubation (OR, 5.07; 95% CI, 1.24–20.65).

The Norwegian Institute of Public Health initiated a national surveillance system for

nosocomial infections in 2002. The system is based on two annual one-day prevalence

surveys recording the four most common types of nosocomial infection: urinary tract

infections; lower respiratory tract infections; surgical site infections and septicaemia. All

acute care hospitals in Norway (N=76) were invited to participate in the four surveys in

2002 and 2003. The total prevalence of the four recorded nosocomial infections varied

between 5.1% and 5.4% in the four surveys. In all surveys, nosocomial infections were

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located most frequently in the urinary tract (34%), followed by the lower respiratory tract

(29%), surgical sites (28%) and septicaemia (8%). The prevalence surveys give a brief

overview of the burden and distribution of nosocomial infections. The results can be used

to prioritize further infection control measures and more detailed incidence surveillance of

nosocomial infections.

A one-day survey was carried out in 88 out of 113 public hospitals in Lombardy to obtain

prevalence rates of hospital-acquired infections (HAIs) by hospital departments and to

identify the pathogens more frequently involved. In total 18 667 patients were surveyed,

representing 72% of the average daily total of occupied beds in public hospitals in

Lombardy. The overall prevalence of HAI was 4.9%. The highest prevalence was

observed in intensive care units and in spinal units. The prevalence of bloodstream

infections was 0.6%; pneumonia 1.1%; urinary tract infections 1.6% and gastrointestinal

infections 0.4%. In surgical patients the prevalence of surgical site infections was 2.7%.

The most frequently isolated pathogen from all sites of infections was Escherichia coli

(16.8%), followed by Staphylococcus aureus (15.0%), Pseudomonas aeruginosa (13.2%)

and Candida spp. (8.7%). Methicillin-resistant S. aureus accounted for 23% of all isolated

S. aureus. The results provide baseline data for rational priorities in allocation of

resources, for further studies and for infection control activities.

A retrospective study was undertaken to compare the nosocomial infection rate in obese

and normal weight surgical patients. All patients undergoing general, urologic, vascular,

thoracic, or gynecologic surgical procedures between October 1 and December 31, 1991,

were reviewed. Nosocomial infection data were obtained from the Department of Hospital

Epidemiology. A total of 849 patients were evaluated, of which 536 (63%) were normal

weight (BMI < 27 kg/m2), 175 (21%) were obese (BMI 27-31 kg/m2), and 138 (16%)

were severely obese (BMI > 31 kg/m2). Age, mortality, and American Society of

Anesthesia (ASA) risk scores did not differ among the three groups. There were

significant increases in the number and percent of nosocomial infections in the obese

populations, with rates of 0.05 per cent in normal weight, compared to 2.8 per cent and 4.0

per cent in obese and severely obese groups (P < 0.01). Infections consisted of seven

wound infections, five C. difficile infections, one pneumonia, and three bacteraemia. No

differences in distribution between groups were evident. Mortality was similar among the

groups. These data support the hypothesis that obesity is a significant risk factor for

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clinically relevant nosocomial infections in surgical patients.

6.1 NEED FOR THE STUDY

Hospital-acquired pneumonia is a growing concern that all nurses need to be aware

of because hospital-acquired infections are a major challenge to patient safety. It is also

estimated that in 2002, a total of 1.7 million hospital-acquired infections occurred (4.5 per

100 admissions), and almost 99,000 deaths resulted from or were associated with a

hospital-acquired infection, making hospital-acquired infections the sixth leading cause of

death. At the same time it is also estimated that approximately one third or more of

hospital-acquired infections are preventable.1

A case-control study was conducted intending to evaluate the influences of

severity of illness and evolution of therapeutic activity on the development of nosocomial

infections, and to estimate the attributable consequences of these infections on ICU

patients. The study concluded that a persistent high level of therapeutic activity and

persistently depressed consciousness on the third day after ICU admission are associated

with the acquisition of nosocomial infection by critically ill patients hospitalized in a

medical ICU. Such nosocomial infections are responsible for excess mortality, prolonged

stay, and increased therapeutic activity independently of the initial severity of illness.

Thus, nosocomial infections exact a heavy toll on all concerned the patient, the medical

staff, and economic resources especially in cases of multiple infections.2

A prospective study was conducted to know the incidence of hospital-acquired

pneumonia in 1886 consecutive admissions to an 1800 bed hospital in Bombay; 991 of

them to general medical wards and 895 to a 17-bed medical intensive care unit (ICU). The

average bed occupancy in the general wards was 56 patients in a ward with 40 beds.

