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ElaElaUniversitatea Transilvania din Braov
coala Doctoral Interdisciplinar
Departament: Discipline Fundamentale, Profilactice i Clinice
TEZ DE DOCTORAT
IERARHIZAREA FACTORILOR DE RISC N
NOSOCOMIALITATEA NREGISTRAT N SECIA DE
ORTOPEDIE A SPITALULUI CLINIC JUDETEAN DE URGEN
BRAOV
Rezumatul tezei de doctorat pentru obinerea titlului tiinific de doctor n domeniul
fundamental tiinele medicale, domeniul Medicin
RANKING OF RISK FACTORS OF NOSOCOMIAL INFECTIONS
REGISTERED IN THE ORTHOPEDIC WARD OF COUNTY
CLINIC EMERGENCY HOSPITAL OF BRASOV
The summary of doctoral dissertation for obtaining the scientific title of doctor of
medical sciences in the fundamental field of Medical Sciences, Medical field
Coordonator: Prof. univ. dr. Nemet Codrua
Doctorand: Rauia Ion Clin
BRAOV, 2015
COMPONENA
Comisiei de doctorat
Numit prin ordinul Rectorului Universitii Transilvania din Braov
Nr. 7348 din 09. 06. 2015
PREEDINTE:
- Prof. univ. dr. Marius MOGA
DECAN Fac. de Medicin
Universitatea Transilvania din Braov
CONDUCTOR
TIINIFIC:
REFERENI:
- Prof. univ. dr. Codrua NEMET
Universitatea Transilvania din Braov
- Conf. univ. dr. Emilian Damian POPOVICI
Universitatea de Medicin i Farmacie "Victor Babe" din Timioara
- Prof. univ. dr. Romulus Fabian TATU
Universitatea de Medicin i Farmacie "Victor Babe" din Timioara
- Conf. univ. dr. Mihaela IDOMIR
Universitatea Transilvania din Braov
Data, ora i locul susinerii publice a tezei de doctorat: 10.07.2015, ora 12, sala KP13,
Facultatea de Medicin, Braov
Eventualele aprecieri sau observaii asupra coninutului lucrrii v rugm s le transmitei
n timp util, pe adresa: calinorto@[Link]
Totodat v invitm s luai parte la edina public de susinere a tezei de doctorat.
V mulumim.
CUPRINS
Pag.
Pag.
Teza
Rezumat
INTRODUCERE
1. PARTEA I- GENERAL
10
10
1.1 O scurt istorie a ortopediei
10
10
1.2 Actualiti n domeniul infeciilor noscomiale
16
10
1.3 Aspecte istorice ale nosocomialitii
17
10
1.4 Agenii etiologici ai infeciilor nosocomiale....................................................
22
11
1.5 Factorii epidemiologici ai infeciilor nosocomiale............................................
26
11
1.6 Infecii nosocomiale postoperatorii
28
12
1.7 Supravegherea i controlul IN......................................................................
30
12
1.8 Strategii de control al rezistenei antimicrobiene...............................................
39
1.9 Antibioprofilaxie................................................................................................
42
1.10 Costurile infeciilor nosocomiale.....................................................................
43
1.11 Eficiena serviciilor medicale...........................................................................
45
1.12 Dimensiunea calitii n spitalul public secia de ortopedie.........................
46
49
13
II.1. SCOP I OBIECTIVE ..
49
13
II.2. MATERIAL SI METOD
50
14
[Link] de analiz
50
14
2.2. Unitatea de nregistrare a datelor..............................................................
56
16
2.3. Tipul de cercetare.......................................................................................
59
18
2.4. Metode de prelucrarea datelor..................................................................
66
18
67
19
3.1 Istoricul infeciilor nosocomiale n Spitalul Judeean de Urgen Braov
67
19
3.2 Istoricul tipurilor de infecii nosocomiale pe secia de ortopedie...............
73
19
3.3 Istoricul germenilor circulani, din spital....................................................
73
20
3.4 Istoricul germenilor circulani, pe ortopedie...............................................
77
21
3.5 Istoricul tipurilor de germeni din infeciile nosocomiale pe ultimii 3 ani, pe
79
21
2. PARTEA A II-A CONTRIBUII PERSONALE
II.3. REZULTATE
spital.......................................................................................................................
3.6 Istoricul tipurilor de germeni din infeciile nosocomiale pe ultimii 3 ani, pe
81
3.7 Corelaii ntre germenii circulani i cei din infeciile nosocomiale............
83
22
3.8 Analiza SWOT a seciei de ortopedie..........................................................
85
22
3.9 Costurile directe cu infeciile nosocomiale din spital...................................
87
24
3.10 Costurile directe cu infeciile nosocomiale de pe ortopedie......................
91
24
3.11 Costurile indirecte cu infeciile nosocomiale din spital i de pe ortopedie
94
25
studiului.............................................................................................................
97
25
3.13 Tipuri de antibiotice utilizate 2011-2013, pe spital i pe ortopedie..........
105
25
3.14 Istoricul costurilor cu antibioticele pe spital .............................................
111
3.15 Istoricul costurilor cu antibioticele pe ortopedie.......................................
111
26
3.16 Rezistena la antibiotice pe spital .............................................................
113
26
120
27
acestora.
131
30
3.19 Calitatea vieii / satisfacia pacientului ortopedic....................................
136
34
3.20 Grila de apreciere a gradului de risc infecios........................................
145
37
III. DISCUII................................................................................................................
148
IV. CONCLUZII
155
39
V. Contribuii originale. Direcii viitoare de cercetare ...
156
42
VI. RECOMANDRI PRACTICE
159
BIBLIOGRAFIE
161
45
ANEXE
174
47
Anexa 1 Grila de apreciere a gradului de risc infecios pe secie
174
47
Anexa 2, Model chestionar
182
55
Anexa 3, Formular de consimmnt informat.
186
58
ortopedie.......................................................................................................
3.12 Costurile cu dezinfectanii din spital si secia de ortopedie pe perioada
3.17 Factorii intrinseci a nosocomiialitii pe ortopedie i ierarhizarea
acestora.......................................................................................................
3.18 Factorii extrinseci a nosocomiialitii pe ortopedie i ierarhizarea
Anexa N-2: Lista publicaiilor proprii
108
Anexa N-1: Rezumatul tezei
109
Anexa N: Curriculum vitae
111
Thesis
Page
Summary
Page
INTRODUCTION
59
1. PART I- GENERAL
10
61
1.1 A brief history of orthopedics
10
61
1.2 Updates in the field of nosocomial infections..
16
61
1.3 Historical aspects of nosocomial infections
17
61
1.4 The etiology of nosocomial infections......................................................
22
62
1.5 Epidemiology of nosocomial infections....................................................
26
62
1.6 Postoperative nosocomial infections
28
63
1.7 Measures to prevent and combat nosocomial infections.............................
30
63
1.8 Strategies to control the antimicrobial resistance...............................................
39
1.9Antibiotic prophylaxis..................................................................................
42
1.10 Cost of nosocomial infections.....................................................................
43
1.11 The efficiency of health services.............................................................
45
1.12 Dimension of quality in public hospital orthopedic ward.........................
46
49
64
II.1. AIM AND OBJECTIVES ..
49
64
II.2. MATERIAL AND METHODS
50
65
2.1. The unit of analysis
50
65
2.2. Data register unit......................................................................................
56
68
2.3. Type of research......................................................................................
59
69
2.4. Methods of data processing..
66
70
67
70
67
70
3.2 History of nosocomial infections types in the orthopedic ward...............
73
3.3 History of the circulating flora in the Hospital.......................................
73
72
3.4 History of circulating strains in the orthopedic ward....................................
77
72
2. PART II PERSONAL CONTRIBUTIONS
II. 2. RESULTS
3.1 History of nosocomial infections in County Clinic Emergency
Hospital of Brasov
3.5 History of germs types isolated in hospital from the nosocomial
5
infections
79
73
81
infections
83
73
3.8 SWOT analysis of the orthopedic ward...............................................
85
74
87
75
ward.........................................................................................................
91
76
3.11 Indirect costs compared to hospital and to orthopedic ward ......
94
76
97
76
2013..........................................................................................................
105
77
3.14 Costs history of antibiotics in hospital.............................................
111
ward...........................................................................................................
111
77
3.16 Antibiotic resistance in hospital.
113
78
3.17 Intrinsic risk factors...
120
79
3.18 Extrinsic risk factors...
131
82
3.19 The quality of life - The patient satisfaction....................................
136
85
3.20 Grid assessment of the risk of infection ........................................
145
88
III. DISCUSSIONS..................................................................................................
148
IV. CONCLUSIONS
155
90
V. Original contributions. Future Research Directions
156
93
VI. PRACTICAL RECOMMENDATIONS ..
159
REFERENCES
161
96
APPENDIX
174
98
Appendix 1 Grid of appreciation of the risk degree on the ward.................
174
98
Appendix 2, Questionnaire
182
104
Appendix 3, Informed consent form
186
3.6 History of germ types from nosocomial infections in the last 3 years, in
orthopedic ward..................................................................................................
3.7 Correlations between circulating strains and germs from nosocomial
3.9 Direct costs correlated with nosocomial infections from the
hospital......................................................................................................
3.10 The direct costs of nosocomial infections in the orthopedic
3.12 The history of antibiotics costs in the hospital between 2011-
2013.
3.13 The history of antibiotics costs in the hospital between 2011-
3.15
The
history
of
antibiotics
expenses
on
the
orthopedic
Appendix a N-2: List of own publications
108
Appendix N-1: Thesis summary
110
Appendix N: Curriculum vitae
114
INTRODUCERE
Actualitatea temei
Infeciile nosocomiale constituie un capitol important n patologia infecioas,
care cunoate o continu dezvoltare ca expresie a diversificrii prestaiilor pentru omul
santos i cel bolnav.
Prezenta lucrare pornete de la premisa c prevalena infeciilor nosocomiale
este unul din indicatorii de calitate ai asistenei medicale spitaliceti, care permite, cu
mare obiectivitate evaluarea omogenitii formei de control asupra factorilor de risc
intrinseci i extrinseci, facilitnd n plus adoptarea i evaluarea strategiilor destinate
reducerii acestora.
Infeciile nosocomiale produc permanent costuri suplimentare :
indirecte - suportate cu greu de pacieni i familiile lor precum i
att costuri
costuri directe
suportate de sistemul sanitar prin creterea numrului de zile de spitalizare, a terapiilor
suplimentare, a ngrijirilor mai diversificate ; deasemeni nu este de neglijat creterea
rezistenei la germenii incriminai i un numr mare de decese.
n cursul activitii mele de chirurg ortoped (peste 2500 cazuri operate) am
observat impactul multidisciplinar al infeciilor intraspitaliceti, att din punct de vedere
clinic ct i socio-economic, ceea ce a dus la prezenta cercetare, care abordeaz
problematica nu numai din aceast perspectiv ci i sub aspectul factorilor de risc
intrinseci
i extrinseci ai nosocomialitii
corelai cu
gradul de
satisfacie
al
pacientului ortopedic internat n Spitalul Clinic Judeean de Urgen Braov
M-a incitat
srcia datelor din literatura de specialitate privind gradul de
satisfacie al pacientului, aprnd astfel ideea unui studiu care s identifice nevoile dar i
cunotinele acestuia despre infecia nosocomial precum i riscul apariiei acesteiea in
urma unei spitalizri
Semnificaia tiinific a lucrrii
-
n baza unui complex de date clinice, epidemiologice i socio-economice s-a efectuat
o analiz amnunit a rezultatelor pe un lot reprezentativ de pacieni cu afeciuni
ortopedice.
n premier s-a efectuat un studiu comparativ asupra calitii vieii pacienilor
ortopedici cu i fr infecie nosocomial.
S-au identificat factorii de risc precum i cei de protecie implicai n infeciile
nisocomiale, realizndu se i o ierarhizare a acestora.
S-a evaluat impactul factorilor de risc intrinseci i extrinseci asupra incidenei IN.
S-au identificat i caracterizat germenii circulani pe Secia clinic de Ortopedie cu
potenial nosocomial.
S-au calculat costurile suplimentare datorate infeciilor nosocomiale pe Secia clinic
de Ortopedie: spitalizare, investigaii diagnostice, tratamente inclusiv antimicrobiene.
S-au identificat dezinfectanii cu cea mai mare eficien antimicrobian utilizai n
Spital..
Pentru prima dat
n istoria spitalului, s-a ncercat o msurare a gradului de
satisfacie a pacientului ortopedic i cu infecie nosocomial. Negsind n literatura
de specialitate nici un chestionar pe aceast tem
am modificat un model de
chestionar MOS-SF36, i am adugat civa itemi caracteristici pacienilor otropedici
cu referire la cunotinele acestora despre IN, alturi de intrebrile EQ-5D i EQVAS cu referire la calitatea vieii.
-
S-au analizat criteriile
profilactice i terapeutice de prescriere i utilizare a
antibioticelor conform profilului bacteriologic al Seciei clinice de Ortopedie.
-
Stabilirea gradului de risc infecios al Seciei clinice de Ortopedie prin analiza
punctajului obinut prin completarea Grilei de risc i a Harii de risc nosocomial a
Spitalului.
Mulumesc pe aceast cale Doamnei Prof. univ. dr. Codrua Nemet pentru
generozitatea de a-mi oferi ansa cercetrii unui subiect major n managementul de
calitate al spitalului, onorndu -m, n acelasi timp, n calitate deconductor stiinific.
9
Nu n ultimul rnd, adresez mulumiri
personalului Compartimentului de
Profilaxie i Control a Infeciilor Nosocomiale - CPCIN
colaboratorilor i ntregii
echipe operatorii de la Spitalului Clinic Judeean de Urgen Braov, pentru sprijinul
constant acordat pe tot parcursul perioadei de studii doctorale.
PARTEA I GENERAL
I.1. REVIZIA LITERATURII MEDICALE
1. 1 O scurt istorie a ortopediei
Dei istoria ortopediei merge napoi pn la secolul V .Hr., la bine-cunoscutul
Hipocrate, care face referire n scrierile sale asupra unor tehnici de traciune i tipuri de
atele de imobilizare pentru a trata fracturile, cuvntul ortopedie este menionat abia n
secolul al XVIII-lea.
1..2. Actualiti n domeniul infeciilor nosocomiale
Comisia European propune pentru combaterea infeciilor intraspitaliceti
(nosocomiale) un set de instrumente pentru aplicarea unor msuri eficiente de prevenire a
infeciilor asociate asistenei medicale. Comisia European a finanat o reea de
supraveghere a infeciilor nosocomiale, n prezent aflat sub coordonarea Centrului
European de Prevenire i Control al Bolilor Transmisibile (ECDC).(9)
1.3. Aspecte istorice ale nosocomialitii
Cercetnd istoria medicinei universale, se remarc existena unor observaii care,
indirect, semnaleaz interesul pentru riscul producerii IN nc din Antichitate (Susruta,
Parcacelsus, Hipocrat). O dat cu evoluia tiinelor i progresul medicinei, apar noiuni i
reglementri legate de modul de prevenire sau tratare a IN (Teodoric 1266; Gerolamo
Francastaro 1488-1533; Ambroise Pare -1517-1590; [Link] -1834; Lemaire, Declat,
Maisonneveuve- 1860; Pirigov -1851-1861; Ignaz Phillip Semmeleweis 1847-1848; L.
Pasteur, J. Janbert, Ch. Chamberland 1878; Ch. Roux, Sedillot; Duclaux 1978; R.
Koch 1879; J. Lister 1827 1912; Alexander Fleming 1929; Gerard Domagk
1932 etc.).(9)
10
n Romnia n 1744 se elaboreaz primele Instruciuni privind funcionarea
lazareturilor, izolarea bolnavilor contagioi, respectarea unor reguli de asepsie i
antisepsie, remarcndu-se implicarea unor personaliti de prestigiu din epoc ([Link]
1877; V. Babe - 1985-1926; I. Cantacuzino 1896-1936 etc.).(10,11)
1.4. Agenii etiologici ai infeciilor nosocomiale
Agenii cauzali ai infeciilor intraspitaliceti sunt foarte diferii i pot avea
proveniene diferite, att endogen, ca autoinfecie, sursa fiind nsui bolnavul, ct i
exogen, prin diferite moduri i ci de transmitere. ntre bacteriile condiionat patogene i
patogene implicate n etiologia IN se pot include: Staphilococcus aureus, Streptococcus
pnuemoniae, Streptococcus fecalis, Streptococcus agalactiae, Escherichia coli, Klebsiella,
Enterobacter, Acinetobacter, Serratia, Proteus, Pseudomonas aeruginosa, Bacteroides
fragilis, Legionella pneumophilla. La bacteriile patogene sau condiionat patogene se
adaug, ntr-un procent considerabil, bacteriile nalt patogene: Salmonella, Shigella,
Neisseria
meningitidis,
Escherichia
coli
(serotipuri
enteropatogene
la
sugar),
Pseudomonas pseudomallei, Streptococcus pyogenes, Mycobacterium tuberculosis,
Clostridium dificille. (12).
1.5. Epidemiologia infeciilor nosocomiale
Polimorfismul epidemiologic, clinic i etiologic din infeciile nosocomiale se
datoreaz factorilor la risc,comportamentali sau socio-economici, i explic procesul
epidemiologic att de complex din aceast patologie. n mod particular, el se constituie
pe grupuri populaionale formate n condiii speciale n ceea ce privete gravitatea bolii,
adresabilitatea i accesibilitatea fa de anumii specialiti sau dotare tehnic.
Manifestrile procesului epidemiologic n IN nu apar att de evidente i individualizate
ca n cele ale bolilor transmisibile nregistrate n populaia general. Estomparea sau
mascarea" din cauza bolilor de baz (transmisibile sau netransmisibile) i a condiiilor
particulare imprimate de prestaiile medico-sanitare sau de atitudinea personalului
implicat n asistena pacienilor fac dificil evidenierea particularitilor fenomenului
epidemiologic. Atipismul" manifestrilor procesului epidemiologic depinde de natura
colonizrii cu ageni patogeni i intensitatea dispersiei lor ambientale.(13,14)
11
1.6. Infecii nosocomiale postoperatorii
n aceast categorie se remarc IN ale plgii operatorii i cele aprute la distan de
locul interveniei chirurgicale (infecii urinare, respiratorii, de cateter, bacteriemii).
Infeciile plgii operatorii se pot instala ntr-un interval variabil de 30 zile i 1 an de la
momentul interveniei. Ele reprezint 15% din toate cauzele de IN i au o inciden
variabil dup tipul de chirurgie (4-5%), crescnd semnificativ n cazul spitalizrii
bolnavului n serviciile de reanimare (9%). Mortalitatea este generat de cauze directe
sau indirecte ale infeciilor plgii operatorii i variaz ntre 0,6 i 4,6%. Durata de
spitalizare poate fi prelungit cu peste 7 zile, n relaie cu tipul infeciilor plgii
operatorii. (15,16)
Factorii de risc extrinseci sunt dependeni de tipul interveniei chirurgicale,
durata spitalizrii preoperatorie,
modalitile
de
pregtire
preoperatorie (igiena
corporal, tipul epilrii), caracteristicile interveniei (tipul cmpurilor, experiena i
mrimea echipei, rezolvarea cazului n regim de urgen).
Factorii intrinseci au o pondere important n aprecierea riscului infeciilor
plgii operatorii dup caracteristicile terenului pacienilor (vrsta, imunodepresie, diabet,
obezitate), tratament prelungit cu antibiotice, starea de oc (17,18).
1.7. Supravegherea i controlul IN
n 1992, OMS a elaborat un Ghid pentru prevenia i controlul IN, menionnduse c reducerea riscului acestor infecii n diferite categorii de uniti medico-sanitare se
poate realiza prin: igienizarea cotidian, decontaminarea general ct mai frecvent,
decontaminarea minilor prin splare cu ap i spun, ori de cte ori acestea prezint
riscul de a fi contaminate; manevre i manopere aseptice pentru explorri i terapie;
pregtirea pre- i postoperatorie care s nlture riscul interveniei unor ageni patogeni
sau condiionat patogeni; protecie optim la recoltarea, conservarea, transportul i
investigarea produselor patologice, msuri difereniate pentru fiecare unitate i loc de
munc, pentru educarea bolnavilor i instruirea personalului de toate categoriile. n
prevenia IN un loc particular il ocup protecia bolnavilor din grupurile cu risc crescut a
cror supraveghere antiinfecioas trebuie realizat cel puin bisptmnal. (19,20)
12
PARTEA A II-A CONTRIBUII PERSONALE
II.1. SCOP I OBIECTIVE
Scopul - implementarea n cadrul Seciei Clinice de Ortopedie a activitilor i
mijloacelor prin care s se realizeze supravegherea i controlul nosocomialitii
.Ca obiective ale cercetrii menionm:
-
identificarea de noi soluii pentru scderea incidenei IN concomitent cu creterea
gradului de satisfacie al pacienilor ortopedici
n contextul actual de subfinanare
a sistemului sanitar;
-
identificarea i ierarhizarea factorilor de risc intriseci i extrinseci implicai n
nosocomialitate i influena lor asupra calitii vieii pacientului ortopedic;
analiza calitii vieii pacientului ortopedic cu infecie nosocomial;
identificarea nevoilor pacientului ortopedic cu infecie nosocomial;
identificarea antibioticoterapiei i antibioprofilaxiei incorect aplicate;
motivarea medicilor pentru a declara n mod real infeciile intraspitaliceti pe care le
trateaz de fapt;
schimbarea legislaiei n acest sens;
ameliorarea formrii profesionitilor din Secia clinic de Ortopedie n aplicarea
msurilor de prevenire a riscului infecios. Promovarea i evaluarea respectrii
Precauiilor standard.
