PREVENTIVE MEASURES IN THE CONTROL OF ACQUIRING NOSOCOMIAL INFECTION AMONG NURSES AT DR. JOSE N.

RODRIGUEZ MEMORIAL HOSPITAL

A Thesis Proposal Presented to the Faculty of Arts and Sciences Our Lady of Fatima University Quezon City

In Partial Fulfillment Of the Requirements for the Degree Bachelor of Science in Nursing

By: Bangloy, Jaleth Angelie S. Buenafe, Glennford E. Gamurot, Ma. Luisa E. Natividad, Minerva Jane C.

October 2011

Chapter 1 THE PROBLEM AND ITS BACKGROUND

Hospital since then is considered as the Hospice of care where medical attention is provided for the attainment of optimum level of health of an individual. On the other hand, being in the hospital is exposing you to harmful microorganisms, becoming at risk for infection.

Nosocomial comes from the Greek word nosokomeio meaning hospital. Nosocomial infection is any infection that is a result of treatment in the hospital or health service unit. Infections are considered nosocomial if they first appear 48 hours or more after hospital admission or within 30 days after discharge. (Wikipedia)

In United States, the Centers for Disease Control and Prevention estimate that roughly 1.7 million hospital associated infections, from all types of microorganisms including bacteria, combined, cause and contribute to 99 deaths each year.

In Europe, where hospital surveys have been conducted, the categories of Gram-negative infections are estimated to account for two-thirds of the 25,000 deaths each year. Nosocomial infection can cause severe pneumonia and infections of the urinary tract, blood stream and other parts of the body. (Wikipedia)

On the special issue about nosocomial infection updates indicated that as we enter the new millennium of infection control, we stand on the shoulders of giantsJenner, Semmelweis, Nightingale, Oliver Wendel Holmes, Thomas Crapper, he father of indoor plumbing. Modern infection control is grounded in the work of Ignaz
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Semmelweis, who in the 1840s demonstrated the importance of hand washing for controlling transmission of infection in hospitals. However, infection control efforts were spotty for almost a century. In 1976, the Joint Commission on Accreditation of Healthcare Organizations published Accreditation Standards for Infection Control, creating the impetus and need for hospitals to provide Centers for Disease Control and Preventions (CDCs) Study of the Efficacy of Nosocomial Infection Control reported that hospitals with four key infection control components-an effective hospital epidemiologists, one infection control practitioner for every 250 beds, active surveillance mechanisms, and ongoing control efforts- reduced nosocomial infection rates by approximately one third.

Alora and Manaloto (1983) conducted a survey on the incidence of nosocomial infection at the Sto. Tomas University, Private Division from June 1981 to January 1982. The results of the survey definitely showed the existence of nosocomial infection in the hospitals, wherein 2.46 % of the patients discharged developed such infections.

Reports from the National Nosocomial Infection Surveillance (NNIS) system have revealed that the urinary tract, respiratory tract blood stream and wounds are the most common nosocomial infection sites. The microorganisms that cause nosocomial infections can originate from the client themselves (an endogenous source) or from the hospital environment and hospital personnel (exogenous source).

Health care providers are health personnel from different disciplines who coordinate their skills to assist clients and their support persons. Their mutual goal is to restore a clients health and promote wellness. The physician is a registered medical practitioner who specializes in the diagnosis and treatment of disease (the Bantam Medical Dictionary, 2004) works hand in hand with a nurse who is a person trained and licensed in nursing matters and entrusted with the care of the sick and the carrying out of medical and surgical routines under the supervision of the
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doctor. In addition, the nurse is considered with the patients response to the problem, providing nurturing and protection in a way that promotes health (the Bantam Medical Dictionary, 2004). Nurses are also the front liners when it comes to the delivery of health services to the patient, they are duly exposed to different microorganisms may it be harmful or not.

On the chain of infection, the nurse may become the susceptible host, the carrier and the vector. Upon the nurses exposure to the patient carrying the infectious agent, if they did not use any standard precaution even performing hand washing before and after handling the patient, the infectious agent can penetrate bodys defenses and will then enter the bodys system. If the hosts immune system is low, it will eventually result them acquiring the same disease that the patient has. In that way, the nurse may become the susceptible host, and if acquired the same disease and carries the infectious agent capable of transmission to other patient, she becomes the carrier. On the other hand, the nurse may also bring along the infectious agent through the clothes used, the devices and instruments used and even the own hands. Hands serve as a vehicle in transmitting the infectious agent from one patient to another.

Nosocomial infection is a result of improper and handling and control of the spread of the infectious agents. In Laymans term, it is referred to as hospital acquired infection. This is a result when hospital personnel become complacent of their jobs and do not practice hand washing correctly and regularly.

In U.S. hospitals today, hand washing is still the exception rather than the rule. Most studies agree that between 40 to 60% of all doctors and nurses fail to wash their hands between patients. Low-level compliance with hand hygiene is particularly poor in ICUs, where studies show that compliance does not exceed 40%. (Americans Mad and Angry)

Haley 1985 stated that in acute-care hospitals in United States in1976, an estimated 2.1 million nosocomial infections complicate the 37.7million admission, for a nationwide infection rate of 5.7 nosocomial infection cases per 100 admissions Based on consecutive estimates of the extra days and hospital charges attributable to these infections, complications, nosocomial infections added over 7.5 million extended hospital care in 1976. There has been little agreement over what proportion over theses infections can be prevented.

Thoburn and Haley (1985) estimated that 100 out of 2500 admissions a month developed nosocomial infections and that 1 out of every 1500 patients are admitted to the hospitals.

Nosocomial infections are considered as one of the challenges of every hospital which can be prevented through the education of health care professionals particularly doctors and nurses.

The study done by Orencia (1984) revealed the 0.89 % cases out of the 100 discharges in St. Lukes Hospital developed nosocomial infections. The urinary tract respiratory tract and surgical wound were the prevalent sites of infection.

While the study done by Basa (1984) at the Cebu Velez General Hospital showed 1.6% of nosocomial infection varied from hospital to hospital. This could be attributed to the fact that probably bigger medical centers on hospitals admit more serious and critically ill patients.

As stated above, the bigger the hospitals and utmost number of nurses then the higher the possibility of spread of infection. Thus, ill patients prefer to go in a bigger hospital for a better treatment.
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According to Vegas (1993), excess length of hospital stays and associated costs were assessed in patients hospitalized in the department of general and digestive surgery who acquired nosocomial infections.

