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Ministry of Higher Education and
Scientific Research
Baghdad University
Al Kindy College of Medicine
Perceptions of SeniorstowardNosocomial
Infections at College of Medicine-Babylon
A study Submitted to the department of Community Medicine in Al
Kindy College of Medicine, Baghdad University in Partial fulfillment of
the Requirement for the Degree of High Diploma in Medical Education
By
Kareem Abed Mobashr
MBChB
Supervised by
Assistant prof.
Mohammed Asaad Ibrahim
MBChB,FICMS/CM
Baghdad
2013 A.D1434Hejri
‫الر ِحيم‬
‫م ِن ََّ‬
‫س ِم ال ََّل ِه ََّ‬
‫الر ْح َ‬
‫ِب ْ‬
‫ِ‬
‫ََ‬
‫َ [‪]1‬‬
‫لق‬
‫ِي خ‬
‫الذ‬
‫بكَ َّ‬
‫ِ ر‬
‫ِاسْن‬
‫ْ ب‬
‫َأ‬
‫ْز‬
‫اق‬
‫َِّ‬
‫ْ‬
‫ََ‬
‫ََ‬
‫َأ‬
‫ْز‬
‫ٍ [‪ ]2‬اق‬
‫لق‬
‫ْ ع‬
‫ِن‬
‫ن ه‬
‫ِن‬
‫اْل‬
‫لق‬
‫خ‬
‫ْسَاَ‬
‫َ ْ‬
‫ََّ‬
‫لن‬
‫ِي ع‬
‫الذ‬
‫ُ [‪َّ ]3‬‬
‫َم‬
‫ْز‬
‫اْلَك‬
‫َر‬
‫و‬
‫بكَ ْ‬
‫َ‬
‫َُّ‬
‫ََ‬
‫ََّ‬
‫ها َلن‬
‫ِن‬
‫اْل‬
‫لن‬
‫ِ [‪ ]4‬ع‬
‫لن‬
‫ِالق‬
‫ب ْ‬
‫ْسَاَ‬
‫َ ْ‬
‫ن َ‬
‫ْ‬
‫َْ‬
‫ْ [‪]5‬‬
‫لن‬
‫يع‬
‫َ‬
‫صدق هللا العلي العظيم‬
‫سورة العلق(ا‪)5-‬‬
‫‪II‬‬
Supervisor’s certification
This is to certify that the preparation of this thesis
entitled:''Perceptions of Seniors toward Nosocomial Infections
College of Medicine- Babylon'' has been made by the student
Kareem Abed Mobashr under my supervision at the Department
of Community Medicine /Al-Kindy College of medicine, Baghdad
University. AS a requirement for the degree of High Diploma in
Medical Education.
Signature
Assistant prof.MohammedAsaad Ibrahim
MBChB,FICMS/CM
III
Committee Certification
We, the members of the examining committee certify this thesis
entitled "Perceptions of seniors toward nosocomial infections at
college of medicine-Babylon" was submitted by Kareem Abed
Mobashr in Al-Kindy college of medicine and after reading the
thesis and examining the student in its contents, it is accepted for
Diploma degree in medical education in
/ / 1434 ,
/ /
2013
(Head of examining)
(Member)
Professor Ibtesam Khalid Salih
Assistant Prof. Yousif Abdul Raheem
MBChB, PHDMBChB, FICMS/CM
Date
20
/ 10 / 2013
D ate
(Member)
20
/ 10 / 2013
(Supervisor)
Lect.Dr. Ahmed Abed Marzook
Assistant prof.MohammedAsaadIbrahim
MBChB,FICMS/CM
Date 20 / 10 /2013
Date 20 / 10 /2013
IV
Dedication
To my beloved family, friends and teachers
who supported me to accomplish this diploma.
To all people who believe that education does
not stop at any point of our life and learning is
infinity.
V
Acknowledgment
First of all, I would like to thank "Allah'' for inspiring me the strength, willingness
and patience to accomplish this work, and I pray that his blessings upon me continue
throughout my life. A special piece is to our God messenger Mohammed(
ṣallAllahuʿalayhiwa-’ālih - S.A.W.W).
My sincere appreciation goes to Assistant Professor Dr.sadiq Al-Mukhtar, Dean of
Al-kindy medical college, University of Baghdad for continuous supporting the
graduate students.
My sincere gratitude and deepest respect go to my supervisorAssistant prof.
Mohammed Asaad Ibrahim for his guidance, kindness, support and continuous
helpful advises throughout my study, his efforts is deeply appreciated.
My grateful thanks go to all members of community medicine department in Al
Kindy College to their efforts to implement and success of medical diploma.
I would like to express my sincere appreciation to my entire colleague of medical
diploma for their continuous helping and supporting me to accomplish this study.
Special thanks and respect to scientific and serious man who I met him in my life
Assistant Professor Dr. Yousif Abdul Raheem for his guidance, kindness, high ethics,
support and continuous helpful advises throughout my study, his effort was deeply
appreciated.
VI
Index
Supervisor’s certification …………………………..…III
Committee certification……………………………..…IV
Dedication ………………………………………………. V
Acknowledgement…………………………………….. VI
Abstract ………………………….…………………..…... 1
Introduction ………….………………………….…..…... 2
Objectives&aims of study …………………………....… 5
Literature Review ……………………………………...... 6
Methodology ………………….…………………………19
Results ………..………………..…………………...…....23
Discussion…………………………………………...….…31
Limitations……..……………...…………………...….…36
Conclusion ........................................................................ 37
Recommendations ……………………………………... 37
References.…….…………………………….…….……. 38
Appendix ((Questionnaire)) ………………….…….…... 43
VII
Abstract
Background: This survey assessed knowledge, attitudes and behaviors of
medical students toward nosocomial infections.
Methods: This is a cross-sectionalstudythat wascarried out on final year
medical (106)students from College of medicine, University of Babylon
(Babil-Iraq).An anonymousquestionnaire consisted of four sections, with 30
items. Students‘ knowledge section was designed to explore students'
knowledge toward nosocomial infections, while another section was
designed to gather information about student's behavior, to explore student
attitudes toward precautionary guidelines and perception of the risk of
acquiring HCAIs by multiples questions and to evaluate advising
information of some items on HCAIs for students. The Chi-square test was
used for significance, a P-value (<0.05) is considered statistically significant
and p<0.01 is considered highly significant.
Results:The study showedthe overall average of the medical students'
knowledge was (68.34%) about HCAIs, however, the knowledge regarding
specific areas was weak, particularly concerning the risk of transmission of
infection to the hospital personnel (41.5%) and stethoscope (43.86%) as a
potential source of infections. In general, their behaviors wereadequate
(69.38%)to reduce the risk of infections, whereas, wearing protective
materials when contact with patient sometimes were only (49.06%) of them
do that. Generally the attitudes werepositive (68.68%).Females had better
attitudes than males. Advising information about some items of HCAIs were
generally acceptable (50, 65%), however, they sometimes have just (39.62
%) been advised about safety (IV) inserted devices and have only (22.16 %)
been advised about Stethoscope cleaning.
Conclusions:The students have adequate knowledge, positive attitudes and
acceptable behaviors to reduce nosocomial infections; however,advising
information about some items of HCAIs was generally acceptable. These
findings emphasize the need of stressing on education about this sort of
infections in the health care curricula.
~1~
Introduction
2
Introduction
Health care-associated infections have long been recognized as crucial factors
bothering the quality and outcomes of health care delivery. "An infection is
considered nosocomial if it becomes evident 48 hours or more after hospital
admission or within 30 days of discharge following inpatient care" [1].
Healthcare-associated infections (HAIs) or nosocomial infections were not
present or incubating at the time of admission, comprise a significant burden of
illness[2].
HAIs are cause of a major and increasing morbidity and mortality in around
the World as well as US. The mortality rates of Healthcare-associated
infections (HAIs) are varying from 5% to 35% that making HAIs is among the
ten top leading cause of death.Nosocomial infection is an identified public
health problem world-wide with a prevalence rate of 3.0-20.7% and an
incidence rate of 5-10 %[3, 4].
All admissions %5 to %10 percent are complicated by HAI in both the US and
Western Europe. Annually, In the US alone 1.7 million infections resulting in
approximately 99,000 deaths occur [5].
More than 177 000 potentially infections (HAIs) occur annually in Australia
with sizable attributable mortality[6].
The World Health Organization (WHO) estimates an average of 9 million
individuals are affected by nosocomial infections and approximately 1 million
patients die each year because of these diseases [7].