Complexitatea aspectelor mai sus amintite justific obiectul studiului nostru.
n aceast cercetare am dorit s elucidez unele ipoteze aprute i s discut
aspecte legate de: profilul bacteriologic al
Seciei clinice de Ortopedie i impactul
utilizrii unor dezinfectante cu aciune intit asupra germenilor circulani prin prisma
incidenei infeciilor nosocomiale, existena unor asociaii epidemiologice ntre infeciile
intraspitaliceti
13
diferii
factori
de
risc,
existena
unor
concordane
ntre
antibioprofilaxie sau antibioterapie incorect i incidena infeciilor rezistente la
tratamentul antimicrobian.
II.1. MATERIAL I METOD
Studiul descriptiv analizeaz
declarate
dar i
a celor
n prima parte incidena infeciilor nosocomiale
nedeclarate
n urma analizei retrospective a foilor de
observaie, din varii motive ( reinerea medicului curant fa de posibile sanciuni,
definiie de caz prea stufoas clinic, microbiologic i epidemiologic). In cea de a doua
parte a studiului am analizat importana germenilor circulani n intregul Spital versus
Secia clinic de Ortopedie, implicaiile prescrierii i utilizarii antibioticelor n scop
profilactic sau terapeutic, am realizat o analiz SWOT a Seciei i impactul asupra
costurilor directe i indirecte induse de infeciile nosocomiale. In ultima parte a lucrrii
am abordat factorii de risc intrinseci i extrinseci implicai n
nosocomialitate, am
analizat Harta riscului epidemiologic pe Spital versus Secia Clinic de Ortopedie i am
analizat gradul de satisfacie al pacientului ortopedic i printr-un studiu observaional,
transversal, de prevalen, aplicnd un chestionar special conceput n acest scop.
1.1. UNITATEA DE ANALIZ
Populaia int din prima parte a studiului descripriv este reprezentat de bolnavii
internai pe secia clinic de ortopedie n perioada 01.01.2011 -31.12.2013, la Spitalului
Clinic Judeean de Urgen Braov: 2515 n 2011, 2609 n 2012 i 2427 n 2013, total de
7551 pacieni.
n prima etap a cercetrii am stabilit din lotul de studiu cazurile cu diagnosticul
de infecie nosocomial, confirmate clinic, microbiologic i epidemiologic. Din cele
7551 cazuri internate pe Secia Clinic de Ortopedie, 116 cazuri posibile de infecii
nosocomiale au fost identificate din foile de observaie , dintre acestea, doar 15 IN au
fost regsite n rapoartele CPCIN, adic declarate de ctre medicii curani, restul de 101
au fost depistate rerospectiv.
Apoi, pentru o bun cunoatere a problemei nosocomialiii am realizat o analiz
SWOT a situaiei iar n partea a treia a cercetrii am evaluat gradul de risc pe Secia
14
clinic de Ortopedie cu ajutorul unei grile de apreciere a riscului infecios i am elaborat
un chestionar pentru msurarea gradului de satisfacie al
pacienilor cu privire la
posibilele infecii ca urmare a unor practici medicale la risc neadecvate effectuate pe
Secia Clinic de Ortopedie.
Suplimentar s-au folosit date culese din rapoartele SPCIN pentru analiza
infectiilor de plag sau alte infecii nosocomiale, rapoarte ale compartimentului de
bacteriologie cu privire la rezistena microbian, circulaia germenilor . S-au mai utilizat
indicatorii de la Serviciul de Statistic al Spitalului pentru anii luai n studiu, precum i
date preluate
de la Serviciul Financiar-Contabil, Serviciul Administrativ pentru
achiziionarea i consumul de substante antiseptice, dezinfectante, antibiotice, reactivi.
Descrierea lotului participant la studiul transversal referitor la gradul
de satisfacie al pacientului ortopedic
Dintre cei 7551 de pacieni internai pe perioada 01.01.2011-31.12.2013, pe secia
de ortopedie, au fost alei aleator 225 de subieci, n vederea realizrii unei analize
amnunite a situaiei cu privire la cunotinele, nevoile pacienilor referitoare la infeciile
dobndite n urma manevrelor medicale efectuate n Secia clinic de Ortopedie i
deprinderile personalului medical de pe secie;
120 dintre acetia au ndeplinit toate
criteriile de includere n studiu i au rspuns chestionarului nostru.
Criterii de includere :
Pacient internat pe secia de ortopedie;
Acceptul pacientului pentru aplicarea chestionarului de apreciere a calitii vieii
Pacient major, n deplintatea facultilor mintale;
Colectarea datelor s-a fcut conform principiilor de etic medical.
Criterii de excludere :
15
Vrsta sub 18 ani;
Boli psihice.
Dezacordul pacientului pentru participarea la cercetare.
Pentru lotul luat n studiu raportul ntre cele doua sexe a fost de 52% brbai (62
de cazuri) i 48% femei (58 de cazuri).
Vrsta pacienilor a fost cuprins ntre 18 i 90 ani cu o medie de 48,67 ani;
pentru brbai media de vrst a fost 45,43 ani, respectiv 52,13 ani pentru femei
Repartiia pe vrste a pacienilor are relevan, evideniind frecvena mare la grupele de
vrste active 18-65 ani, de mare randament social. (grafic nr.1)
Grafic nr. 1 - Distribuia populaiei int pe grupe de vrst
80 % din cei chestionai provint din mediu urban. n seria analizat doar 48%
sunt salariai, 50% sunt vduvi, necstorii sau divorai, veniturile la doar 19 % sunt
peste 1500 lei i 13% din respondeni au ntre 0-500 lei pe cap de membru de familie,
ceea ce denot o populaie extrem de srac.
1.2. UNITATEA DE INREGISTRARE A DATELOR
Diagnosticul infeciei nosocomiale s-a bazat pe definiia de caz stipulat de
Ordinul Ministerului Sntii Publice nr. 916 / 2006, fiind declarat i raportat de
ctre medicul curant ctre medicul epidemiolog al SPCIN, conform Ordinului MS 916 /
2006 i Protocolului operaional 203 cu privire la sistemul informaional de declarare a
infeciilor nosocomiale n Spitalul Clinic Judeean de Urgen Braov.
16
Calitatea vieii a fost un alt criteriu de baz examinat la pacieni. Evaluarea
acesteia s-a efectuat dup o scar de autoapreciere a calitii vieii n Secia Clinic de
Ortopedie. Am utilizat chestionarul pentru identificarea efectelor factorilor de risc
endogeni i exogeni corelai cu nosocomialitatea. Chestionarul l-am conceput ca o
succesiune logic i psihologic de intrebri, n raport cu ipoteza cercetrii - existena
unor asociaii epidemiologice ntre infeciile intraspitaliceti i diferii factori de risc,
existena unor concordane ntre antibioprofilaxia sau antibioterapia incorect, care
determina din partea celui anchetat un comportament nonverbal, ce urmeaz a fi
nregistrat n scris. n ceea ce priveste prile chestionarului acestea sunt: una care se
refer la obiectul propriu-zis al anchetei; factorii de risc endogeni i exogeni de infecie
nosocomial, alta care permite cunoaterea determinanilor sociali ai populaiei int. Am
folosit o parte introductiv n care am ncercat s spargem gheaa i s dm celui
anchetat sentimentul de ncredere, apoi am trecut la date de identificare, sociodemografice. ntrebrile de trecere au fost cu privire la modul de via din afara
spitalului, comportamente la risc (fumat, alcool, alimentaie, comorbiditi). Am cutat s
msurm att comportamentul la risc al pacientului dar i al personalului pentru infecia
nosocomial. Prin nterabrile de control, care nu aduc informaii noi am cutat s
verificm fidelitatea, constan opiniei exprimate. Aprecierea gradului de afectare a
calitii vieii s-a efectuat dup chestionarul nostru cu 43 de ntrebri i fiecare participant
a primit i un Formular de consimmnt informat.
Pentru evaluarea gradului de risc infecios am ntocmit Harta sectoarelor cu
risc epidemiologic n care sunt punctai factorii endogeni ce in de imunitatea
pacientului i factorii exogeni ce in de mediul de spital, de deprinderile corecte al
personalului, de spaiile existente, de circuite. Gradul de risc poate fi stabilit dup
completarea unei grile de apreciere a acestuia. Grila cuprinde obiective, criterii majore i
minore, punctaj de ndeplinire a obiectivelor, pondere a criteriilor, nsumarea acestora
concretizndu-se ntr-un punctaj final n funcie de care se va stabili gradul de risc
epidemiologic: minim: punctaj 90-100 (zona verde), mediu: punctaj 70-89 (zona
galben), maxim: punctaj sub 70 (zona roie).
17
1.3. TIPUL DE CERCETARE
Studiu longitudinal, analitic, de cohort, cu caracter retrospectiv, prin care am
evideniat aspect legate de nosocomialitatea nregistrat n Secia Clinic de Ortopedie,
corelate cu factorii de risc i cu calitatea vieii pacientului. S-a urmrit studierea
impactului infeciei nosocomiale asupra calitii vieii, alterarea parametrilor strii de
sntate, la cei 7551 pacieni luai n studiu, pe perioada 01.01.2011.-31.12.2013 . n
urma acestui studiu au rezultat nite msuri ale forei asocierii dintre factorul de risc i
efect, reprezentate prin riscul relativ (dup studiile de cohort) atunci cnd variabilele
studiate (factorul de risc i efectul) au fost nominale, dihotomice. Dac variabilele a cror
asociere au fost numerice, msura asocierii a fost redat prin mrimea coeficientului de
corelaie (r). La valorile r de 0,3-0,4, se estimeaz o corelaie slab, la valori de 0,5-0,7 se
atest o corelaie medie, iar la o valoare de peste 0,7 prezint o corelaie de semnificaie
nalt. nafara forei asocierii, studiul a msurat i impactul expunerii, prin intermediul
riscului atribuibil.
Pentru a verifica n continuare ipoteza cercetrii tiinifice- pentru certitudinea
concluziilor i a stabili dac exist diferen semnificativ ntre cele dou loturi (expui
respectiv neexpui) s-a utilizat metoda 2 test de semnificaie statistic. Rezultatul
calculului s-a comparat pentru un risc de 5% (probabilitate 95%) cu valoarea existent n
tabelul chi-ptrat. S-a ales pragul de semnificaie = 0,05 i 2 cu 1 grad de libertate ,
valoarea 2 = 3,84 , astfel c n acest caz regiunea critic a fost intervalul [3,84, ). Sa calculat 2 , obinndu-se valoarea necorectat, iar dac acesta a fost mai mare de 3,84
s-a considerat situaie n care ipoteza nul Ho a fost respins cu un risc inferior lui 5%.
1.4. METODE DE PRELUCRAREA DATELOR
Analiza documentar a fost realizat cu ajutorul unor programe de prelucrare
statistic a datelor cum ar fi: Epi Info 2002, versiunea 3.4.3. din 2007 noiembrie i
Excel.
18
II.2. REZULTATE I DISCUII
2.1. Istoricul infeciilor nosocomiale n Spitalul Clinic Judeean de Urgen Braov
Grafic nr. 2 Trendul incidenei infeciilor nosocomiale n SCJUBv
In perioada 2006- prezent, rata
uor cresctor, de menionat
incidenei infeciilor nosocomiale are un trend
c pentru perioada 2011-2013 a crescut incidena
nosocomialitii nregistrat n Spitalul Clinic Judeean de Urgen Braov de la 0,08%
la 0,18%. (cu 225%).
Dublarea incidenei semnific de fapt o mai atent urmrire a acestor evenimente
petrecute n SCJU Braov i un interes mai mare al clinicianului, al serviciului SPCIN i
al laboratorului n diagnosticarea i declararea infeciilor nosocomiale
In 2013 cele mai multe infecii nosocomiale au fost de tipul infeciilor de plag
chirurgical, urmat de bronhopneumonii i infecii digestive cu Clostridium dificille.
Pe Secia Clinic de Ortopedie trendul incidenei infeciilor nosocomiale cretere
pe perioada 2007-2013 , de la 0.1 n 2007 la 0.17 n 2013,
urmnd
tendinele
nregistrate pe spital.
rata incidentei
Trendul incidentei infectiilor nosocomiale pe secia de ortopedie
(2007-2013)
0.3
0.25
0.2
0.15
0.1
0.05
0
incidenta infectiilor
nosocomiale ortopedie
incidenta infectiilor
nosocomiale spital
2007
2008
2009
2010
2011
2012
2013
0.1
0.21
0.13
0.07
0.28
0.15
0.17
0.06
0.107
0.04
0.058
0.08
0.1
0.18
Grafic nr. 4 Trendul incidenei infeciilor nosocomiale pe secia de ortopedie
19
Din cele 116 cazuri posibile de IN doar 15 (10%) au fost declarate oficial de
ctre medicii curani, restul de 101 fiind depistate pasiv prin analiza retrospectiv a foilor
de observaie.
Tabel nr. 10.- Tipurile de infecii nosocomiale pe secia de Ortopedie
Frequency Frequency Frequency
Diagnostic infectie Nosocomiala- Declarate
(D)sau Nedeclarate (Nd)
Infecie plag chirurgical profund
2013
2012
Nd
29
Infecie plag chirurgical superficial
2011
Nd
Nc
22
28
14
Septicemie
Infecie urinar
1
29
Total
30
2.3. Mediul de spital - Istoricul germenilor circulani n Spitalul Clinic Judeean
de Urgen Braov
n anul 2011
ponderea cea mai mare de tulpini izolate pe spital aparin
Escherichiei coli - 37%, urmat de
Staphylococcus aureus - 22% i Klebsiella -10%.
Pentru anul 2012, ponderea Escheruichiei coli scade la 33%, ponderea de tulpini
circulante de Enterococcus, Klebsiella i Enterobacter ajung fiecare la 8%.
n anul 2013
ponderea tulpinilor
circulante
de Escherichia coli rmne
nemodificat- 32%, trendul circulaiei stafilococului este descendent comparativ cu anul
precedent - 19% dar ponderea tulpinilor circulante de Klebsiella i Enterococ este
ascendent 14% respectiv 11%.
20
2.4. Mediul de spital - Istoricul germenilor circulani pe Secia Clinic de
Ortopedie
n anul 2011 ponderea cea mai mare o nregistreaz Staphylococcus aureus 45%, urmat de Escherichia coli - 15% , Klebsiella, Enterococcus i Acinetobacter cu
8% fiecare.
n anul 2012, ponderea Staphylococcus aureus rmne neschimbat - 45%,
Escherichia coli, Enterococcus i Klebsiella au i ele tendin staionar 15% respectiv
9% . Circulaia Acinetobacter cunoate o uoar ascenden la 11%.
n anul 2013, se intensific circulaia Staphylococcus aureus la 48%, frecvena
tulpinilor de Escherichia coli scade la 11%.
Circulaia tulpinilor de Acinetobacter i
Enterococcus staioneaz la 10% , ponderea tulpinilor izolate de Klebsiella scade la 8%.
2.5. Istoricul tipurilor de germeni izolai din IN pe Spital
Ponderea infeciei cu Staphyilococcus aureus este una descresctoare de la 31%
n 2011 la 29% n 2012 i 19 % n 2013, ca urmare a sensibilizrii permanente a
personalului asupra importanei igienei minilor
n anul 2011, 72% din infeciile nosocomiale au etiologie Gram +: Stafilococcus
aureus, Enterococcus, Clostridium dificille, cu mare probabilitate datorndu-se portajului
prin colonizare a personalul medical i/sau al pacientului (nas, gt, piele, intestine) sau
prin mna murdar, iar 28 % dintre IN se datoreaz transmiterii prin elemente de mediu
de spital contaminate a germenilor Gram -: Proteus, Escherichia coli, Acinetobacter,
Klebsiella, Pseudomonas.
n anul 2012 etiologia infeciilor nosocomiale pe Secia Clinic de Ortopedie se
schimb radical spre flora Gram negativ, incriminnd transmiterea germenilor prin
mediul de spital, obiecte contaminate i manevre medicale la risc nosocomial.
n 2013 infeciile nosocomiale se datoreaz n proporie de 50% germenilor
Gram negative i 50% celor Gram pozitivi.
21
2.7. Corelaii ntre germenii circulani i cei din infeciile nosocomiale
In studiul nostru am cutat s identificm factorii de risc pentru nosocomialitate
i s msurm asocieri ntre germenii circulani i cei din infeciile nosocomiale att la
nivelul spitalului ct i la nivelul Seciei Clinice de Ortopedie. Datele prelucrate la nivelul
anului 2013 au artat mrimea coeficientului de corelaie ntre germenii circulani din
spital i cei din infeciile nosocomiale de pe ntreaga unitate de 0,158 , ceea ce
demonstreaz o lips de corelaie. Dac msurm aceai asociere pe secia de ortopedie
constatm deja o corelaie medie, de 0,5326, ntre germenii circulani i cei implicai n
infeciile nosocomiale.
Grafic nr. 2 Ponderea germenilor circulani versus ponderea celor din infeciile
nosocomiale n secia de ortopedie n anul 2013
2.8. Analiza SWOT a seciei de ortopedie
Pentru Spitalul Clinic Judeean de Urgen Braov, ca unitate cu activitate de
servicii medicale, obiectivul principal este reprezentat de satisfacerea
maxim a
cerinelor i ateptrilor pacienilor i aparintorilor acestora. n acest scop, Secia
Clinic de Ortopedie depune eforturi pentru a fi la nlimea ateptrilor
22
Analiza SWOT a Seciei Clinice de Ortopedie
Puncte tari
Oportuniti
-Personal medical acreditat, calificat.
- Servicii medicale validate i decontate
100% de ctre CAS Braov.
- Echip capabil s aplice instrumentele
manageriale pentru a deveni cea mai
primitoare unitate sanitar din ora,
preocuprile se axeaz pe: obinerea
satisfaciei pacienilor, perfecionarea continu
a personalului.
- Adresabilitate 100% din raza judeului
i 30% din cazurile din jud. Covasna Harghita.
- Educaia medical continu a angajailor
pe tema nosocomialitii.
- Procent (5%) utilizat din bugetul
spitalului i al seciei pentru dezinfectante,
antiseptice i materiale de unic folosint.
- Pentru diminuarea cheltuielilor de
personal i reducerea riscurilor de contaminare
s-au externalizat unele servicii: prepararea
hranei pentru pacieni i spltoria.
- Creterea valorii contractului ncheiat cu
CAS Braov prin acte adiionale pentru servicii
efectuate n secia de ortopedie (proteze) i
creterea punctului de complexitate DRG.
Puncte slabe
Ameninri
- Personal medical insuficient;
- Funcionarea SPCIN din structura
unitii doar cu 3 persoane, 1 medic i 2
asisteni de igien;
- Dotare minim cu dispensere pentru
antiseptice la nivelul seciei i prosoape de
hrtie n cantitate suficient att pentru
personal ct i pacieni.
- Lipsa grupurilor sanitare la fiecare
salon.
- Nerespectarea normelor cu privire la
suprafa saloanelor i numr paturi admise,
conform Ord. 914/2007. Exist saloane cu 8
paturi.
- Nu exist spaii gospodreti
suficiente conform Ord. 914/2007 (lipsesc
spaiile pentru depozitare material curenie,
actualmente ele ocup un du al pacienilor.
- Nu exist depozit temporar de deeuri
periculoase i menajere, separate, pe secie
conform Ord. 1226/2012, ele sunt depozitate
impropriu ntr-un dulap nchis cu cheia pe
scara de incendii.
- Nu exist dou sli de tratament,
separate pentru septic i aseptic.
- Apariia de noi competitori pe pia
(spitale private);
- Insuficiena personalului medical poate
crea situatii de malpraxis;
- Dotarea deficitar poate duce la
insatisfacia pacienilor i al personalului.
23
2.9. Costurile directe correlate cu infeciile nosocomiale din Spital
Costurile induse de ngrijirile acordate cazurilor cu infecii nosocomiale pot
influena semnificativ evoluia procesului de management al ntregului sistem de sntate
nu numai al Seciei Clinice de Ortopedie.
Media costurilor totale de spitalizare la pacienii cu infecti nosocomiale pe 2011
a fost de 19 537.54 ron, i a crescut cu 500 lei in 2012 ajungnd la 20084 ron. Media
costurilor de spitalizare datorate strict IN pe 2011 a fost de 6326.42 ron, aproape c s-a
dublat suma n 2012, 11958.47 ron. Media costurilor pentru antibiotice la pacientii
declarati cu IN pe 2011 a fost de 1056,6 ron/ pacient, media a crescut cu 200 ron/ pacient
n 2012.
Media costurilor totale de spitalizare la pacienii cu infecii nosocomiale pe 2013
a fost de 14655 ron, tendin descresctoare, fiind chiar mai mic dect n 2011.
Media costurilor de spitalizare datorate strict IN
a fost de 6939,7 ron, trend
descresctor. Media costurilor pentru antibiotice la pacienii declarai cu IN a fost de
609 ron/ pacient cu infecie nosocomial, trend descresctor, ceea ce denot succesul
sensibilizrii medicilor cu privire la riscurile antibioterapiei i antibioprofilaxiei haotice
sau incorecte.
2.10. Costurile directe cu infeciile nosocomiale de pe Secia Clinic de Ortopedie
n anul 2011 pentru cazurile de infecie nosocomial declarate pe Secia Clinic
de Ortopedie media costurilor de spitalizare a fost de 26200 ron, o medie mult peste
costurile medii de la nivelul ntregului spital (19537 ron), ceea ce denot c pacientul
ortopedic cu infecie nosocomial postoperator consum mult mai mult dect un alt
pacient al spitalului cu IN. Aceiai tendin cresctoare pentru consumul de antibiotice.
n anul 2012 i respective 2013 media costurilor cu spitalizarea a cazurilor cu infecie
nosocomial este mult mai mic comparativ cu anul 2011i comparative cu spitalul.