Superficial surgical wound infection prolonged the average hospital stays of the nosocomially infected patients by an average of 12.6 days, wound infection (deep and superficial) by 14.3 days and infections other than wound infection by 7.3 days.

Patients with superficial surgical wound infection with minor cuts will prolong the patients stay in the hospital. Having said that, the more opening is being exposed the higher the risk of infection to nosocomially infected patients.

Zacarias et al (1983) conducted a study on the nosocomial infection in Sto. Tomas University Hospital from December 1982 to February 1983, both at the Private and Clinical Division and the results showed that 2.15% of the patients discharged developed nosocomial infection.

As stated above, both Private and Clinical Division patients that are being discharged developed nosocomial infection due to prolonged stay in the hospital.

Since hospitals have been the most entrusted institution for the delivery of medical care and treatment to the ill and injured, it is the responsibility of the nurses as part of the institution, to directly educate not only for themselves regarding good health practices but also to the patients family as well as to the other health care providers. The ownership of the hospital is also considered a factor in the efficiency of services rendered by the health care providers.
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The government controlled hospitals, known as the public hospitals are financed through the taxes paid by both national and local levels and health services are given for free by health care providers such as nurses. The non-government controlled hospitals or also referred to as private hospitals are market oriented and all the health care services are paid by the patient according to the services being utilized. On Philippine settings, services are well provided to patients from the private hospitals than in public hospitals. These may be due to inadequacy of health facilities and personnel, the large volume of patients admitted to public hospitals, the strict implementation of hospital rules and even the dissatisfaction of nurses when it comes to the services they render, thus, resulting them losing their interest in their job and unable to perform their job efficiently. As a result of this, the nurse may take for granted even the simplest procedure that he or she can perform to control the spread of infection, the practice of hand washing before and after dealing with the patient.

According to Amednews.com, Sample steps can protect patients, a new study says. But some physicians say quality metrics encourage antibiotic use and increase the number of infections.

Preventive measures must be practiced by all health care providers to esure he quality of the health services they render. As discussed in the article about Preventive measures shown to cut hospital C. Diffrates on the Amednews.com, "Often the trash can in the patient room was in the back near the window, and if you took off your gown and gloves, you could potentially recontaminate yourself. Now we always have the can at the door," said Mark Mellow, MD, lead author of the study and director of the Integris Digestive Health Center. "Now we also make the sink easily accessible, so people wouldn't have excuses for not cleaning."

But because of continuous attitude of being complacent of some health care providers, it was also stated by PPI prescribing, "It's been a hard habit to break".

As stated by Pittet in his article, hand hygiene prevents cross-infection in hospitals, but health-care workers' adherence to guidelines is poor. Easy, timely access to both hand hygiene and skin protection is necessary for satisfactory hand hygiene behavior. Alcohol-based hand rubs may be better than traditional handwashing as they require less time, act faster, are less irritating, and contribute to sustained improvement in compliance associated with decreased infection rates. This article reviews barriers to appropriate hand hygiene and risk factors for noncompliance and proposes strategies for promoting hand hygiene. . According to Kozier, hand washing is considered the most effective infection control measure. Instead of spending another set of antibiotic therapy, lengthening the time being admitted to the hospital and even risking the patients life, hand washing is a good preventive measure to lessen the risk of acquiring nosocomial infection and lighten the burden carried by the patient and its family.

An ounce of prevention is worth a pound of cure- Benjamin Franklin

As discussed in Wikipedia, hand washing frequently is called the single most important measure to reduce the risk of transmitting skin microorganisms from one person to another or from one site of infection to another. Washing hands as promptly as thoroughly as possible between patient contacts and after contact with blood, body fluids, secretions, excretions and equipment or articles contaminated by them is an important component of infection control and isolation precautions. The spread of nosocomial infections among immunocompromised patients is connected
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with health care workers hand contamination in almost 40% cases and it is really a challenging problem.

With all these, the researchers decided to conduct a research on the practice of hand washing among nurses in wards of Dr. Jose N. Rodriguez Memorial Hospital to lessen the risk and in the future to probably eliminate the occurrence of nosocomial infection in the hospital through the help of nurses, the administration of the hospital and this research. Since the occurrence of nosocomial infection is preventable, it is in the nurses and other health workers hands to control the risk of the occurrence of these hospital acquired infections. At the same time, as researchers and future nurses, it is the responsibility to be able to be educated not only the researchers but also the patients and their families.

Statement of the Problem The main objective of this study is to determine the preventive measures practiced to control the spread of nosocomial infection among nurses. Specifically, the research will answer the following questions: 1. How may the demographic profile of the respondents may be described in terms of: 1.1. 1.2.
1.3.

age, gender, ward assignment, and length of nursing service? What are the most common nosocomial infections?

1.4. 2.

3.

What is the level of awareness of nurses towards the preventive measures in nosocomial infection?

4.

Is there a significant relationship between the demographic profile of the respondents and the preventive measures in the control of nosocomial infection?

Hypothesis There is no significant relationship between the common nosocomial infections measures and the level of awareness of nurses towards the preventive in the control of nosocomial infections.

There a significant relationship between the common nosocomial infections and the level of awareness of nurses towards the preventive in the control of nosocomial infections. measures

There is no significant relationship between the demographic profile of the respondents and the preventive measures in the control of nosocomial infection. There is a significant relationship between the demographic profile of the respondents and the preventive measures in the control of nosocomial infection.

Significance of the Study The study is beneficial to the following:

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Patients.

To lower down the risk of acquiring nosocomial infections and if

they found out that nurses at Dr. Jose N. Rodriguez Memorial Hospital are following the said precautionary measures promptly, they will be assured and satisfied to the quality of nursing care being rendered. To also minimize the hospitalization time, to maximize the patients time for work and his family, to decrease disability, discomfort and prevent the loss of life. Nurses. The result of this study will help the nurses at Dr. Jose N.