Staffing in the general ward was two nurses for 56 patients, and in the ICU three nurses

for 17 beds. One hundred and sixty-eight patients developed nosocomial pneumonia: 18

(1·8%) in general wards and 150 (16·7%) in the ICU. Common isolates included

Pseudomonas spp (44%) and Klebsiella spp (34%). The most frequently used antibiotics

were cefotaxime (34%), amikacin (25%), gentamicin (23%) and ofloxacin (13%). Crude

mortality in general ward patients was 88·9 vs 14·6% in patients without pneumonia. The

6

corresponding figures for ICU patients were 67·4 vs 37·1%; 40% of the crude mortality in

ICU patients with pneumonia was attributable to the infection. Infected patients stayed an

additional 5·8 days in the ICU and 6·7 days in the general ward. Costs of additional stay

and antibiotics accounted for 18·6% of the ICU budget. The incidence of nosocomial

pneumonia was lower than expected, despite occupancy exceeding bed capacity, low

nurse: patient ratios, and extensive reuse of disposable respiratory therapy equipment.

Nevertheless, nosocomial pneumonia imposes a significant financial burden on the

already scarce resources available for intensive care in developing countries like India.3

According to the most recent statistics from the CDC, hospital-acquired

pneumonia accounts for nearly 15% of all hospital-acquired infections and is associated

with the highest mortality rates (20% to 33%). It's second only to urinary tract infections

as the most common Hospital acquired infections.4

Throughout the world, including Asia, Nosocomial infection is an important public

health problem, often with pneumonia as a significant consequence. Hospital-acquired

pneumonia is associated with significant morbidity and mortality and increased costs of

treatment. Hospital acquired pneumonia is associated with crude mortality rates of up to

70% and attributable mortality rates as high as 33% to 50%. A study conducted in India

showed that the Mortality rates relating to nosocomial pneumonia was 37% to 47.3% and

the Incidence of ventilator associated pneumonia was 8.95 per 1000 ventilator days and

the incidence of hospital acquired pneumonia was 53.9%.5

A study was conducted to identify knowledge deficits concerning nosocomial

pneumonia prevention among critical care nurses. A survey design using a mailed self-

administered questionnaire was used. A sample of 134 critical care nurses was included in

the study. The results showed that nurse practioners knowledge score ranged from 21% to

92%. The mean (and median) was 48%. Items related to knowledge about nosocomial

risks had the highest mean score (67%) compared to items addressing nosocomial

pneumonia prevention (43%) or the role of devices in the transmission of NP (45%). No

nurse demographic or workplace characteristic was associated with nosocomial

pneumonia knowledge. The study concluded that nurse practioners knowledge score

ranged from 21% to 92%. The mean (and median) was 48%. Items related to knowledge

about nurse practioners risks had the highest mean score (67%) compared to items

addressing nurse practioner prevention (43%) or the role of devices in the transmission of

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nurse practioner (45%). No nurse demographic or workplace characteristic was associated

with nurse practioner knowledge.6

A study was conducted to evaluate the extent to which nurses working in intensive

care units implement best practices when managing adult patients receiving mechanical

ventilation. Nurses attending education seminars in the United States completed a 29-item

questionnaire about the type and frequency of care provided. Twelve hundred nurses

completed the questionnaire. Most (82%) reported compliance with hand-washing

guidelines, 75% reported wearing gloves, half reported elevating the head of the bed, a

third reported performing subglottic suctioning, and half reported having an oral care

protocol in their hospital. Nurses in hospitals with an oral care protocol reported better

compliance with hand washing and maintaining head-of-bed elevation, were more likely

to regularly provide oral care, and were more familiar with rates of ventilator-associated

pneumonia and the organisms involved than were nurses working in hospitals without

such protocols. The study concludes that guidelines for the prevention of ventilator-

associated pneumonia from the Centers for Disease Control and Prevention are not

consistently or uniformly implemented.7

A prospective study was conducted to determine the epidemiology for

postoperative nosocomial infections. The study concludes that Nosocomial pneumonia

with resistant gram-negative bacteria now predominates along with increased incidence of

fungal infections. Currently, postoperative infections are now more severe, involve critical

organs, and require close monitoring of the changing patterns of pathogens.8

Hospital-acquired pneumonia and ventilator-associated pneumonia are significant

public health issues in Asian countries, as they are worldwide. Mortality attributable to

hospital acquired pneumonia and especially ventilator associated pneumonia is very high.5

Hence the investigator strongly feels that there is a need for conducting a structured

teaching programme on prevention of nosocomial pneumonia.