Aceiai tendin descresctoare i pentru consumul de antibiotice.
24
2.11. Costurile indirecte comparative pe Spital i pe Secia Clinic de Ortopedie n
anii 2011-2013
Pe Secia Clinic de
Ortopedie
n anul
2011, la pacienii cu infecie
nosocomial, media zilelor totale de spitalizare a fost de 73 zile, mult mai mare dect
cea nregistrat la nivelul Spitalului 35 de zile. Media zilelor de spitalizare pe Ortopedie
datorate strict IN este 10 zile. n 2012, pe Ortopedie media zilelor totale de spitalizare a
fost de 70,4 zile, apropiat celei din 2011. Media zilelor de spitalizare datorate strict IN
a fost de 12,5 zile, trend cresctor comparativ cu anul 2011. n 2013 media zilelor totale
de spitalizare a fost de 55,15zile, tendin descresctoare fa de anul 2011 i respectiv
2012, dar mult peste media pe Spital -26,6 zile. Media zileleor datorate strict IN pe
ortopedie a fost de 15,71zile , medie peste nivelul pe spital i un trend cresctor fa de
2011, 2012 cu toate c numrul infeciilor a sczut. nc odat se confirm ipoteza c
pacientul ortopedic cu infecie nosocomial este mai scump dect pacientul cu IN de pe
alte secii al spitalului.
2.12. Costurile aprovizionrii cu substane dezinfectante n Secia Clinic de
Ortopedie ntre anii 2011-2013
Conform datelor furnizate de Serviciul de Achiziii al Spitalului bugetul lunar
alocat Seciei Clinice de Ortopedie, de exemplu pentru aprovizionarea cu substane
dezinfectante este n 2011 - de 30000 ron, n 2012 35000 ron, iar n 2013 - 40000
ron. Aceste sume sunt insuficiente pentru cantitatea necesar n mod real i conform
Planului de achiziii. Se cumpr aproximativ 60% din necesarul pentru dezinfectantele
de suprafee i 20% din necesarul pentru antiseptice.
2.13. Istoricul cheltuielilor cu antibioticele prescrise ntre anii 2011- 2013 n Spital
n anul 2011 costurile cu antibioticele utilizate a nsumat la nivelul ntregului
Spital - 972 993.13 ron, cu un consum mare pentru antibioticele Oframax, Gentamicin
i Ampicilin. n 2012 valoarea total a consumului de antibiotice pe Spital este de
823322.16
ron, crescnd mul
consumul de Oframax - antibiotic din clasa
cefalosporinelor de generaia a III-a, cu spectru larg de aciune i care induce foarte
repede rezisten dar este cel mai ieftin pe pia, ceea ce face ca la Spitalele de stat s fie
foarte cutat. n 2013 costul total al antibioticelor prescrise ajunge la 945425.65 ron.,
25
consumul de Oframax meninndu se n continuare la nivelul crescut al cantitiilor din
anul precedent. Studiul nostru relev c la nivelul ntregului Spital dar i n cadrul Seciei
Clinice de Ortopedie
sunt prescrise i utilizate n exces antibiotice din grupul
cefalosporinelor de generaia III
precum i
cantiti foarte mari de Oxacilin i
Gentamicin, att profilactic ct i terapeutic, dei tulpinile circulante n mediul de
spital i n infeciile nosocomiale sunt rezistente la aceste antibiotice.
2. 15. Istoricul cheltuielilor cu antibioticele pe Secia Clinic Ortopedie
Pe Secia Clinic de Ortopedie, n anul 2011, valoarea total a antibioticelor
prescrise i utilizate a fost de 109119,71 lei la 2308 pacieni, cu o medie de 47,27 ron
/pacient cu tratament antiinfecios. Cantitatea total a fost de 38606 uniti. Costurile
totale, cu antibioticele n anul
2012, a fost de 81319.34 ron la 2343 pacieni, cu o
medie de 34,7 roni/pacient cu tratament antiinfecios. Cantitatea total a fost de 32151
uniti. Trendul este descresctor pentru suma cheltuit pentru antibiotice iar numrul
pacienilor a fost aproximativ acelai. n anul 2013 costul total a crescut uor, 83381,26
ron, la
2221 pacienti, media a fost de 37,5 ron /pacient cu tratament antibiotic.
Cantitatea total a fost de 26564 uniti. Trendul este cresctor comparativ cu anul 2012.
Costurile cu antibioticele a crescut lor dei nrumrul pacienilor tratai a sczut.
Studiul nostru evideniaz srcia gamei de antibiotice utilizate, n anul 2011
indicnd resurse financiare modeste . In anii n 2012 i 2013 gama antibioticelor
utilizate este mult mai variat, dar observm i costuri foarte ridicate cu antibioticul
Targocid, antibiotic foarte scump.
2.16. Rezistena la antibiotice pentru Staphylococcus aures
Studiul nostru demonsrtreaz o deosebit rezisten a stafilococilor circulani n
Spitalulul Clinic Judeean de Urgen Braov. 28% sunt MRSA, 50 % sunt rezisteni la
Eritromicin i 43% la Clindamicin.
26
Rezistenta bacteriana 2013
Stafilococcus aureus
100%
9.4
10
90%
28.1
80%
50
43.8
70%
60%
50%
40%
30%
Rezistent %
20%
Intermediar
10%
Sensibil %
0%
linezolid
clindamicina (cu D test)
eritromicina
ciprofloxacina
doxiciclina
TMP/SMX
rifampicina
vancomicina
meticilinorezistenta
Grafic nr. 35. Rezistena microbian pentru Stafilococcus aureus
2.17. Factori de risc intrinseci
Literatura de specialitate afirm c vrstele extreme sunt factori de risc endogeni
pentru infecia nosocomial.
Aa cum am menionat n metodologie, n partea de
descriere a eantionului, populaia respondent este una activ social, vrsta medie a
lotului este de 48,7 ani, cu minima de 18 ani i maxima de 90 ani. Vrsta medie a celor cu
infecie nosocomial este de 57,7 ani (minim 47, maxim 80 ani).
n studiul impactului vrstei peste 65 ani asupra infeciei nosocomiale, pentru
intervalul de ncredere de 95%, riscul relativ (RR) este de 11,78 (2,48<RR< 56,8) Chiptrat statistic este 14.9738.
Valoarea lui P value este 0.001. Acest rezultat este
semnificativ statistic. Riscul de a face infecie nosocomial la cei peste 65 de ani este de
11,7 ori mai mare desct la cei sub 65 de ani.
Sexul masculin este considerat factor de risc pentru infeciile
nosocomiale.
Studiul nostru arat o probabilitate de 1,24 ori mai mare de a face infecie nosocomial la
sexul masculin dect la femei dar datele nu sunt semnificative statistic. RR este de 1,24
(0,29<RR< 5,33) Chi-ptrat statistic este 0.08. Valoarea lui P value este 0.53.
Venitul sczut un alt potenial factor de risc endogen studiat se dovedete a fi
adevrat, existnd asociere epidemiologic ntre venitul mic i infecia nosocomial. RR
este de 10,36 (1,28<RR< 83,3) Chi-ptrat statistic este 7,7. Valoarea lui P value este
0.009 Acest rezultat este semnificativ statistic. Ins venitul pe cap membru familie nu
27
este factor de risc conform rezultatelor noastre. RR este de 0,98 (0,23<RR< 4,2) Chiptrat statistic este 0.004. Valoarea lui P value este 0.63, RA = - 0,085.
Pornind de la ipoteza c un pacient cu studii are acces la educaie i informaii
privitoare la infecii nosocomiale, am considerat factor de risc lipsa studiilor. Cercetarea
noastr demonstreaz lipsa de asociere epidemiologic pentru acest factor. RR este de 0 ,
Chi-ptrat statistic este 2.26. Valoarea lui P value este 0.073.
Fumatul se consider n literatura de specialitate un factor de risc endogen pentru
infecia nosocomial. Datele lucrrii noastre arat existena riscului de 1,25 ori mai mare
la fumtori de a face infecie nosocomial dar nu exist i asociere epidemiologic
dovedit statistic. RR este de 1,25 (0,29<RR< 5,33) Chi-ptrat statistic este 0.09.
Valoarea lui P value este 0.52.
Obezitatea este cosiderat n mod cert un factor de risc pentru infecia
nosocomial, cei care sunt obezi sau supraponderali au o probabilitate de 6,6 ori mai
mare de a face infecie nosocomial dect normoponderalii, datele sunt i semnificative
statistic. RR este de 6,59 (1,34<RR< 32,32) Chi-ptrat statistic este 7,19. Valoarea lui P
value este 0.016.
Consumul de alcool este considerat factor de risc endogen pentru infecia
nosocomial. Studiul nostrum arat o probabilitate de 1,65 ori mai mare la alcoolici de a
face infecie comparative cu cei care nu consum alcool, dar datele nu sunt semnificative
statistic. RR este de 1,65 (0,21<RR< 12,5) Chi-ptrat statistic este 0.23. Valoarea lui P
value este 0.49. Acest rezultat este nesemnificativ statistic.
Ipoteza noastr care afirm c alimentaia neechilibrat este factor de risc
pentru infecie nosocomial este infirmat de datele obinute. Exist un risc de 3,88 ori
mai mare la cei cu alimentaie nesntoas de a face infecie nosocomial, dar rezultatul
este nesemnificativ statistic. RR este de 3,88 (1,22<RR< 14,6) Chi-ptrat statistic este
3.24. Valoarea lui P value este 0.08. Acest rezultat este nesemnificativ statistic.
Comorbiditile asociate cresc riscul infeciilor nosocomiale dei literatura de
specialitate i studiile demonstreaz acest lucru, n lucrarea noastr rezultatele nu sunt
28
semnificative statistic dar arat un risc de 2,48 mai mare la cei cu boli asociate de a face
infecie nosocomial. RR este de 2,48 (0,58<RR< 10,56) Chi-ptrat statistic este 1.6.
Valoarea lui P value este 0.19. Acest rezultat este nesemnificativ statistic.
Printre
factorii endogeni ai infeciei nosocomiale amintim i caracterul
internrii, cert este c urgenele cresc riscul de nosocomialitate comparativ cu bolile
cronice. Studiul nostru arta un risc de 2,47 mai mare la cei cu urgene medicale sau
chirurgicale dact la cei internai pentru afeciuni cronicee. RR este de 2,47 (0,3<RR<
19,77) Chi-ptrat statistic este 0.79. Valoarea lui P value este 0.34. Acest rezultat este
nesemnificativ statistic. Un nou posibil factor de risc pe care l-am studiat a fost depresia,
studiul nostru a ncercat s demonstreze o asociere epidemiologic ntre depresie i
infecia nosocomial. Datele au artat un risc de 1,5 ori mai mare la cei deprimai de a
face infecie nosocomial comparativ cu cei fr depresie. RR este de 1,5(0,18<RR<
11,87) Chi-ptrat statistic este 0.15. Valoarea lui P value este 0.57. Acest rezultat este
nesemnificativ statistic.
Dup identificarea factorilor de risc intrinseci am dorit o ierarhizare a acestora
pentru a realiza care factor determin probabilitatea cea mai mare de a face infecie
nosocomial pe Secia Clinic de Ortopedie. n acest sens am ordonat, n sens cresctor
riscurile relative, calculate pentru fiecare factor. (vezi grafic nr. 6) Vrsta extrem cu
riscul relativ de 11,78, urmat de factorul venit mic cu RR de 10,36 i obezitatea cu
RR 6,56 au fost identificai cu cel mai mare impact i semnificative statistic.
29
Grafic nr. 41 Ierarhizarea factorilor de risc intrinseci de pe secia de ortopedie
(RR)
2.18. Factori de risc extrinseci
Dintre factorii de risc exogeni am studiat n primul rnd lungimea duratei de
spitalizare. Rezultatele au artat un risc de 24 ori mai mare de a face infecie
nosocomial, la cei spitalizai peste 7 zile versus cei spitalizai pe perioade scurte de
timp. Pentru
noiunea
lungimea duratei de spitalizare am inut cont de
media
recomandat pentru o secie de ortopedie de ctre Ministerul Sntii - cea de 7 zile.
RR este de 24 (3,03<RR< 190,05) Chi-ptrat statistic este 20.06. Valoarea lui P value
este 0.000. Acest rezultat este semnificativ statistic.
Studiul calitii vieii a fost una dintre obiectivele cercetrii. Pentru a cuantifica
starea de bine a pacienilor ortopedici , i-am rugat s-i dea o not pentru stare lor
actual de la 0 la 100, nota maxim pentru bine. Dup ce am calculat media lor la
respondeni am obinut o not de 66,5, ([Link] 19,81). Am considerat notele ntre 80 100 stri de bine i notele sub 80 factori de risc pentru nosocomialitate. Astfel studiul
nostrum a artat un risc de 1,29 ori mai mare la nota sub 80 fa de cei cu stare de bine.
30
RR este de 1,29 (0,26<RR< 6,39) Chi-ptrat statistic este 0.105. Valoarea lui P value
este 0.55. Acest rezultat este nesemnificativ statistic.
Unii dintre factorii extrinseci dovediii n studiile din literatura de specialitate a fi
implicai n nosocomialitate sunt condiiile de spitalizare, condiiile hoteliere. Am
analizat riscul asociat cu aglomerarea din saloanele de pe secia de ortopedie tiind c
aceasta este cea mai aglomerat secie din spital, cu 70 de paturi, n unele saloane
depindu-se cu mult suprafaa per pat admis n normele din Ordinul MS. 914/2007
respectiv 7 mp per pat, conform normelor maxim 5 paturi pentru saloanele mari.
Cercetarea noastr a demonstrat c dei riscul de a face infecie nosocomial n saloanele
aglomerate este mai mare de 2,3 ori fa de saloanele neaglomerate, datele nu sunt
semnificative. RR este de 2,32 (0,47<RR< 11,58) Chi-ptrat statistic este 1.16. Valoarea
lui P value este 0.24. Acest rezultat este nesemnificativ statistic.
O importan major n supravegherea infeciilor nosocomiale o are instruirea
personalului cu privire la Precauiunile universale, cunoscndu se faptul c banalul
splat pe mini este cel mai eficient mod i cel mai sigur de a preveni i controla
nosocomialitatea. Am cutat s identificm gradul de informare ale pacienilor cu privire
la riscul dobndirii unei infecii asociate ngrijirilor medicale. Cercetarea noastr a
identificat o puternic asociere epidemiologic ntre
lipsa de cunotine i infecia
nosocomial. Riscul celor neinformai este de 4,3 ori mai mare de a face infecie dect a
celor informai. RR este de 4,3 (0,87<RR< 21,31) Chi-ptrat statistic este 3.86. Valoarea
lui P value este 0.03. Acest rezultat este semnificativ statistic.
Universal cunoscut este faptul c antibioprofilaxia este un factor de protecie
pentru infecia nosocomial. Spre surprinderea noastr datele au demonstrate contrariul,
faptul c antibioprofilaxia este factor de risc pentru nosocomialitate i c riscul celor care
fac profilaxie cu antibiotic este de 7,58 mai mare de a face infecie dect cei fr
profilaxie. RR este de 7,58 (3,85<RR< 59,39) Chi-ptrat statistic este 5.28 Valoarea lui P
value este 0.02. Acest rezultat este semnificativ statistic. Pornind de la rezultatele de mai
sus am analizat posibilele cauze i am cutat s demonstrm c o profilaxie incorect
crete riscul nosocomialitii de 8,21 ori. RR este de 8,21 (1,68<RR< 40,05) Chi-ptrat
31
statistic este 9.61 Valoarea lui P value este 0.007. Acest rezultat este semnificativ
statistic.
Studiul nostru demonstreaz c pe Secia Clinic de Ortopedie lungimea duratei
de spitalizare are impactul cel mai mare, RR de 24, urmat de profilaxia incorect cu RR
de 8,21 i paradoxal antibioterapia, RR de 7,58, i impactul pacientului neinformat, RR
de 4,3. toate cele 4 riscuri sunt demonstrate a fi semnificative statistic. (vezi grafic nr. 8)
Grafic nr. 8 Ierarhizarea factorilor de risc extrinseci pe secia de ortopedie
Impactul factorilor de risc cercetai asupra lotului de studiu
Riscul atribuibil
este diferena dintre frecvena unei afeciuni n populaia
expus i frecvena acelei afeciuni n populaia neexpus. Riscul atribuibil fa de riscul
relativ caracterizeaz att agresivitatea factorului de risc ct i frecvena afeciunii
respective, motiv pentru care servete pentru identificarea acelor probleme care pot fi
adresate i rezolvate cu eficacitate maxim, folosind n mod optim resursele disponibile.
Factorii de risc intrinseci sunt greu de controlat, sunt unii asupra crora nu putem
interveni. Din analiza datelor noastre putem afirma c prin eliminarea fumatului la
pacieni s-ar reduce cu 0,013% infeciile nosocomiale de pe secia de ortopedie. Printr-un
control adecvat al greutii corporale s-ar elimina cu 0,129% nosocomialitatea. Prin
alimentaie sntoas, s-ar elimina cu 0,079% infecia nosocomial. Prin eliminarea
consumului de alcool s-ar reduce cu 0,036% infeciile i prin creterea veniturilor
32
pacienilor nosocomialitatea s-ar reduce cu 0,123%. Riscurile atribuibile sunt foarte mici
i nu aici trebuie s cutm soluii.(grafic nr.44)
Grafic nr.44 - Riscurile atribuibile factorilor de risc intrinseci studiai
Pentru un control optim al infeciilor nosocomiale trebuie s acionm pe factorii
extrinseci de risc. Studiul nostru arat c o scdere a duratei spitalizrii, ct mai aproape
de durata optim pentru ortopedie de 7 zile, ar reduce nosocomialitatea de pe secie cu
23,95%, printr-o antibioprofilaxie corect
am reduce infeciile cu 15,68%. Un rol
important n supravegherea i controlul infeciilor nosocomiale l are informarea
pacientului. Un pacient care tie ce este nosocomialitatea i metodele de prevenire reduce
incidena infeciilor cu 8,73%. Respectarea normelor sanitare cu privire la numr paturi
admise pe suprafaa salonului deasemeni reduce cu 4,61% din infeciile nosocomiale.
(vezi grafic nr. 45)
33
Grafic nr.45 - Riscurile atribuibile factorilor de risc extrinseci
[Link] vieii - Satisfacia pacientului
Calitatea vieii a fost criteriul de baz examinat la lotul nostru de studiu, alturi
de examenele microbiologice de laborator. Evaluarea acesteia s-a fcut dup scara de
apreciere a calitii vieii. Analiza statistic a parametrilor strii sntii a artat c
durerea influeneaz mult parametrii activitilor cotidiene i reduce semnificativ
calitatea vieii pacienilor.
Dintre subiecii respondeni care acuzau unele probleme n deplasare sau chiar
obligativitatea de a sta n pat, media strii de sntate este de 66,42 ceea ce denot o stare
alterat. Media celor cu infecie nosocomial este de 57,85, o stare mult sub nivelul
mediei lotului studiat (66,5). Din cei chestionai 90% au invocat durerea, 81%
imobilitatea, 17,5% atitudinea indiferent a personalului i 81% depresia ca factor de
alterarea a calitii vieii. (vezi tabel nr. 14)
34
Tabel nr. 14 Frecvena alterrii calitii vieii
Alterarea calitii vieii
Frequency Percent 95% Conf Limits
108
90.0% 65.4%
81.7%
imobilitatea
97
80.9% 54.9%
72.7%
suparare atitudine personal
21
17.5% 15.9%
38.7%
Depresie
97
80.9% 54.9%
72.7%
durere-discomfort
Condiiile de spitalizare, curenia, hrana
Scopul revizuirii standardelor de calitate const n mbuntirea continu a
calitii serviciilor furnizate i a modalitilor de a produce aceste servicii. n acest sens,
un bun management al calitii const n planificarea, aplicarea practic, controlul i
revizuirea msurilor necesare modelrii serviciilor i proceselor, astfel nct acestea s
corespund permanent nevoilor pacientului.
Studiul nostru arat o satisfacie de 53% a celor mulumii de curenia de pe
secie i a hranei (limita de confiden 44%- 62,8%).
Deprinderile personalului
Tratarea tuturor pacienilor cu acelai nivel de baz al Precauiilor standard
implic practici eseniale pentru asigurarea unui grad nalt de protecie a pacienilor, a
personalului i a vizitatorilor. Acestea includ urmtoarele: splatul pe mini ( igiena
minilor); folosirea echipamentului personal de protecie cnd se mnuiete snge, alte
substane corporale, excreii i secreii; mnuirea adecvat a echipamentului de ngrijire a
pacientului i a lenjeriei murdare; prevenirea nepturilor/ tieturilor/ rnirilor cu
instrumentar i mnuirea adecvat a reziduurilor. n acest scop am dorit s identificm
lipsurile personalului n implementarea protocoalelor de bune practici i am cuprins n
chestionarul nostru cteva ntrebri cu referire la splatul pe mini al personalului,
splatul corect i la purtarea mnuilor. (interval de incredere 89%-98,1%). 95% au
purtat mnui la pansat dar numai 78% au i schimbat mnuile de fa cu bolnavul.
35
(interval de incredere 69,9%-85,5%). Datele studiului nostru arat c dei splatul pe
mini este cel mai ieftin, simplu i eficient mod de a preveni infeciile nosocomiale, doar
60% din personal s-a splat pe mini, 6,9% dup fiecare pacient i 31% omite splatul.