Rodriguez Memorial Hospital on their awareness on the preventive measures to control the spread of nosocomial infections. If found out that they do not practice any preventive measure, it should then be converted into a hospital protocol to ensure the quality of care provided by nurses in wards as well as it can also help them prevent from acquiring the infections form their patients. In the other hand, if the nurse promptly observed the different preventive measures, they will just continue what they are doing Hospital Administration. The study will provide a basis to improve the quality of health care services provided by the hospital, the reliability and it will attract more people to go into this institution, it will increase the financial state of the whole hospital. Moreover, this will serve as a tool for the development of effective measures designed to control the risk of acquiring nosocomial infection. Health Care Professionals. To ensure the quality of their services and to be able to effectively reach out to their patients needs. Nursing Schools. This will help for the early strict implementation of the hospital rules such as hand washing to their students who are taking up the course for the assurance of the quality of nursing care provided by their students. Researchers. This will serve as a tool for the awareness and continual practice of hand washing as the researchers go along with their duties as future health care providers. Future Researchers. This will serve as a basis of conducting a research if there are changes in occurrence of nosocomial infection may it be in this hospital or to another.
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Scope and Limitation of the Study This study is conducted to determine the practice of preventive measures to control acquiring nosocomial infections. Specifically, this aims to find out if hand washing is still being practiced by nurses before and after dealing with patients. At the same time, it discusses the four most common types of nosocomial infections. It does not discuss further the different nosocomial infections cures. The study will be conducted from July 15, 2011 September 29, 2011. Finally, this study would also like to find out if there is a significant relationship between the common nosocomial infections and the level of awareness of nurses towards the preventive measures in the control of nosocomial infections and the significant relationship between the demographic profile of the respondents and the preventive measures in the control of nosocomial infection. Data gathering will commence on the third week of September 2011 at Dr. Jose N. Rodriguez Memorial Center in Tala, Caloocan City.

Definition of Terms In order to understand some of the terminologies used in the study, the researchers define them operationally. Chain of Infection is a process where an infection starts and ends. Cross Contamination is a process acquiring a disease from one person to another. Hand washing is a procedure where a person washes his or her hands to minimize the microorganisms that are present. Hospice of Care a place in history where the soldiers who are injured from the battle are taken care of by the nurses and other health care providers.

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Infectious agents are microorganisms which can cause illness and disease in the body. Intravascular Injection is medical procedure wherein medications are administered diectly into the patients vein. Nosocomial infection is an infection that is acquired by the patient within the hospital stay. Nosocomial Pneumonia is an infection of the lung that can be caused by nearly any class of organism known to cause human infections and is acquired in the hospital within 48 hors after admission. Preventive Measures is a practice to prevent, minimize or even eliminate he occurrence of diseases. Standard Precaution is a preventive measure used to prevent acquiring illness by using gloves, mask, and washing hands. Urinary Tract Infection is an infection that affects the urinary tract that occurs in he hospital because of the unsterile use of catheter.
Wound Infection is an infection on the surgical site due to deposition and

multiplication of microorganisms in the surgical site of a susceptible host .

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Chapter 2 REVIEW OF RELATED LITERATURE This chapter contains a compilation of materials such as local and foreign books, theses dissertations and periodicals that have a direct bearing on this study. The following are summaries of the findings, excerpts, principles and concepts.

Related Literature

In the history of nursing practice, Florence Nightingale and her nurses transformed the military hospitals by setting up sanitation practices such as hand washing and washing clothes regularly. Nightingale is credited to with performing miracles; the mortality rate in the Barrack Hospital in Turkey, for example, was reduced from 42 to 2 percent. (Donahue, 1196, p.197)

Since then, hand washing has already been considered a preventive measure among medical staff to control the occurrence of nosocomial infection.

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Nosocomial infection, this term is originated from a Latin word nosoconium meaning hospital. It is synonymous to hospital acquired infections. It is an infection acquired 48 hours after the admission in the hospital and developed after discharge within 24-48 hours (Philippine Hospital Infection Control Society, Inc. undated)

Chow (1980) defined nosocomial infection as infection not present or inhibiting at the time of hospital admission. When the incubation period is known, an infection is generally considered nosocomial if it becomes apparent 48 or 12 hours after the patient is hospitalized.

The concept of nosocomial infection is sometimes expanded to include other health care-associated infections, including those acquired in institutions other than acute care facilities (e.g. nursing homes); infections acquired through outpatient care such 2008) as day surgery, dialysis, or home parental therapy (http://www.infectioncontroltoday.com/articles/351clinical.html,retrieved May 8,

There are two special situations in which an infection is considered nosocomial (a) infection that is acquired in the hospital but does not become evidence until after hospital discharge and (b) infection in a neonate that results from the passage through the birth canal (Garner, 1996)

There are also two special situations in which an infection is not considered nosocomial: (a) an infection that is associated with a complication or extension of infection already present on admission, unless a change in pathogen or symptoms strongly suggests the acquisition of a new infection, and (b) in an infant, an infection that is known or proven to have been acquired transplacentally (e.g. toxoplasmosis, rubella, cytomegalovirus, or syphilis) and become evident at or before 48 hours after birth.
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There are two conditions that are not infections: (1) colonization, which is the presence of organisms (on skin, mucous membranes, in open wounds or in excretions or secretions) that are not causing adverse clinical symptoms , and (2) inflammation, which is a condition that results from tissue response to injury or stimulation by non infectious agents, such as chemicals.

Two additional definitions points are important to understand with regard to the definitions of nosocomial infections. First, the preventability or inevitability of an infection is not a consideration when determining whether it is nosocomial or not. For example, preventing the development of nosocomial infection Clostridium deficile gastroenteritis after extensive antibiotic treatment may not be possible.

Some medical practitioners argue that neonatal infections acquired during vaginal delivery are inevitable and therefore, should not be counted as nosocomial. However, these neonatal infections (e.g. group B Streptococcal bacteremias with early onset) are considered nosocomial because they can be identified as maternally acquired and the analysis of their incidence can be disseminated to obstetricians for interventional strategies. Surveillance definitions are not extended to define clinical diseases for the purpose of making therapeutic decisions. Some true infections will, therefore, be missed while other conditions may erroneously be counted as infections. (CDC definitions for nosocomial infections, 1996)

Hospital acquired infections constitute a significant problem throughout the world. Hospital acquired or nosocomial infections contribute a significant medical, social, and economic problem in both developed and developing countries, causing morbidity, mortality, and extended hospital stays. In the developing world, the methods employed to tackle such infections should not simply copy those employed in developed countries because of the different economic and cultural contests. (World Health Forum)
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A study was done by Infection Control Committee of the Philippine General Hospital where determined the prevalence of nosocomial infection in each department, the wards and the higher units, to identify the microorganisms present in the area. Sites of infections and antibiotic resistance patterns were also studied. Also revealed in the study the following microorganisms from the patient with nosocomial infection: Pseudomonas aureginosa, klebsiella species, acinobacter bacteria, E. coli, Anterobacter species and Staphylococcus epidermis, Staphylococcus aureus and Staphylococcus saprophylisus. Esguerra (1982).