6.2 REVIEW OF LITERATURE

Review of literature refers to activities involved in identifying and searching for

information on a topic and developing and understanding the state of knowledge on the

topic .researcher never conduct a study in intellectual vacuum their studies are usually

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undertaken within the context of an existing basic knowledge

The literature is reviewed and presented under the following headings

1. Studies related to incidence of nosocomial infection

2. Studies related to nosocomial infection

3. Studies related to nurses knowledge on nosocomial infection

4. Studies related to structured teaching programme

1. Studies related to incidence of nosocomial infection

A study was conducted to find out the incidence of nosocomial infection, It’s

found that the incidence of pneumonia was identical with ventilator circuit changes every

48 h and with no ventilator circuit changes. The study prospectively assessed whether

keeping ventilator circuits clean with a heat and moisture exchanger exhibiting

antimicrobial barrier properties affects patient colonization and the incidence of

nosocomial pneumonia in patients receiving mechanical ventilation for more than 48 h.

Consecutive patients were randomly allocated to humidification with either a heat and

moisture exchanger (Group 1, n = 61) or a heated humidifier (Group 2, n = 70). In both

groups, no circuit changes were performed throughout ventilatory support. Duration of

mechanical ventilation was identical in both groups (10 +/- 8.6 d (range: 2 to 47) in Group

1 and 12.5 +/- 14.2 d [range: 2 to 85] in Group 2). The incidence of pneumonia (positive

quantitative culture of protected brush specimen) was similar in both groups (6/61 and

8/70 in Groups 1 and 2, respectively; p = 0.8), as was duration of ventilation prior to

pneumonia (9 +/- 5.9 versus 8.2 +/- 5.7 d; p = 0.8). Ventilator tubing contamination was

considerably reduced with the use of a heat and moisture exchanger. In contrast, bacterial

colonization of the pharynx and trachea was identical in both groups. These results suggest

9

that circuit colonization plays little or no role in the occurrence of ventilator-associated

pneumonia, provided usual maintenance precautions are applied (50)

A retrospective study was carried out to determine the current status of nosocomial

infection in China between 2003 and 2007. Nosocomial infections were defined according

to the definitions of Centers for Disease Control and Prevention. The overall patient

nosocomial infection rate, the incidence density rate of nosocomial infections, the excess

length of stay, and distribution of nosocomial infection sites were determined. Among

1980 patients admitted over the period of time, the overall patient nosocomial infection

rate was 26.8% or 51.0 per 1000 patient days., Lower respiratory tract infections (LRTI)

accounted for most of the infections (68.4%), followed by urinary tract infections (UTI,

15.9%), bloodstream (BSI, 5.9%), and gastrointestinal tract (GI, 2.5%) infections. There

was no significant change in LRTI, UTI and BSI infection rates during the 5 years.

However, GI rate was significantly decreased from 5.5% in 2003 to 0.4% in 2007. In

addition, A. baumannii, C. albicans and S. epidermidis were the most frequent pathogens

isolated in patients with LRTIs, UTIs and BSIs, respectively. The rates of isolates resistant

to commonly used antibiotics ranged from 24.0% to 93.1%. The study concluded that

there was a high and relatively stable rate of nosocomial infections in the ICU of a tertiary

hospital in China through year 2003–2007. Guidelines for surveillance and prevention of

nosocomial infections must be implemented in order to reduce the rate of infection.12

A study was conducted on 48 ventilated patients with nosocomial pneumonia identified on

the basis of results of protected specimen brush quantitative culture and identification of

intracellular organisms in cells recovered by bronchoalveolar lavage. For matching cases

and their respective controls, the following variables were used: age (± 5 years),

Simplified Acute Physiologic Score (± 3 points), indication for ventilatory support, date of

admission, and duration of exposure to risk.Successful matching was achieved for 222 of

240 (92.5%) variables. The mortality rate in cases was 26 of 48 (54.2%) compared with

13 of 48 (27.1%) in controls. The attributable mortality was 27.1% (95% confidence

interval [CI], 8.3% to 45.9%; p < 0.01) and the risk ratio for death was 2.0 (95% CI, 1.61

to 2.49). The mean length of stay was 34 days for cases and 21 days for controls (p <