Developing countries were reported to have up to 20 times the risk of
contracting a nosocomial infection compared with developed countries [8]. Thus;
spread of infection serves as a major source of worry for managers in health
care practice, particularly in developing countries where the health care system
is already overstretched.
The prevalence rate in Africa of nosocomial infections stills high .The reported
rates in Tunisia9.4% Algeria 16.2%, Gabon 11% and Mali 9.6 % [7].
The economic cost of nosocomial is highly increasing in the world due to
increased rates of infections, long stay in hospitals and by multiple drugresistant organisms (MDROs) increases. More than 70% of the bacteria cause
resistant to at least one of the drugs used to treat them.Only in USA according
to health economist at the CDC has recently estimated hospital costs of HAIs
costs $28–45 billion annually [9].
The most important types of healthcare‐associated infections are central
line‐associated bloodstream infections, catheter‐associated urinary tract
infections and surgical site infections (specifically those following abdominal
hysterectomies or colon surgeries) during hospitalization. These account for a
large proportion of illnesses and deaths associated with healthcare[10].
3
Although infections occur in patients upon admission, healthcare workers
among them medical students play a significant rule as potential factors for
pathogenic agents' transmission pathway for spread of infections, due to poor
infection control & prevention practices & overcrowding in the most clinical
settings. In one survey, 27% of participating health care students reported
insufficient teaching about infection control in their training study, whilst 50%
expressed a desire for isolation procedures during their training [1].According to
documentations the level of compliance with the use of proven HAIs measures
by healthcare workers (HCWs) has been disappointing , in spite of the fact that
evidence-based procedures promoting practices in HCWs environments are
published, for example,compliance with hand hygiene among health care
providers is as low as less than 40% [11,12].
This scenario should alert clinical teachers and supervisors to pay more
attention to give their students throughout period of their study enough
knowledge about measures to reduce nosocomial infections [13].
Thus efforts should be toward education of standard infection control in theory
and practice as well as encourage the health care workers and students stick to
aseptic practice technique, can reduce extension of nosocomial risks on
patients, families and community.
Knowledge; up-date information and self-learning, skills , a role modeling and
compliance are necessary of the preventive measures to restrict the spread of
nosocomial infections; in addition, Patient safety education can be made
significant to students by placing the principles in context with their current
and future practical roles[14].
Hypotheses of the study
1. The students' knowledge about HAIs was not assessed from different
aspects.
2. Better understanding may help to decrease the morbidity and mortality rate
of HAIs.
3. tries to decrease economic burden, hospital stay and drugs resistance.
4
Objectives of study
The objectives of this study are;
To assess the knowledge, attitudes and behaviors of medical students
towardhealth care- associated infections (HCAIs) or nosocomial infections.
5
Literature Review
6
Literature Review
1.1DEFINITION AND SCOPE OF NOSOCOMIAL INFECTION
Nosocomial infection, also known as hospital-based infection or health careassociated infection is a serious global public health issue, causing the
suffering of 1.4 million people across the world at any given time [8].Infections
are considered nosocomial when they become clinically evident during
hospitalization and were not present or incubating before admission to the
hospital; an infection acquired in hospital by a patient who was admitted for a
reason other than that infection. An infection is occurring in a patient in a
hospital or other health care facility in whom the infection was not present or
incubating at the time of admission. This includes infections acquired in the
hospital but appearing after discharge, and, also occupational infections among
staff of the facility[15].
Health care-associated infection is such a severe problem that the World Health
Organization (WHO) made it a priority in 2002, when member states approved
a World Health Assembly resolution on patient safety[8].Deaths due to hospital
acquired infections are the fourth leading cause of death after heart disease,
cancer, and strokes[16].
According an excellent article, ―Diseases From Within Our Doors‖ gives three
contributing factors to nosocomial infections: overuse of antimicrobials, which
has led to resistant strains of ―super-bugs,‖ failure to follow infection control
procedures, and aging hospitals being renovated, releasing dust and spores into
the air[16].
1.2 Health care-associated infection in developed countries (HAIs)
HCAI affects 5–15% of hospitalized patients and can affect 9–37% of those
admitted to intensive care units (ICUs).
Recent studies had done in Europe reported hospital-wide prevalence rates of
patients affected by HAIs ranging from 4.6% to 9.3% and about 5 million in
acute care hospitals HAIs are estimated to occur in Europe annually that means
around 25 million extra days of hospital stay and cost of €13–24 billion. In
general, death rate due to HAIs in Europe is 1% (50 000 deaths per year)[17].
The estimated HCAIs incidence rate in the USA was 4.5% in 2002, and 1.7
million affected patients; approximately 99 000 deaths were due to HAIs.
7
The economic burden of HCAIs in the USA was approximately US$ 6.5 billion
in 2004[18].
The position in other industrialized countries is similar as the USA. For
instance,it is estimated that there is an overall infection prevalence of 2.8% was
found and 3.5% of the elderly used antibiotics in Netherlands and about 4
million HCAIs per year in the European Union, leading to 37,000 deaths per
year[19].
1.2 Burden of health care-associated infection in developing countries
The dimension of the problem is particularly relevant in settings where basic
infection control measures are virtually nonexistent.
This is the result of the combination of numerous unfavorable factors such as
understaffing, poor hygiene and sanitation, lack or shortage of basic
equipment, and inadequate structures and overcrowding, almost all of which
can be due to limited financial resources. In addition to an unfavorable social
background and malnutrition and other types of infection and/or diseases
contribute to increase the risk of HCAIs in developing countries[17].
The extent and scope of the HCAI burden worldwide appears to be very
important and greatlyunderestimated. The annual 5% of budget of a county
hospital in Trinidad and Tobago and up to 10% of Thailand hospital budgets
and 70% of the entire health budget for Mexico [23].
When referring to endemic HCAIs, many studies conducted in developing
countries report hospital wide rates higher than in developed countries.
Nevertheless, it is important to pay attention to most of these studies concern
single hospitals and therefore may not be representative of the problem across
the whole country. For example, in one-day prevalence studies recently
achieved in single hospitals in Albania, Morocco,Tunisia,and the United
Republic of Tanzania,HAIs prevalence rates were 19.1%, 17.8%, 17.9%, and
14.8%,respectively[17].
The risk of developing surgical site infection (SSI) in developing countries is
meaningfully higher than in developed countries for instance 30.9% in a
pediatric hospital in Nigeria,23% in general surgery in a hospital in the United
Republic of Tanzania and 19% in a maternity unit in Kenya [17].
In Mali, earlier studies on nosocomialinfections revealed varying frequencies.
The rate of HCAIS foundin the surgical and rehabilitation services of Gabriel
Toure hospital and of the CHU Point G was 10.2% and 13.8%respectively[7].
The burden of device-associated infection rates is several-fold higher than in
developed countries.
Pediatric ICUs 3–20 times higher are among hospital-born babies in
developing than in developed countries[17].
8
HISTORY OF NOSOCOMIAL INFECTION CONTROL
Active control of nosocomial infection has been a part of medicine for over
300 years.
A Scottish doctor, Sir John Pringle, used the term ‗antiseptic‘ in 1750 and
carried out experiments on septic substances during his career [18].
Ignaz Semmelweis (1818-1865), a Hungarian-born doctor who practiced in
Austria as an obstetrician in Vienna, ―father of infection control,‖ observed that
women who delivered their babies with midwives had a much lower rate (2%)
of infection than those whose babies were delivered by doctorswhere rate death
(13-18%) higher because of they did not wash hands after dealing with
Cadaverbefore delivering babies, which lead to infection.
Semmelweis implemented a case-control study that involved mandatory handwashing among medical students and washing of medical instruments, which
lead to reduce the nosocomial infection rate below than of midwife-assisted
delivery.He theorized that sterilizing hands could prevent transmission of
infection from a diseased cadaver to a pregnant patient. Therefore, on May 15,
1847, he commanded all medical students and physicians to wash their hands
with chlorinated lime before assisting in deliveries, which resulted in a
dramatic outcome - deaths on the maternity ward fell fivefold.So he was the
first healthcare professional to demonstrate through experiments that handwashing could prevent infections[20].Oliver Wendell Homes made this same
discovery but sadly, both Holmes and Semmelweis were not believed by their
peers at the time of their writings.
Sir James Young Simpson, working in Scotland in the mid-1800s, derived a
campaign against hospital cross-infection, or the transmission of infection from
one patient to another via doctors and nurses[18].
Joseph Lister, a professor of surgery at Glasgow, Scotland, he observed high
mortality rates from post-surgical sepsis during his professional in late1800s.Who is the first using sterilization with carbolic acid in the Operating
Room Before surgery.The result was the mortality rate from amputation
dropped from 45% to 15 %[21].