Gradul satisfaciei personalului medical este legat de calitatea actului medical, dar
deriv i din condiiile n care si desfsoar munca, iar existena satisfaciei duce la
creterea performanei. Acesta este un element de msurare ce poate fi folosit n
evaluarea
calitii muncii prestate de acesta. Dintre respondenii notri 94% sunt
mulumii de profesionalismul medicilor, 91% de prestaia asistentelor i cu o tendin
descendent, 88% de infirmiere. (vezi tabel nr. 57)
Tabel nr. 57 Ponderea aprecierii profesionalismului medicilor
Mulumit de
profesionalismul Freq Percent
Cum
Percent
medicilor
da
109
94.0%
94.0%
nu
6.0%
100.0%
116 100.0%
100.0%
95% Conf Limits
da 88.0% 97.5%
nu 2.5%
Total
36
12.0%
Tabel nr. 58Ponderea aprecierii profesionalismului asistentelor
Mulumit de
95% Conf Limits
Cum
profesionalismul Freq Percent
Percent
asistentelor
da 84.7% 95.8%
nu 4.2% 15.3%
da
106
nu
10
91.4%
91.4%
8.6% 100.0%
116 100.0% 100.0%
Total
Tabel nr. 59 Ponderea aprecierii profesionalismului infirmierelor
Mulumit de
Cum
profesionalismul Frec. Percent
Percent
infirmierelor
da
103
nu
13
Total
88.8%
88.8%
95% Conf Limits
da 81.6%
93.9%
nu 6.1%
18.4%
11.2% 100.0%
116 100.0% 100.0%
Un pacient bine instruit cu privire la prevenirea infeciilor intraspitaliceti ar fi un
ctig de necontestat pentru Secia Clinic de Ortopedie n controlul i supravegherea
nosocomialitii. Din rndul celor informai despre infecia nosocomial 41,6% au avut
cunotine corecte despre mijloacele de prevenire a acesteia.
2.20. Grila de apreciere a gradul de risc infecios
n studiul nostru am stabilit gradul de risc epidemiologic pentru Secia Clinic de
Ortopedie, ceea ce a implicat analiza anumitor criterii legate de organizarea seciei,
dotare, igien, personal, aprovizionare cu materiale, starea pacienilor de tratat, tipul de
manopere efectuate i antecedente de infecii nosocomiale. Media punctajului per spital a
37
fost de 73,99, ceea ce corespunde zonei galbene respectiv risc mediu. Secia de ortopedie
se situeaz n zona galben cu un punctaj de 71,15, uor sub media pe spital.(grafic nr.
43)
Grafic nr. 43 Harta seciior cu risc
Secia Clinic de Ortopedie a obinut pentru primul obiectiv care ine de starea
pacientului
64 de puncte din totalul de 100. La analiza specificului interveniilor,
obiectiv de 10%, interveniile de urgen, manevrele invazive, asistaii respirator i
terapiile parenterale au redus punctajul de la 100 la 50. La obiectivul referitor la normele
pentru asigurarea condiiilor generale de igien, calitatea apei, existena rezervoarelor,
saloane, cabinete, sli de tratament prevzute cu lavoar cu ap cald i rece, starea
cldirii, finisajele cu soluii lavabile, managementul deeurilor periculoase, utilizarea de
biocide avizate, existena planului de deratizare dezinfecie, Secia Clinic
de
Ortopedie a obinut 84 de puncte din 100. Organizarea funcional a seciei reprezint o
pondere de 20% din scorul final, din maximul de 100 s-au realizat 30 de puncte.
Asigurarea de materiale sterile, investigarea spaiilor destinate sterilizrii, a aparaturii i
instruirii personalului responsabil cu sterilizarea a atins nota maxim, 100. Circuitele
funcionale ale Seciei Clinice de Ortopedie, obiectiv de 10%, fie c este vorba de
pacieni, alimente, lenjerie, personal, instrumente sterile sau deeuri, a atins punctajul
maxim. Personalul de pe secie, obiectiv de 5% din gril, a primit 99 de puncte din 100,
38
au fost analizate normativele cu privire la angajri, fiele de post, calificarea personalului,
controlul medical periodic, asigurarea cu echipament de protecie adecvat i respectarea
precauiunilor universal. Autocontrolul cu privire la testele de sanitaie a primit nota
maxim de 100. Acest obiectiv are o pondere de 10% n calcularea punctajului final.
Serviciile gospodreti , anexe seciei, oficiul alimentar, spltoria, vestiarul personalului
i al pacienilor a obinut 80 de puncte din 100. Protocoalele de igien afiate, dotarea cu
frigidere i aparatur medical a adus nc un total pe obiectiv de 60 puncte.
IV. CONCLUZII
-
n baza unui complex de date clinice, epidemiologice i socioeconomice s-a efectuat
o analiz amnunit a rezultatelor pe un lot reprezentativ de pacieni cu afeciuni
ortopedice internai n perioada 2011 -2013- 7551 pacieni, din care s-au evideniat
activ i retrospectiv un total
116 pacieni cu IN pe baza definiiilor de caz
S-au identificat germenii circulani
i cu potenial de nosocomialitate de pe Secia
Clinic de Ortopedie , pe primul loc se situndu-se Staphilococcus aureus, care se
regsete i n etiologia n IN de pe secie mpreun cu Acinetobacter, urmat de E.
coli, apoi Klebsiella i Enterococcus.
-
Din analiza gradului de rezisten al germenilor identificai reiese
rezisten a stafilococilor circulani. Dintre acestia
o deosebit
28% sunt MRSA, 50 % sunt
rezisteni la eritromicin i 43% la clindamicin.
-
Administrarea
incorect
a antiobioprofilaxiei
n preoperator
o transform pe
aceasta din factor de protecie recunoscut n factor de risc cu potenial nosocomial.
- Practica antibioterapiei conform profilului bacteriologic al Seciei Clinice de Ortopedie
aduce pe primul loc consumul de cefalosporine generaia III, urmat de consumul de
gentamicin i oxacilin. Pe perioada studiului apare o tendin descresctoare a utilizrii
cefalosporinelor datorit i activitii SPCIN care a sensibilizat cu succes personalul n
implementarea corect a protocoalelor de antibioterapie i antibioprofilaxie.
-
Studiul nostru evideniaz srcia gamei tipurilor de antibiotice utilizate puse la
dispoziie de unitatea sanitar n anul 2011, aceast situaie se schim n anii 2012 i
2013 dar antreneaz i costuri foarte ridicate.
39
Identificarea dezinfectanilor i antisepticelor cu cea mai mare eficien n controlul
mediului de spital i al igienei personalului a oferit consultan profesional pentru
procurarea acestora, a cror consum a crescut simitor pe perioada studiului pentru
dezinfectantele de nivel inalt de la 1l la2 l de soluie concentrat pe lun i pentru
antiseptice de la 180 la 210 l pe lun
Calculul costurilor suplimentare pentru infeciile nosocomiale au confirmat ipoteza
c pacientul ortopedic cu infecie nosocomial este mai scump dect pacientul cu IN
de pe alte secii al spitalului. Media zilelor de spitalizare a celor cu IN pe spital este
de 25-35 zile versus pacient ortopedic cu IN de 73 zile, ceea ce antreneaz chletuieli
mult mai mari
n urma analizei SWOT a Seciei Clinice de Ortopedie am identificat punctele slabe
dintre care enumerm: personalul insuficient, neconcordana dintre recomandrile
legiuitorului privind suprafaa saloanelor i numr de paturi admise, lipsa spaiilor
gospodreti i a slii de tratament pentru septic dar i punctele tari: adresabilitate
100% pentru judeul Braov, echip capabil, instruit prcum t i oportunitiile i
ameninrile - dotare cu echipamente deficitar.
Utilizarea Grilei de apreciere a gradului de risc n apariia infeciilor nosocomiale
pe Secia Clinic de Ortopedie a fost de un real folos pentru ierarhizarea factorilor
de risc i pentru elaborarea Hrii riscurilor.
S-au evaluat impactul factorilor de risc intrinseci i extrinseci asupra incidenei IN.
Ca factori de risc intrinseci cu semnificaie epidemiologic enumerm: vrsta, venitul
mic, sub 1000 lei, obezitatea dar i altii nesemnificativi pentru studiul nostrum i:
fumat, consum de alcool, sexul masculin, accidentele casnice sau rutiere, lipsa
studiilor, comorbiditi sau alimentaie dezechilibrat. Dintre
factorii de risc
extrinseci cu semnificaie epidemiologic enumerm: durata lung de spitalizare,
antibioprofilaxia sau antibioterapie incorect i lipsa informrii pacientului (63%informai)., Factorii extrinseci cum ar fi starea de discomfort sau aglomerarea din
salon care s-au dovedit a fi nesemnificative n cercetarea noastr.
- Ierarhizarea factorilor de risc i identificarea celor de protecie au o mare importan
n practica curent a specialitilor chirurgicale.. Vrsta extrem cu riscul relativ de
11,78, urmat de factorul venit mic cu RR de 10,36 i obezitatea cu RR 6,56 au fost
40
identificai cu cel mai mare impact i semnificative statistic. Este dovedit de cercetarea
noastr i faptul c igiena corect a minilor precum i informarea pacientului cu privire
la modul de transmitere a infeciilor nosocomiale crete gradul de satisfacie a pacientului
devin factori de protecie n controlul nosocomialitii (RR de 4,4).
-
Pentru prima dat n istoria spitalului, s-a incercat o msurare a satisfaciei calitii
vieii pacientului ortopedic care are i infecie nosocomial. Nu am gsit n literatura
de specialitate referitoare la aceast problematic. De aceea am modificat un model
de chestionar MOS-SF36, pentru pacientul ortopedic i am adugat i civa itemi
cu referire la cunotinele bolnavilor despre IN, alturi de intrebrile EQ-5D i EQ-
VAS cu referire la calitatea vieii.
S-au obinut noi date despre nevoile i gradul de satisfacie al pacienilor cu infecii
nosocomiale. Media strii de sntate a pacientului ortopedic este de 66,42 ceea ce
denot o stare alterat, iar a celor cu IN este de 57,85, o stare mult sub nivelul mediei
lotului studiat.
Studiind atent
deprinderile personalului medical am identificat lipsurile n
implementarea protocoalelor de bune practice. Un exemplu chiar dac 95% purtau
mnui doar 60% se splau pe mini i doar 7% se splau dup fiecare pacient.
-
Din analiza Grilei de apreciere a gradului de risc n apariia infeciilor nosocomiale
s-a constatat c pe Harta seciilor cu risc,Secia Clinic de Ortopedie se afl n zona
galben, zon cu risc mediu, cu un punctaj de 71, sub media spitalului, foarte aproape
de zona roie , cu risc maxim (sub 70 puncte).
Ca concluzie final infeciile nosocomiale se constituie ntr o surs important de
cheltuieli i de efort pentru pacient i pentru sistemul medical, o cauz major de
cretere a morbiditii, a mortalitii i a ratei de reinternare n spital, afectnd n mod
serios i calitatea
vieii pacientului cu risc nosocomial. Reducerea riscului de
nosocomialitate, prin implicarea real a ntregului personal al spitalului n combaterea
acestora constituie un obiectiv major al managementului calitii serviciilor medicale.
41
V. Contribuii originale. Direcii viitoare de cercetare.
1. Contribuii personale i originale
In prezenta Tez de doctorat
ne am propus i am realizat tratarea
nosocomialitii nregistrat n Secia Clinic de Ortopedie a Spitalului Clinic Judeean de
Urgen Braov din multiple perspective: medical chirurgical, microbiologic, financiar
contabil, administrativ
i nu n ultimul rnd social, demonstrnd pe parcursul
prezentei lucrri c numai cunoaterea n amnunime a riscurilor corelate permite
controlul nosocomialitii ntr-o unitate sanitar.
-
Pentru prima dat n istoria spitalului, s-a incercat o msurare a satisfaciei
pacientului ortopedic cu infecie nosocomial. Negsind n literatura de specialitate
date referitoare la aceast problematic am modificat un model de chestionar MOSSF36, pentru pacientul
ortopedic i am adugat
i civa itemi cu referire la
cunotinele bolnavilor despre IN, alturi de intrebrile EQ-5D i EQ-
VAS cu referire la calitatea vieii.
2. Contribuii cu caracter de sintez
Legat de coninutul tiinific:
-
n baza unui complex de date clinice, epidemiologice i i socioeconomice s-a efectuat
o analiz amnunit a rezultatelor pe un lot reprezentativ de pacieni cu afeciuni
ortopedice i infecii nosocomiale n Secia Clinic de Ortopedie a Spitalului Clinic
Judeean de Urgen Brasov.
S-a identificat prin depistare activ i studiu retrospectiv cazurile de infecii
nosocomiale nregistrate n perioada 2011- 2013 n Secia Clinic de Ortopedie.
S-au identificat germenii circulani cu potenial nosocomial.
S-a analizat gradul de rezisten al florei circulante.
S-a analizat practica administrrii antiobioprofilaxiei preoperator.
S-a analizat practica antibioterapiei conform profilului bacteriologic al Seciei Clinice
de Ortopedie.
S-au calculat costurile antibioticelor prescrise i utilizate n Secia Clinic de
Ortopedie.
42
S-au calculat costurile suplimentare ale spitalizrii pacienilor cu infecii
intraspitaliceti n aceast secie.
S-au identificat antisepticele i dezinfectanii cei mai eficieni n controlul mediului
de spital i al igienei personalului.
S-au obinut date despre gradul de satisfaciei al pacienilor ortopedici cu infecii
nosocomiale a cror concluzii se vor utiliza n practica curent.
3. Contribuii cu caracter teoretic i experimental:
Am realizat un studiu longitudinal, analitic, de cohort, cu caracter retrospectiv,
prin care am pus n eviden aspecte din nosocomialitatea de pe secia de ortopedie,
corelate cu factorii de risc apoi am realizat un studiu observaional, transversal, de
prevalen pentru studiul calitatii vieii pacientului.
-
Am analizat germenii circulani pe spital versus secia de ortopedie, antibiorezistena,
am realizat o analiz SWOT al seciei i impactul asupra costurilor directe i indirecte
induse de infeciile nosocomiale, am abordat factorii de risc intrinseci i extrinseci
pentru nosocomialitate, am evaluat gradul de risc pe spital versus secia de ortopedie
i am analizat satisfacia pacientului de pe ortopedie
4. Contribuii cu caracter tiinific curricular:
-
Analiza stadiului actual al cercetrilor de la nivel naional i internaional referitoare
la infeciile nosocomiale.
Elaborarea rapoartelor de cercetare tiinific din cadrul programului de cercetare la doctorat.
- Finalizarea Tezei de doctorat.
5. Noutatea tezei de doctorat:
ideea unui studiu care s identifice nevoile pacientului ortopedic i cu infecie
nosocomial i ceva inedit, aprecierea cunotinelor acestuia despre infecia
nosocomial.
multitudinea itemilor utilizai n cercetare
aplicabilitatea practic a concluziilor n asistena spitaliceasc de specialitate
6. Valorificarea i diseminarea rezultatelor cercetrii n mediul academic tiinific:
publicare de articole in publicaii acreditate CNCSIS
realizarea rapoartelor de cercetare tiinific din cadrul programului de pregtire
tiinific.
43
finalizarea tezei de doctorat.
6. Direcii viitoare de cercetare:
impactul anumitor tipuri de dezinfectani utili n controlul
infeciilor
nosocomiale- studii de caz
corelaii clinico-epidemiologice ntre educaia/informaia pacientului i incidena
infeciilor nosocomiale
Teza conine:
187 pagini, din care 140 pagini (75%) contribuii personale.
45 grafice.
62 tabele
5 figuri
Bibliografia conine 247 titluri.
44
VI. BIBLIOGRAFIE SELECTIV
1. Angelescu M., Alexandru C. Infeciile nosocomiale- Infeciile nosocomiale
postoperatorii; antibioprofilaxia n chirurgia general, Viaa Medical, nr.9/26
feb., 2000, pag 2-3.
2. Zulian C, Descamps P, Samyn B et al (1999) Inquiry into the incidence of
nosocomi al infections and evaluation of the transmission of methicillin-resistant
Staphylococcus aureus in an orthopedic surgical unit. Pathol Biol 47:445448
3. Mihalache, D., Azoici, D., Mihalache, C., C., Infeciile nosocomiale, Editura
U.M.F. [Link], Iai, 2004.
4. Angus DC, Carlet J, 2002 Brussels Roundtable Participants: Surviving intensive
care: a report from the 2002 Brussels Roundtable.
5. Azoici, D., Ancheta epidemiologic n practica medical, Editura Polirom, Iai,
1998.
6. Bocan, I., S., Epidemiologie practic pentru medicii de familie, Editura Medical
a Universitii Iuliu Haieganu, Cluj-Napoca, 1997.
7. Popescu, I., Dinu, A., Tratat de chirurgie, volumul X - Ortopedie-Traumatologie,
Editura Academiei Romne, Bucureti, 2009.
8. Edwards J., R., Peterson, K., D., Andrus, M., L., Dudeck, M., A., Pollock, D., A.,
Horan, T., C., National Healthcare Safety Network (NHSN) Report, data
summary for 2006 through 2007, American Journal of Infection Control, Iunie
2008, Vol. 36, Nr. 9, Pag. 609-626.
9. Peltier, Leonard F. (1993). Orthopedics: a History and Iconography. San
Francisco: Norman Publishing. pp. 2123. ISBN 978-0-930405-47-2.
10. Geubbels EL, Nagelkerke NJ, Mintjes-De Groot AJ, et al. Reduced risk of
surgical site infections through surveillance in a network. Int J Qual Health
Care. 2006;18:127133. [PubMed]
11. Ghidul de management al infeciilor nosocomiale, sub coordonarea Azoici,
D.,Editura SRL Art , Bucureti 2011
12. Horan, T., C., Gaynes, R., P., Surveillance of nosocomial infections. Appendix A:
CDC definitions of nosocomial infections. Hospital Epidemiology and Infection
Control, Editura Lippincot Williams and Wilkins, Philadelphia, 2004.
13. World Health Organization. Report on infectious diseases, 2000. Overcoming
antimicrobial resistance. World Health Organization. Geneva, 2000; http://
[Link] /infectious disease - report-2000.
14. Iigo, J., J., Bermejo, B., Oronoz, B., Herrera, J., Tarifa, A., Prez, F., Miranda,
C., Lera, J., M., Surgical site infection in general surgery: 5-year analysis and
assessment of the National Nosocomial Infection Surveillance (NNIS), Cirugia
espanola, Aprilie 2006, Vol. 79, Nr. 4, Pag. 199-201.
15. Oliveira, A., C., Martins, M., A., Martinho, G., H., Clemente, W., T., Lacerda, R.,
A., Comparative study of surgical wound infection diagnosed in-hospital and post
discharge, Revista de Saude Publica, Brasil, Decembrie 2002, Vol. 36, Nr. 6, Pag.
717-22.
16. Oncul O, Ulkur E, Acar A, Turhan V, Yeniz E, Karacaer Z, et al. Prospective
analysis of nosocomial infections in a burn care unit, Turkey. Indian J Med
Res. 2009;130(6):75864. [PubMed]
45
17. Zanetti G, Giardina R, Platt R. Intraoperative redosing of cefazolin and risk for
surgical site infection in cardiac surgery. Emerg Infect Dis. 2001;7(5):828831.
18. Zelenitsky SA, Ariano RE, Harding GK, et al. Antibiotic pharmacodynamics in
surgical prophylaxis: an association between intraoperative antibiotic
concentrations and efficacy. Antimicrob Agents Chemother. 2002;46(9):3026
3030.
19. Irving M. Care of emergencies in the United Kingdom". Br Med J (Clin Res
Ed) 283 (6295):
847
[Link].1136/bmj.283.6295.847. PMC 1507078. PMID 6794724.
20. Arthur Rocyn Jones, F.R.C.S., London. "JONES, Sir ROBERT, Bart.". Welsh
Biography Online. Retrieved 2010-12-31.
21. Witte, W., Grimm, H., Occurrence of quinolone resistance in Staphylococcus
aureus from nosocomial infection, Epidemiology and Infection Journal,
Decembrie 1992, Vol 109, Nr. 3, Pag. 413421.
22. American Osteopathic Board of Orthopedic Surgery. "AOBOS 2012 Candidate
Handbook". 2012. Retrieved 19 September 2012.
23. Garrett, WE, et al. American Board of Orthopaedic Surgery Practice of the
Orthopedic Surgeon: Part-II, Certification Examination. The Journal of Bone and
Joint Surgery (American). 2006;88:660-667.
24. Weiss AJ, Elixhauser A. (March 2014). "Trends in Operating Room Procedures in
U.S. Hospitals, 20012011.". HCUP Statistical Brief #171. Rockville, MD:
Agency for Healthcare Research and Quality.
25. Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The
impact of surgical-site infections following orthopedic surgery at a community
hospital and a university hospital: adverse quality of life, excess length of stay,
and extra cost. Infect Control Hosp Epidemiol. 2002;23:1839. doi:
10.1086/502033. [PubMed][Cross Ref]
26. Wilcox M. H., Spencer R.C.- Hand- washing agents and nosocomial infections
(letter, comment)
27. Gaynes, R., P., Surveillance of nosocomial infections: a fundamental ingredient
for quality, Editura Williams and Wilkins, Baltimore, 1996.
46
ANEXE
Anexa 1 : GRIL DE APRECIERE A GRADULUI DE RISC DE APARIIE A IN
PE SECIE/SECTOR
OBIECTIV
Criterii
I. STAREA
PACIENTULUI
10%
Imunodeficiene
20
Boli metabolice,
malnutriie, comorbiditi
(diabet, boli neoplazice,
cardiovasculare etc.)
