CHAPTER ONE

                                                          INTRODUCTION

This chapter  reviews in brief, Health Care Associated Infections (HAI), elements required for transmission of infectious agent within a health care setting (chain of infection, sources of infection, susceptible host, mode of transmission, portal of entry and portal of exit), HAI among health-care workers, Universal Precautions (UP), Body Substances Isolation (BSI) and Standard Precautions (SP).

1.1 HEALTH CARE- ASSOCIATED INFECTIONS (HAI):

Health-care associated infection (HAI), also referred to as nosocomial infection and hospital acquired infection, is defined by Center of Disease Control and Prevention (CDC) as an “infection caused by a wide variety of common and unusual bacteria, fungi, and viruses during the course of receiving medical care”(CDC, 2012). It either occurs while patients receive care or may develop after discharge. It also involves occupation infection among staff. HAI can also be defined as an “infection occurring in patients during the process of care in a hospital or health care facility which was not present or incubating at the time of admission. This includes infection acquired in the hospital, but appearing after discharge and also occupational infections among staff or facility” (WHO, 2012).HAI is considered an important public health problem (WHO, 2012). Globally, hundreds of millions of patients are infected by HAI every year in both developed and developing countries. According to WHO, its prevalence in developed countries varied between 3.5% and 12%, while in developing countries it varied between 5.7% and 19.1% (WHO, 2012). The highest occurrence of HAI were in acute surgical, orthopedic wards and Intensive Care Unit (WHO, 2002). The prevalence rate of ICU-acquired infection in high-income countries was 30%, while in middle and low-income countries, it was at least 2-3 times higher than that in high -income countries(WHO, 2009; WHO, 2012).

The consequences of HAI at patients’ level imply more suffering, more complications, more treatments, and increase in hospitalization periods. For example, in Europe duration of hospitalization increased to nearly 16 million extra days (WHO, 2012).This is in itself considered a risk factor for acquiring HAI, and it means an increase in costs (WHO, 2012). In addition, it increases economic burden on the health care systems of countries. For example, in England, the annual financial costs topped 1.3 billion euro’s, while in the United States of America, the costs amounted to approximately 3.5 billion euro’s and 7 billion euro’s in Europe (WHO, 2012; WHO, 2012; Agozzino et al., 2012).

1.2 HEALTH-ASSOCIATED INFECTIONS AMONG HEALTH CARE WORKERS NURSES:

HAI  can  affect  both  patients  and  health-care  workers. It   involves  Occupational  infections among nurses. Due to  the  nature  of  their occupations, the major occupational hazard is the transmission of blood-borne disease such as hepatitis B and AIDS by being exposed to injuries caused by contaminated sharp objects such as scalpels and broken glass and needle stick (CDC, 2012). Nurses can be infected by HAIs while dealing with patients or providing them with health treatment. They can play a role in the widespread of infections. For example, the nurses played an important role in the amplification of the outbreak of Marburg viral hemorrhage fever in Angola (WHO, 2015). The mode of transmission depends on many factors such as immunity of HCW and amount of blood transferred during injuries (CDC, 2012). According to WHO, nearly three million HCW are exposed to percutaneous blood borne pathogens each year worldwide; 2 million of those were exposed to HBV ,0.9 million to HCV and 170, 000 to HIV. These sharp injuries resulted in 15,000 HCV, 70,000 HBV and 500 HIV infections. About 90% of these events happened in the developing countries (WHO, 2014). The infectious agent is transmitted to nurses mainly via droplet: direct contact or contact with inanimate contaminated objects by infectious material. The risk of transmission of infectious agents would increase if infection control practice and standard precautions were not applied (WHO, 2013).

1.3 SOLUTIONS TO THE PROBLEM

Solutions of this problem include the following (WHO, 2012):

    Determination of the local factors of the HAI burden.

    Encouragement of the reporting and surveillance system.

    Improvement of education  and  training of nurses in applying safety precaution.

4.Implementation and application of standard precaution which is simple and low-cost but helpful in controlling spread of HAI as it saves money and saves life.