The first nationwide commitment to researching and eradicating nosocomial
infection in the United States came in 1958, in the midst of the first antibioticresistant staphylococcus aureus pandemic [18].
During the 1960s, nurses became the primary infection control specialists due
to their close contact with patients.
Garcia and colleagues in the 1970s note that the expansion of using medical
equipment's and treatment options, so he did the understanding of deviceassociated infection, such as catheter- and respirator-related infection.
9
In the early 1970s the database system was based to monitor the incidence of
nosocomial infections, the responsible pathogens and the associated risk
factors.
The Healthcare Infection Control Practices Advisory Committee (HICPAC)
was formed in 1991 by the CDC. Many guidelines have been produced by this
group.
Since the late 1990s, infection control has become a global issue, with the
WHO instituting a Patient Safety Initiative in 2002.
In 2005 hospitals began giving data to NHSN (National Healthcare Safety
Network). . NHSN was developed for the purpose of accumulating, exchanging
and integrating relevant information on infectious and noninfectious adverse
events associated with healthcare delivery[22].
Many developing countries established national policies to promote infection
control during the 1980s and 1990s.
Over the past 25 years, CDC‘s National Nosocomial Infections Surveillance
(NNIS) system has received monthly reports of nosocomial infections from
many hospitals of United States; more than 270 institutions report.
The nosocomial infection rate has remained notably stable (nearly 5 to 6
hospital-acquired infections per 100 admissions); however, because of
progressively shorter inpatient stays over the last 20 years, the rate of
nosocomial infections per 1,000 patient days has actually increased 36%, from
7.2 in 1975to 9.8 in 1995.It is estimated that in1995, nosocomial infections one
death every 6 minutes [22].
All current organizations around the World can help us to avoid greater than
100,000 deaths of nosocomial infections annually.
10
2.1 What students need to know (knowledge requirements):
Students should know the extent of the problem [23] ;
A number of antimicrobial-resistant organisms found in hospital settings such
as MRSA, (methicillin-resistant staphylococcus aureus) and VRE
(vancomycin-resistant enterococcus) also make treatment extremely difficult.
Many infected patients (about 25%) are in an ICU with more than 70% of the
patients having micro-organisms resistant to one or more antibiotics.
Today, antibiotics are often ineffective and more than 70% of hospital acquired
bacterial infections are resistant to at least one of the drugs commonly used to
treat them among health care-associated infections [23]. But 30.9% students did
not know at least one multidrug-resistant bacterium[24].
In one study, the increased cost ofMRSA was calculated approximately$4000
per infection. In addition, another group of researchers recently found
thatClostridium difficile is occurring almost as frequently in the hospital setting
as MRSA and the costs ofC. difficile-associated diarrhea to be approximately
$4500 per patient [9].
Students should usually know how to apply universal precautions as soon as
they enter the hospital environment. It is better to learn how to do something
right the first time than trying to reverse bad habits. A 2006 cross-sectional
study of medical staff and medical students in Iran reported that 54% of
students had not heard about universal precautions[23].
Students should know the main causes, types of infections and Factors that
predispose to nosocomial infections.
Nosocomial infections are caused by multiple pathogenic micro-organisms
such as bacteria, viruses, parasites or fungi; the diseases can be spread from
one person to another which is entering the body through one or more of the
following routes.
• Person–person via hands of health-care provider's patients and visitors;
• Personal equipment (e.g. stethoscopes, computers) and clothing; a study
conducted in Australia reported that 86.8% of all sampled health care
equipment was contaminated, but with 70% alcohol reducing the levels of
contamination on equipment by(82.1%), which is a significant source of NI[25],
furthermore,in Turkey a study in 2011 found bacterial and fungal
contamination on (76%) of the stethoscopes[26].
• Environmental contamination;
• Airborne transmission;
• Carriers on the hospital staff;
• Rare common-source outbreaks.
The following four types of infections account for more than 80% of all health
care-associated infections:
• Urinary tract infections usually associated with catheters:
11
- Catheter-associated urinary tract infections are the most frequent, accounting
for about35% health care-associated infections;
• Surgical infections: - these are second in frequency, about 20%;
• Bloodstream infections associated with the use of an intravascular device: about 15%;
• Pneumonia associated with ventilators: - about 15%[27].
The evidence shows that infections rates in thefirst two categories can be
reduced when healthcareworkers comply with infection controlguidelines and
patients leave hospital as soon aspossible.
Factors that predispose to nosocomial infection
Related to underlying health status areadvanced age, malnutrition
, Alcoholism, Heavy smoking, chronic lung disease and Diabetes
Related to acute disease process are Surgery, Traumaand Burns
Related to invasive procedures are Endotracheal or nasal intubation, Central
venous catheterization, extracorporeal renal support, surgicaldrains,
Nasogastrictube, Tracheostomyand Urinary catheter
Related to treatmentare, Bloodtransfusion, recent antimicrobial therapy,
Immunosuppressivetreatments, Stress-ulcer prophylaxis
Recumbent position, parenteral nutrition and Length of stay[28].
Students should learned the need to routinely undertake activities to prevent
infection such as correct hand washing, effective sterilization procedures and
correct gloving and gowning.
Infections are preventable when the right techniques use by health-care
workers and remain on the lookout for unclean and unsafe situations.Study
conducted in Malaysia, showed that 80% of medical students washed their
hands but only 41.6% performed effective hand washing[29].
Medical students should be understood why hands need to be decontaminated,
Which refers to the process for physical removal of blood, body secretions and
the removal or destruction of micro-organisms from the hands.one study
conducted in Saudi Arabia was showed that the average awareness concerning
the positive indications of hand hygiene was 56% And the 44% of students
were either not sure or unaware of the indications of hygiene. Only 17%of
students were Compliance as assessed during OSCE[12].
Students should be learned the safe use and disposal of sharps such as needle
to avoid the significant problem for health-care workers caused by needle stick
injuries, for instance blood borne viruses. The risk of HIV transmission
through a needlestick to infected blood is nearly 0.3%; the risk of hepatitis C is
1.8% while the risk of hepatitis B is 6% to 30%. Susceptible individuals are
(those who have not received the hepatitis B vaccination)[30].
12
In addition, students need to:
• know how to clean hands;
• The rationale for choice of clean hand practice;
• Techniques for hand hygiene;
• How to protect hands from decontaminants;
• promote adherence to hand hygiene guidelines
2.2 What students need to do (performance requirements):
• apply universal precautions;
• be immunized against Hepatitis B;
• use personal protection methods;
• know what to do if exposed;
• encourage others to use universal precautions.
Medical students should have effort to reduce the spread of infection and to
encourage patients and other health-care workers to actively engage in
practices that reduce the spread of infection in the community, hospitals and
clinics sittings.
Students need topractise universal precautions;be immunized against Hepatitis
B;use personal protection methods;know what to do if exposed to infection
andencourage others health care workers to use universal precautions.
Practise universal precautions
WHO has developed the following checklist for health-care workers.
Students must hand wash after any direct contact with patients.
Before contact with each and every patient a student should clean their
hands before touching a patient.
This is to protect the patient against harmful micro-organisms carried on the
hands of Students during travelling on a bus before entering the hospital and
the ward where they engage with a patient to take history, perform a physical
examination and so on.
A student should clean hands before an aseptic taskto protect the patient
against harmfulmicro-organisms, including the patient‘s ownmicro-organisms,
entering his or her body.
Students must protect against transmission through contact with body
secretions.
After contact with each and every patient a student should clean hands after
any risk of exposure to body fluids.
Students should usually clean their hands immediately after an exposure risk to
body fluids and after glove removal.Retrospective studies indicate that
percutaneous exposure incidents (PEIs) would be reduced by more than 50%
by behavioral interventions, either through education or adoption of new
techniques[31].
Students should wash hands after actual patient contact.
13
All students should clean their hands after touching a patient and his or her
immediate surroundings.
Forgetting to wash hands (health care providers) due to rash in work can lead
to get the student an infection and increasing the chances of the
microorganisms spreading throughout the environment
Students must handwash after contact with patient surroundings
Students should clean hands after touching any object or furniture in the
patient‘s immediate surroundings when leaving them, even without touching
the patient.
Students should be immunized against Hepatitis B
Students are at risk of infection with blood borne viruses, like all health-care
workers. So it is important to be immunized as soon as they start seeing
patients in hospitals, clinics and the community. The annual number of
occupationally acquired hepatitis B infection has decreased 95% since the
introduction of the hepatitis B vaccine.