All hospitals in the Philippines are a risk of acquiring nosocomial infections and nurses and other health professionals are duly exposed to the different infectious agents.

The incidence of nosocomial infections in various hospitals in the Philippines ranges for 3 to 15 %, on rare occasion maybe as high as 25%. This variation probably reflects the effectiveness of infection control problem, compliance of hospital personnel, and the accuracy of the surveillance which is conducted. (Limason, 1985)

Kroper (1993) in his study revealed that Pseudomonas aureginosa and Staphylococcus aureus colonization rate on admission were 5% and 36.5% respectively. Only 10 patients (6.5%) were colonized with Pseudomonas auroginosa during hospitalization, and only 7 patients acquired Staphylococcus aureus in the special intensive care unit. Pseudomonas auroginosa is a common bacterium that can cause disease in humans. Thus, when these bacteria settle to patients it has a higher cause of hospitalization.

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Factors promoting nosocomial infections shows there are age, duration of hospitalization, surgery. (Control Society, incorporated, undated)

Among bacterial hospital acquired infections, bacteremias and surgical site infections were most common in infants younger than two months than in older children. However, urinary tract infections were reported more frequently in children older than 5 years in younger children.

Medical care for patients with nosocomial infections. Symptomatic treatment of shock, hypoventilation and other complications should be provided along with the administration of empiric broad spectrum antimicrobials, antifungals and antivirals.

Infections caused by methicillin resistant Staphylococcus aureus (MRSA) are not worse that those caused by susceptible strains of Staphylococcus aureus, MRSA strains that carry the loci for Panton valentine leukocidin can be hypervirulent and can cause lymphonemia, rapid tissue necrosis, and severe sepsis. (http://www.emedicine.com/ped/topic1619.html, retrieved May 15, 2008)

In the prevention and control of nosocomial infections, Backford-Ball and Hainsworth (2004) published an article on the control and prevention of hospitalacquired infections at Nursing Times.net. They cited the work of Agliffe et al (2000), on the basic principles of infection control by treating infections and decontamination process and procedure; prevention of the transfer with good hand hygiene, aseptic procedures and appropriate isolation, enhancement of resistance with good nutrition and appropriate implementation of antibiotic prophylaxis or vaccination.

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Hospitals

have

sanitation

protocols

regarding

uniforms,

equipments

sterilization, washing and other preventive measures. Thorough hand washing and/or use of alcohol rubs by all medical personnel before and after each patient contact is one of the most effective ways to combat nosocomial infections. More careful use of antimicrobial agents, such as asantibiotics, is also considered vital.

But in the Philippines, not all hospitals observe sanitation protocols due to lack of hospital employees to monitor and supervise the quality of the services they render.

Despite sanitation protocol, patients cannot be entirely isolated from infectious agents. Furthermore, patients are often prescribed antibiotics and other antimicrobial drugs to help treat illness; this may increase the selection pressure from the emergence of resistant strains.

Hand washing frequently is called the single most important measure to reduce risks of transmitting skin microorganisms from one person to another or from one site to another on the same patient. Washing hands as promptly and thoroughly as possible between patient contacts and after contact with blood, body fluids, secretions, excretions and equipment or articles contaminated by them is important component of infection control and isolation precautions. The spread of nosocomial infections among immunocompromised patients is connected with health care workers hand contamination in almost 40% cases and it is a real challenging problem in the modern hospitals. The best way for health workers to overcome this problem is acting right hygiene procedures, this is why the WHO launched in 2005, the GLOBAL patient safety challenge.

Two categories of microorganisms can be present on health care workers hand: transient flora and resident flora. The first one is represented by the
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microorganisms taken by the health care worker from the environment, and the bacteria in it capable of surviving on human skin and sometimes to grow. The second group on the other hand, is represented by the permanent microorganisms that lived on the skin surface (on the stratum corneum or immediately under it). They are capable of surviving on the human skin and to grow freely on it. They have low pathogenicity and infection rate, and they create a kind of protection from the colonization from other more pathogenic bacteria. The microorganisms creating the resident flora are: Staphylococcus aureus, Staphylococcus hominis, Micrococci, Propionibacterium, Corynebacterium, Dermobacterium, pitosporum, while in the transitional could be found Staphylococcus aureus, Klebsiella pneumoniae, Acinobacter species, Enterobacter species, Enterobacter species, and Candida species.

The goal of hand hygiene is to eliminate the transient flora with a careful and proper performance of hand washing, using different kind of soap, from the normal one to the antiseptic and alcohol based gel. The main problems found in the practice of hand hygiene are connected with the lack of available sinks and time consuming performance of hand washing. An easy way to resolve this problem would be the use of alcohol based hand rub, because of its faster application compared to a correct handwashing. (Wikipedia)

Hand washing theory is the teaching, as opposed the practice, of the first line of defense against cross contamination of pathogenic microorganisms. The U.S. Center for Disease control maintains that hand washing is one of the most effective means of preventing the spread of disease. Beginning in the 1800s, medical professionals began to implement hand washing rules, which largely reduced in stay hospital fatality counts. In modern times, hand washing is still a critical element of proper hygiene. Cross contamination is still largely to blame for food borne viral infections and cases of hospital disease transference. (Ehow Health)

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The term hand hygiene includes several actions intended to decrease colonization with transient flora. This objective can be achieved through handwashing or hand disinfection. Handwashing refers to washing hands with an unmedicated detergent and water or water alone. Its objective is to prevent cross-transmission by removing dirt and loose transient flora. Hygienic handwash refers to the same procedure when an antiseptic agent is added to the detergent. Hand disinfection refers to use of an antiseptic solution to clean hands, either medicated soap or alcohol. Some experts refer to the action of "degerming" as the use of detergentbased antiseptics or alcohol. Hygienic hand rub is rubbing hands with a small quantity (2 mL to 3 mL) of a highly effective, fast-acting antiseptic agent. If hands are known to be or suspected of being contaminated, transient flora must be eliminated by washing or disinfecting the hands to render them safe for the next patient contact. Plain soap with water can physically remove a certain level of microbes, but antiseptic agents are necessary to kill microorganisms. Hand antiseptic agents are designed to rapidly eliminate most transient flora by their mechanical detergent effect and to exert an additional sustained antimicrobial activity on remaining flora. The multiplication of resident flora may be retarded as well, so that hand disinfection may be useful in situations in which microbiologically clean hands are required for extended periods.