20
Zone de minim rezisten
induse patologic (plgi
deschise sau alte soluii de
continuitate)
20
Stri fiziologice cu
rezisten redus (vrste
naintate sau copii)
20
Contagiozitatea pacienilor
20
Total obiectiv:
II. SPECIFICUL
INTERVENIILO
R DIN SECIE
(SECTOR) 10%
47
Punctaj
alocat
100
Intervenii n urgen
(chirurgicale)
20
Manevre cu invazivitate
crescut
20
Asistai respirator
20
DA
NU
Parial
Punctaj
obinut
Cateterism venos
10
Terapie parenteral
10
Terapii care reduc
rezistena antiinfecioas a
organismului
20
Total obiectiv:
III. NORME
PRIVIND
ASIGURAREA
CONDIIILOR
GENERALE DE
IGIEN 20%
Calitatea apei corespunde
normelor n vigoare,
indiferent de surs
10
Exist rezervor de
acumulare care s asigure
o rezerv de consum de 13 zile, amplasat n circuitul
general
Fiecare salon, cabinet de
consultaie, sal de
tratamente are prevzut
un lavoar amplasat ct mai
aproape de intrarea n
ncpere
48
100
Exist ap cald curent
n regim permanent la
toate punctele de
distribuie
10
Starea cldirii
Finisajele sunt lavabile
Unghiurile dintre
pardoseal i perei sunt
concave
Se asigur o bun
ventilaie, fie prin sisteme
mecanice, fie prin aerisire
Colectarea separat a
deeurilor la locul de
producere
Spaiu amenajat pentru
depozitarea temporar a
deeurilor
Asigurarea cu materiale de
curenie
10
Asigurarea cu materiale
pentru igiena personal i
a minilor
10
Produsele biocide utilizate
sunt notificate i avizate
Se respect concentraiile
i modul de utilizare a
biocidelor
Exist plan DDD
Se respect planul DDD
Total obiectiv:
[Link]
A
FUNCIONAL
GENERAL A
SECIEI
(SECTORULUI)
20%
49
Se urmresc elementele
legiferate n Ordinul MSP
nr. 914/2006 privind
capacitatea spaiilor de
cazare a pacienilor,
ariile utile/pat, nr.
grupuri sanitare, dotri
minime obligatorii, spaii
anexe, spaiu izolator
5
100
etc.
Total obiectiv:
IV.
ASIGURAREA
MATERIALULUI
STERIL
NECESAR 5%
Exist spaiu separat
pentru sterilizare
20
Aparatur de sterilizare
autorizat
10
Exist instruciuni de lucru
specifice aparatului de
sterilizare afiate
Pregtirea preliminar a
instrumentarului
20
Caietul de sterilizare este
completat dup fiecare
arja de sterilizare
Exist teste de autocontrol
al sterilizrii
15
Se face etichetarea
truselor i verificarea
sterilitii
10
Se face verificarea
periodic a aparatului de
sterilizare
10
Existena unui registru n
care s fie notate
verificrile tehnice
Total obiectiv:
50
100
100
VI. CIRCUITELE - pacient
FUNCIONALE
- instrumentar
ALE
steril/nesteril
SECIEI/SECTO
RULUI 10%
- alimente
51
20
20
- deeuri
20
- personal
10
100
Se respect normativele n
vigoare cu privire la
personalul angajat
10
Exist fie-post pentru
ntreg personalul
10
Personalul are calificarea
necesar ndeplinirii
atribuiilor din fia postului
20
Personalul are control
medical periodic efectuat*
20
Asigurarea cu echipament
de protecie adecvat
20
Respect precauiunile
universale de protecie
20
Total obiectiv:
VIII.
AUTOCONTROL
UL 10%
20
- lenjerie curat/murdar
Total obiectiv:
VII.
PERSONALUL
CE
DESERVETE
SECIA/SECTO
RUL 5%
10
100
Teste de sanitaie sub
10% necorespunztoare
20
Teste de verificare a
sterilitii materialelor sub
20
10% necorespunztoare
Teste de aeromicroflor
sub 10%
necorespunztoare
20
Existena a sub 5%
purttori sntoi n rndul
personalului
20
Selectarea de tulpini cu
nalt potenial de
patogenitate (rezisten
multipl la antibiotice
i/sau antiseptice)
20
Total obiectiv:
100
Buctrie, oficii
alimentare, depozite
alimente
IX. SERVICII
GOSPODRETI
5%
52
- recepia i depozitarea
produselor alimentare
neprelucrate
- spaii pentru prelucrri
primare
- spaii pentru prelucrri
finale
- spaiu pentru depozitarea
alimentelor pentru o zi
(depozit de o zi )
- oficiu de distribuie
- vestiar cu grup sanitar i
du, separate pe sexe,
lng accesul personalului
Externalizare - se
puncteaz ca total
"bucatarie" 54 de puncte
Frigider pentru probe
alimentare
Triajul epidemiologic zilnic
al personalului
Spltoria
- camer pentru primirea i
trierea rufelor murdare
- spaiu pentru dezinfecia
rufelor prevzut cu czi
pentru nmuiere n
dezinfectant
- spltoria propriu-zis
- spaii pentru usctorie i
clctorie
- ncpere pentru
repararea rufelor
- depozit de rufe curate
- camer de eliberare a
rufelor curate
- vestiar cu grup sanitar i
du
Serviciu externalizat - se
puncteaz ca total
"spltorie" 40 de puncte
53
Servicii anexe pentru
personal i pacieni
- garderob pacieni
10
- vestiare pentru
personalul medical i
tehnic
10
Total obiectiv:
X. ALTE
CERINE 5%
100
Exist protocoale de
igien, sterilizare i de
utilizare a substanelor
dezinfectante afiate
25
25
Exist dotarea necesar
cu aparatur i materiale
sanitare
25
25
Exist frigidere cu
congelator suficiente pe
fiecare secie
25
10
Exist termometru i
termogram la frigidere
25
10
Total obiectiv:
100
TOTAL GENERAL:
GRAD DE RISC CALCULAT:
FORMULA DE CALCUL:
Suma obinut pe fiecare obiectiv x % de obiectiv = Total obiectiv
Exemplu: Pentru obiectivul X: 25 + 25+10+10 = 70 x 5% = 3,5
puncte
54
TOTAL GENERAL = suma totalurilor celor 10 obiective
ANEXA nr. 2
Model chestionar
Calitatea vieii este un concept, conform OMS, prin care se nelege
bunstarea fizic, psihic i social, precum i capacitatea pacienilor de a-i
ndeplini sarcinile obinuite, n existena lor cotidian.
V rugm s avei amabilitatea de a rspunde ntrebrilor acestui chestionar
punnd X n dreptul rspunsului care vi se potrivete sau s menionai prerea
dumneavoastr la ntrebrile deschise.
Chestionarul nu conine informaii confideniale despre persoana d-voastr
i nu va fi semnat.
Dorim prin acest studiu s nelegem care sunt nevoile bolnavilor internai
pe secia de Ortopedie a Spitalului Clinic Judeean de Urgen Braov n vedeerea
mbuntirii permanente a calitii serviciilor acordate pacienilor nostri.
1. Vrst:
2. Sex:
F
B
3. Domiciliu: urban
rural
4. Salariat : da nu
5. Studii: superioare liceul 8 clase 4 clase
6. Starea civil: cstorit() divorat() vduv()
7. Venitul dumneavoastr este de: - 0- 500 ron
- 500 1000 ron
-1000 1500 ron
- peste 1500 ron
55
necasatorit()
8. Venitul familiei dumneavoastr pe cap de membru este de:
- 0- 500 ron
- 500 1000 ron
- 1000 1500 ron
- peste 1500 ron
9. Fumai ? da nu
10. Consumai alcool frecvent? da nu
11. Avei o alimentaie echilibrat? da nu
12. Suntei:
obez
supraponderal cu greutate normal
13. Ce boli avei
..
14. Cauza spitalizrii actuale: - accident de munc/ accident domestic
- alte boli cornice sau acute
15. Ct timp a trecut de la internare: ..
16. Avei durere sau discomfort? nu
uneori
permanent
17. Avei probleme cu mobilitatea? - nu am probleme in a ma deplasa
- am unele probleme
- sunt obligat () s stau n pat
18. Suntei deprimat () / nelinitit() ?deloc uneori extrem de
deprimat()
19. Dac cea mai bun stare este notat cu 100 i cea mai rea stare de sntate
cu 0, starea dumneavoastr este: ..
20. Avei complicaii la boala dumneavoastr ortopedic? da nu
21. Dac ai rspuns cu da, ce fel de complicaii? infecioase altele
22. Dac avei complicaii infecioase, cu ce germene(microb) ?
- nu tiu
23. Dac avei complicaii infecioase, acestea sunt: - din spital
- din afara spitalului
24. Ce v supr cel mai tare? durerea imobilitatea atitudinea
personalului condiiile hoteliere din spital lipsa medicamentelor
25. Ce nevoi avei n spital i nu v sunt oferite?.....................................
26. Suntei mulumit() de dotrile seciei de ortopedie? da nu
27. Ci bolnavi sunt n salon cu dumneavoastr?..................
56
28. Suntei mulumit() de profesionalismul: - medicilor ? da nu
- asistentelor? da nu
- infirmierelor? da nu
29. Suntei mulumit() de: - curenia din spital? da nu
- hrana din spital? da nu
30. Ai fost instruit() de personal s v splai pe mini ori de cte ori este
nevoie, nainte i dup mas i dup folosirea toaletei?
da nu
31. Ai observat ct de des se spal personalul pe mini n prezena
dumneavoastr?
- nainte de fiecare pacient
- dup fiecare manevr la acelai pacient
- omite splatul pe mini dese ori
32. La pansat personalul a folosit:
- mnui da nu
- a schimbat mnua n prezena dumneavoastr da nu
- s-a splat pe mini n prezena dumneavoastr da nu
33. tii ce sunt infeciile nosocomiale (intraspitaliceti) ?
da nu
34. Incercai o definiie a infeciilor nosocomiale cu cuvintele dumneavoastr:
....
35. Cum credei c pot fi evitate infeciile nosocomiale pe secia de ortopedie?
36. Ai primit antibiotice nainte de intervenia chirurgical? da nu
37. Dac ai rspuns cu da, precizai ct timp:1 doz 3 zile 5 zile 7 zile
38. Dac ai rspuns cu da, precizai care a fost antibioticul
- nu stiu
39. Dup intervenie ai primit imediat antibiotic?
da nu
40. Dac ai rspuns cu da, precizai ct timp: 1 zi 3 zile 5 zile 7
zile peste 10 zile
41. Dac ai rspuns cu da, precizai care a fost antibioticul
- nu stiu
42. Ai avut pe parcursul internrii vreun semn de infecie cu care nu ai
venit la spital ci le-ai dobndit ulterior (roea, edem, durere sau supuraia
plgii chirurgicale, febr, tuse cu febr, urinare frecvent cu durere) ?
da nu
57
43. Ce considerai c nu au facut i ar putea s fac membrii echipei
de pe oropedie pentru dumneavoastr?
..
V mulumim pentru colaborare!
Anexa 3:
Formular de consimmnt informat
Stimate pacient,
n cadrul doctoratului desfurat la Universitatea Transilvania din Braov
doresc s elaborez
teza
cu titlul Ierarhizarea factorilor de risc n
nosocomialitatea nregistrat n secia de Ortopedie a Spitalului Clinic Judeean de
Urgen Braov.
Considerm c suntei n msur de a oferi informaii, impresii i opinii
privind acest subiect datorit experinei dumneavoastr n ceea ce privete boala
i nevoile care apar odat cu ea.
Participarea la acest studiu este voluntar i prerile dumneavoastr legate
de subiect vor rmne anonime, astfel nct persoana care v-a interpreta
rezultatele nu v-a avea acces la numele participanilor. Confidenialitatea este
obligatorie pentru toi pacienii care vor rspunde la chestionar.
Acest studiu ncearc s identifice nevoile pacienilor i s gseasc soluii
viabile, diferite activiti i mijloace ce duc la scderea incidenei infeciilor
nosocomiale, pe care s le implementeze n cadrul seciei de ortopedie.
Va multumim pentru nelegere i colaborare!
58
INTRODUCTION
Actuality of the theme
Nosocomial infections represent an important chapter in infectious
pathology that knows a continuous development as an expression of the diversity
of practices for the healthy and sick people.
This paper starts from the assumption that the prevalence of nosocomial
infections is one of the indicators of quality of hospital care, which allows with
greater objectivity the evaluation of the homogeneity of control form over intrinsic
and extrinsic risk factors, facilitating further adoption and evaluation of strategies
intended for reducing them.
Nosocomial infections cause additional permanent costs: both indirect costs
barely supported by patients and their families as well as direct costs covered by
the health system by increasing the number of hospital days, additional therapies,
and diversified care. It is also not negligible the increase resistance to germs and a
large number of deaths.
During my work as an orthopedic surgeon (over 2,500 cases operated) I
noticed the multidisciplinary hospital-acquired infections impact, both clinical and
socio-economic, which led to this research. This not only addresses the issue from
this perspective but also in terms of intrinsic and extrinsic risk factors of
nosocomial infections correlated with patient satisfaction that is hospitalized in
the orthopedic ward of County Clinic Emergency Hospital of Brasov.
I was incited by the poverty of data from the literature regarding patient
satisfaction; thus the idea of a study to identify the patients needs and knowledge
about nosocomial infection and the risk of their occurrence after hospitalization.
59
The significance of the scientific work
-
On the basis of a complex set of clinical, epidemiological and socio-economical data
a thorough analysis of the results was conducted on a representative group of patients
with orthopedic disorders.
For the first time a comparative study was carried out regarding the quality of life for
the orthopedic patients with and without nosocomial infection.
The risk and the protective factors involved in nosocomial infections were identified,
their hierarchy also being carried out.
The impact of intrinsic and extrinsic risk factors on the incidence of nosocomial
infections was evaluated.
The strains from the orthopedic ward with nosocomial potential were identified and
characterized.
The extra cost due to nosocomial infections from the orthopedic ward was calculated:
hospitalization, diagnostic investigations, treatments, including the antimicrobial one.
The disinfectants with the highest antimicrobial efficiency used in the hospital were
identified.
For the first time in the hospital history, it was tried to measure the patients
satisfaction hospitalized in an orthopedic unit, suffering a nosocomial infection. We
did not find in the literature any standard questionnaire regarding this theme, so we
modified a MOS-SF36 questionnaire and added a few items characteristic for
orthopedic patients with reference to patients knowledge about nosocomial
infections, with questions referring to quality of life (EQ-5D and EQ-VAS).
The criteria for prophylactic and therapeutic use of antibiotics were analyzed
according to bacteriological profile of the orthopedic unit.
The establish of infectious risk of the orthopedic ward by analyzing the scores
obtained by filling the Risk Grid and the Risk Map of nosocomial infections of the
hospital.
I express my gratitude to Mrs. Professor Codrua Nemet for the generosity to give
me a chance to research a major topic of quality management of the hospital, honoring
me, at the same time as the scientific coordinator. Last but not least, I thank to the staff of
the Department of Prevention and Control of Nosocomial Infections (CPCIN), to
60
collaborators and to the entire team from County Clinic Emergency Hospital of Brasov,
for their support throughout the entire period of doctoral studies.
PART I - GENERAL
I.1. MEDICAL LITERATURE REVIEW
1. 1 A brief history of orthopedics
Although the orthopedics history goes back to the fifth century BC, to the wellknown Hippocrates, who referred in his writings techniques of traction and types of
splints for immobilization in order to treat fractures, the word "orthopedics" is mentioned
only in the eighteenth century.
1.2. Updates in the field of nosocomial infections
The European Commission proposes for control of the hospital-acquired
infections (nosocomial infections) a set of tools for implementing effective measures to
prevent healthcare associated infections. The European Commission funded a network of
surveillance of nosocomial infections, currently under the coordination of the European
Centre for Disease Prevention and Control (ECDC).(9)
1.3. Historical aspects of nosocomial infections
Researching the history of universal medicine, the existence of observations stands
out, indirectly indicating the interest for the risk of infections since antiquity (Susruta,
Parcacelsus, and Hippocrates). Along with the development of science and the
advancement of medicine, concepts and rules on how to prevent or treat nosocomial
infections appear (Teodoric 1266; Gerolamo Francastaro 1488-1533; Ambroise Pare 1517-1590; [Link] -1834; Lemaire, Declat, Maisonneveuve- 1860; Pirigov -18511861; Ignaz Phillip Semmeleweis 1847-1848; L. Pasteur, J. Janbert, Ch. Chamberland
1878; Ch. Roux, Sedillot; Duclaux 1978; R. Koch 1879; J. Lister 1827 1912;
Alexander Fleming 1929; Gerard Domagk 1932 etc.).(9)
In 1744 in Romania, the first instructions are developed regarding the functioning
of the lazar houses, the isolation of the contagious patients, the compliance with aseptic
61
and the antiseptic rules, pointing out the involvement of prestigious personalities of the
time ([Link] 1877; V. Babe - 1985-1926; I. Cantacuzino 1896-1936 etc.).(10,11)
1.4. The etiology of nosocomial infections
Causative agents of hospital-acquired infections are very different and may have
different origins, both endogenous as autoinfection, the source being the patient himself
and exogenous, through various ways and means of transmission. Among pathogenic
bacteria involved in the etiology of nosocomial infections can be included:
Staphilococcus aureus, Streptococcus pnuemoniae, Streptococcus fecalis, Streptococcus
agalactiae, Escherichia coli, Klebsiella, Enterobacter, Acinetobacter, Serratia, Proteus,
Pseudomonas aeruginosa, Bacteroides fragilis, Legionella pneumophilla. To the
pathogenic bacteria are added in a significant proportion, highly pathogenic bacteria:
Salmonella, Shigella, Neisseria meningitidis, Escherichia coli (enteropathogenic
serotypes on the infant), Pseudomonas pseudomallei, Streptococcus pyogenes,
Mycobacterium tuberculosis, and Clostridium dificille. (12).
1.7. Epidemiology of nosocomial infections
The epidemiological, clinical and etiological polymorphism of nosocomial
infections is due to risk factors, behavioral or socio-economic factors and explains the so
complex epidemiological process from this pathology. It particularly consists on
population groups formed under special circumstances regarding the disease severity,
addressability and accessibility to certain specialists or technical equipment. The
manifestations of the epidemiological process in nosocomial infections are not that
obvious and individualized as those in transmissible diseases registered among the
general population. Blurring or "masking" because of the underlying diseases
(communicable or non-communicable) and of the particular conditions required by the
medical practices or by the attitude of the staff involved in patient care makes it difficult
to highlight the epidemiological phenomenon. Atypical manifestations of the
epidemiological process depend on the nature of colonization with pathogens and on the
intensity of their dispersion in the environment. (13,14)
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1.8. Postoperative nosocomial infections
In this category it stands out surgical site nosocomial infections and those that are
away from surgical site (urinary, respiratory, catheter infections, bacteremia).
Surgical site infections can be installed within 30 days and one year after the
intervention. They represent 15% of all cases of nosocomial infections and have a
variable incidence by the type of surgery (4-5%), increasing significantly if the patient is
hospitalized in the intensive care unit (9%). Mortality is caused by direct or indirect
causes of surgical site infections and varies between 0.6 and 4.6%. The length of
hospitalization can be extended by more than 7 days related to the type of surgical site
infections. (15,16)
Extrinsic risk factors are dependent on the type of surgery, the length of
preoperative hospital stay, preoperative preparation methods (personal hygiene, types of
hair removal), intervention characteristics (type of operating fields, experience and size
of the team, solving the case in emergency).
Intrinsic risk factors have an important share in the risk assessment of surgical
site infections after patients characteristics (age, immunosuppression, diabetes, obesity),
prolonged treatment with antibiotics, the shock (17,18).
1.7. Surveillance and control of nosocomial infections
In 1992, WHO has developed a guide for the prevention and control of
nosocomial infections, indicating that reducing the risk of these infections in various
categories of medical units can be achieved by: daily cleaning, general decontamination
as frequent as possible, hand washing with water and soap, every time they are at risk of
being contaminated; aseptic maneuvers and manipulations for exploration and therapy;
pre- and post-operative care to prevent the risk of intervention of pathogenic agents;
optimal protection to collection, preservation, transportation and investigation of
pathological products, differentiated measures for each unit and job, to educate patients
and training of personnel of all categories. In the prevention of nosocomial infections a
particular place is occupied by the protection of high-risk groups of patients whose
antiinfective surveillance must be done at least twice a week. (19,20).
63
PART II - PERSONAL CONTRIBUTIONS
II.1. AIM AND OBJECTIVES
The aim - the implementation within the orthopedic ward of the activities and means
by which to realize the surveillance and control of nosocomial infections
The research objectives are:
-
Identifying new solutions to reduce the incidence of nosocomial infections while
increasing the satisfaction of orthopedic patients in the current underfunding of the
health system;
Identifying and ranking the intrinsic and extrinsic risk factors involved in nosocomial
infections and their influence on the quality of life of orthopedic patient;
Analyzing of the quality of life of orthopedic patients that also suffer from a
nosocomial infection;
Identifying the needs of orthopedic patients with nosocomial infection;
Indentifying the antibiotic prophylaxis and antibiotic therapy incorrectly applied;
Motivating the physicians to effectively declare the hospital acquired infections that
they actually treat;
Changing the legislation for this matter;
Improving the training of professionals from the orthopedic ward to implement
measures to prevent the infectious risk. Promotion and assessment of compliance with
standard precautions.
The complexity of the issues mentioned above justifies the objective of our study.