Students should use personal protection methods
They should use needle stick prevention devices where possible and
Provide feedback to the health-care team about the personal protective
equipment.
Students should know what to do if exposed
If a student is mistakenly exposed or becomes infected they should
immediately tell the appropriate staff in the hospital or clinic as well as a
supervisor to receive appropriate medical attention.
Students should encourage others to participate in infection control
Students should act as a role model to encourage each other to use correct
handwashing techniques.
Students can be leaders in this respect to help another health-care provider have
poor technique.
Also Students can teach patients about the importance of handwashing. It is
also a good time to practise their skills on educating patient about health care
and prevention.
Addition things might students to do
• Needles should never be recapped;
• All sharps should be collected and safely disposed;
• Students should use gloves when in contact with bodily fluids, non-intact skin
and mucous.
• Students should wear a face mask, eye protection and a gown if there is the
potential for blood or other bodily fluids to splash;
• Students should cover all cuts and abrasions including their own;
• Students should always clean up spills of blood and other bodily fluids;
• Students should make themselves aware of how the hospital waste
management system works.
Learning sources information of HCAIs.
14
Strengthening the contribution of medical doctors and medical students to
HCAIs prevention programs should include measures that enhance knowledge,
improve practice and develop appropriate attitudes to the safety and quality of
patient care(32). In the existing traditional curriculum, the topic of nosocomial
infections is taught through an instructive lecture on facts related to the
etiology, pathogenesis and control measures. However there is neither a
module which involves practical training of students to acquire skills of hand
washing and waste disposal, nor any method to evaluate these skills. This
creates a big gap in the constructive years of undergraduate studies, as the
students are likely to undervalue the importance of these preventive measures
and a lack of compliance in adhering to these measures leading to the spread of
nosocomial infections[33].
Although HCAIs is taught in most medical schools around the world, but
HCAIs prevention or infection control is largely ignored or insufficiently
addressed in the curricula of most medical schools. For instance, The Hospital
Infection Society (HIS) funded a review of medical education on HCAIs
throughout medical schools in the UK and the Republic of Ireland. The
prevalence and transmission of HCAI were taught by 97% and 100% of
medical schools, respectively, but the importance of HCAI as a quality and
safety issue was covered in only 60% of medical schools [32].Likewise, in china,
health-care associated infections are introduced only briefly to preclinical
students in the Infection and Immunity module. There are neither formal
lectures nor bedside teaching on ward rounds for clinical students during their
study[34].
Effective student learning depends on teachers using a range of educational
methods such as shared knowledge, demonstrating skills, introduce gradually
attitudes—all are essential for patient safety education [35].
Teachers of patient safety should use according to ''The WHO Patient Safety
Curriculum Guide for Medical Schools''.
• Problem-based teaching (facilitated group learning); Small group discussion
session. The class can be divided up into smallgroups be asked to lead a
discussion about the causes and types of infection.The tutor facilitating this
session should also be familiar with the content so information can be added
about the local health system and clinical environment.
• Simulated-based learning (role plays and games);
• Lecture-based teaching (interactive/didactic);Use the accompanying slides as
a guide covering the whole topic. The slides can be PowerPoint or converted to
overhead slides for a projector. Start the session with a case study selected
from the Case Study Bank and get the students to identify some of the issues
presented in the story.
15
• Mentoring and coaching (role models).Educators may adopt a variety of
styles including roles as information provider, role model, facilitator, assessor,
planner and resource provider
These activities can start from the very first years in the hospital and clinic
environments, In addition to, Self-learning by reading current scientific
articles, online material and log books which has a positive influence on the
knowledge and practice of HCWs[23, 35].
The Patient Safety Curriculum Guide for Medical Schools has been
implemented in curricula across the world.one study confirmed that Faculty
who participated in the study have approved that the Curriculum Guide was an
important resource and helped them implement patient safety teaching in their
curricula.
Students reported positive awareness to patient safety and that their knowledge
of patient safety increased after the teaching [36].
A study reported in UK that Lectures, discussion of cases and practical
demonstrations were considered useful by >90% of respondents and online
material and log books by 67% and 60%, respectively. An agreed curriculum
should be developed for educating medical students in HCAI prevention and
control, to outline optimum methods for assessment and develop a shared unite
of educational resources[32].
But the questions are all medical schools or medical doctors and supervisors
around the world emphasis on encouraging and enhancement the medical
students to learn about HAIS, have they professionalism competences, are they
perform and implement what they are learned.
For instance, a study was conducted in Serbian at School of Medicine;
University of Kragujevac revealed that about (54.4%) of the students knew that
contact was the most frequent mode of NI transmission while hand washing as
preventive measure was quoted by only 18.8% of student. It means the students
need more information and practical intervention to get complete knowledge
about nosocomial infections[24].
Moreover a study was doneat University of Sri Jayewardenepura revealed that
participants had adequate knowledge (77%) but attitudes, practices of all the
participants was overall weak (<50%). However the nursing students had better
knowledge (p=0.023), attitudes (p<0.001), practices (p<0.001 [37].
16
Medical teacher on-the-job role model of
learning(role model)
The importance of the teacher as a role model is well documented. The General
Medical Council (1999) in the UK acknowledges that '' the example of the
teacher is the most powerful influence upon the standards of conduct and
practice of every trainee, whether medical student or junior doctor'.
The teacher as a clinician should model or illustrate to students what should be
learned. Students learn by observation and imitation of their clinical teachers
they respect not just from what they say but from what they do in their clinical
practice and the knowledge, skills and attitudes they exhibit [38].
The student needs expert coaching rather than a knowledgeablephysician
talking about supporting theories. When teachers observe and give feedback
about student performance the student will continuously improve and
[23]
eventually master many of the patient safety skills .
Role modeling is one of the most powerful means of transmitting values,
attitudes and patterns of thoughts and behavior to students. In fact, role
modeling may have a greater effect on the student than other teaching methods;
for example, found role modeling to be educationally more effective than
lecture/discussion sessions in enhancing the students‘ ability to communicate
with patients about immunodeficiency virus[38].
The importance of the role model was emphasized too by Sir Donald Irvine
(1999), President of the General Medical Council in the UK. He suggested that
'' the model of practice provided by clinical teachers is essential because
students learn best by good example'[38].
―We need to teach medical staff — especially medical students — about the
importance of hygiene, and we need experienced physicians who will serve as
good role models for proper infection control later on,‖ Ralf-Peter Vonberg,
MD, of Hannover Medical School, told Infectious Disease News.
Further, medical students tended to believe that more experienced physicians
conformance toward hand hygiene would decrease[39].
Squires (1999) noted that '' it is important to identify modeling as a distinct
function and heading in order to draw attention to what is a pervasive but
sometimes unconscious, and even denied process in education. Teachers may
not see themselves as models, and may even regret the very idea as pretentious
and paternalistic, but it is difficult for learners not to be influenced by the
living example set before them''[38].
17
Shouldn’t Medical Students Be Taught Hygiene?
What else needs to be done?Medical students as the future clinicians
andleaders in health care system. They will need to know aboutpatient safety,
the qualityand safety of health care system and management of these
challenges.
Medical students learn very quickly about how doctors behave and what is
expected of them, and because they are novices they wish to fit in as soon as
possible. Many students and junior doctors think their survival of the early
years and their careers depends on their fitting in.
The system of medical progression relies on reports from supervising
clinicians about the performance and development of students and young
doctors. Medical students are low in the medical hierarchy and very dependent
upon supervisors for their instructions and learning[35].
Medical schools should be teaching future doctors the precautions they must
take to from infection. It‘s hard to believe, but most medical schools commit
actually no timeto showing their students how bacteria are transmitted from
patient to patient on clothing, equipment, and gloves, and what they should be
doing to prevent transmission of infections.
Dr. Frank Lowey, a professor at the New York-Presbyterian Hospital at the
Columbia University Medical Center says, ―It’s something we should have
done quite a while ago.‖ Lowey says it‘s ironic that ―there are curriculum
committees devoted to making sure that bioterrorism is covered, and the risk of
nosocomial infections far outweighsthat "but some medical schools are
stressing the importance of restraining the use of antibiotics. That is nice,
because overuse of antibiotics lead to waste money and cause bacteria to
change into new, drug resistant strains. But that is not stopping hospital
infections. Patients who adhesion MRSA get it from bad hygiene for instance
unclean hands, contaminated equipment, clothing and not from taking
antibiotics.
No hospital can ever eradicate infection only by controlling the use of these
drugs.
When students put on their white coats and swear theHippocratic Oath, they
should be taught how to do no harm. The essential issue isof topic that is
preventing the spread ofinfected bacteria.