1.4 UNIVERSAL PRECAUTIONS (UP):

In 1983, CDC disseminated a document called (Guidelines for Isolation Precautions in Hospitals). This document included a section about precautions that must be taken when dealing with blood and body fluid of suspected patient infected by blood-borne pathogen (CDC, 2001).In 1985, in response to HIV /AIDS epidemic(CDC, 2007), CDC developed precautions to be applied to all patients irrespective of their blood-borne infection status. They were called universal precautions. These precautions are defined as ” a set of precautions devised to prevent, and minimize accidental transmission of all known blood-borne pathogens including HIV, hepatitis B virus, and hepatitis C virus to/from health care personnel when providing first aid or other health care services” (Vaz et al., 2010). These universal precautions can also be defined as an “approach to infection control to treat all human blood and certain human body fluids as if they were known to be infectious for HIV,HBV and other blood borne pathogens” (NIOSH,2016). These precautions apply to blood, body fluid containing visible blood, semen, cerebrospinal, synovial, pleural, peritoneal and amniotic fluid but don’t apply to feces, nasal secretion, sputum, sweat, tears, urine and vomits unless blood appears (Vaz et al., 2010).

1.5 BODY SUBSTANCES ISOLATION (BSI):

BSI appeared in 1987. This precaution supposed that all moist substances except sweat (execrations and secretions) were infectious (not just blood in UP) (Vaz et al., 2012). It depended mainly on using gloves, and it was advised to use clean gloves before dealing with or touching mucous membranes or contact with body fluids or moist substances, but after removing gloves there would be no need for hand washing if there was recommended(CDC, 2007; Vaz et al., 2010). UP and BSI were presented nearly in the same period.Some hospitals adapted UP while others adapted BSI. This problem and other problems required additional precautions to prevent transmission of diseases that are transmitted via airborne and droplet routes. However, there was no agreement on the washing of hands after using gloves. The existence of such problems led to emergence of another system of precautions called Standard Precautions (SP) (Vaz et al., 2012).

1.6 STANDARD PRECAUTIONS (SP)

The main principles of Universal Precautions and Body Substance Isolation practice were mixed by CDC in a new precaution system called Standard Precautions (SP) which now has replaced the “Universal Precautions”. Standard precautions are defined as “group of infection prevention practices that apply to all patients, regardless of suspected or confirmed diagnosis or presumed infection status” (CDC, 2012). These precautions are the basic level of infection control precautions which are to be used, as a level of precautions (CDC, 2012; WHO, 2013). The fact is that “standard precautions” are recommended when delivering the care to all patients,regardless of their presumed infection status. It is also recommended that when handling equipment and devices that are contaminated or suspected of contamination, and in situations of contact risk with blood, body fluids, secretions and excretions except sweat, without considering the presence or absence of visible blood and skin with solution of continuity and mucous tissues. They included precautions against agents that are transmitted by the following routes of transmission: air-borne, droplet and contact routes (CDC, 2007; Vaz et al., 2013).

The aims of standard precautions are the following: prevention and/ or reduction of transmission of HAI, and, at the same time, protection of nurses from sharp injuries. These aims can be achieved by the application of SP measures which consist of the following elements: hand hygiene, personal protective equipment (gloves, gown, gaggle, facemasks, head protection, foot protection and wearing face shields) and prevention of sharp injuries (CDC, 2015; WHO, 2012).

1.6.1 HAND HYGIENE:

Hand washing is the most important element of SP measures. This concept includes hand washing with soap (plain or antiseptic soap) and water or rubbing hands by using alcohol-based products without using water.

Hand hygiene is recommended in following situations (WHO, 2013):

i.After direct contact with patients

ii.Before direct contact with patients.

iii.After exposure to blood, body fluids, secretions, excretions, non-intact skin, and contaminated items.

iv.After contact with patients surrounding

v.Before doing aseptic tasks like using an invasive device.

1.6. 2 PERSONAL PROTECTIVE EQUIPMENTS (PPE):

The second part in the SP is PPE. It is defined as a group of barriers that are used alone, or in combination, to prevent transmission of infectious agents to mucous membrane, skin, airways and clothing of nurses when they are in contact with infectious agents. It is also used when contamination or splashing with blood or body fluids is anticipated and it is important to protect nurses from getting infections during contact with patients. This PPE should be found in each hospital, and the selection of this PPE is dependent on the nature of procedures, skills of nurses, nature of patients and mode of transmission. PPE includes the following: disposable gloves, face protection (masks, safety glasses, goggles) and gowns or aprons ) (Vaz et al., 2010; WHO, 2012).