Rotter showed that hand hygiene with unmedicated soap and water removed some transient flora mechanically; preparations containing antiseptic or antimicrobial agents not only removed flora mechanically but also chemically killed contaminating and colonizing flora, with long-term residual activity.

Prevention of bacterial contamination and subsequent infection requires timely hand cleansing. Guidelines have delineated indications for hand cleansing but without reliance on evidence-based studies of microbiologic contamination acquired during routine patient care. To provide such evidence, we studied the dynamics of bacterial contamination of health-care workers' hands in daily hospital practice. Our
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findings Control)

should

help

identify

patient-care

situations

associated

with

high

contamination levels and improve hand cleansing practices. (Center for Disease

Washing the hands with soap penetrates some of the pathogenic material on the hands and kills some germs. Soap loosens the germs from the surface of the hands to assist the hand washing process. Merely rinsing the hands without using soap does not suffice. The Center for Disease Control does not recommend one type of soap over another.

Water rinses away the loosened germs on the hands. It is not possible to wash hands with water that is hot enough to kill germs because this would create severe burns to the skin. Soap and hand scrubbing together, loosen the germs and dirt. Water that is warm in temperature aids in the process of removing the germs. Effective hand washing involves the vigorous rubbing of the hands together, creating a friction that further kills germs while loosening them from the surface of the hands. A portion of hand washing should include interlocking the fingers together to rid the crevices between the fingers of germs. A fingernail cleaning brush used during the hand washing process will remove bacteria lodged underneath the nails. Sanitize the fingernail brush with alcohol prior to use. After washing your hands, do not turn the water faucet off directly with your hand. Proper hygiene involves the use of a sanitary towel held between the skin and the faucet handle to avoid germ transference when turning off the water. Healthcare workers must always wash their hands before dealing with each patient.

According to Pittet, several barriers to appropriate hand hygiene have been reported. Risk factors for noncompliance with hand hygiene have been determined objectively in several observational studies or interventions to improve compliance. Factors influencing reduced compliance, identified in observational studies of hand hygiene behavior, included being a physician or a nursing assistant rather than a nurse; being a nursing assistant rather than a nurse; being male; working in an
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intensive care unit (ICU); working during weekdays rather than the weekend; wearing gown and gloves; using an automated sink; performing activities with high risk for cross-transmission; and having many opportunities for hand hygiene per hour of patient care.

Reasons reported by health-care workers for the lack of adherence with recommendations include skin irritation, inaccessible supplies, interference with worker-patient relation, patient needs perceived as priority, wearing gloves, forgetfulness, ignorance of guidelines, insufficient time, high workload and understaffing, and lack of scientific information demonstrating impact of improved hand hygiene on hospital infection rates.

Additional barriers to hand hygiene compliance include lack of active participation in promotion at the individual or institutional level, of a role model for hand hygiene, of institutional priority assigned to hand hygiene, of administrative sanctions for noncompliance; and of an institutional climate encouraging safety. Lack of scientific information on the definitive impact of improved hand hygiene on hospital infection rates has been reported as a possible barrier to adherence with recommendations. Hospital infections have been recognized for more than a century as a critical problem affecting the quality of patient care provided in hospitals. Studies have shown that at least one third of all hospital infections are preventable. A substantial proportion of infections results from cross-contamination, and transmission of microorganisms by the hands of health-care workers is recognized as the main route of spread. Seven quasi-experimental hospital-based studies of the impact of hand hygiene on the risk of hospital infections were published from 1977 to 1995. Despite limitations, most reports showed a temporal relation between improved hand hygiene practices and reduced infection rates. We recently reported the results of a successful hospital-wide hand hygiene promotion campaign, with emphasis on hand disinfection, which resulted in sustained improvement in compliance associated with a significant reduction
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in hospital infections and methicilllin-resistant Staphylococcus aureus crosstransmission rates over a 4-year period. The beneficial effects of hand hygiene promotion on the risk of cross-transmission have also been reported in surveys conducted in schools, day-care centers, and a community. Although additional scientific and causal evidence is needed for the impact of improved hand hygiene on infection rates, these results indicate that improvement in behavior reduces the risk of transmission of infectious pathogens. (Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach by Didier Pittet)

If hand washing will strictly be implemented by the hospital and nurses conscientiously follow it, the rate of occurrence of nosocomial will be reduced or totally eradicated.

Theoretical Framework This study is greatly influenced by the Germ Theory of Ignaz Semmelweis. Germ Theory is the concept that microorganisms can cause disease, and this theory is the foundation of modern medicine (Experiment-Resources.Com) Semmelweis' germ theory was introduced when Semmelweis saw a connection between puerperal fever and disinfected hands of the hospital staff. During his job at the hospital, Semmelweis closely concerned himself with the study of puerperal fever causing high maternal and neonatal mortality. The Vienna General Hospital operated two maternity clinics the first clinic and the second clinic
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for different classes of patients. The treatment was given by the medical students and midwives in the first and the second clinic respectively. He observed that the death rate in the first obstetrical clinic was 13.10%; much higher than the 2.03% death rate in the second clinic. However, there were no explanations for the high contrasting statistics and several mysterious causes were attributed towards the disease.

During a research on the autopsy of his friend who died because of a fatal dissection wound, Semmelweis noticed symptoms similar to those of childbed fever. This observation prompted him to connect cadaveric contamination with puerperal fever. Soon after he declared that medical students carried infectious substances on their hands from dissected cadavers to the laboring mothers. This also provided the logical explanation for a lower death rate in the second clinic, operated by midwives because they were not involved with autopsies or surgery.

Semmelweis discovered that puerperal sepsis (a type of septicaemia) commonly known as childbed fever in new mothers could be prevented if doctors washed their hands. Based on his analysis, he established a simple but revolutionary prophylaxis system in 1847. He insisted upon the use of chlorinated lime solutions for handwashing by medical students and doctors before they treated obstetrical patients.

The application of his method instantly reduced the cases of fatal puerperal fever from 12.24% to 2.38%, while in some months there were no deaths from childbed fever at all. Besides the hands, he initiated using preventive washing for all instruments making contact with the patients which literally removed puerperal fever from the hospital. This was the beginning of an antiseptic era. (Microbiology @ suite 101)

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In connection to the study, if nurses will practice hand washing, here will be a great risk of the occurrence of hand washing in the wards of the hospital.

This study is also influenced by the idea of Florence Nightingales Environmental Model.