Medical students should learn it before they go out on the hospital floors and
touch their first patient.
Medical schools should be teaching their students the precautions of infections
that will be help to protect them and patients from each other's [40].
18
Methodology
19
Methodology
Study design
The research is a cross-sectional study to assess knowledge, behavior,
attitudes of medical students.
Settings:
The study was conducted during the period from January to October 2013 at
teaching hospitals, (al Hilla teaching hospital), (maternity&children hospital)
and (Margan teaching hospital), located at Babil. It was carried out on one
hundred and six (106) students; assess knowledge, behavior and attitude of
medical students on nosocomial infections, in addition to their information
resources of nosocomial infections.
Participants
The study carried out on final year students of college of medicine,
University of Babylon, located at Babil. They were separated to four main
groups, medicine, surgery, pediatric, gynecology and obstetrics on the main
hospitals at Babil. The questionnaire was distributed to the students after
consent was sought and obtained from head master of medical college of
medicine of Babil and all departments' masters at different hospitals where
the students presented.
Prior to the study, participants were given a brief introduction to the purpose
of the study, after which their consent was sought and obtained. The
participants did not all complete and return the questionnaire. About ten
students did not return the questionnaire.
Survey instruments
The Infection Control Questionnaire prepared by researcher according to
international guidelines and another questionnaire on standard isolation
precautions, hand hygiene, prevention and control measures of nosocomial
infections and resources of information was used in this
study[41,44,47,48,49,50].The questionnaire consisted of four main domains, with 30
items. Students‘ knowledge section was designed to explore student's
knowledge related to health care associated infections (HAIs) or nosocomial
20
infections. For each statements are whether student agree, uncertain or
disagree.it consisted of (10 items).Response to each item was coded and
scored as a correct answer (2), uncertain (1), incorrect answer (0).The
second section was behaviors section which consisted of (10 items).This
section is designed to gather information about student's behaviors. For each
statement check whether student always sometimes never adopt each of the
practices to reduce the risk of HAIs. Responsive scored was (2), (1), and (0)
consequently.
The third was Attitude's section (5 items) of the
questionnaire, was designed to explore student attitudes toward
precautionary guidelines and perception of the risk of acquiring HAIs by
multiples questions. Each item was scored (2) for correct answer and (0) for
incorrect answer. The last information's section (5 items) was designed to
ask questions about sources of student's information on nosocomial. For
each statement check whether student always sometimes never learned about
HAIs during curricula implementation through their study. Response to each
item was coded and scored (2), (1), and (0) consequently.
The equation (NO x0 +NO x1+NO x 2/ 2 x106) x100%, (NO=number) was
used to estimate the mean percentage of any question in the research that
needs to assess results of the questionnaire. The Iraqi grading rate system
was used to interrupt any grading scale anywhere in the study as following:
Excellent………….. 100-90%
Very good………….80-89%
Good……………….70-79%,
Adequate………….60-69%
Acceptable………. 50-59%
Weak…………….. 0-49%[51]
The content of the questionnaire was validated after interviews and
discussions with three experts in the field, and it was modified where
necessary.
21
Ethical consideration
The study protocol as well as the questionnaire was authorized by Ethical
Committee of the Al kindy college of Medicine, Baghdad University
Statistical Analysis
Data was analyzed by Minitab 13.1 software. Calculation of the Chi-square
test for significance was used. P-value of less than (0.05) is considered
statistically significant, and less than 0.01 is considered highly
significant.Tally test from Minitab also was used in calculation the
percentage and the number of males and females together of answered
question while Cross tabulationused in calculation the percentage and the
number of males and females separately of answered question.Variables data
presented as tables and figures in the study.
22
Results
23
Results:
Table no.1 Demographic characteristics
Student
NO
%
Male
37
34.91%
Female
69
65.09%
Total
106
100%
The number, gender and percentage of students included in the study are
shown in table (1), the sample is composed of 106 students from sixth year,
and the number of females is two third more than the number of males.
24
Table no (2) Knowledge about health care-associated infections and
control measures
Question
1.Hand hygiene measures before and
after dressing
2.Your stethoscope is a potential
source of infections.
3.Healthcare workers caring of
patient with MRSA
4.Changes in antibiotics use lead to
antibiotics resistance
5. The risk of transmission infection
to the hospital personnel.
6.The environment is source
nosocomial infection.
7.prevalence of Nosocomial infection
in the world
8. the risk of Invasive procedures on
nosocomial infection
9.Duration of intubation and
mechanical ventilation related to
Ventilator Associated Pneumonia.
10. Gloves do not obviate the need
for hand hygiene.
Disagree
No
%
0
0
Uncertain
No %
7
6.60
36
33.96 47
44.34
29
27.36 47
44.34
14
13.21 17
16.04
59
55.66 11
10.38
25
23.58 11
10.38
8
7.55
65
61.32
4
3.77
14
13.21
2
1.89
14
13.21
35
33.02 14
Agree
NO %
99 93.4
0
23 21.7
0
30 28.3
0
75 70.7
5
36 33.9
6
70 66.0
4
33 31.1
3
88 83.0
2
90 84.9
1
13.21 57
53.7
7
N0 (CA) & %
NO
%
205
96.69
93
43.86
107
50.47
167
78.77
83
41.50
151
71.22
131
61.79
190
89.62
194
91.50
128
60.37
Note; correct answers (CA).
Answers concerning the knowledge of HCWs are shown in table 2.
Themajority (96.69%) knew about hand hygiene measures before and after
dressing changes by health care workers and also toward the risk of Invasive
procedures (89.62%) and duration of intubation (91.50%) related to Ventilator
Associated Pneumonia. But only 83 (41.5%) recognized the risk of measles &
chickenpox more than hepatitis B and HIV transmission infection to the
hospital personnel. Furthermore, Just 93 (43.86%) knew that stethoscope is a
potential source of infections. The overall average of the medical students'
knowledge is (68.34%) about HAIs.
25
Table no (3) Behaviors distribution of the students practices to reduce the
risk of HCAIs
Never
Sometimes
Always
N0 of (CA) & %
NO %
No
NO
%
No
%
98
46.22
%
Question
1.Wearing protective
materials/eyewear &
mask
2.handwashing/moving
From infected to clean
site
3.handwashing/before
&after gloves wearing
4.disposal materials
Needle or sharp
5.stay home / infectious
illness
6.hepatitis B/
Vaccination
7.role model
/prevention measures
8.handwashing/before
&after dressing
9.role educator
/clients
10.respiratory
hygiene/cough etiquette
31
29.25 52
49.06 23
21.7
16
15.09 27
25.47 63
59.43 153
72.16
22
20.75 26
24.53 58
54.72 142
66.98
12
11.32 24
22.64 70
66.04 164
77.35
24
22.64 51
48.11 31
29.25 113
53.3
17
16.04 23
21.70 66
62.26 155
73.11
14
13.21 51
48.11 41
38.68 133
62.73
6
5.66
17
16.04 83
78.30 183
86.32
7
6.60
20
18.78 79
74.53 178
83.96
9
8.49
42
39.62 55
51.89 152
71.69
Thetable no (3) of behavior is showing that respondents wearing protective
eyewear & mask when contact with patient sometime was only (49.06%).
Hands washing after hands move from infected body site to clean site, before
and after wearing gloves was ( 59.43%), (54.72%) respectively but, hand
washing after dressing changes and any contact with the surgical site was
(78.30%). The respondents sometime (48.11%) stayed home when they have
infectious diseases such as respiratory illnesses or diarrhea.
They sometime took (62.26%) vaccination against hepatitis B, however, they
reacted just (51.89%) toward respiratory hygiene/cough etiquette during
period of increased prevalence respiratory infections in the community. They
sometime played (48.11%) as a role modeling to health care providers, clients
and families with regard to infection prevention and control strategies; in
26
contrast, they played an educator role (74.53%) to encourage patients to
report to their health-care provider any changes in their catheter site or any
new discomfort. In general, the students behaviors were(69.38%) toward
prevention and control of nosocomial infections.