In this research I wanted to elucidate some hypotheses appeared and to discuss
issues related to: bacteriological profile of the orthopedic ward and the impact of the
disinfectants used with targeted action on hospital flora through the incidence of
64
nosocomial infections, the existence of epidemiological associations between hospital
acquired infections and various risk factors, the existence of associations of antibiotic
prophylaxis or incorrect antimicrobial treatment and the incidence of antibiotic resistant
infections.
II.2. MATERIAL AND METHODS
In the first part the descriptive study analyses the incidence of nosocomial infections,
the reported ones, but also the ones unreported after the retrospective review of patients
observations chats for various reasons (the fear of the physician of a possible sanction,
case definition too thick clinically, microbiologically and epidemiologically).
In the second part of the study we analyzed the importance of circulating flora in the
entire hospital versus the orthopedic ward, the implications of prescribing and the
prophylactic and therapeutic use of antibiotics, we conducted a SWOT analysis of the
ward and the impact on direct and indirect costs caused by nosocomial infections.
In the last part of the paper I approached the intrinsic and extrinsic risk factors
involved in nosocomial infections, I analyzed the Epidemiological Risk Map on hospital
versus the orthopedic ward. I also analyzed the orthopedic patient satisfaction through an
observational, transversal and prevalence study, applying a questionnaire specially
designed for this purpose.
2.1. THE UNIT OF ANALYSIS
The target population for the first part of the descriptive study is the inpatients
from the orthopedic ward during 01.01.2011 -31.12.2013, 2515 in 2011, 2609 in 2012
and 2427 in 2013, a total of 7551 patients.
In the first part of the research we have established from the study group the cases
with the diagnosis of nosocomial infection confirmed clinically, microbiologically and
epidemiologically. From the 7551 cases admitted to the orthopedic ward, 116 cases were
identified as possible nosocomial infections from the patients observation charts, of
65
these, only 15 nosocomial infections were found in CPCIN reports that are declared by
the treating physicians, the remaining 101 have not been officially reported.
Then, for a good knowledge of nosocomial infections problem we conducted a
SWOT analysis of the situation and in the third part of the research we evaluated the risk
degree from the orthopedic ward using a grid of infectious risk assessment. We
developed a questionnaire to measure the satisfaction of patients regarding the possible
infections as a result of inadequate medical practices performed on the orthopedic ward.
Additional data were collected from CPCIN reports used for analyzing wound
infections or other nosocomial infections, bacteriology department reports on microbial
resistance and circulating flora. For the years included in the study indicators have been
used from the Statistics Service of the Hospital, as well as data from Financial
Accounting Service, Administrative Service for the purchase and use of the antiseptics,
disinfectants, antibiotics, reagents.
The description of participant group on the transversal study regarding the
orthopedic patient satisfaction
Of the 7551 patients admitted during 01.01.2011-31.12.2013 in the orthopedic
ward, 225 subjects have been randomized to complete a thorough analysis of the situation
regarding the knowledge, the needs of the patients for infections acquired from medical
practices conducted in the orthopedic ward and clinical skills of medical staff; 120 of
them fulfilled all the criteria for inclusion in the study and answered our survey.
Inclusion criteria:
66
Inpatient in the orthopedic ward;
Patient consent for the questionnaire for assessing the quality of life;
Patient over 18 years, of sound mind;
Data collection was done according to the principles of medical ethics.
Exclusion criteria:
Patient under 18 years.
Mental illness.
Patient disagreement for the participation in research.
For the studied group the relation between genders was 52% men (62 cases) and
48% women (58 cases).
The age of patients ranged between 18 and 90 years with an average of 48.67
years; the average age for men was 45.43 years, 52.13 years for women respectively. The
age distribution of patients has relevance, highlighting the high frequency to active age
groups 18-65 years, high social yield. (chart no.1)
Chart no.1- Target population distribution by age
80% of respondents are from urban area. In the studied group only 48% are
employed, 50% are widowed, unmarried or divorced; only 19% of them have incomes
more than 1500 lei and 13% of respondents have between 0-500 lei per family member,
which shows a population extremely poor.
67
2.2. DATA REGISTER UNIT
Nosocomial infection diagnosis was based on case definition stipulated by the
Public Health Ministry Order no. 916/2006, declared and reported by the physician to the
SPCIN epidemiologist, according to the Order MS 916/2006 and to the Protocol 203
regarding the informational system for the declaration of nosocomial infections in County
Clinic Emergency Hospital of Brasov.
The quality of life was another key criteria examined in patients. Its evaluation
was made after a self-assessment quality of life scale in the orthopedic ward. We used a
questionnaire to identify the effects of endogenous and exogenous risk factors correlated
with nosocomial infections. We designed the questionnaire with logical and
psychological questions in relation to the research hypothesis - the existence of
epidemiological associations between hospital acquired infections and different risk
factors, the existence of consistency between antibiotic prophylaxis and incorrect
antibiotic therapy, which determines from the interviewed person a nonverbal behavior
that will be recorded in writing. The parts of the questionnaire are: one that relates to the
subject of the investigation itself; endogenous and exogenous risk factors for nosocomial
infection, another that allows knowledge of the social determinants of target population.
We used an introduction part in which we tried to "break the ice" and give the feeling of
confidence to the interviewed person, then we moved to the identification, sociodemographics data. Crossing questions were related to the way of life outside the
hospital, risk behaviors (smoking, alcohol, nutrition, comorbidities). We tried to measure
both patients and staffs risk behavior for nosocomial infection. Through the control
questions that do not bring new information we tried to verify the fidelity and constancy
of the opinion expressed. Estimation of the degree of impairment of quality of life was
made after our questionnaire with 43 questions and each participant received an
"informed consent form".
For infectious risk assessment we have drawn the risk map of the
epidemiological sectors " which scores the endogenous factors related to patients
immunity and exogenous factors related to the hospital environment, the correct skills of
staff, the existing spaces, the circuits. The risk may be determined after completing a grid
68
of appreciation. The grid includes objectives, major and minor criteria, scoring to achive
the objectives, criteria share, summing them materialized in a final score according to
that it will be determine the epidemiological risk: minimum: 90-100 points (green area),
average: 70-89 points (yellow area), maximum: score below 70 (red zone).
2.3. TYPE OF RESEARCH
This is a longitudinal, analytic, cohort, retrospective study; through which we
highlighted the aspects related to nosocomial infections registered in the orthopedic ward,
correlated with risk factors and patient quality of life. The aim was to study the impact of
nosocomial infection on quality of life, alteration of the health parameters to the 7551
patients studied, during 01.01.2011.-31.12.2013. Following this study some measures of
strength of association have resulted between the risk factor and effect, represented by
relative risk (as cohort studies) when studied variables (risk factor and effect) were
nominal dichotomous. If variables whose association were numerical measure the degree
of association was shown by the size of the correlation coefficient (r). The r values of 0.30.4, a weak correlation is estimated; at 0.5-0.7 values showed an average correlation and
a value of over 0.7 shows a high correlation. Outside the strength of association the study
measured the impact of the exposure through attributable risk.
To further verify the hypothesis of scientific research, for the certainty of
conclusions and establish whether there is a significant difference between the two
groups (exposed respectively unexposed) 2- test method was used for statistical
significance. The calculation result was compared to a 5% risk (probability 95%) with the
existing value in the chi-square table. We chose significance threshold = 0,05 and 2 and
1 degree of freedom, 2 value = 3.84, so in this case was the critical region interval
[3.84, ). 2 was calculated, the uncorrected value was obtained, and if it was greater
than 3.84 it was considered a situation in which the null hypothesis Ho was rejected with
a lower risk of 5%.
69
2.4. METHODS OF DATA PROCESSING
Documentary analysis was performed using the statistical data processing
programs such as Epi Info 2002, version 3.4.3. 2007 - November and Microsoft Excel.
II.2. RESULTS
3.1. History of nosocomial infections in County Clinic Emergency Hospital of
Brasov
incidence rate
The trend of the incidence of nosocomial infections
(2006-2013)
0,2
0,18
0,16
0,14
0,12
0,1
0,08
0,06
0,04
0,02
0
2006
2007
2008
2009
2010
2011
2012
nosocomial infections
incidence
0,081
0,062
0,107
0,041
0,058
0,08
0,1
2013
0,18
Chart no. 2 The trend of the incidence of nosocomial infections in County Clinic
Emergency Hospital of Brasov
From 2006 till today the incidence rate of nosocomial infections is trending
slightly upward, noted that for 2011-2013 the incidence of nosocomial infections
registered in County Clinic Emergency Hospital of Brasov has increased from 0.08% to
0.18%. (225 %).
The doubling of the incidence means a closer look on these events occurred in
County Clinic Emergency Hospital of Brasov and a greater interest of the clinician, of the
SPCIN department and of the laboratory in the diagnosis and declaration of nosocomial
infections.
70
In 2013 most nosocomial infections were surgical site type, followed by
bronchopneumonia and digestive infections with Clostridium dificille.
The incidence of nosocomial infections in the orthopedic ward registered a rising
trend over the period 2007-2013, from 0.1 in 2007 to 0.17 in 2013, following the trends
in hospital.
Chart no. 3 The incidence trend of nosocomial infections in the orthopedic ward
Only 15 (10%) from the 116 possible cases of nosocomial infections were
officially reported by the treating physicians, the remaining 101 being passive detected
by retrospective analysis of patients observation charts.
Table 1. The types of nosocomial infection on the orthopedic ward
Nosocomial infection
Frequency
Frequency
Frequency
2013
2012
2011
diagnosis Reported (R) or
29
22
28
unreported (UR)
deep
surgical
infection
71
wound
superficial
surgical
14
wound infection
septicemia
urinary infection
Total
29
30
42
3.3. Hospital environment History of the circulating flora in the County Clinic
Emergency Hospital of Brasov
In 2011 the highest share of isolated strains from hospital belongs to Escherichia
coli - 37%, followed by Staphylococcus aureus - 22% and Klebsiella -10%. For 2012, the
percentage drops to 33% for Escherichia coli, the share of circulating strains of
Enterococcus Klebsiella and Enterobacter reach 8% each.
In 2013 the share of Escherichia coli circulating strains remains the same - 32%,
Staphylococcus trend is downward compared to the previous year - 19%, while the share
of circulating strains of Klebsiella and Enterococ is upward 14% and 11% respectively.
3.4. Hospital environment - history of circulating strains in the orthopedic ward
In 2011 the largest share is registered by Staphylococcus aureus - 45%, followed
by Escherichia coli - 15%, Klebsiella, Enterococcus and Acinetobacter with 8% each.
In 2012, the share of Staphylococcus aureus remains unchanged - 45%,
Escherichia coli, Enterococcus and Klebsiella have also a stationary trend 15% and 9%.
The circulation of Acinetobacter is slightly descending to 11%.
In 2013, the circulation of Staphylococcus aureus intensifies to 48%, Escherichia
coli strains frequency drops to 11%. The strains circulation of Acinetobacter and
Enterococcus is stationary at 10%, the share of Klebsiella strains drops to 8%.
72
3.5. History of germs types isolated in hospital from the nosocomial infections
The share of Staphylococcus aureus infection is decreasing from 31% in 2011 to
29% in 2012 and 19% in 2013, due to ongoing staff awareness on the importance of hand
hygiene.
In 2011, 72% of nosocomial infections are Gram positive etiology: Stafilococcus
aureus, Enterococcus, Clostridium dificille, probably due to the carriage by colonization of
medical personnel and / or the patient (nose, throat, skin, and intestine) or dirty hands. 28% of
nosocomial infections are due to transmission of Gram negative germs through
contaminated environmental elements of the hospital: Proteus, Escherichia coli,
Acinetobacter, Klebsiella, and Pseudomonas.
In 2012 the etiology of nosocomial infections in the orthopedic ward radical
changes to flora Gram negative, incriminating the transmission of germs in the hospital
environment, through contaminated items and through medical practices with nosocomial
risk.
In 2013 nosocomial infections are due 50% to Gram negative and 50% to Gram
positive germs.
3.7. Correlations between circulating strains and germs from nosocomial infections
In our study we tried to identify the risk factors for nosocomial infections and to
measure the association between circulating strains and germs from nosocomial
infections both in the hospital and in the orthopedic ward. In 2013 the processed data
showed the correlation coefficient between the hospital flora and the germs isolated in
nosocomial infections of the entire unit of 0.158, which demonstrates a lack of
correlation.
If we measure the same association in the orthopedic ward we found an average
correlation of 0.5326, between circulating germs and those involved in nosocomial
infections.
73
Chart no. 4The share of the circulating strains versus the sare of the germs
involved in nosocomial infections in the orthopedic ward in 2013
3.8. SWOT analysis of the orthopedic ward
For the County Clinic Emergency Hospital of Braov, as a medical services
business unit, the main goal is the maximum satisfaction of the requirements and
expectations of patients and their families. Thus the orthopedic ward strives to live up to
expectations.
Table 2. SWOT analysis of the orthopedic ward
Strong points
- Professional, accredited medical
personnel.
- Medical services validated and
settled 100% by the National Health
Insurance House of Braov.
- Team capable to apply the
management tools to become the most
welcoming health unit in the city;
concerns focus on: achieving patient
satisfaction, continuous improvement
of staff.
74
Opportunities
- Continued medical education for
employees on nosocomial infections.
- Percentage (5%) used from hospital
and ward budget for disinfectants, antiseptics
and disposable materials.
- To reduce staff costs and reduce
risks of contamination some services have
been outsourced: preparing food for
patients and laundry.
- Increase the value of the contract with
the National Health Insurance House of
Braov through additional acts for services
- 100% addressability of the
people from the county and 30% from
the people in the counties of Covasna
and Harghita.
Weak points
- Insufficient medical personnel;
- Functioning of the hospital SPCIN
with only 3 people, 1 doctor and 2 infection
control nurses;
- Minimal equipment with antiseptic
dispenser on the ward and paper towels in
sufficient quantity for both staff and
patients.
- Lack of toilets in each ward.
performed in the orthopedic ward (prostheses)
and increasing complexity of the DRG point.
Ameninri
- The appearance of new competitors in
the market (private hospitals);
- Insufficient healthcare staff can create
malpraxis situations;
- Insufficient equipment can lead to
patient and healthcare staff dissatisfaction.
- Lack of compliance regarding
the ward area and number of beds
admitted, according to Order no.
914/2007. There are wards with 8 beds.
- There are no sufficient
household services spaces according to
Order no. 914/2007 (missing the
storage areas for cleaning material, they
currently occupy a shower of patients).
- There is no temporary storage
of hazardous and household waste
separate on the ward according to Order
no. 1226/2012; it is improperly stored
in a locked cabinet on the fire escape.
- There are no two separate
treatment rooms, for septic and aseptic.
3.9. Direct costs correlated with nosocomial infections from the hospital
The costs induced by the care provided in cases of nosocomial infections can
significantly influence the progress of the entire health system management not only for
the orthopedic ward.
The average total cost of hospitalization of patients with nosocomial infections
was in 2011 19 537.54 lei, and in 2012 it increased by 500 lei reaching 20084 lei. The
average cost of hospitalization due to strict nosocomial infections in 2011 was 6326.42
75
lei, almost double the amount in 2012, 11958.47 lei. In 2011 the average costs for
antibiotics in patients with reported nosocomial infections was 1,056.6 lei / patient, in
2012 the average increased by 200 lei / patient.
In 2013 the average total cost of hospitalization in patients with nosocomial
infections was 14655 lei, a downward trend even lower than in 2011. The average cost of
hospitalization due to strict nosocomial infections was 6939.7 lei, a downward trend. The
average costs for antibiotics in patients with reported nosocomial infections was 609 lei /
patient with nosocomial infection, a downward trend, which shows the success of
awareness of the physicians about the risks of chaotic or incorrect antibiotic prophylaxis
or antibiotic therapy.
3.10. The direct costs of nosocomial infections in the orthopedic ward
In 2011 the cases of reported nosocomial infection in the orthopedic ward had the
average cost of hospitalization of 26200 lei, a value more than the average costs of the
entire hospital (19,537 lei), which shows that the orthopedic patient with postoperative
nosocomial infection consumes much more than another patient with nosocomial
infection. The same upward trend was for the consumption of antibiotics. In 2012 and
2013 the average cost of hospitalization for the cases with nosocomial infection is much
lower compared to 2011 and compared to the hospital. The same downward trend was
registered for the consumption of antibiotics.
3.11. Indirect costs compared to hospital and to orthopedic ward between 2011-2013
In 2011 in the orthopedic ward in patients with nosocomial infections, the average
total days of hospitalization was 73 days more than the one recorded in the hospital (35
days). In the orthopedic ward the average days of hospitalization due to strict nosocomial
infections is 10 days. In 2012, in orthopedic ward the average total days of hospitalization
was 70.4 days, similar to 2011. The average days of hospitalization due to strict
nosocomial infections was 12.5 days, an upward trend compared to 2011. In 2013 the
average total days of hospitalization was 55.15 days, a downward trend compared to
2011 and 2012, but well above hospital average -26.6 days. The average of days due to
strict nosocomial infections in the orthopedic ward was 15.71 days, an average over the
76
value of the hospital and an increasing trend towards 2011, 2012, although the number of
infections decreased. Once again it confirms that the care of the orthopedic patient with
nosocomial infection is more expensive than the care to other patient with nosocomial
infection of the hospital wards.
3.12. Costs of supply with disinfectants in the orthopedic ward between 2011-2013
According to the data from the Hospital Acquisitions Service the monthly budget
allocated to orthopedic ward, for example for the supply of disinfectants is in 2011 30000 lei, in 2012- 35000 lei, and in 2013- 40000 lei. These sums are insufficient for the
amount that is actually required and is according to Procurement Plan. It is purchased
about 60% of the surfaces disinfectants and 20% of antiseptics from what is needed.
3.13. The history of antibiotics costs in the hospital between 2011- 2013
In 2011 the costs of antibiotics used in the entire hospital amounted 972993.13
lei, with a high consumption of Oframax, Ampicillin and Gentamicin.
In 2012 the total consumption of antibiotics in the hospital is 823,322.16 lei, with
a high consumption of Oframax, a third-generation cephalosporin, with broad spectrum
and very quickly induces resistance, but it is the cheapest on the market, highly sought in
public hospitals.
In 2013 the total cost of antibiotics reaches 945,425.65 lei, keeping Oframax
consumption at high level. Our study reveals that in the entire hospital as well as in the
orthopedic ward third generation cephalosporins are overused and overprescribed as well
as large amounts of Oxacillin and Gentamicin, both prophylactically and therapeutically,
although the strains circulating in the hospital and the ones isolated from nosocomial
infections are resistant to these antibiotics.
3. 15. The history of antibiotics expenses on the orthopedic ward
In 2011 on the orthopedic ward, the total amount of antibiotics prescribed and
used was 109,119.71 lei in 2308 patients, with an average of 47.27 lei / patient with
antiinfective therapy. The total amount was 38606 units. In 2012 the total costs of
antibiotics was 81,319.34 lei in 2343 patients, with an average of 34.7 lei / patient with
77
antiinfective therapy. The total amount was 32151 units. The trend for the amount spent
on antibiotics is downwards and the number of patients was approximately the same.
In 2013 the total cost increased slightly at 83,381.26 lei, in 2221 patients, the
average was 37.5 lei / patient with antibiotic treatment. The total amount was 26,564
units. The trend is increasing compared with 2012. Although the number of patients
treated decreased the costs with antibiotics use increased.
Our study highlights the poverty range of antibiotics used in 2011 indicating
modest financial resources. In 2012 and 2013 the antibiotics range used is more varied,
but we note very high costs of Targocid, a very expensive antibiotic
3.16. Antibiotic resistance for the Staphylococcus aures
Our study demonstrates the great strength of staph strains circulating in Clinic
County Emergency Hospital of Brasov. 28% are MRSA, 50% are resistant to
Erythromycin and 43% to Clindamycin.
Chart no. 5 Microbial resistance for the Staphylococcus aureus
78
3.17. Intrinsic risk factors
The literature states that extreme ages are endogenous risk factors for nosocomial
infections. As mentioned in the methodology, in the sample description, the respondent
population is a socially active one; the average age of the lot is 48.7 years, minimum 18
years and maximum 90 years. The average age of those with nosocomial infection is 57.7
years (minimum 47, maximum 80 years).
Regarding the impact of the age over 65 years on nosocomial infection, for the
confidence interval of 95%, the relative risk (RR) is 11.78 (2.48 <RR <56.8), Chi-square
statistic is 14.9738. P value is 0.001. This result is statistically significant. The risk of
nosocomial infection in patients over 65 years is 11.7 times greater than in those under 65
years.
The male gender is considered a risk factor for nosocomial infections. Our study
showes a 1.24 times greater probability to develop nosocomial infections in males than in
females, but the data is not statistically significant. RR is 1.24 (0.29 <RR <5.33), Chisquare statistic is 0.08. The P value is 0.53.
The low income is another potential endogenous risk factor that proves to be true;
there is a epidemiological association between the low income and the nosocomial
infections. RR is 10.36 (1.28 <RR <83.3), Chi-square statistic is 7.7. The P value is
0.009. This result is statistically significant. The income per family member is not a risk
factor according to our results. RR is 0.98 (0.23 <RR <4.2), Chi-square statistic is 0.004.
The P value is 0.63, RA = - 0.085.
Assuming that an educated patient has access to education and informations
regarding the nosocomial infections, we considered the lack of studies a risk factor. Our
research demonstrates the lack of epidemiological association of this factor. RR is 0, Chisquare statistic is 2.26. The P value is 0.073.