0.02). In the case of pneumonia due to Pseudomonas or Acinetobacter species, the

mortality rate was 71.4%, the attributable mortality was 42.8% (95% CI, 14.5% to

10

69.0%), and the risk ratio was 2.50 (95% CI, 1.31 to 4.61). Pneumonias occurring in

ventilated patients, especially those due to Pseudomonas or Acinetobacter species, are

associated with considerable mortality in excess of that resulting from the underlying

disease alone, and significantly prolong the length of stay in the intensive care unit.(51)

2. studies related to nosocomial infection

A study was conducted to define the prevalence, risk factors, spectrum of

organisms and sensitivity patterns, and the outcome in patients with severe hospital

acquired pneumonia (HAP) in the Medical Intensive Care Unit (SCU) in a hospital in

Singapore. Consecutive patients admitted to the MICU over a 6-month period were

studied and assessed daily to determine whether patients had developed HAP based on

defined clinical criteria. Sputum or endotracheal aspirate was obtained and results

recorded from each patient on admission and every subsequent three days throughout the

stay in the MICU. Mortality during hospital stay was the main outcome measure recorded.

A total of 136 patients (150 admissions) were studied; 24 patients were identified as

having HAP. The prevalence of HAP was 17%. The spectrum of organisms which caused

HAP were polymicrobial, Klebsiella pneumoniae, Pseudomonas aeruginosa, methicillin-

resistant Staphylococcus aureus and coagulase negative Staphylococcus. The mortality of

patients with VAP and HAP were 72.7% and 76.9% respectively. The study concludes

that HAP in the MICU is common with a high mortality. The spectrum of organisms was

comparable to previous studies.9

A prospective study to define how many and what kind of nosocomial infections

are occurring, what are the causative microbes and what kind of drugs can be used in

treatment of infection at Al-Hada Armed Forces Hospital, Taif, Saudi Arabia during the

year 2004. Determination of nosocomial infections was performed using standardized

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CDC criteria. A total of 1382 patients had developed infection during hospital admission

and were included in the study. Of them, 668 (48.3%) had nosocomial infection and 714

(51.7%) had community-acquired infection. Among those who developed nosocomial

infections, 216 (32.3%), 172 (25.7%) and 124 (18.6%) had respiratory tract (RTI), urinary

tract (UTI) and blood stream infections (BSI) respectively. Surgical site infection (SSI)

was reported in 86 cases (12.9%). Gram-positive organisms were reported in 31.8%.

MRSA (Methicillin-resistant S. aureus) was the commonest (10.2%), followed by

coagulase negative staphylococci (8.5%) and MSSA (Methicillin-susceptible S. aureus,

7.4%). While Gram-negative organisms were reported in 66.2%, E. coli was the

commonest (22.3%), followed by Pseudomonas aeruginosa (17.6%) and Klebsiella

pneumoniae (9.9%). Acinetobacter spp. and MRSA were highly sensitive to Imipenem

(88.6%) and Vancomycin (98.5%) respectively. E. coli were highly sensitive to most of

the antimicrobial agents except ampicillin (26.6%). The study concluded that Pneumonia,

urinary tract infections, and blood stream infections made up the great majority of

nosocomial infections.10

A study was conducted to determine the epidemiology, microbial etiology, risk

factors and clinical manifestations of HAP and VAP. The study concludes that Hospital-

acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are important

causes of morbidity and mortality, with mortality rates approaching 62%. HAP and VAP

are the second most common cause of nosocomial infection overall, but are the most

common cause documented in the intensive care unit setting. In addition, HAP and VAP

produce the highest mortality associated with nosocomial infection. Thus prevention and

risk-reduction strategies to reduce the risk of acquiring these infections were collated.

Future initiatives to enhance more rapid diagnosis and to effect better treatment for

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resistant pathogens are necessary to reduce morbidity and improve survival.11

A prospective cohort study was conducted over 18 months in five intensive care

units to determine if Pneumonia is a very common nosocomial infection in intensive care

units (ICUs). The results showed that among the 1,876 patients who were admitted a total

of 158 patients developed nosocomial pneumonia. The main risk factors for nosocomial

pneumonia were elective surgery, emergency surgery, usage of a nasogastric tube, and

mechanical ventilation. Nosocomial pneumonia prolonged the length of ICU stay but was

not directly associated with a fatal outcome. The study concluded that more studies using

competing risk models, which provide more accurate data compared to naive survival

curves or logistic models, should be carried out to verify the impact of risk factors and

patient characteristics for the acquisition of nosocomial infections and infection-associated

mortality.13

A case- control study was performed in order to confirm that re-intubation can be

a risk factor of nosocomial pneumonia in mechanically ventilated patients. Forty

consecutive patients needing re- intubation were selected as cases. Each case was paired

with a matched control for the previous duration of mechanical ventilation. The results

showed that 47% of the cases developed pneumonia after re-intubation compared with