Table no (4) Attitudes distributiontoward precautionary guidelines and
perceptions of the risk of acquiring HCAIs
Question
Female (CA) male (CA)
Total (CA)
NO %
NO
%
NO
%
p-value
55
51.89
33
31.13
88
83.02
0.215
2.Handwashing with 47
alcohol hand gel
44.34
9
8.49
56
52.83
0.000
3.cleaning spoiled
58
floor
4.disposing medicals 40
materials
54.72
18
16.98
76
71.7
0.000
37.74
15
14.15
55
51.89
0.087
5.protactive
materials
55.66
30
28.3
89
83.96
0.554
1.surplus budget
59
CA ;( correct answer)
In table no [4] is shown that the overall perceived of medical students was
(68.68%) about HAIs.females are (48.87%) more than males (19.81%)
concerning the perceived risk of acquiring a HAIs. Their attitudes were
(83.02%) when they act as hospital manger to Organize financially supported
courses with training to support behaviorsfighting infections and when they
are in the surgical emergency unite attendance ( 83.96%) to be always
wearing gloves and mask whatever the case. However, they showed
acceptable perceived( 52.83%) ,(51.89%) respectively towardhands washing
with alcohol hand gel after any events of examination despite of
overcrowding and disposing medicals waste always making sure of disposing
by yourself.
27
90
80
70
60
50
40
30
20
10
0
female
surplus budget
Hand wasing
Cleaning floor
male
Disposing of
waste medical
materials
Protective
materials
correct answer%
Figure no(1) Demographic Attitudes'distribution and correct answers
In general, the figure no (1) shows that females had more correct answers than
males in all questions.
28
Table no. (5)Curriculum evaluation of advising information ofsome
items of HCAIs
Question
Never
Sometimes
Always
Total
Answering
No &%
F
No, %
M
no,%
F
no,%
M
no, %
F
no,%
M
no,%
6
11
27
16
36
10
1.standard
handwashing
2. standard
precautions
5.66%
10.38% 25.47% 15.09% 33.96% 9.43% 63.67%
6
4
36
5.66%
3.77%
33.96% 25.47% 25.47% 5.66% 60.84%
3. safe (IV)
or inserted
devices
4.stethoscope
cleaning
17
12
27
5. contact
precaution
27
15
27
25
6
10
153
129
112
16.04% 11.32% 25.47% 14.15% 23.58% 9.43% 52.84%
43
25
6
3
40.57% 23.58% 18.87% 8.49%
5.66%
2.83% 22.16%
12
21
7
8
11.32% 7.55%
20
9
36
22
47
114
33.96% 20.75% 19.81% 6.60% 53.77%
The table no 5 shows that the females students have been advised always
(33.96) about standard hand-washing measures, while, males were
(9.43%).Advising
toward
standardprecautions
was
that
femalessometimes(33.96%)were advised, whereas, males (25.47%). Most of
males (40.57%) and females (23.58%) were neverbeen advised of
stethoscope cleaning. Female Students sometimes(33.96%), males (20.75%)
advised aboutcontact precaution. The overall advising information of
medical students to some items of HCAIswas(50.65%).
29
Figure no (2)shows the advising Information receiving on HCAIs during
college courses
The figure no (2) is showing the responsive of medical students toward some
items of getting their information's about HCAIs during graduation both
clinical and classroom sessions. Only (43.40%) always of students have been
advised about the standard hand-washing, while, sometime (59.43 %) heard
about precautions standard. They sometimes have Just (39.62 %) been
advised toward safe intravenous (IV) cannulation or inserted devices. The
students have never (64.15 %) been advised about Stethoscope cleaning
during courses of their study, furthermore, they sometimes (54.72%) have
been informed of contact precaution measures.
30
Discussion
31
Discussion
Medical students need to learn how to convey safer care due to the growing
identification of the harms caused by health care. Knowing" what "is
advancement to know“how” and ultimately to “doing”. Through hands-on
experience with feedback from trainers is the best learning, along with
mentoring and coaching.Students need to learn safe health care practice even
if the current medical culture is not supportive of this, and deal with the
conflicts this may produce[14].
In this survey participants‘ knowledge concerning the various aspects of
HCAIs was generally adequate (68.34%), however, there are many areas
where the knowledge was excellent (93.4%)especially regarding hand
hygiene measures before and after dressing, the risk of Invasive procedures
were very good (89.26%) on nosocomial infection and duration of
intubation and mechanical ventilation was excellent (91.5%).In contrast,
there are other areas where the knowledge was weak, particularly concerning
the risk of transmission of infections to the hospital personnel(41.50%)and
stethoscope as a potential source of infections(43.86%). Established upon
these considerations, these medical students need to learn more in order
todiminish the rate of HCAIs.
According to another studies conducted in same field they foundin Italyhigh
(very good)knowledge (86.3%)of medical students about HCAIs[41].While
another studies found good knowledge(70.58%) of nosocomial infections
among medical students at the College of Health Sciences, University of
Ghana. Another study was conducted at Qazvin University of medical
science in Iran revealed that the students'goodknowledge (79.9%)on
nosocomial infections [1, 42], furthermore, at the Medical University of Graz
in Austria, a study found the knowledge on hygiene guidelines appears to be
good(70%) among medical students[43].
In contrast, a study carried out among medical students attending Shantou
University Medical College (SUMC) in China, demonstrated that medical
students have limited (acceptable) knowledge (52.5 %)[34], Moreover,
32
another study achieved to measure students‘ knowledge of infection control
measures and their sources of information, at Rouen University (Rouen,
France), found the knowledge of nursing students was better than medical
students in three areas, hand hygiene, standard precautions, and nosocomial
infection also the same results were found in Italy [41,44].
In general, students' behaviors in current study were adequately
(69.38%).Results from this study indicated that most respondents always
performed hands hygiene measures after dressing changes and any contact
with the surgical site were very good( 86.32%) attendance for the
prevention of the HCAIs. They showedvery good (83.96%)desirefor
encouraging patients to inform their health-care providers any changes in
their devices or any new discomfort. Whereas, they perceived acceptable
(62.73%) manner to act as a role model to health care providers, clients and
families with regard to infection prevention and control strategies, however,
they need to be more encouraged to play this role by their teachers and
expert staffs in classrooms and bedside teaching.
The students responded to take vaccination against hepatitis Bwas
good(73.11%). Thehepatitis Bvirus (HBV)considers the most common
occupational viral infections; however, it can be prevented by vaccination.
For instance, in 1990, the HBV infection rate among unvaccinated US
healthcare personnel was three to five times greater than in the US general
population while the rate was reversed in 2010 five times less than in the US
general population due to the introduction of routine HBV immunization
and comprehensive occupational health and safety policies[31].
The students reactedgood (72.16%)to hands washing after hands move from
infected body site to clean site andadequately (66.98%) before and after
wearing gloves.The hand hygiene, wearing gloves and protective
materialsconsider the corner stone in preventive pathogens transmission but
not all students or health care workers are disposed to it, for instance, a study
carried out in Tikrit,Iraq
revealed
(75%) of medical staff and
[52]
employees had contaminated hands .
According toSulaiha S A, et al, that most of students either fail to wash their
hands or fail to follow the correct steps in effective hand washing during
clinical practice, the overall frequency of hand washing before and after
contact with patients were (6.7%) and( 23.7%) respectively which are mostly
very weak[29].
Another study conducted in Qassim College of Medicine, Saudi Arabia to
evaluate the consciousness, and compliance of hand hygiene among
33
undergraduate medical students during their clinical study. It had revealed
the average awareness regarding the positive indications of hand hygiene
was (56%) while the(44%) of students were either not sure or unaware of the
indications of hygiene [12]. Generally compliance rates of hand hygiene (HH)
among healthcare providers (HCPs) stay low, in spite of, identifying that HH
is very important in reducing infection rates.
In a recent systematic review by Mukerji A,et al, of 96 studies (with 65
studies in intensive care settings) on HH compliance of HCPs from
developed nations, it was found that compliance rates were as weak as 30–
40% in intensive care settings compared with 50–60% in other settings[45].
In this study the students reacted weakly (46.22%) towardwearing protective
eyewear and/or mask when they were at direct contact with a patient.
Eyewear protects transmission infections trough out cornea of the eye by
droplets or splashes of body fluid secretions or blood such as HIV &HBV.
The awareness was acceptable (53.3%)regarding staying home when they
have infectious diseases such as febrile respiratory illnesses, Cold sores or
diarrhea so that they will be a potential source of causing iatrogenic
nosocomial infection for their colleagues and patients in clinical sittings.
They need to learn when they had infectious illnesses then they must stay
home by their teacher's advice or consider as medical schools protocol. The
British General Medical Council (GMC) in its booklet, serious
communicable diseases, states that ―You must always take actionto protect
patients when you have good reason to suspect thatyour own health, or that
of a colleague, is a risk to them. Youmust consider how any infection you
have may put patients atrisk‖ [46].