In literature smoking is considered an endogenous risk factor for nosocomial
infection. The details of our work show that the smokers have a risk of 1.25 times higher
to develop a nosocomial infection, but there is no epidemiologically association
79
statistically proven. RR is 1.25 (0.29 <RR <5.33), Chi-square statistic is 0.09. The P
value is 0.52.
The obesity is clearly a risk factor for nosocomial infections, those who are obese
or overweight have a 6.6 times higher probability to develop a nosocomial infection than
those with normal weight; the data are statistically significant. RR is 6.59 (1.34 <RR
<32.32), Chi-square statistic is 7.19. The P value is 0.016.
Alcohol is considered an endogenous risk factor for nosocomial infections. Our
study shows a probability of 1.65 times higher in alcoholics to develop nosocomial
infections compared to those who did not consume alcohol, but the data are not
statistically significant. RR is 1.65 (0.21 <RR <12.5), Chi-square statistic is 0.23. The P
value is 0.49. This result is not statistically significant.
Our hypothesis that states that the unbalanced nutrition is a risk factor for nosocomial
infection is refuted by the obtained data. There is a risk of 3.88 times higher in those with
unhealthy diet to develop nosocomial infections, but the results are not statistically
significant. RR is 3.88 (1.22 <RR <14.6), Chi-square statistic is 3.24. The P value is 0.08.
This result is not statistically significant.
Associated comorbidities increase the risk of nosocomial infections; although
the literature and the studies demonstrate this in our work the results are not statistically
significant, but they demonstrate a higher risk of 2.48 in those with associated diseases to
develop nosocomial infections. RR is 2.48 (0.58 <RR <10.56), Chi-square statistic is 1.6.
The P value is 0.19. This result is not statistically significant.
Among the endogenous factors of nosocomial infection we mention the hospital
admission; it is certain that emergencies increase the risk of nosocomial infection
compared with chronic diseases. Our study showed a higher risk of 2.47 in those with
medical or surgical emercencies than in those hospitalized with chronic conditions. RR is
2.47 (0.3 <RR <19.77), Chi-square statistic is 0.79. The P value is 0.34. This result is not
statistically significant.
80
A new possible risk factor that we studied was depression; our study tried to
show an epidemiological association between depression and nosocomial infections. The
data showed a risk of 1.5 times higher in those suffering from depression to develop a
nosocomial infection compared to those without depression. RR is 1.5 (0.18 <RR
<11.87), Chi-square statistic is 0.15. The P value is 0.57. This result is not statistically
significant.
After identifying the intrinsic risk factors we wanted to prioritize them in order to
achieve the highest probability for developing a nosocomial infection in the orthopedic
ward. Thus, we ordered upwards the relative risks calculated for each factor (see chart no.
6). The "extreme age" with a relative risk of 11.78, followed by the "low income" (RR=
10.36) and "obesity" (RR= 6.56) were identified with the highest impact and statistically
significant.
Chart no. 6 Hierarchy of the intrinsic risk factors on the orthopedic ward
81
3.18. Extrinsic risk factors
Among the external risk factors we first studied the length of the hospital stay.
The results showed a 24 times higher risk of developing nosocomial infections at those
hospitalized for more than 7 days versus those hospitalized for shorter periods of time.
For the length of the hospital stay we took into consideration the average recommended
by the Ministry of Health for the orthopedic ward - 7 days. RR is 24 (3.03 <RR <190.05),
Chi-square statistic is 20.06. The P value is 0.000. This result is statistically significant.
The study of quality of life was one of the objectives of the research. To quantify
the wellbeing of orthopedic patients, we asked them to give a note of 0 to 100 for their
current status, the highest mark beeing for good. Once we have calculated the average of
the responses we have obtained a mark of 66.5 ([Link] 19.81). We considered the marks
between 80 -100 as wellbeing and risk factors for nosocomial infections the marks below
80. Thus our study showed a 1.29 times higher risk to the mark under 80 than to those
with wellbeing. RR is 1.29 (0.26 <RR <6.39), Chi-square statistic is 0.105. The P value is
0.55. This result is not statistically significant.
The hospitalization conditions are some of the extrinsic factors proven in studies
from the literature to be involved in nosocomial infections. We analyzed the risk
associated with crowding in the wards from the orthopedic unit. We know that this is the
most crowded unit of the hospital, with 70 beds in some wards, exceeded by more the
surface per bed admitted by the rules of the Order MS. 914/2007, 7 sqm per bed,
according to specifications up to 5 beds for large wards. Our research showed that
although the risk of nosocomial infection in crowded wards is more than 2.3 times higher
than in the uncrowded wards, the data are not significant. RR is 2.32 (0.47 <RR <11.58),
Chi-square statistic is 1.16. The P value is 0.24. This result is not statistically significant.
A major importance in the surveillance of nosocomial infections has healthcare
staff training on universal precautions, knowing that the ordinary hand washing is the
most effective and safest way to prevent and control the nosocomial infections. We tried
to identify the patient awareness about the risk of acquiring a healthcare-associated
infection. Our research identified a strong epidemiological association between the lack
82
of knowledge and the nosocomial infections. The risk of the uninformed to develop
infection is 4.3 times higher than to those informed. RR is 4.3 (0.87 <RR <21.31), Chisquare statistic is 3.86. The P value is 0.03. This result is statistically significant.
Antibiotic prophylaxis is universally known to be a protective factor for
nosocomial infections. To our surprise the data have demonstrated the opposite, that
antibiotic prophylaxis is a risk factor for nosocomial infections and that the risk of the
patients with antibiotic prophylaxis is 7.58 higher to develop an infection than those
without prophylaxis. RR is 7.58 (3.85 <RR <59.39), Chi-square statistic is 5.28, the P
value is 0.02. This result is statistically significant. Based on the results above we
analyzed the possible causes and we tried to demonstrate that an incorrect antibiotic
prophylaxis increase the risk of nosocomial infections with 8.21 times. RR is 8.21 (1.68
<RR <40.05), Chi-square statistic is 9.61, the P value is 0.007. This result is statistically
significant.
Our study demonstrates that in the orthopedic ward the length of hospital stay has
the largest impact (RR= 24), followed by the incorrect antibiotic prophylaxis (RR= 8.21)
and paradoxically by the antibiotic therapy (RR= 7.58), and by the uninformed patient
impact (RR 4.3). All four risks are statistically significant. (see chart no. 7)
Chart no. 7- The hierarchy of the extrinsic risk factors on the orthopedic ward
83
The impact of the investigated risk factors on the study group
The attributable risk is the difference in rate of a condition between an exposed
population and an unexposed population. The attributable risk towards the relative risk
characterizes the aggressiveness of the risk factor and the frequency of the condition in
question, therefore serves to identify those issues that can be addressed and resolved with
maximum efficiency, making the best use of available resources. Intrinsic risk factors are
difficult to control; we cannot intervene on some of them. From our analysis we can say
that by eliminating smoking it would reduce the nosocomial infections from the
orthopedic ward with 0.013%. Through proper control of the body weight it would be
eliminated 0.129% of nosocomial infections. Through healthy diet, it would be
eliminated 0.079% of nosocomial infection. By eliminating alcohol consumption
infections would be reduced with 0.036% and by increasing patients revenue the
nosocomial infections would be reduced with 0.123%. The attributable risks are very
small so we do not have to look for solutions here. (Chart no. 8)
Chart No. 8 The attributable risks of the intrinsic risk factors
84
For an optimal control of the nosocomial infections we must act on the extrinsic
risk factors. Our study shows that a decrease in the lenth of the hospital stay, closer to the
optimal one for orthopedics (7 days) would reduce the nosocomial infections on the unit
with 23.95% and a correct antibiotic prophylaxis would reduce the infections with
15.68%. Informing the patient has an important role in the surveillance and control of
nosocomial infections. A patient that knows what the hospital acquired infections are and
the methods to prevent the nosocomial infections reduces the incidence of infections with
8.73%. Compliance with the sanitary norms regarding the number of beds allowed in the
ward reduces 4.61% of the nosocomial infections (see chart no. 9).
Chart no. 9 - The attributable risks of the extrinsic risk factors
3.19. The quality of life - The patient satisfaction
In our study group the quality of life was the key criteria examined alongside the
microbiological laboratory examinations. Its evaluation was made after assessing the
quality of life scale. Statistical analysis of the health status parameters showed that the
pain affects considerably the parameters of daily activities and significantly reduce the
quality of life.
85
From the subjects who reported locomotion deficits or were required to stay in
bed, average health status is 66.42 which show an altered state. The average of patients
suffering from nosocomial infection is 57.85, well below the average of the study group
(66.5). 90% of respondents reported pain, 81% immobility, 17.5% indifferent attitude of
the medical staff and 81% depression as a factor for impaired quality of life (see table 3).
Table 3 The frequency of impaired quality of life
Impaired quality of life
Frequency
Percent 95% Conf Limits
108
90.0% 65.4%
81.7%
Immobility
97
80.9% 54.9%
72.7%
Staff attitude
21
17.5% 15.9%
38.7%
Depression
97
80.9% 54.9%
72.7%
Pain - discomfort
The conditions of hospital stay, cleanliness, food
The purpose of the quality standards review is to improve continuously the
quality of services provided and the ways to produce those services. Thus, a good quality
management consists in planning, practical application, control and review of measures
necessary for the services and processes, so that they correspond to permanent needs of
the patient.
Our study shows a 53% satisfaction of those pleased with the cleanliness of the
ward (confidence interval (CI) 95%: 44-62.8%).
Healthcare staff skills
Treating all patients with the same basic levels of standard precautions involve
key practices to ensure a high level of protection for patients, medical staff and visitors.
These include: hands washing (hand hygiene); the use of personal protective
equipment when it handles blood samples, body substances, excretions and secretions;
appropriate handling of patient care equipment and soiled linen; preventing bites / cuts /
86
injuries with proper waste handling and instruments. For this purpose we wanted to
identify the gaps in the implementation of good practice protocols by medical staff and
we introduce in our survey some questions concerning the staff hand hygiene and the
wear of gloves (confidence interval 69,9%-85,5%). 95% wore gloves when bandaging the
patients, but only 78% have changed gloves in front of the patient (confidence interval
95%: 69.9-85.5%). Our survey data shows that although hand washing is the most
inexpensive, a simple and effective way to prevent nosocomial infections, only 60% of
medical staff washed their hands, 6.9% after each patient and 31% skip washing.
Healthcare staff satisfaction level is related to quality of care, but derives from
the conditions in which they work; the existence of satisfaction increases the
performance. In conclusion, this is a factor that can be used as criteria for evaluating the
quality of work performed by the medical team. 94% of our respondents are satisfied
with the professionalism of doctors, 91% of nurses and a downward trend, 88% of
hospital housekeepers (table 4,5,6).
Table 4. The share of appreciation of doctors professionalism
Satisfied with the
professionalism of
Freq Percent
Cum
Percent
doctors
yes 88.0% 97.5%
da
109
94.0%
94.0%
nu
6.0%
100.0%
116
100.0%
100.0%
Total
87
95% Conf Limits
no 2.5% 12.0%
Table 5. The share of appreciation of nurses professionalism
Satisfied with the
Cum
professionalism
Freq Percent
Percent
95% Conf Limits
of nurses
yes 84.7% 95.8%
106
yes
91.4%
91.4%
no 4.2% 15.3%
no
Total
10
8.6%
100.0%
116
100.0%
100.0%
Table 6. The share of appreciation of housekeepers professionalism
Satisfied with the
Cum
professionalism
Frec. Percent
Percent
of housekeepers
yes
103
88.8%
88.8%
no
13
11.2%
100.0%
116
100.0%
100.0%
Total
95% Conf Limits
yes 81.6% 93.9%
no 6.1% 18.4%
A patient well informed about what and how to prevent a nosocomial infection is a
win for the orthopedic ward in surveillance and control of hospital acquired infections.
Among those aware of nosocomial infection 41.6% had correct knowledge about the
ways to prevent it.
3.20. Grid assessment of the risk of infection
In our study we determined the degree of epidemiological risk for orthopedic
ward, which involved analyzing certain criteria related to the organization of the ward,
equipment, cleanliness, healthcare staff, materials supply, patients wellbeing, the type of
88
maneuvers performed and the history of nosocomial infections. The average score per
hospital was 73.99, which corresponds to the yellow zone, respectively medium risk. The
orthopaedic ward is in the yellow zone with a score of 71.15, slightly below the average
of the hospital. (Chart no. 10)
Chart no. 10- Wards risk map
The orthopedic ward achieved 64 points out of 100 on the first objective which is
related to the patient's condition.
The analysis of the specific interventions, 10% objective, emercency intervention,
invasive maneuvers, assisted breathing and parenteral therapies reduced the score from
100 to 50. On the objective regarding the regulations to ensure the general hygiene
conditions, water quality, the existence of tanks, wards, offices, treatment rooms
equipped with lavatory with hot and cold water, the building status, the washable
finishing solutions, hazardous waste management, use of biocides, the existence of
deratization - disinfection plan, the orthopedic ward achieved 84 points out of 100. The
functional organizing of the orthopedic ward represents a share of 20% of the final score;
30 points were scored out of 100. Providing sterile materials, investigating spaces for
sterilization, for equipment and for healhtcare staff training that is responsible for
sterilization has achieved the highest grade, 100. The functional circuits on the orthopedic
ward, a 10% objective, whether it is about patients, food, linen, staff, sterile instruments
or waste materials, achieved the maximum score. The healthcare staff on the orthopedic
89
ward, a 5% objective, got 99 points out of 100; normatives on employment, job
descriptions, qualifications of the healthcare staff, periodic medical examinations,
providing appropriate protective equipment and compliance with universal precautions
were analyzed. Self-tests on sanitation has received the highest score of 100. This target
has a share of 10% in calculating the final score. The household services, extension of the
ward, food office, laundry room, dressing room of healthcarestaff and patients gained 80
points out of 100. The display of the hygiene protocols, the endowment with refrigerators
and medical equipment brought another total of 60 points.
IV. CONCLUSIONS
-
On the basis of a clinical, epidemiological and socio- economic complex a thorough
analysis of the results was conducted on a representative group of patients with
orthopedic conditions during 2011 -2013 - 7551 hospitalized patients, of which based
on case definitions a total of 116 patients with nosocomial infections were
distinguished actively and retrospectively.
Circulating strains were identified with potential for nosocomial infections in the
orthopedic ward, Staphylococcus aureus ranks first, which is found in the etiology of
nosocomial infections on the ward with Acinetobacter, followed by E. coli, then
Klebsiella and Enterococcus.
The identified resistance of germs showed a distinct resistance of circulating staph.
28% of these are MRSA, 50% are resistant to erythromycin and 43% to clindamycin.
Incorrect antibiotic prophylaxis for preoperative care transforms it from protection
factor to risk factor with nosocomial potential.
According to the profile of the orthopedic ward the antibiotic therapy brings on the
first place the third generation cephalosporins consumption, followed by the
consumption of gentamicin and oxacillin. During the study period there is a
downward trend regarding the use of cephalosporins due to the activity of SPCIN
who successfully sensitized the personnel in proper implementation of antibiotic
prophylaxis and antibiotic therapy protocols.
90
Our study highlights the poverty range of the antibiotics types used by the healthcare unit
provided in 2011; this situation constantly changes in 2012 and 2013 but also drives high
costs.
The identification of the disinfectants and antiseptics with the highest efficiency in
environmental control and healthcare staff hygiene provided professional guidance
for their procurement, whose consumption has increased significantly over the study
period for high level disinfectants from 1 liter to 2 liters of concentrated solution per
month and antiseptic from 180-210 liters per month.
The calculation of the additional costs for the nosocomial infections has confirmed
the hypothesis that the care for orthopedic patient with nosocomial infection is more
expensive than the care for another patient with nosocomial infections from the other
hospital wards. The average of days for hospitalization for those with nosocomial
infections is 25-35 days versus the orthopedic patient with nosocomial infections of
73 days, which involve much higher costs.
Following the SWOT analysis on the orthopedic ward we identified the weak points;
among them we include: insufficient staff, inconsistency of the legal advice on the
ward area and the number of beds admitted on the ward, the lack of household and
room space for septic treatment. The strong points are: 100% addressability for the
people from Brasov County, a capable and trained team, opportunities and threats
poor equipment.
Using the grid for assessing the risk degree in the occurrence of nosocomial
infections from the orthopedic ward was helpful for prioritizing the risk factors in
developing the risk map.
The impacts of intrinsic and extrinsic risk factors on the incidence of nosocomial
infections were evaluated. As intrinsic risk factors with epidemiologically
significance we include: age, low income, below 1,000 lei, obesity and also others
insignificant for our study: smoking, alcohol consumption, male gender, domestic and
road accidents, and lack of education, comorbidities or unbalanced diet. Among the
extrinsic risk factors with epidemiologically significance we include: long lenth of
hospitalization, antibiotics prophylaxis or incorrect antibiotic therapy, and the lack of
91
patient information (63% - informed patients). Extrinsic risk factors such as
discomfort or ward crowding proved to be insignificant in our research.
-
The hierarchy of the risk factors and the identification of protective ones have a great
importance in the current practice of surgical specialties. The extreme age with
relative risk of 11.78, followed by the low income (RR- 10.36) and the obesity (RR 6.56) were identified with the highest impact and are statistically significant. It is
proven by our research that proper hand hygiene and patient information regarding
the way of transmission of nosocomial infections increases the satisfaction of the
patient and they are becoming protective factors in controlling the nosocomial
infections (RR 4.4).
For the first time in the hospital history, we tried to measure the satisfaction level in
patients hospitalized in an orthopedic unit and suffering a nosocomial infection. We
did not find in the literature any standard questionnaire regarding this theme; so we
modified a MOS-SF36 questionnaire and added a few items characteristic for
orthopedic patients with reference to patients knowledge about nosocomial
infections, with questions referring to quality of life (EQ-5D and EQ-VAS).
New data was obtained regarding the needs and satisfaction level of patients with
nosocomial infections. The average health status of orthopedic is 66.42, which shows
an altered state, and the average of those with nosocomial infections is 57.85, well
below the average of the study group.
By studying closely the skills of medical staff we identified the gaps in the
implementation of best practice protocols. For example even if 95% wore gloves only
60% washed their hands and only 7% washed their hands after each patient.
From the analysis of the Grid for assessing the degree of risk in the occurrence of
nosocomial infections it was found that the on the Risk Map the orthopedic ward is in
the yellow zone, a medium risk area, with a score of 71, below the hospital average,
very close to the red zone, with the highest risk (under 70 points).
As a final conclusion: nosocomial infections constitute a significant source of
expense and effort for the patient and the medical system, a major cause of increased
morbidity, mortality and readmission rate in hospital, seriously affecting the quality
of life of the patient with nosocomial risk. Reducing the risk of nosocomial infections
92
through the genuine involvement of the entire staff of the hospital in combating is a major
objective of quality management of medical services.
V. Original contributions. Future Research Directions
1. Personal and original contributions
In this PhD thesis we proposed and we realized to approach the nosocomial
infections registered in the orthopedic ward of County Clinical Emergency Hospital of
Brasov from multiple perspectives: medical surgical, microbiological, financial
accounting, administrative and not least social, demonstrating throughout this paper that
only depth knowledge of correlated risk allows the control of the nosocomial infections
in a health care facility.
-
For the first time in the hospital history, we tried to measure the satisfaction level in
patients hospitalized in an orthopedic unit and suffering a nosocomial infection. We
did not find in the literature any standard questionnaire regarding this theme; so we
modified a MOS-SF36 questionnaire and added a few items with reference to
patients knowledge about nosocomial infections, with questions referring to quality
of life (EQ-5D and EQ-VAS).
2. Contributions with synthetic character
Regarding the scientific content:
-
On the basis of a clinical, epidemiological and socio- economic complex it was
conducted a thorough analysis of the results on a representative group of patients with
orthopedic conditions and nosocomial infections in the orthopedic ward of the County
Clinical Emergency Hospital of Brasov.
The cases with nosocomial infection registered during 2011- 2013 in the orthopedic
ward have been identified by active screening and retrospective study.
Circulating strains with nosocomial potential were identified.
The degree of resistance of circulating flora was analyzed.
The antibiotic prophylaxis as preoperative care was analyzed.
93
The antibiotic therapy according to bacteriological profile on the orthopedic ward was
analyzed.
Costs were calculated of used and prescribed antibiotics on the orthopedic ward.
The additional costs were calculated regarding the hospitalization of patients with
hospital acquired infections in this ward.
The most efficient antiseptics and disinfectants in environmental control and
healthcare staff hygiene were identified.
Data were obtained about the level of satisfaction of orthopedic patients with
nosocomial infections; the conclusions will be used in practice.
3. Theoretical and experimental contributions:
We conducted a longitudinal, analytic, cohort and retrospective study, through
which we highlighted the aspects of the nosocomial infections from the orthopedic ward
correlated with risk factors, and then we realized an observational, transversal prevalent
study regarding the patient quality of life.
-
We analyzed the circulating strains versus the hospital flora from the orthopedic
ward, the antibiotic resistance, we conducted a SWOT analysis of the department and
the impact on direct and indirect costs caused by the nosocomial infections, we
approached the intrinsic and extrinsic risk factors for nosocomial infections, we
evaluated the risk degree of the hospital versus the orthopedic ward and we analyzed
the orthopedic patient satisfaction.
4. Scientific curricular contributions
-
The analysis of the current state of the research related to the nosocomial infections at
national and international level.
Reporting of scientific research in doctoral research program.
Completing the PhD thesis.
5. The novelty of the PhD thesis:
94
The idea of a study to identify the needs of the orthopedic patient with nosocomial
infection and something new, assessing his knowledge about nosocomial
infection.