 GLOVES

Gloves are used while dealing with or touching blood, secretion, body fluids, execration, impaired membranes and mucous membranes, handling contaminated equipment and when in contact directly with patients who are infected with disease transmitted by direct contact. After removing them, hand hygiene should be done. In addition to this, nurses must know that gloves have to be changed if there was risk of cross contamination when dealing with the same patient and before going to another patient to prevent transmission of infections and prevent the occurrence of HAI (WHO, 2010). Removal of gloves has to be considered.

ISOLATION GOWN

This is worn to protect the clothes and skin of nurses from contact and contamination with blood or body fluid. The gown covers the body from neck to mid-thigh or below to prevent contamination of skin or clothe (WHO, 2010). Removal of gown has to be considered.

FACE PROTECTION (MASK,GOGGLES AND FACE SHIELD)

MASK:

This must be used when there is a possibility for splashing or spraying of blood or body substances,and when nurses are doing procedures requiring sterile condition to prevent transmission of infection or infectious agents to patients. In addition to this, sometimes patients must wear mask especially if patient is suffering from coughing to limit spreading of his or her infection (CDC, 2010; WHO, 2012; WHO, 2013). Mask must be removed in a correct way as described in Figure 1.

GOGGLES:

Infectious agents can enter body from mucous membrane in eyes, by direct route through exposure to infectious agents from splash of blood or from cough, or by an indirect way through touching of the eye by contaminated hands. Many types of infectious agents are transmitted in this way including both viruses (for example, adenovirus) and bacteria (for example, hepatitis C) (CDC, 2010).

FACE SHIELD

Face protection can be used with other PPE if there is potential splashing of blood, body and respiratory secretions. Face shield can be worn as an alternative to goggles but face shield covers more face area than goggles which covers only the eyes (CDC, 2010).Like other PPE, caution  must be taken when removing face protection, taking into account its removal after removing gloves.

1.7 SHARP INJURIES (SI) :

SI are defined as “an exposure to event occurring when any sharp penetrates the skin” (CDC, 2012). These include needles, scalpels, broken glass, and other sharps. This term is interchangeable with percutaneous injury. It is considered a serious hazard in hospitals because it may allow the contaminated blood that has pathogen to be in contact with nurses. SI and NSI lead to infection. They expose nurses to blood- borne pathogens which mean ” pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus” (CDC, 2012). SI and NSI are considered a major source of Hepatitis C Virus ( HCV ) infection among HCWs. Nearly (39%) of cases of HCV that occurred worldwide happened among HCWs, while hepatitis B virus (HBV) formed (37%) (Goniewicz et al., 2012). Furthermore, needle stick injuries can transmit more than twenty types of infections such as malaria, syphilis and herpes (Elizabeth 2012).

SI and NSI are challenges that threaten health workers especially nurses and form a significant risk in professional nursing. This is due to their daily activities which may expose nurses to NSI and SI. These activities or procedures include the following: recapping needle, suturing, placing intravenous line, drawing blood, failing to get rid of used needles in puncture-resistant sharps containers, using needles or glass equipment to transfer body fluid between containers, disassembling needle or sharp device, giving injections to patients, filling injection, opening the lid of the injection and many others (CDC, 2012; CDC, 2013). These tasks and activities of nurses in daily work may expose them to SI or NSI. Therefore, to prevent transmission of blood borne pathogens to nurses after being exposed to such injuries, they should quickly  wash the wound with water and soap. On the other hand, squeezing the wounds is not recommended as this will not reduce the risk of blood- borne pathogen. In case of the splash of blood or body fluid touches the nose or the mouth or the skin, they must flush these splashes with water and in case of blood or body fluid comes in contact with the eye, they should irrigate eyes with clean water or saline. Then they should inform the supervisor about injury to begin a reporting system (incidence report). At the same time, they should test the source patient for hepatitis B, hepatitis C and AIDS. After that, infected nurses should receive the appropriate treatment, and post exposure prophylaxes (PEP) should be taken if the source patient was unknown or the source patients’ test was positive (CDC, 2007; NHMRA, 2010).