According to several researches there were weak practices and adherence
regarding HCAIs prevention measures among medical students, for instance, in
Iran, and China practices toward standard isolation precautions were weak
(33.3%) ,(44.5% ) respectively and also in Austria adherence is limited( weak)
( 49%) and requires improvement due to only( 43%) performed hygienic hand
disinfection according to WHO guidelines[ 34,42,43].
The attitudes of students toward nosocomial infection in this study
wereadequate (68.68%), since there were significant trendedvery good
(83.02%) to support training of medical providers to fight infection when
they are at the top of administration pyramid during their career.
They showed positively perceivedvery good (83.96%) through compliance
using of protective materials to control infections transmission in the
surgical emergency unite. In another hand, they were acceptable(52.83%)
tendency toward hand washing with alcohol gel after any event of
examination
during
overcrowding
situations
and
also
they
exhibitedacceptable (51.89%) attitudes about disposing medicals waste by
their self, whereas, it is considered as a part of the duty of medical staffs to
34
preserve perfective cleaning environments in clinical sittings. The medical
students must take responsibility as early as possible in controlling
infections because they are tomorrow doctors. Females were statistically
significant differences (P =0.000) than malesgender in some aspects; for e.g.
females were noted highly significant attitudes in hand washing with alcohol
hand gel and cleaning spoiled floor (p=0.000).
This outcome seems to be nearly the same with findings by Barikani A,et al,
who reported that medical students had positive attitudes (73.7%)toward
Standard Isolation Precautions[42].
In contrast, a study was done at University of Sri Jayewardenepura revealed
that participants had weak (<50%) attitudes.The study shows the need for
further improvement of the existing hand hygiene training programs to address
the gaps in knowledge, attitudes and practices [37].
The outcome of this study exhibited that advising information of students'
knowledge about HAIs were generallyacceptable (50.65%), since, majority of
them werewhere just only (22.16%) advised to clean their stethoscope.
In addition to, they sometimes had been advised about safety (IV) cannulation
or inserted devices (52.84%),whereas,Batool A. Al-Shawii, et al found all
neonates (100%) who had invasive procedures (cannula or intravenous set)
or received oxygen therapy (O 2) had bacterial infection and out of the total
neonates, 9.3% had bacterial infection in the Neonatal Intensive Care Unit
(NICU) of the Baghdad Teaching Hospital, Iraq [53]. In present study also
approximately half of students had not been informedregarding contact
precaution measures (53.77%), whereas, these subjects are considered crucial
foundations in preventive measures and control of HCAIs. The problem seems
due to defect in curriculum which may be not properly covered or neglected
this topic, in another hand, clinical teachers have not acted as a role model in
transfer knowledge and practices about preventive nosocomial infections to
their students.
The results of advising information during college courses of this study
followed with findings by other researches, for instance,Yuanchun Huang et
aldemonstrated that medical students have limited knowledge and practice
(52.54%) regarding HCAIs due to substantial deficiencies in their learning
resources[34].
Herbert VG, et al found (79%) of the respondents asked to an obligatory
course on hygiene standards in medical education and the demand for an
optimum education in hygiene is high[43].
Barikani A,et al, clarified the necessity of standard isolation in prevention of
disease in patients in all duration of education must be emphasized and
facilities should be improved[42].
35
Our students should know the extent of problem regarding nosocomial
infections in our society for e.g. a study was done in Basrah General
Hospital, Iraq, found (65%) patients were suffering from Pseudomonas
aeruginosa infectionwhich considers a high antibiotic resistant
microorganism [54].
Another study by Alrifai S.B.et al carried out in Tikrit, Iraq, found
nosocomial diarrhoea in children (32.4%) aged < 5 years, which emphasis
on personal hygiene and improved care practices[52].
Merdaw M. A. found in the surgical wards of 4 hospitals in Baghdad city
between 2010 -2011,the incidence ofpostoperative infections78.43% was
from the 102 admitted patients.The most frequent microorganism
presented in the wards, Pseudomonas aeruginosa (23.3%) in the internal
wards, in Gynecology wards Coagulase positive Staphylococci(25.0%), in
Urology wards the Escherichia coli (27.2%) and Orthopedics wards
Acinetobacter baumannii (27.2%).The study was emphasis on shortening
the hospitalization time,permanent education, strong application of
protocols and urging the implementation of strict infection control policy
frequent [55] .
WHO emphasizes oncontinuing medical benefits in the hospital environment
require continuing educational input [14].
Limitations
1. The time of the questionnaire distribution was not sufficient and suitable
because it was coincident with hot fasting month (Ramadan), so that, the
students looked upset during answering the questionnaire.
2. Some students demonstrated unseriousness during answering the
questionnaire.
36
Conclusion
The consequences of the current study demonstrate that:
1. The overall medical students' knowledge about nosocomial infectionswas
adequate, in spite of this; the knowledge was weak, particularly concerning
the risk of transmission of infections to the hospital personnel and
stethoscope as a potential source of infections.
2. They had positive attitudes, while, students revealed acceptableattitudes
about disposing medical wastes by their self.
3.Practices to reduce the risk of nosocomial infection were adequate,
however, reacted weaklytoward wearing protective materials when they are
at direct contact with a patient.
4. The overall advising information of medical students to some items of
HCAIs was acceptable; however, majority of themhad not been advised to
clean their stethoscope.
Recommendations
1. encouraging an adherence regarding HCAIs among students in order to
reduce the prevalence of infections and compliance with intervention are
mandatory.
2. For final (senior) students it is best to do extra courses on nosocomial
infection prevention and control measures during clinical training to stick the
information in their mind for long period.
3. Encouraging and inducing clinical teachers to act a role model for students
to comply on HCAIs prevention and control measures.
4. Other researches in different medical schools in Iraq prefer to be done to
explore knowledge and awareness toward HCAIs among students to give us
clear view of our educational system.
5. A review of health care curricula would need to pave the way for more
practice infection controlling teaching in all our educational system.
37
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42
APPENDEX
The nosocomial Infections Control Questionnaire
1. Hand hygiene measures before and after dressing changes and any
contact with the surgical site reduce HAIs.
2. Your stethoscope is a potential source of infections.
3. Healthcare workers with eczema or psoriasis should not be involve in the care
of patient with MRSA
4.Changes in antibiotics use patterns lead to parallel changes in
prevalence of antibiotics resistance
5. Measles & chickenpox more than hepatitis B and HIV risk of infection
transmission related to the hospital personnel.
6. The environment (air, water, inert surfaces) is the major source of
bacteria responsible for nosocomial infection.
7. Nosocomial infection has a prevalence of 7-10% in the world.
8.Invasive procedures increase the risk of nosocomial infection
9. Reduced duration of intubation and mechanical ventilation may prevent
Ventilator Associated Pneumonia.
10. Gloves do not obviate the need for hand hygiene.
43
Disagree
female□
Knowledge'ssection of the questionnaire
This section is designed to explore your knowledge related to health care-associated
infections (HAIs) or nosocomial infections. . For each statement check whether you
agree, uncertain or disagree.
Uncertain
male □
agree
Gender:
Behavior's section of the questionnaire:
1. Wearing protective eyewear and/or mask when at direct contact with a
patient
2. Decontaminate hands if hands will be moving from a contaminatedbody site to a clean-body site during patient care.
3. Decontaminate hands before doing gloves and after removing gloves.
4. Never uncap a needle or sharp unless y I know where I will dispose
immediately after use
5. Stay home when I have febrile respiratory illness, Diarrhea, Cold sores
6. I take vaccinations against hepatitis B & Annual influenza
immunization
7. I act a role model to health care providers, clients and families with
regard to infection prevention and control strategies
8. Perform hand hygiene before and after dressing changes and any
contactwith the surgical site.
9. Encourage patients to report to their health-care provider any changes
in their catheter site or any new discomfort
10. Respiratory Hygiene/Cough Etiquetteduring periods of increased
prevalence of respiratory infections in the community
Information's section of the questionnaire
This section is designed to ask questions about your sources of information.
In the course of your medical education (lectures & clinical teaching):
In the course of your medical education (lectures & clinical
teaching):
1. Have you been advised about standard hand-washing?
2. Have you been advised about precautions standard?
3. Have you ever been advised about safe intravenous (IV)
cannulation or inserted devices?
4. Have you ever been advised about stethoscope cleaning?
5. Have you ever been advised about contact precaution?
44
never Some
times
Always
Never
Alway
s
Some
Times
This section is designed to gather information about your behaviors. For each statement
check whether you Always Sometimes Never adopt each of the following practices to
reduce the risk of HAIs nosocomial
Attitude's section of the questionnaire
This section is designed to explore your attitudes towards HAIs. Choose
your proper answer?