10% of the controls. Regression analysis demonstrated that re-intubation was the only

significant factor related to the development of pneumonia. The results also showed that

semirecumbency during the period between extubation and re-intubation may play a role

in nosocomial pneumonia development in patients who need re-intubation. Mortality rate

were also higher in re-intubated patients when compared with controls. The study

concludes that re-intubation is a risk factor for ventilator-associated pneumonia and might

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be avoided in a substantial number of cases.14

A study was conducted to identify the several ways to prevent ventilator-

associated pneumonia in patients on a ventilator, according to researchers who analyzed

the medical literature on this topic. Effective methods include raising the patients head to

a 45-degree angle, using sucralfate instead of H(sub 2)-blockers to prevent stress ulcers,

and suctioning the throats of patients who are on a ventilator for more than three days. On

the other hand, changing ventilator circuitry or filters frequently did not lower the risk of

pneumonia.15

A study to evaluate that continuous aspiration of throat secretions may reduce the

incidence of ventilator-associated pneumonia. Pneumonia is common among

mechanically ventilated patients, occurring when bacteria enter the lungs through the cuff

of endotracheal tubes. Of 153 patients receiving mechanical ventilation with the same

kind of tube, 76 also received continuous aspiration (suction) of secretions from below the

voice box and 77 did not (control group). Fourteen (18.4%) of the patients receiving

aspiration developed pneumonia, versus 25 (32.5%) of the control patients. Pneumonia

developed later on average in the aspiration group than in the control group (12 days vs

six days). Analysis of the aspirated secretions revealed microorganisms that often cause

ventilator-associated pneumonia, suggesting that suctioning these secretions can help

prevent the bacteria from entering the endotracheal tube, thus reducing the risk of

pneumonia.16

A prospective study of 213 patients admitted to a medical intensive care unit was

done to determine the frequency of colonization of the respiratory tract with Gram-

negative bacilli and the relation of such colonization to nosocomial infection. Ninety-five

14

patients (45%) became colonized, 22% on the first hospital day. Associated with

colonization were respiratory tract disease, coma, hypotension, tracheal intubation,

acidosis, azotemia, and either leukocytosis or leukopenia. Antimicrobial therapy may have

promoted colonization in some patients. Nosocomial infections developed in 26 patients

(12.2%), 22 of whom were colonized with Gram-negative bacilli. Nosocomial respiratory

infections occurred in 23% of colonized patients but in only 3.3% of noncolonized

patients. The study concludes that control of nosocomial pneumonia may require the

development of methods for preventing or interrupting the colonization of hospitalized

patients with Gram-negative bacilli.17

A prospective, randomized, case-controlled clinical trial was conducted to assess

the effectiveness of 0.12% chlorhexidine gluconate oral rinse in decreasing microbial

colonization of the respiratory tract and nosocomial pneumonia in patients undergoing

open heart surgery. (0.12% chlorhexidine gluconate) was the experimental drug, and

Listerine (phenolic mixture) was the control drug. A total of 561 patients undergoing

aortocoronary bypass or valve surgery requiring cardiopulmonary bypass were

randomized to an experimental (n = 270) or a control (n = 291) group. Nosocomial

pneumonia was diagnosed by using the criteria established by the Centers for Disease

Control and Prevention. The results showed that The overall rate of nosocomial

pneumonia was reduced by 52% in the Peridex-treated patients. The incidence rate of

nosocomial pneumonia was 71% lower in the Peridex group than in the Listerine group.

The study concludes that although rates of nosocomial pneumonia were lower in patients

treated with Peridex than in patients treated with Listerine, the difference was significant

only in those patients intubated more than 24 hours who had the highest degree of

bacterial colonization.18

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3. Literatures related to nurses knowledge on nosocomial infection

A study was conducted to identify whether nosocomial infections can lead to

complications in the patients admitted to neurosurgery intensive care units. The most

common causes were ventriculitis, shunt infections, meningitis, surgical wound infections,

urinary tract infections, pneumonia, intravascular catheter related to infections and

gastrointestinal infections. The results showed that In order to reduce infection rates it is

useful to inform intensive care nurses about the infection sources and it is useful to change

their behaviours. The study concludes that Infection control measures are to be viewed as

priority and have to be integrated fully into the continuous process of improvement of

quality of care.19

A study was conducted by using a validated multiple-choice questionnaire, developed to

evaluate nurses' knowledge of VAP prevention. The questionnaire was distributed and

collected during the annual congress of the Flemish Society for Critical Care Nurses .638

questionnaires were collected (response rate 74.6%). Nineteen percent of the respondents

recognized the oral route as the recommended way for intubation. It was known by 49%

of respondents that ventilator circuits should be changed for each new patient. Heat and

moisture exchangers were checked as the recommended type of humidifier by 55% of

respondents, but only 13% knew that it is recommended to change them once weekly.