Florence Nightingale, often considered the first nurse theorist, defined nursing more than 100 years ago as the act of utilizing the environment of the patient to assist him in his recovery (Nightingale, 1860/1969). The environmental theory by Florence Nightingale includes the following components: First in the Health of Houses. Nightingale discussed the importance of the

health of houses as being closely related to the presence of the pure air, pure water, efficient drainage, cleanliness and light. To support the importance of hospital based nursing attending to these. Nightingale said Badly constructed houses do for the healthy what badly constructed hospitals do for the sick. Once the air is stagnant, sickness is certain to follow Nightingale also noted that the cleanliness outside the house affects the inside. Just as she noted that garbage begins affected the health of houses in her time, so too can modern families be affected by toxic waste, contaminated water and polluted air. The second is Ventilation and Warning. Nightingale emphasized that it is essential to keep the air the patient breathes as pure as the external air, without chilling him. The caregiver most consider the source of the air in the patients room. The air might be full of fumes from gas, mustiness of open sewage if the source was not the freshes. Nightingale believe that the person who repeatedly breathed his or her own air would become sick or remain sick. Nightingale was very concerned about noxious air or effluvia or foul odors that came from excrement. In many public places as well as hospitals, raw sewage could be found near patients, in articles under or near the house, or contaminated drinking water. She concerns about effluvia also included bed pans, urinals and other utensils use to discard excrement.

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She also criticized fumigations for she believe that the offensive source, not the smell must be removed. ***

These environment factors attain significance when one considers that sanitation conditions in the hospitals of the mid 1800s were extremely poor and that women working in the hospitals were often unreliable, uneducated, and incompetent to care for the ill. In addition to these factors, Nightingale also stressed the importance of keeping the client warm, maintaining a noise-free environment, and attending to the clients diet in terms of assessing intake, timeliness of the food, and its effect on the person.

Nightingale set the stage for further work in the development of nursing theories. Her general concept about ventilation, cleanliness, quiet, warmth and diet remains an integral part of nursing and health care today. (Kozier, 2004)

Profile of respondents: Awareness of If cleanliness cannot be practiced in the hospital, cleanliness staff equipment the in the and Age, gender, ward and proper hand hygiene within the nurses and other health staff, nosocomial administration assignment, infection will arise. on the risk of position in hospital Questionnaires acquiring hospital, length of , interviews nursing service. nosocomial Ways how nurses Input practice handwashing Duration of performing handwashing by the nurse. Reasons why they cannot perform handwashing Tes of significant relationship of hand washing to nosocomial infection

and direct Process observation of the nurses in wards of the hospital to be able to know if they are practicing hand washing as a preventive measure for nosocomial infection.

infection in Output their hospital.

Implementati on of a program related to the promotion of nosocomial infection control in the hospital.

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Figure 1 Research Paradigm Figure 1 above shows the relationship between the practice of hand washing and the control of the risk of acquiring nosocomial infection. The first box shows the different factors interconnected to the nurses performance of hand washing. The second box is the list of methods on how the researchers, the nurses and its administration will find out if their hospital is already at risk of acquiring nosocomial infection through the nurses not practicing hand washing. The third box is the goals of this research.

Patient A carrying the infectiuos agent

Transmission of infectious agent through the nursess hands

Nurse who did not wash hands touches patient B becomes at risk for nosocomial Patient B affected infection. by infectious agents fully acquired infection within the hospital stay.

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Figure 1.2 shows the process of acquiring nosocomial infection from the carrier to the susceptible host. Box 1 shows that the carrier is the patient A. in example, patient A carries staphylococcus aureus from the open superficial wound. The nurse performs wound dressing however, there are a lot of patients in the ward. Since she is the only available nurse duty, she needs to attend to other patients needs even without washing her hands. The infectious agent from patient A will transferred directly to patient B. Patient B fully acquires the infection during his hospital stay.

Conceptual Framework

The source of nosocomial infection is the improper handling of soiled materials as well as the health care providers complacent behavior of not practicing hand washing in the control of nosocomial infection in wards, the reason may be acceptable or not.

Based on the previous discussions that reveal the different causes and effects of acquiring nosocomial infections, this succeeding conceptual planning was drawn. All health care providers, personnel and all the individuals who maintain the contact with patient particularly the nurses since they are the focus of this study should have the responsibility to maintain the cleanliness by contentiously practice the Standard Precautionary Measures such as proper hand hygiene before and after dealing with the patients to ensure the control of the risk of acquiring nosocomial infection, and everyone should have a knowledge of the six chain of infection and how to break the link. Since nurses are the ones who provide the bedside care to their patients and

29

who have the responsibility in providing health education to the patient and its family, thus the focus of this study is about nurses.

Through this study, the researchers would like to evaluate if nurses still nowadays practice hand washing as a part of their routine. Therefore the researchers would like to investigate the factors that hinder the nurses from practicing this nosocomial infection control procedure that will serve as a basis for the proposal of a program.

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Chapter 3 RESEARCH METHODOLOGY This chapter presents the research method used in the collection and gathering of data, the respondents of the study, the sources of data and the statistical treatment of data.

Research Design The descriptive method will be utilized in the study. Calderon and Gonzales (2004) states that descriptive method is concerned with state of relationship that exist, practices that prevail, effects that are being felt or trends that are being developed. Descriptive research design portrays characteristic of persons, situations or groups and the incidence with certain phenomena occur. The study determines the practices of nurses towards the prevention of nosocomial infection this method gave the researchers the opportunity to discover and analyze the relationship of the above mentioned variables using appropriate statistical procedure.

This is the best method to be used according to Calmorin-Piedad. Particularly, the descriptive-evaluative is the most appropriate method on the inquiry about the present status of the hospital and nurses when it comes to the contentious
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practicing of hand washing as a control measure for the control of the risk of acquiring nosocomial infection in the wards of the hospital. Concepts and procedures of general description, analysis and classification are discussed and illustrated in considerable details. This study tends to use both qualitative and quantitative analysis of inquiry such as the present investigations.

Qualitative analysis of this study includes the examination of articles, journals, published and unpublished thesis and other documents. Interview and observation of nurses if they really practice hand washing to control the risk of acquiring nosocomial infection will also be conducted to support the validation of the data gathered. To gather more valid information, the researchers will also conduct a Quantitative analysis through survey questionnaire to be able to identify each of the respondents idea as well as knowing if the entire institution has a high or low risk of acquiring nosocomial infection through the nurses answers to the researchers inquiry.

Sampling Technique The non-probability sampling is the technique used by the researchers in taking the sample in this study. This does not offer fair opportunity to each member of the population to be induced in this study.