1. You are now a hospital manger with an annual budget surplus and with
increased incidence of HAIs; you suggest
a. Increase thepurchaseoffurniture
b. Increase buysantibiotics
c. Organize financially supported courses with training to support
behaviorsfighting infections
2. You are now in the outpatient with a lot of patients waiting your
examination. You have alcohol sterilization as hand gel
a. you will wash your hand after an examination of a patient with infectious
diseases only.
b. you will wash your hands whenever you have an opportunity because of
overcrowding.
c. you will wash your hand after any events of examination despite of
overcrowding
3. You are now in the ward and it is not your duty time. You see some Spots
of blood on the floor
a. you will leave the place because you are tired and try to take a rest
b. you will inform the hospital administration
c. you will inform cleaning workers and make sure that they manage the
situation properly
4. Now you have national campaign to vaccinatepoliovaccine; and you are
the General Supervisor Campaign. At the end of the each campaign day you
must disposed medical waste
a. you will try to send anyone to make sure of disposing
b. sometimes you will do that by yourself
c. you will always making sure of disposing by yourself
5. Now you are in the surgical emergency unite
a. you are wearing gloves and mask only when you deal with a wound of
patients
b. you are not wearing gloves and mask because the paramedical suturing
the wounds
c. you are always wearing gloves and mask whatever the case
45
‫الوعً لدى طلبة المرحلة المنتهٌة من كلٌة طب بابل‬
‫حول عدوى المستشفٌات‬
‫بحث مقدم الى كلٌة طب الكندي ‪ /‬جامعة بغداد‬
‫كجزء من متطلبات نٌل درجة الدبلوم العالً فً التعلٌم الطبً‬
‫من قبل‬
‫د‪ .‬كرٌم عبد مباشر‬
‫بكالورٌوس طب وجراحة عامة‬
‫بأشراف‬
‫االستاذ المساعد الدكتور محمد اسعد ابراهٌم‬
‫‪1434‬‬
‫‪2013‬‬
‫‪46‬‬
‫خالصة البحث‪:‬‬
‫اسس البحث‪:‬‬
‫ْزا انثحس نرم‪ٛٛ‬ى انًعشفح‪ ,‬االذداِ انشعٕس٘ ٔانً‪ٕٛ‬ل انعًه‪ٛ‬ح نذٖ طالب انًشحهح انًُرٓ‪ٛ‬ح نكه‪ٛ‬ح طة‬
‫تاتم حٕل عذٖٔ انًسرشف‪ٛ‬اخ تاإلضافح نًعشفح يصذس انًعهٕياخ انر‪ ٙ‬نذ‪ٓٚ‬ى حٕل انعذٖٔ‪.‬‬
‫طرق البحث‪:‬‬
‫ْز ِ دساسح ٔصف‪ٛ‬ح ٔيشحه‪ٛ‬ح اخش‪ٚ‬د عهٗ ‪ 106‬يٍ طالب كه‪ٛ‬ح انطة ف‪ ٙ‬خايعح تاتم انٕالعح ف‪ٙ‬‬
‫يحافظح تاتم ‪ .‬اسرخذو ف‪ٓٛ‬ا اسرث‪ٛ‬اٌ يكٌٕ يٍ أستعح اخزاء‪ .‬اندزء االٔل خصص السرمصاء‬
‫انًعشفح انًعهٕياذ‪ٛ‬ح حٕل عذٖٔ انًسرشف‪ٛ‬اخ ت‪ًُٛ‬ا اندزء انًخصص نهً‪ٕٛ‬ل انعًه‪ٛ‬ح نذٖ انطالب‬
‫خصص ندًع انًعهٕياخ حٕل ك‪ٛ‬ف‪ٛ‬ح ذصشف انطالب نردُة االصاتاخ انًشض‪ٛ‬ح انًعذ‪ٚ‬ح‪ .‬أيا‬
‫اندزأ‪ ٍٚ‬ا‪ٜ‬خش‪ًْٔ ٍٚ‬ا أٔال انً‪ٛ‬م انشعٕس٘ ٔك‪ٛ‬ف‪ٛ‬ح ي‪ٕٛ‬ل انطالب نردُة اإلصاتح تأيشاض عذٖٔ‬
‫انًسرشف‪ٛ‬اخ ٔاندزء ا‪ٜ‬خش ْٕٔ حٕل يصذس انًعهٕياخ نذٖ انطهثح حٕل اإلصاتاخ انًعذ‪ٚ‬ح‬
‫اسرعًم ف‪ْ ٙ‬زا انثحس انً‪ ُٙٛ‬ذاب ‪ٔ13.1‬اسرخذو يُّ ‪ ٔ Chi – square‬ال ‪ٔ P- value‬انر‪ٙ‬‬
‫اعرثشخ يًٓح إرا كاَد الم يٍ ‪ٔ 0.05‬ذعرثش عان‪ٛ‬ح األًْ‪ٛ‬ح إرا كاَد الم يٍ ‪0.01 .‬‬
‫النتائج ‪-:‬‬
‫‪ (68.34‬حٕل عذٖٔ‬
‫أظٓشخ ْزِ انذساسح انًعذل انعاو نهًعشفح انًعهٕياذ‪ٛ‬ح نذٖ انطالب (‪%‬‬
‫انًسرشف‪ٛ‬اخ يع ْزا ذعرثش ْزِ انًعشفح ف‪ ٙ‬خٕاَة يع‪ُٛ‬ح ضع‪ٛ‬فح ٔخصٕصا حٕل احرًان‪ٛ‬ح اَرمال‬
‫اإلصاتاخ إنٗ أعضاء انفش‪ٚ‬ك انصح‪ٔ ٙ‬كاَد انُسثح ‪ 41.5 %‬كزنك حٕل احرًان‪ٛ‬ح كٌٕ انسًاعح‬
‫‪ 43.86%.‬تصٕسج عايح كاٌ انرصشف انعًه‪ ٙ‬نهطالب يرٕسطا‬
‫انطث‪ٛ‬ح كًصذس نُالهههعذٖٔ‬
‫( ‪ )%69.38‬يٍ انً‪ٛ‬م نهرمه‪ٛ‬م يٍ َسثح اإلصاتاخ ٔنكٍ ف‪ ٙ‬خٕاَة يع‪ُٛ‬ح ضع‪ٛ‬فح يثال عذو اسذذاء‬
‫انًٕاد انٕال‪ٛ‬ح نهرمه‪ٛ‬م يٍ االصاتاخ ٔ كاَد انُسثح ‪.49.06%‬كًا أظٓشخ انذساسح انً‪ٕٛ‬ل انشعٕس٘‬
‫انعايا‪ٚ‬دات‪ٛ‬ا ٔتُسثح ‪ٔ 68.68 %‬كاٌ انً‪ٛ‬م انشعٕس٘ نإلَاز أفضم يٍ انزكٕس نردُة اإلصاتاخ‪ .‬أيا‬
‫يصادس انًعشفح انًعهٕياذ‪ٛ‬ح نذٖ انطهثح تصٕسج عايح يمثٕل ( ‪)%50.38‬ح‪ٛ‬س كاٌ أح‪ٛ‬اَا ‪39.62%‬‬
‫‪ 64.15%‬نى‬
‫فمظ يُٓى لذ َصح تانطشق ا‪ٜ‬يُح نٕضع أخٓزج اإلعطاء انٕس‪ٚ‬ذ٘ ٔيا شاتّ ت‪ًُٛ‬ا‬
‫‪ُٚ‬صحٕا ترُظ‪ٛ‬ف سًاعاذٓى انطث‪ٛ‬ح‪.‬‬
‫الخالصة‪-:‬‬
‫انًعشفح انًعهٕياذ‪ٛ‬ح نذٖ انطالب يرٕسطح ٔاالذداِ انشعٕس٘ كاٌ ا‪ٚ‬دات‪ٛ‬ا ٔذصشفٓى انعًه‪ ٙ‬يرٕسطا‬
‫نهرمه‪ٛ‬م يٍ االصاتاخ يع ْزا يصادس يعهٕياذٓى كاَد ضع‪ٛ‬فح خذا ف‪ ٙ‬عذج خٕاَة ‪ْ.‬زِ انُرائح ذؤكذ‬
‫انحاخح انًاسح إنٗ انرشذد انرعه‪ ًٙٛ‬حٕل عذٖٔ انًسرشف‪ٛ‬اخ ف‪ ٙ‬انًُٓاج انذساس‪ ٙ‬انطث‪ ٙ‬انعًه‪ٙ‬‬
‫ٔانُظش٘‪.‬‬
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