Closed suctioning systems were identified as recommended by 17% of respondents, and

20% knew that these must be changed for each new patient only. Sixty percent and 49%,

respectively, recognized subglottic drainage and kinetic beds to reduce the incidence of

VAP. Semi-recumbent positioning is well known to prevent VAP (90%). The average

knowledge level was higher among more experienced nurses (> 1 year experience) and

those holding a special degree in emergency and intensive care. They concluded that

Nurses lack knowledge regarding recommendations for VAP prevention. Nurses'

schooling and continuing education should include support from current evidence-based

guidelines 20

4. literatures related to structured teaching programme

A study was conducted over a four month period, on one surgical ward of a large general

hospital. A total of forty subjects met the criteria of the study, and their informed consent

was obtained. The first twenty subjects were assigned to the control group, and received

the unstructured, pre-existing preoperative instruction from the staff nurses. The second

16

twenty subjects made up the experimental group and received structured preoperative

teaching in small groups conducted by the investigator, with the aid of a slide-taped

programme developed specifically for the study. Prior to discharge, each subject was

given two questionnaires to complete, and data were collected by means of a patient

profile sheet. The two groups of subjects were found to be similar when compared on

selected characteristics. The alternative hypotheses of the study were analyzed by means

of a t-test, and chi square test at the .05 level of significance. The results revealed no

significant effect of the structured preoperative teaching programme upon the adult

surgical patient's length of hospital stay, postoperative complications, and number of

analgesics administered postoperatively, or the degree of satisfaction attained from the

preoperative teaching he received. However, statistical significance was found for the

patient's ability to recall knowledge explained preoperatively. Implications of this study

and recommendations for future research were also suggested.21

A study was conducted to find out the effectiveness of structured teaching program in

improving knowledge and attitude of school going adolescents on reproductive health.

Selected schools with similar settings in Dharan town of Nepal. All the subjects were

divided into two groups experimental and control, each comprising of two subgroups of

50 boys and 50 girls. Structured teaching program consisting of information on human

reproductive system was used as a tool of investigation for the experimental group,

whereas conventional teaching method was used for the control group.22

A total of 200 Adolescent school students were included in this study. The mean (±SD)

pretest score of the experimental group on knowledge of reproductive health was 39.83 (±

16.89) and of the control group was 39.47(±0.08). The same of experimental group after

administration of the structured teaching program (84.60±10.60) and of the control group

with conventional teaching method (43.93±10.08) was statistically significant

(p<0.001).Similarly, the post-test scores of knowledge of the groups on responsible sexual

behaviour and their attitude towardsreproductive health were better in the experimental

group than in the control group (p<0.001). They Concluded: The knowledge of adolescent

school students on reproductive health is inadequate. The use ofstructured teaching

program is effective in improving knowledge and attitude of the adolescents on

reproductive health.

This experimental study was designed to determine the effectiveness of a structured

preoperative teaching programme for the adult surgical patient as measured by several

17

indicators. The major questions asked in this study were: What are the effects of a

structured preoperative teaching programme upon the adult surgical patient's length of

hospital stay, postoperative complications, number of analgesics administered

postoperatively, recall of knowledge explained preoperatively, and satisfaction with his

preoperative teaching. 23

STATEMENT OF THE PROBLEM

effectiveness of structured teaching programme regarding knowledge on management and

prevention of nosocomial pneumonia among staff nurses working in paediatric ward in

selected hospitals, Bangalore

6.3 OBJECTIVES OF THE STUDY

6.3.1 To assess the existing level of knowledge on prevention of nosocomial pneumonia

among staff nurses working in paediatric ward through self administered questionnaire.

6.3.2 To develop and conduct structured teaching programme on prevention of

nosocomial pneumonia among staff nurses.

6.3.3 To assess the effectiveness of structured teaching programme regarding prevention

of nosocomial pneumonia among staff nurse trough post test.