The multitude of the items used in the research
The applicability of the conclusions to the specialist hospital care
6. The valorization and dissemination of the scientific research results in the academic
environment:
Publishing the articles in accredited publications CNCSIS.
Achieving the scientific research reports in the scientific training program.
The PhD thesis completion.
7. Future Research Directions:
The impact of certain types of disinfectants useful in the control of nosocomial
infections - case studies
Clinical and epidemiological correlation between education / patient information
and the incidence of nosocomial infections
The thesis contains:
187 pages, of which 140 pages (75%) personal contributions.
45 graphics.
62 tables
5 figures
The bibliography contains 247 titles.
95
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97
APPENDIX 1: Grid of appreciation of the risk degree of the appereance of
nosocomial infections on the ward
OBIECTIVE
Criteria
Allocated
score
I. PATIENT STATUS
10%
Immunodeficiencies
20
Metabolic diseases, malnutrition,
comorbidities (diabetes, neoplastic
diseases, cardiovascular etc.)
20
Regions of minimal resistance
pathologically induced (or other open
wounds)
20
Low resistance physiological
conditions (old age or children)
20
Patients contagiousness
20
Total obiective:
II. SPECIFIC WARDS
INTERVENTIONS 10%
Emergency interventions (surgical)
20
Maneuvers with increased
invasiveness
20
Mechanic ventilation
20
Venous catheterization
10
Parenteral therapy
10
Anti-infective therapies that reduce
the resistance of the body
20
Total obiective:
III. RULES FOR
INSURANCE GENERAL
HYGIENE CONDITIONS
98
100
100
Water quality complies the standards,
regardless of source
10
There is a storage tank to ensure a
reserve for 1-3 days consumption,
placed in general circulation
YES
NO
Partially
Score
OBIECTIVE
Criteria
Allocated
score
20%
Each ward, medical consultation room,
treatment room is provided with a sink
located closer to entering the room
There is hot water running on a
permanent basis at all points of
distribution
10
Building status
The finishes are washable
The angles between floor and walls are
concave
It ensures proper ventilation, either by
mechanical systems or by ventilation
Separate collection of waste at the
workplace
Space arranged for temporary storage
of waste
Provision with cleaning materials
10
Provision with materials for personal and
hand hygiene
10
Biocidal products used are notified and
approved
Concentrations and the use of biocides
are respected
There is DDD plan
It respects the DDD plan
Total obiective:
99
100
YES
NO
Partially
Score
OBIECTIVE
Criteria
III. GENERAL
FUNCTIONAL
ORGANIZATION OF
THE WARD 20%
Shall be pursuing the elements of
the MS Order no. 914/2006 of the
patients accommodation,
capacity of useful areas / bed, no.
toilets, facilities requirements,
ancillary areas, isolator etc.
Total obiective:
IV. PROVIDING THE
STERIL MATERIAL 5%
100
100
There is a separate room for
sterilization
20
Authorized sterilization equipment
10
There are specific working instructions
of the sterilization device displayed
Preliminary preparation of the
instruments
20
Booklet sterilization is completed after
each batch sterilization
There is self-sterilization tests
15
Is made labeling kits and checking
sterility
10
It makes periodic verification of
sterilization device
10
The existence of a log to be noted the
technical verifications
Total obiective:
VI. FUNCTIONAL
CIRCUITS OF THE
WARD 10%
Allocated
score
100
- pacient
10
- sterile / non-sterile instruments
20
- food
20
- clean /dirty linen
20
YES
NO
Partially
Score
OBIECTIVE
Criteria
- waist
20
- healthcare staff
10
Total obiective:
VII. HEATHCARE
STAFF FROM THE
WARD 5%
100
It complies with the legal relating to
healthcare staff
10
There are job descriptions for all staff
10
The medical personnel has a
qualification required to fulfill the
responsibilities of the job
20
The medical personnel has regular
medical control
20
Providing appropriate protective
equipment
20
Respect universal precautions
20
Total obiective:
VIII. SELF CONTROL
10%
Allocated
score
100
Inadequate sanitation tests below 10%
20
Verification test of the materials sterility -
20
inadequate below 10%
Tests regarding the microflora of air inadequate below 10%
20
The existence of under 5% healthy
carriers among medical staff
20
Selecting high potential pathogenic
strains (multiple resistance to antibiotics
and / or antiseptics)
20
Total obiective:
IX. HOUSEHOLD
SERVICES 5%
Kitchen, food pantries, food
storage
- reception and storage of unprocessed
101
100
YES
NO
Partially
Score
OBIECTIVE
Criteria
Allocated
score
food
- facilities for primary processing
- final processing spaces
- space for food storage for one day
(deposit of one day)
- distribution Office
-locker room with toilet and shower,
separated by gender, next to the access
of staff
externalization - is scored as a total
"kitchen" 54 points
5
refrigerator for food samples
daily epidemiological triage of the staff
The laundry room
- room for receiving and sorting dirty
linen
- space for linen disinfection equipped
with soaking tubs with disinfectant
- The laundry room
- spaces for drying room and ironing
services
- room for laundry repairing
- Clean laundry deposit
- Clean laundry release room
- locker room with toilet and shower
Outsourced service - is scored as a total
102
YES
NO
Partially
Score
OBIECTIVE
Criteria
Allocated
score
YES
NO
"laundry room" 40 points
Ancillary services for staff and
patients
10
- dressing room for patients
- lockers for medical and technical
staff
Total obiective:
X. OTHER
REQUIREMENTS 5%
10
100
There are hygiene, sterilization and use
of disinfectants protocols displayed
25
There is the necessary endowment with
equipment and sanitary materials
25
There are refrigerators with freezer
sufficient for each ward
25
There are thermogram and thermometer
for refrigerators
25
Total obiectiev:
100
GENERAL TOTAL:
CALCULATED RISK LEVEL:
CALCULATION FORMULA:
The amount obtained by objective x% = Total objective
Example: for X objective: 25 + 25+10+10 = 70 x 5% = 3,5 points
GENERAL TOTAL = the total sum of 10 objectives
103
Partially
Score
Appendix 2: Questionnaire
According to OMS, the quality of life is a concept through which you
understand the physical, mental and social well being, as well as the capability of
patients to fulfill their regular duties in their daily existence.
Please have the courtesy to answer the questions of this questionnaire
marking an X next to the answer that suits you or tell us your opinion to the
opened questions.
The questionnaire does not contain confidential information about you and
will not require your signature.
Through this study, we would like to understand the needs of the inpatients
on the orthopedic ward of County Clinical Emergency Hospital of Brasov in order
to permanently improve the quality of services given to our patients.
1. Age:
2. Gender:
F
M
3. Residence: urban
rural
4. Wage-earner: yes no
5. Studies: university degree high school 8 grades 4 grades
6. Marital status: married divorced widow/widower
unmarried
7. Your income: - 0- 500 ron
- 500 1000 ron
-1000 1500 ron
- peste 1500 ron
8. Your family income per capita membership is:
-0- 500 ron
- 500 1000 ron
- 1000 1500 ron
- over 1500 ron
9. Do you smoke? yes no
10. Do you frequently consume alcohol? yes no
11. Do you have a balanced diet? yes no
12. Are you:
obese
overweight of normal weight?
104
13. What diseases do you
have
..
14. The cause of actual hospitalization : - work accident/domestic accident
- other chronic or acute diseases
15. How much time has passed since hospitalization: ..
16. Do you have pain or discomfort? no
sometimes
permanently
17. Do you have mobility problems? - I dont have problems moving
- I have some problems
- I am compelled to stay in bed
18. Are you depressed/ anxious? never sometimes extremely depressed
19. If the best state condition is noted with 100 and the worst with 10, your state
is: ..
20. Do you have complications in your orthopedic illness? yes
no
21. If the answer is yes, what is the complication? infectious others
22. If you have infectious complications, what is the germ( micobe)
.................
I dont know
23. If you have infectious complications, these are from:
- the hospital
- outside the hospital
24. What upsets you the most? pain imobility staff attitude
conditions in the hospital lack of medicines
25. What are your needs in the hospital and that are not offered?
26. Are you satisfied with the facilities of the orthopedic ward?
yes no
27. How many patients are with you in the ward?..................
28. You are satisfied with the proffessionalism of:
- physician ? yes no
- nurse? yes no
- hospital housekeeper? yes no
29. Are you satisfied with : - the cleanliness of the hospital? yes no
- hospital food? yes no
30. Did the staff instruct you to wash your hands every time, before
and after meals and after going to the restroom?
yes no
105
31. Din you notice how many times the staff washes their hands in your
presence?
- before each patient
- before each maneuver on the same patient
- washing hands frequently omitted
32. When bandaging the staff used:
- gloves yes no
- did they change gloves in your presence
yes no
- they washed their hands yes no
33. Do you know what nosocomial infections are ( hostipal acquired
infections) ?
yes no
34. Using your words try to define nosocomial infections:
....
35. How do you think nosocomial infections can be avoided on the
orthopedic ward?
36. Did you receive antibiotics before surgery? yes no
37. If the answer is yes, for how long? 1 dose 3 days 5 days 7 days
38. If the answer is yes, what was the antibiotic
- I dont know
39. After the surgery did you immediately receive antibiotic? yes no
40. If the answer is yes, for how long? : 1 day 3 days 5 days 7 days
Over 10 days
41. If the answer is yes, what was the antibiotic
- dont know
42. During hospitalization did you have any indication of infection that you
did not have before hospital but being later acquired (redness, swelling, pain
or surgical wound suppuration, fever, cough with fever, frequent pain during
urination?
yes no
43. What do you consider that the orthopedic staff did not do but
might have done for you?
..
106
Thank you!
107
ANEXA 2
LISTA LUCRRILOR TIINIFICE PUBLICATE
1. THE IMPACT OF NOSOCOMIAL INFECTIONS ON ORTHOPEDIC
PATIENTS' QUALITY OF LIFE
CLIN RUIA1, CODRUA NEMET2
1
Transilvania University of Brasov, Romania, Faculty of Medicine, County Clinic
Emergency Hospital of Brasov, Romania, 2 Transilvania University of Brasov, Romania,
Faculty of Medicine:
n ACTA MEDICA TRANSILVANICA volume XX, Nr.1, 2015, Sibiu, Romania
pp. 1 3.
2. RISK FACTORS INVOLVED IN NOSOCOMIAL INFECTIONS REGISTERED
TO ORTHOPEDIC PATIENTS FROM THE COUNTY CLINIC EMERGENCY
HOSPITAL OF BRASOV, ROMANIA
RAUTIA CALIN1 , NEMET CODRUTA2
1
Faculty of Medicine, Transilvania University of Brasov, County Clinic Emergency
Hospital of Brasov, Romania
2
Faculty of Medicine, Transilvania University of Brasov, Romania:
n MEDICINE IN EVOLUTION Volume XXI, Nr. 1, 2015, Timioara, Romania
ISSN 2065-376X pp. 76 81.
3. BACTERIOLOGICAL PROFILE OF NOSOCOMIAL INFECTIONS
IDENTIFIED IN THE ORTHOPEDIC WARD OF COUNTY CLINIC
EMERGENCY HOSPITAL OF BRAOV. CORRELATIONS WITH THE
MICROORGANISMS FROM HOSPITAL ENVIRONMENT
RAUTIA CALIN1, NEMET CODRUTA2 , IDOMIR MIHAELA1, GODRI DORA3
1
Faculty of Medicine, Transilvania University of Brasov, County Clinic Emergency
Hospital of Brasov, Romania
2
Faculty of Medicine, Transilvania University of Brasov, Romania
3
County Clinic Emergency Hospital of Brasov, Romania
n FIZIOLOGIA, Timisoara, Romania - n curs de publicare
4. COSTURILE INFECIILOR NOSOCOMIALE N SPITALUL CLINIC
JUDEEAN DE URGEN BRAOV
RAUTIA CLIN1, GODRI DORA ANA2, RUSU BOGDAN2, NEMET CODRUA3
1
Facultatea de Medicin, Universitatea Transilvania Brasov; Spitalul Clinic Judeean de
Urgen Braov, Romnia
2
Facultatea de Medicin, Universitatea Transilvania Braov
3
Spitalul Clinic Judeean de Urgen Braov, Romnia
n JURNAL MEDICAL BRAOVEAN n curs de publicare
108
ANEXA 3
REZUMAT SCURT
Prezenta lucrare pornete de la premisa c prevalena infeciilor nosocomiale este
unul din indicatorii de calitate ai asistenei medicale spitaliceti, care permite, cu mare
obiectivitate evaluarea omogenitii formei de control asupra factorilor de risc intrinseci
i extrinseci, facilitnd n plus adoptarea i evaluarea strategiilor destinate reducerii
acestora.
n baza unui complex de date clinice, epidemiologice i socio-economice s-a
efectuat o analiz amnunit a rezultatelor pe un lot reprezentativ de pacieni cu afeciuni
ortopedice. n premier s-a efectuat un studiu comparativ asupra calitii vieii pacienilor
ortopedici cu i fr infecie nosocomial. S-au identificat factorii de risc precum i cei de
protecie implicai n infeciile nisocomiale, realizndu se i o ierarhizare a acestora. S-a
evaluat impactul factorilor de risc intrinseci i extrinseci asupra incidenei infectiilor
nosocomiale. S-au identificat i caracterizat germenii circulani pe Secia clinic de
Ortopedie cu potenial nosocomial. S-au calculat costurile suplimentare datorate
infeciilor nosocomiale pe Secia clinic de Ortopedie: spitalizare, investigaii
diagnostice, tratamente inclusiv antimicrobiene. S-au identificat dezinfectanii cu cea mai
mare eficien antimicrobian utilizai n spital.
Pentru prima dat n istoria spitalului, s-a ncercat o msurare a gradului de satisfacie a
pacientului ortopedic i cu infecie nosocomial. Negsind n literatura de specialitate nici
un chestionar pe aceast tem am modificat un model de chestionar MOS-SF36, i am
adugat civa itemi caracteristici pacienilor otropedici cu referire la cunotinele
acestora despre infectiile nosocomiale, alturi de intrebrile EQ-5D i EQ-VAS cu
referire la calitatea vieii. S-au analizat criteriile profilactice i terapeutice de prescriere i
utilizare a antibioticelor conform profilului bacteriologic al Seciei clinice de Ortopedie.
Stabilirea gradului de risc infecios al Seciei clinice de Ortopedie prin analiza
punctajului obinut prin completarea Grilei de risc i a Harii de risc nosocomial a
Spitalului.
109
BRIEF SUMMARY
This paper starts from the assumption that the prevalence of nosocomial
infections is one of the indicators of quality of hospital care, which allows with greater
objectivity the evaluation of the homogeneity of control form over intrinsic and extrinsic
risk factors, facilitating further adoption and evaluation of strategies intended for
reducing them.
On the basis of a complex set of clinical, epidemiological and socio-economical
data a thorough analysis of the results was conducted on a representative group of
patients with orthopedic disorders. For the first time a comparative study was carried out
regarding the quality of life for the orthopedic patients with and without nosocomial
infection. The risk and the protective factors involved in nosocomial infections were
identified, their hierarchy also being carried out. The impact of intrinsic and extrinsic risk
factors on the incidence of nosocomial infections was evaluated. The strains from the
orthopedic ward with nosocomial potential were identified and characterized. The extra
cost due to nosocomial infections from the orthopedic ward was calculated:
hospitalization, diagnostic investigations, treatments, including the antimicrobial one.
The disinfectants with the highest antimicrobial efficiency used in the hospital were
identified.
For the first time in the hospital history, it was tried to measure the patients
satisfaction hospitalized in an orthopedic unit, suffering a nosocomial infection. We did
not find in the literature any standard questionnaire regarding this theme, so we modified
a MOS-SF36 questionnaire and added a few items characteristic for orthopedic patients
with reference to patients knowledge about nosocomial infections, with questions
referring to quality of life (EQ-5D and EQ-VAS). The criteria for prophylactic and
therapeutic use of antibiotics were analyzed according to bacteriological profile of the
orthopedic unit. The establish of infectious risk of the orthopedic ward by analyzing the
scores obtained by filling the Risk Grid and the Risk Map of nosocomial infections of the
hospital.
110
ANEXA 4
Curriculum vitae
Europass
Informaii personale
Nume / Prenume
Adresa(e)
Telefon(-oane)
E-mail(uri)
Ruia Ion Clin
Str. Bujorului Nr. 31A, Braov
0720536433
calinorto@[Link]
Nationalitate(-tati) romn
Data naterii 18.03.1969
Sex brbtesc
Experiena profesional
Perioada
Funcia sau postul ocupat
Numele i adresa
angajatorului
Tipul activitii sau sectorul
de activitate
Perioada
Funcia sau postul ocupat
111
15.08.1995-prezent
Medic primar ortoped
Spitalul Clinic Judeean Braov
Ortopedie-traumatologie
1995-prezent
Asistent universitar
Numele i adresa
angajatorului
Tipul activitii sau sectorul
de activitate
Perioada
Funcia sau postul ocupat
Numele i adresa
angajatorului
Tipul activitii sau sectorul
de activitate
Perioada
Funcia sau postul ocupat
Numele i adresa
angajatorului
Tipul activitii sau sectorul
de activitate
Univ. Transilvania Braov/Facultatea de medicin
Catedra de discipline chirurgicale. Semiologie chirurgical i ortopedie
traumatologie
2005-aprilie 2012
Membru n Consiliul de conducere
Casa Judeean de Sntate Braov
Casa Judeean de Sntate Braov
15.08.1994-15.08.1995
Medic rezident ortoped
Spitalul Clinic Judeean Timioara
Ortopedie-traumatologie
Educaie i formare
Perioada
Perioada
Calificarea / diploma obinut
Numele i tipul instituiei de
nvmnt / furnizorului de
formare
Perioada
Calificarea / diploma obinut
Discipline principale studiate
/ competene dobndite
Numele i tipul instituiei de
nvmnt / furnizorului de
formare
2009 Diplom i licen la Institutul Diplomatic Romn
1999-2000
Medic specialist ortoped
Universitatea de medicin i farmacie Cluj-Napoca
15.09.1988-15.07.1994
Diplom de licen
Medicin general
Universitatea de medicin i farmacie Carol Davila Bucureti
Aptitudini i competene
personale
Limba matern
Limbi strine cunoscute
112
Romn
Englez, German (Avansat)
nelegere
Autoevaluare
Nivel european (*)
Ascultare
Vorbire
Citire
Participare la
conversaie
Scriere
Discurs oral
Exprimare scris
Englez
B2
Utilizator
independent
B1
Utilizator
independent
A2
Utilizator
elementar
A2
Utilizator
elementar
A2
Utilizator
elementar
German
C1
Utilizator
experimentat
C2
Utilizator
experimentat
B2
Utilizator
independent
B2
Utilizator
independent
B2
Utilizator
independent
(*) Nivelul cadrului european comun de referin pentru limbi
Competene i abiliti Spirit de echip activiti tiinifice realizate n echip, atitudine creativ,
sociale i organizatorice suport pentru colegi, disponibilitate la efort intelectual
Competene i aptitudini de Microsoft Office (Word, Excel, Powerpoint,etc.)
utilizare a calculatorului
Alte competene i aptitudini Adaptabilitate, flexibilitate, iniiativ, sensibilitate interpersonal
Permis(e) de conducere Categoria B
Informaii suplimentare Referine, diplome, certificate de atestare pot fi furnizate la cerere
113
Europass
Curriculum Vitae
Personal information
First name(s) / Surname(s) Ruia Ion Clin
Address(es) 31A Bujorului Street, Braov
Telephone(s) 0720536433
E-mail calinorto@[Link]
Nationality Romanian
Date of birth 18.03.1969
Gender male
Work experience
Dates
Occupation or position held
Main activities and
responsibilities
Name and address of
employer
114
15.08.1995-today
Physician - orthopedic surgeon
Orthopedic surgery and tramatology
County Clinic Emergency Hospital of Brasov
Dates
Occupation or position held
Main activities and
responsibilities
Name and address of
employer
Dates
Occupation or position held
Main activities and
responsibilities
Name and address of
employer
Dates
Occupation or position held
Main activities and
responsibilities
Name and address of
employer
1995-today
University assistant
Department of surgical disciplines. Orthopedic surgery and traumatology
Transilvania University of Brasov, Faculty of Medicine
2005- 2012
Member of the Board
Brasov County Health Insurance House
Brasov County Health Insurance House
15.08.1994-15.08.1995
resident physician
Orthopedic surgery and tramatology
County Clinic Hospital of Timisoara
Education and training
Dates 2009- Diploma and licenses from the Romanian Diplomatic Institute
Dates 1999-2000
Title of qualification awarded Specialist - Surgeon in orthopaedic specialty
Name and type of University of Medicine and Pharmacy Cluj-Napoca
organisation providing
education and training
Dates 15.09.1988-15.07.1994
Title of qualification awarded Bachelor's degree doctor, General Medicine
Name and type of organisation University of Medicine and Pharmacy "Carol Davila", Bucuresti
providing education and
training
Personal skills and
competences
Mother tongue(s) Romanian
115
Other language(s)
Self-assessment
Understanding
European level (*)
Listening
Reading
Speaking
Spoken interaction
Writing
Spoken production
English
B2
Independent
user
B1
Independent
user
A2
Elementary
user
A2
Elementary
user
A2
Elementary
user
German
C1
Proficient
user
C2
Proficient
user
B2
Independent
user
B2
Independent
user
B2
Independent
user
(*) Common European Framework of Reference for Languages
Social skills and competences Team spirit - scientific activities carried out in teams, creative attitude,
support for colleagues, availability to intellectual effort
Computer skills and Microsoft Office (Word, Excel, Powerpoint,etc.)
competences
Driving licence B category
Additional information References, diplomas, certificates can be provided on request
116
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