Sharp injuries and needle stick injuries are costly; these injuries have direct and indirect cost at the same time. The direct cost includes the cost of laboratory test of exposed nurses and source patient, in addition to the cost of treatment that may be required or post exposure prophylaxis. On the other hand, the indirect cost includes loss of nurses, loss of productivity, loss of time during reporting or taking of treatments and cost for replacing the infected nurses (NIOSH, 2011). According to CDC’s estimation, there were nearly (385,000) SI cases yearly among HCWs, and most reported cases occurred among nursing staff, but laboratory staff, physicians and other HCWs were also injured (NIOSH, 2011). Nearly half of SI were not reported; this was due to many reasons: lack of time to report, lack of knowledge of the reporting procedure, possibility of getting in trouble for having the exposure, belief the source patient was low for hepatitis B or hepatitis C or AIDS,and underestimation of the importance of reporting

1.8 SHARP DISPOSAL CONTAINERS (OR BOX):

Sharp objects must be disposed in separate containers in every hospital to prevent risk of transmission of infection. These containers are called sharp disposal containers and they must be puncture-resistant, liquid –proof, closed when not used and sealed and when (75%) of them are filled. They should be put nearby work place and close to place where sharp is used. This would reduce the occurrence of recapping needles and needle-stick injuries that are associated with recapping (OSHA, 2011;WHO,2012).

1.9 PROBLEM STATEMENT

Nurses get in contact with patients on a daily basis, so they are exposed to sharp injuries and many types of infections due to the nature of their occupation. It is important to follow standard precautions to reduce transmission of infections. In Palestine, despite of the availability of protocol for infection control in hospitals, it is applicable in varied degree from hospital to hospital. In addition, after reviewing documents from Palestinian Health Information Centre in MOH, it doesn’t have any statistics regarding nurses’ knowledge and practice of SP measures and those related to SI among health care workers. In addition, it doesn’t have any statistics regarding health care workers  who have SI or who acquired infection during work. As an expected outcome , this study will identify the importance of nurses’ knowledge about SP measures and those related to SI. Also it will highlight the size of problem of stick injuries among  workers during work.

1.10 SIGNIFICANCE OF THE STUDY:

This research, the first of its kind to be done in governmental hospitals in West Bank, to assesses knowledge and practice of SP measures and those related to SI among health care workers. Globally, many studies have been conducted about knowledge and practice of SP measures and those related to sharp injuries. Safety of Nurses and patients is considered an important issue in controlling and limiting the transmission of infectious disease between health care providers and patients. Following such standard precautions, which are easy and simple, would reduce the transmission of many types of contagious disease, thus reducing the economic burden of treating these diseases.

This study also calculated SI and NSI among participants. It is important to know prevalence of SI and NSI because needle sticks and sharps injuries represent a significant hazard in professional health care providers  and exposure to blood and body fluid has been considered as part of nurses’ job. It is expected that this study will play an important role in highlighting the importance of knowledge and compliance with SP among health care workers during daily work. It is also expected to highlight the size of the problem of SI and NSI.

1.11 OBJECTIVES

Main objective :

To assess health care worker’ knowledge and compliance with standard precaution measures and those related to sharp injuries and their compliance with those related standard precautions.

Specific objectives :

    To compare mean of score of knowledge about standard  precaution  measures  and  those  related  to  SI  among  different educational level of health care workers in federal teaching hospital, Edo-ekiti.

2.To compare mean of score of practice of standard precaution measures and those related to SI among different educational level of health care workers in federal teaching hospital, Edo-ekiti .

3.To identify the correlation between health care workers’ knowledge and their practices of standard precaution measures in federal.

4.To identify the correlation between health care workers’ knowledge and their practices of standard precaution measures related to sharp injuries.

5.To identify level of health care workers’ knowledge of SP measures, those related to SI which might be attributed to variables of years of experience, place of work and gender of participants.

6.To estimate the prevalence of sharp injuries and needle stick injuries among nurses in the target hospitals.

7.To identify the percentage of needles sticks as a result of sharp injuries.

    HYPOTHESES:

1.The nurses don’t have a good level of knowledge about SP and those related to SI

2.There is no difference in mean of knowledge of SP measures and different educational level of nurses.

3.There is no difference in mean of practice of SP measures and different educational level of nurses.

4.There is no difference in mean of practice of SP measures related to SI and different educational level of nurses.

5.There is no difference in mean of knowledge of SP measures related to SI and different educational level of nurses.

6.There is no linear relationship between nurses’ knowledge and their practice of SP measure related to SI.

7.There is no linear relationship between nurses’ knowledge and their practice of SP measures.

8.There is no association between good level of nurses’ knowledge about SP measures related to SI and their years of experience, place of work and gender.

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