6.3.4 To find out the association between knowledge scores of staff nurses with selected

demographic variables like age ,sex, years of experience ,educational qualification ,source

of information, income, area of work.

6.4 HYPOTHESES

H1 There is a significant difference between pre-test and post-test knowledge scores.

18

H2 There is an association between knowledge scores with selected demographic

variables.

6.6 OPERATIONAL DEFINITIONS

Assess: In this study assess refers to the organized ,systematic and continues

process of collecting data from staff nurses working in paediatric ward.

Knowledge: in this study knowledge refers to the correct responses of

respondents to knowledge items on management and prevention of nosocomial

infection.

Effectiveness: in this study Effectiveness refers to the gain in knowledge as

determined by the significant difference in pre-test and post-test knowledge scores.

Structured teaching programme: In this study STP Refers to planned and

organized teaching programme aimed at educating the participants to prevent

nosocomial pneumonia

Prevention: In this study prevention refers to Precautionary measures taken to

avoid the occurrence of nosocomial pneumonia.

Nosocomial pneumonia: In this study Nosocomial pneumonia refers to, infection

which develops after 72 hours of admission of the patient to the hospital.

Staff nurses: Registered nurses working in paediatric ward at selected hospital,

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Bangalore.

7. MATERIALS AND METHODS:-

7.1 SOURCE OF DATA

Data will be collected from the staff nurses in selected hospitals at Bangalore.

7.2.1 RESEARCH APPROACH

Evaluative survey approach will be used to carry out the study.

7.2.2 RESERCH DESIGN

Quasi experimental (01 x02) one group pre test post test design will be used.

7.2.3 SETTING

The setting of the study is selected hospital at Bangalore.

7.2.4 VARIABLES UNDER STUDY

Structured interview schedule method will be used to collect the data.

INDEPENTENT VARIABLE

- Structured teaching programme

DEPENDENT VARIABLE

- Knowledge regarding management and prevention of nosocomial pneumonia

among staff nurses working paediatric ward in selected hospital, Bangalore.

EXTRANEOUS VARIABLE

- Age, religion, education, type of family, family income etc.

7.2.5 POPULATION

The population of the present study consists of staff nurses working in paediatric ward

selected hospitals at Bangalore.

7.2.6 SAMPLE SIZE

The sample size of the study consists of 40 staff nurses working in paediatric

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ward in selected hospital.

7.2.7 SAMPLING TECHNIQUE

The Non probability purposive sampling technique will be adopted to select the

sample.

7.2.8 SAMPLING CRITERIA

INCLUSION CRITERIA

1. Staff nurses who are working in paediatric ward.

2. Staff nurses who are willing to participate in the study.

3. Staff nurses who are available at the time of study.

4. Staff nurses who can read and write English .

EXCLUSION CRITERIA

1. Staff nurses who are not willing to participate in the study.

2. Staff nurses who are not available during study period.

7.2.9 TOOLS FOR DATA COLLECTION

The tool for the data collection consists of two sections:-

Sec A: - Socio-demographic Performa of the study participants. Items on selected

demographic variables like age, religion, type of family, occupation, educational status,

marital status, dietary patterns, and family income and access health care facilities.

Sec B: - Structured questionnaire to assess the knowledge on management and prevention

of nosocomial pneumonia.

7.2.10.METHODS OF DATA ANALYSIS AND PRESENTATION

Data analysis will be through descriptive and inferential statistics.

Descriptive statistics:-

Selected demographic variables are to be analyzed in the terms of frequency and

percentage.

21

Assessing the knowledge regarding prevention and management of nosocomial

pneumonia among staff nurses working in paediatric ward will be interpreted by

descriptive statistics such as mean, median and standard deviation.

Inferential statistics:-

Effectiveness of Structured teaching programme regarding prevention and

management of nosocomial pneumonia among staff nurses will be analyzed by ‘t’

test.

Association between knowledge with selected demographic variables is analyzed

by chi-square(x2).

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION

TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF

SO PLEASE DESCRIBE BRIEFLY.

Yes, structured teaching programme regarding prevention and management of

nosocomial pneumonia among staff nurses will be administered to the study

participants as a part of the research study.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3?

Yes, ethical clearance certificate enclosed.

.

8. LIST OF REFERENCES

1. Anton Y Peleg, and David C Hooper. Hospital-Acquired Infections Due to Gram-

Negative Bacteria. Engl J Med 2010 May 13 ; 362:1804-1813.

2. The sixth annual meeting of the Society for Healthcare Epidemiology of America,

Washington DC ; Nov 12, 2008.