The

researchers

will

use

the

purposive

sampling.

According

to

ChangingMinds.com, purposive sampling starts with a purpose in mind and the sample is thus selected to include people of interest and exclude those who do not suit the purpose. Since the nurses are the respondents of the study, *****

Instrumentation
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Questionnaire The researchers will use questionnaire to justify the idea of the Part I Civil status, age and length of nursing service. Part II will deal on their practice of hand washing to control nosocomial infection in wards of the hospital. The questionnaire as designed by the researchers will include items and ideas from books, journals, published and unpublished thesis, observation and interviews.

The questionnaire is composed of two parts. Part I will aim to gather information on the nurses personal data as to his/her name (optional), and ward assignment. The researchers will use descriptive value in answering the questionnaire.

4 3 2 1

Most Occurring Occurring Less Occurring Not Occurring

4 3 2 1

Highly Effective Effective Less Effective Not Effective

Validation of the Research Instruments The researchers researched the most appropriate instruments to be used to gather data from the respondents which are the following: questionnaire and interview guide. Thus the adviser requested us to submit the instruments the following week.

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Data Gathering Procedure

The researches went to different libraries to find books, thesis and journals about the topic in this study. The different data gathered was compiled and furthered researched and validated through the websites. The researchers planned on how to conduct the study in the location of choice. The following morning, the researchers visited the location, Dr. Jose N. Rodriguez Memorial Hospital. The researchers built the questionnaire that will be used for the data gathering from the respondents.

The data gathered based from the respondents response to the questionnaire and the researchers observation at the hospital serves as a basis for creating a conclusion and recommendations for improvement of the hospital policies.

Locale of the Study

The respondents who are involved in this study are from Dr. Jose N. Rodriguez Memorial Hospital.

Dr. Jose N. Rodriguez Memorial Hospital is a secondary hospital located at Tala, Caloocan City. It is a former sanitarium composed of 1,800 beds and in (year) it instituted a general medicine facility with 200 bed capacity. It is composed of different wards, namely Philhealth Ward, Male Medical Ward, Female Medical Ward, Male
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Surgical Ward, Female Surgical Ward, Pediatric Ward, Dengue Ward, Mother-Baby Friendly Ward, ICU, Infectious and Isolation Ward, Male Custodial Ward and Female Custodial Ward. It is composed of 74 nurses with two vacant positions, 14 are male and 60 are female. The researchers asked 29 respondents to answer questionnaires about the preventive measures in the control of nosocomial infection.

Statistical Treatment

Chapter 4 PRESENTATION, INTERPRETATION AND ANALYSIS OF DATA This chapter presents the research collected data, interpretation of the results and the analysis.

Table 1.1
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Frequency and Percentage Distribution of Respondents In Terms of Age

Age Interval 21-26 27-32 33-38 39-44 45-50 51-56 Total

Frequency 10 6 2 4 4 3 29

Percentage 34.48% 20.68% 6.89% 13.79% 13.79% 10.34% 99.97%

Table 1.1 shows that in terms of age out of 29 respondents there were 34.48 % between 21-36 years of age, 20.68 % between 27-32, for 39-44 and 45-50 there were 13.79% and 6.89 % for 33-38%. The result of the study shows that most of the nurses were between 21-26 years of age and the least would be from 33-38 years of age.

Table 1.2 Frequency and Percentage Distribution of Respondents In Terms of Gender

Gender Female

Frequency 16

Percentage 53.57% 36

Male Total

13 29

46.42% 99.99%

Table 1.2 shows that in terms of gender out of 29 respondents. The 53.57 % of the respondents are females and 46.42 % are males.

Table 1.3 Frequency and Percentage Distribution of Respondents In Terms of Ward Assignment
Ward Assignment PHW FMW PW ICU IIW ER OPD PEMAC DW Total Frequency 5 2 3 1 5 6 4 1 2 29 Percentage 17.24% 6.89% 10.34% 3.44% 17.24% 20.68% 13.79% 3.44% 6.89% 99.95%

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Table 1.3 shows that in term of ward assignment out of 29 respondents 20.68% were from Emergency Room, Infectious and Isolation ward there were 17. 24%, for OPD theres13.79%, for Pedia ward 10.34 %, FMW and DW theres 6.89% and the least would be PEMAC for 3.44 %. The result of this study shows that most of the nurses are from Emergency room and the least is PEMAC. Table 1.4 Frequency and Percentage Distribution of Respondents In Terms of Length of Service
Length in Service < 1 year 1-5 years 6-10 years 11-15 years 16-20 years 21-25 years Total Frequency 3 14 6 3 1 2 29 Percentage 10.34% 48.27% 20.68% 10.34% 3.44% 6.89% 99.96%

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Table 1.4 shows that in terms of length of service out of 29 respondents 48.27 % under 1-5 years in service, 20.68% under 6-10 years, for less than a year and 11-15 years of service theres 10.34 % and 3.44 % for the 16-20 years. The result of this study shows that most of the nurses are working in the hospital for 1-5 years and the least is 16-20 years. Table 2 Nosocomial Infection Nosocomial Pneumonia Urinary tract Infection Intravascular Infection Wound Infection Weighted mean 2.45 2.03 2.17 2.17 Verbal Interpretation Not occurring Most occurring Less occurring Less occurring Rank 4 1 2.5 2.5

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Table 2 shows the most common nosocomial infection in the hospital. For Nosocomial Pneumonia, 3% of the respondents answered it is the most occurring nosocomial infection. 52% answered it is occurring. 31% of the respondents answered it is less occurring and 13% answered it is not occurring. This result is also anchored in the study conducted by. For Urinary tract Infection,44% of the respondents answered it is the not occurring nosocomial infection. 24% of the respondents answered it is less occurring. 17% of the respondents answered it is the most occurring. While 13% of the respondents answered it is occurring. This result is also anchored in the study conducted by. For Intravascular Infection, 37% of the respondents answered it is less occurring nosocomial infection. 31% of the respondents it is not occurring,17% of the respondents answered most occurring. While 13% of the respondents answered occurring. This result is anchored in the study conducted by. For Wound Infection,44% of the respondents answered it is less occurring nosocomial infection. 37% of the respondents answered it is not occurring. 10% of the respondents answered it is most occurring. While 6% of the respondents answered it is occurring. This result is anchored in the study conducted by. The result shows that Urinary tract Infection is the highest risk of occurring nosocomial infection on the awareness of the nurses. While Nosocomial Pneumonia is the least occurring according to the awareness of nurses.

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Table 3 Preventive Measures Hand washing Use of protective gears Proper sanitation Controlling spread of infection Surveillance Sterilization of instruments Isolation of patients Personal hygiene Safe injection practices Cleaning hospital environment Disinfection of equipment
30 25 20 15 10 5 0 4 3 2 1

Weighted mean 4.0 3.793 3.793 3.655 3.62 3.62 3.62 3.793 3.759 3.689 3.410

Verbal interpretation Highly effective Highly effective Highly effective Highly effective Highly effective Highly effective Highly effective Highly effective Highly effective Highly effective Effective

rank 1 3 3 7 9 9 9 3 5 6 11

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Table 4.1

Age interval 21-26

f 4 12

5.38 20.62 1.45 5.55 0.62 2.38 0.21 0.79 0.21 0.79 0.21 0.79
0.21

X2 0.3539 3.6035 1.45 0.3788 0.2329 0.0607 2.9719 0.79 0.21 0.0558 0.21 0.0558
10.373 3

RT 26

Critical Value

27-32

0 7

33-38

1 2

39-44

1 0

45-50

0 1

51-56

0 1

total

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Table 4.2 Gender Male f 3 10 female 3 13 total 29 2.69 10.31 3.31 12.69 X2 0.0357 0.0093 0.0920 0.0076 0.0816 26 RT 13 Critical Value

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Table 4.3 Ward assignment PHW f 0 6 FMH 0 2 PW 0 3 DW 0 2 IIW 3 3 ER 2 3 OPD 1 3 ICU 0 1 PEMA 0 1 Total 29 1.24 4.76 1.45 5.55 0.62 2.38 0.41 1.59 1.24 4.76 1.03 3.96 0.62 2.38 0.21 0.79 0.21 0.79 X2 1.24 1.5376 1.45 2.2707 0.62 0.1615 0.41 0.1057 2.4981 0.6508 0.9135 0.2327 0.2329 0.0606 0.21 0.0558 0.21 0.0558 12.9157 1 1 3 5 6 2 3 7 RT 6 Critical Value

Table 4.4 Length of nursing service f X2 RT Critical Value

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<1 year

0 3

0.62 2.37 2.89 11.10 1.03 3.96 0.62 2.37 0.62 2.37 0.20 0.79

0.6200 0.1675 0.0042 0.0009 0.0009 0.0004 0.0609 0.0578 0.2329 0.0578 0.2000 0.0558 1.4591

1-5 years

3 11

14

6-10 years

1 4

11-15 years

1 2

16-20 years

1 2

21-25 years

0 1

total

29

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BIBLIOGRAPHY

Books Axhick, Karen J. and Yarbrough B., Infection Control: An Integrated Approach, Saint Louis CV Mosby Company Calmorin, Lurentina and Piedad, Ma. Lauremelch. Nursing Research, National Bookstore, 2008, 49 pp. Dubay E. and Rebecca G. Infection Prevalence and Control. 1973. Saint Louis: the CV Mosby Company Kozier, Barbara et al. Historical and Contemporary Nursing Practice, Fundamentals of Nursing: Concepts, Process and Practice, 7th ed. Pearson Education Incorporated, New Jersey, 2004, 3 pp. Smeltzer, Suzanne C. and Bare, Brenda G. Management of Patients with Dermatologic Problems, Medical and Surgical Nursing, vol. 2 10th ed., Lippincott, William and Wilkins, 2004
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The editors of Market House Books, LTD. The Bantam Medical Dictionary, 5th ed. Bantam Dell, A Division of Random House, Inc, New York, 2005 Venzon, Lydia M., Introduction to Nursing Research: Quest for Quality Nursing, C&E Publishing, Inc., 2004, 105 pp.

Journal Carrol, Patricia, Preventive Nosocomial Pneumonia, RN Vol.61, No. 6, June 1998. Chuan, Lee & Lam San, Infectious Exposures & the Health Care Worker in Southeast Asia, Journal on infection Control, Vol. 1 No. 1, 1998 Philippine Hospital Infection Control Society, Hospital Acquired Infection: Prevention and Control, 1995 Published Theses Cobacha-Balisado, Asuncion D., A thesis on the Practices of Nurses towards the Control of Nosocomial Infection at the Ospital ng Maynila Medical Center: An Assessment ,February 20, 2001, 8-11 pp. Frias, Jaul Grace A., RN, A thesis on the Implementation of Infection Control System by Nursing Staff at Teresita Lopez Jalandoni Provincial Hospital-San Augustin, Ilo-Ilo City, June 2007 Papa, Geldia T., RN, A thesis on the Evaluation of the Incidence of Nosocomial Infection and the Infection Control Program at the De La Salle University Medical Center, DLSU Aguinaldo, Dasmarinias, Cavite, May 1996 Unpublished Theses

Websites Americans Mad and Angry

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http://www.americansmadandangry.org/know-why_dont_doctors_wash.php
Amednews.com

http://www.ama-assn.org/amednews/2010/11/01/prsb1101.htm Center fo Disease Control http://www.cdc.gov/ncidod/eid/vol7no2/pittet.htm East Avenue Medical Center http://www.eamc.gov.ph/history Ehow Health http://www.ehow.com/about_5417834_handwashing-theory.html Enotes: Encyclopedia of Nursing and Allied Sources http://www.enotes.com/nursing-encyclopedia/nosocomialinfections Experiment-Resources.Com http://www.experiment-resources.com/semmelweis-germ-theory.html Infection Control Today http://www.infectioncontroltoday.com/articles/357clinical.html Microbiology @ suite 101 http://www.suite101.com/content/germ-theory-of-disease-a34391 Mosfield Ohio State University http://www.mosfield.ohio-state.edu/sabedon/bio/2053.html Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2631736/pdf/11294714.pdf Nosocomial Infections Update
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www.ncbi.nlm.nih.gov/pmc/articles/PMC2640303/pdf/9716961.pdf Scribd http://www.scribd.com/doc/44800919/Thesis-Prevention-of-Nosocomial-Infectionsas-Percieved-by-Staff-Nurses Web MD: Better information. Better Health http://www.webmd.com/nosocomialinfections Wikipedia http://www.wikipedia.com/nosocomialinfections Wikipilipinas http:// en.wikipilipinas.org/index.php?title=East Avenue Medical Center Utmb Health http://www.utmb.edu/Policies_And_Procedures/Departmental/Healthcare_Epidemiol ogy_Policies/PNP_034835

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