3. M. Merchan. Incidence of nosocomial pneumonia in a medical intensive care unit and

22

general medical ward patients in a public hospital in Bombay India. Med J 2008; 39:

143-148,

4. Linda K. Goss R, Cohn. Nursing Made Incredibly Easy. 2008,

5. Rajesh Chawla, , National prevalence survey of hospital acquired infections.J hospital

infection, 2008 February13; 8: 72-85.

6. Kim Lam Soh, Jane Koziol-Mclain, Jan Wilson, Kim Geok Soh. Critical care nurses'

knowledge in preventing nosocomial pneumonia, Australian Journal of Advanced

Nursing .2007.

7. Carolyn L. Cason, Tracy Tyner, MSN, Sue Saunders. Nurses Implementation of

Guidelines for Ventilator-Associated Pneumonia From the Centers for Disease

Control and Prevention. American Journal of Critical Care.2007;16: 28-37.

8. Wallace WC, Cinat ME, Nastanski F, Gornick WB, Wilson SE.Division of Trauma

Surgery and Critical Care.University of California, Irvine Medical Center, 2003

Dec;8(1):54-69.

9. A E L Stebbings, T Y Ti, W C Tan, Singapore Medical Journal, Hospital Acquired

Pneumonia in the Medical Intensive Care Unit. 2005, 121: 182-205.

10. Al-Hada Armed Forces Hospital, Taif, Saudi Arabia. Epidemiololgy and Research

Unit, Preventive Medicine Department, GMS Ger Med Science 2005; 3:Doc06.

11. Canadian J Infect Dis Med Microbiol. 2008 January; 19(1): 19–53. October 24, 2004.

12. Ji-Guang Ding, Qing-Feng Sun, Ke-Cheng Li, Ming-Hua Zheng, Xiao-Hui Miao,

BMC Infect Dis. 2004; 9: 115.

13. Risk factors for the development of nosocomial pneumonia and mortality on intensive

care units: application of competing risks models. Crit Care. 2004; .

14. A Torres, JM Gatell, E Aznar, M el-Ebiary, J Puig de la Bellacasa, J Gonzalez, M

Ferrer and R Rodriguez-Roisin. Re-intubation increases the risk of nosocomial

pneumonia in patients needing mechanical ventilation. American journal of respiratory

and critical care medicine Am. J. Respir. Crit. Care Med., Vol 152, No. 1, Jul 2004,

137-141.

15. Jordi, Rello, Jordi, Bonsoms, Natalia, Fontanals,Annals of Internal Medicine,

American College of Physicians, Health Methods to prevent ventilator associated

pneumonia, 2003.

16. Fernandez, Rafael, Artigas, Antonio, Valles, Dionisia, Blanch, Lluis, Baigorri,

Francisco, Mestre, Jaume . Publisher: American College of Physicians Annals of

23

Internal Medicine,2003

17. Waldemar G. Johanson. JR., M.D. Alan k. Pierce, M.D., F.A.C.P.; Jay p. Sanford,

M.D., F.A.C.P.; and Grace d. Thomas, R.N. Dallas, American journal of medicine,

Nosocomial Respiratory Infections with Gram-Negative Bacilli, 2002, 91, Supplement

3B, 185-191.

18. Susan Houston, Paul Hougland, Jacqueline J. Anderson, and Virginia Kennedy,

American Journal of Critical Care, 2002: 11: 567-570.

19. Celik SA, Nosocomial infections in neuro surgery intensive care units, J Clin Nurs.

2002 Sep; 13(6):741-7.

SIGNATURE OF THE CANDIDATE :

REMARKS OF THE GUIDE : The research topic is selected by the candidate is relevant as there is an increased incidence of nosocomial pneumonia in IndiaNAME AND DESIGNATION OF THE GUIDE: Mrs. GOWRI.S Asst. ProfessorGUIDE NAME AND ADRESS : Mrs. GOWRI.S Asst. Professor pragathi college of nursing, #33 byrathi(ext),near ebenezar hospital,hennur begalur main road ,kothanur post, bangalore-77SIGNATURE OF THE GUIDE :

HEAD OF THE DEPARTMENT: Mrs. GOWRI.S Asst. Professor ,pragathi college of nursing, #33 byrathi(ext),near ebenezar hospital,hennur begalur main road ,kothanur post, bangalore-77SIGNATURE OF HOD :

REMARKS OF THE PRINCIPAL: The research topic selected by the

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candidate is appropriate SIGNATURE OF THE PRINCIPAL:

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