The National Ribat University

Faculty of Graduate Studies and Scientific Research

Effect of Health Educational Program On Nurses Knowledge

& practice Regarding Infection Control in Neonatal Intensive

Care Unit at Pediatric Hospitals in Khartoum State.

(Sudan 2015)

Thesis Submitted for fulfillment the Requirement for

Degree of PH.D Pediatric Nursing

By: Suhair Salah Mohmmd Mohmmed Noor

Supervisor: Dr. Hanan Mabruok Ramadan

Co - Supervisor: Dr. Kalthoum Ibrahim Yousif

2016

االـــــــــــــــــــــــــــــــــــــخ

: لبل رؼبن

مض ي اندع ف انخ ء ي كى ثش نجه (

* انز بثش ش انظ ثش شاد انث فظ ال ال الي

* ساخؼ إب إن إرا أطبثزى يظجخ لبنا إب لل

ى طه أنئك ى أنئك ػه خ سح ى سث اد ي

) زذ ان

( 591-599) انجمشح :

I

List of contents

Page Contents

I - II list of content

III- IV List of table and figure

V Dedication

VI Acknowledgment

VII Abstract English

VIII Abstract Arabic

IX List of abbreviations

Chapter one: INTRODUCTION

1 1.1 Introduction

2 1.2 Problem statement

3 1.3 Justification and rational

4 1.4 Objectives

Chapter two: literature review

5-6 2.1Introduction and definition

7-8 2.2Infection control in heath facility

9-10 2.3Infection control in NICU

10-11 2.4 Standard Infection Control Precautions

(Universal) - to be observed

11-12 2.5 Administrative arrangement

12-13 2.6 Chain of infection

13-17 2.7 Prevention and Control of Infections

II

17-19 2.8. Daily Routines duties and responsibilities for

nurses in NICU

19 2.9 Outbreak Control

20-29 2.10 Routine Practices in Perinatology

30-38 2.11 Previous study

Chapter three :materials and method

39-41 3.1 Materials

41-42 3.2Method

42-43 3.3 Data Management and Analysis

43 3.4 Ethical Considerations

Chapter four :results

44-60 Results

Chapter five: discussion

61-63 Discussion

64 Conclusion

65 Recommendations

Chapter six: References

66-72 References

Appendices:

73-75 Sample of Questionnaire in Arabic

76-79 Sample of Questionnaire in English

80-81 Sample of Check List

82-83 Copy from letters to hospitals

III

List of Tables and Figures

Page number of table and figure

44 1-Figure (1) Distribution of the study sample according to age

45 2- Figure (2) Distribution of the study sample according to qualifications

46 3- Figure (3) Distribution of the study sample according to experience

47 4- Table (4.1) Distribution of the study sample according to their knowledge regarding

the definition of sterilization

48 5- Table (4.2) Comparison of knowledge of the study sample regarding the definition

of sterilization

49 6- Table (4.3) Distribution of the study sample according to their knowledge regarding

the definition of disinfectant

50 7- Table (4.4) Comparison of knowledge of the study sample regarding the definition

of disinfectant

51 8- Table (4.5) Distribution of the study sample according to their knowledge towards

standard precaution, use of PPE

52 9- Table (4.6) Comparison of knowledge of the study sample regarding standard

precaution, use of PPE

53 10- Table (4.7a) Distribution of the study sample according to their practices regarding

infection control (hand washing)

54 11-Table (4.7b) Comparison of practices of the study sample infection control

according to their practices regarding infection control (hand washing)

55 12- Table (4.7c) Distribution of the study sample according to their practices regarding

infection control (equipment)

56 13-Table (4.7d) Comparison of the statistical significance of the study sample

according to their practices regarding infection control (equipment)

57 14- Table (4.7e) Distribution of the study sample according to their practices regarding

infection control (sharp tools)

IV

58 15-Table (4.7f) Comparison of the study sample according to their practices regarding

infection control (sharp tools)

59 16- Table (4.7g) Distribution of the study sample according to their practices regarding

infection control (daily routine practice)

60 17- Table (4.7h) Comparison of the study sample according to their practices

regarding infection control (daily routine practice)

V

Dedicated in love and gratitude to:

My parents

My brothers

My sisters

My husband

My friends and colleagues

VI

First I would like to thank the National Ribat University Graduate

faculty represented in the College of Nursing and foremost .I would like to

thank Dr. Hanan Mabrouk Ramadan and Dr. Kalthoum Ibrahim Yousif

for thier constant support, for the useful advices and excellent supervision.

A very special thanks to Dr. Saida Abdul Majeed Refai to help me

take out this research as required.

I would like to acknowledge the help and cooperation of the Nurses in

Maternity Hospital and Gafar Ibn Ouf Pediatric Hospital and Omdurman

Maternity Hospital.

Thanks also extended to my family members for the generous support

and patience during the whole period of this study.

VII

Abstract

Background: The pathogenic organism and various form of illness they

produce can easily spread in an environment such as neonatal intensive care

unit. All newborn infants are especially liable to nosocomial infection

because of their intrinsic susceptibility to infection as well as the invasive

procedures. Study design: An Intervention study (Quasi-experimental: pre

and posttest design for the same group). Objectives: To evaluate the effect of

educational program for nurses knowledge &practice regarding infection

control in neonatal intensive care unit in pediatric hospital in Khartoum state

in order to reducing morbidity and mortality of newborns by improving the

quality of nursing care in neonatal intensive care unit. Methods: The study

was conducted in two pediatric hospitals in Khartoum state, Gaffer Ibin Ouf

specialized pediatric hospital and Omdurman Maternity Hospital. The study

sample consisted of 61 nurses. Data was collected using a questionnaire (to

measure knowledge) and checklist (to measure practice). Data was analyzed

using Statistical Packages for Social Sciences (SPSS). Results: Significant

differences were found in knowledge of nurses between the pre test and

posttest (P < 0.05) regarding definition of sterilization(36.1% of the nurses

gave correct answer about the definition of sterilization before attendance of

the program, while, correct answer was mentioned by 95.1% of them after

attendance), disinfectant(29.5% of the nurses gave correct answer about the

definition of disinfectant before attendance of the program, while, correct

answer was mentioned by 78.7% of them after attendance) and the standard

precaution, use of PPE at NICU care the nurses who correctly answered the

statements about the standard precaution, use of PPE at NICU care were

lower percentages before the program compared to the higher percentages of

their answers after the program. The mean value of nurses answers regarding

their first statement was (0.64±0.48) at pretest measurement, which increased

at posttest measurement to (0.87±0.34), with improved knowledge. Also

there is significant differences were found regarding correct practices on

prevention of infection at NICU care (P < 0.05), with improved practices at

posttest than at pretest. Conclusion: The educational program had a

significant impact related to the improvement of the nurse's knowledge and

practical skills post application of the program.

VIII

يستخهع انذساسخ

خهفيخ انجحج :

إ انكشثبد انغججخ نأليشاع يخزهف أشكبل انشع انز رزدب ك أ رزشش ثغنخ ف

ثئخ يثم حذح انؼبخ انشكضح نحذث انالدح. خغ الؽفبل ف حذث انالدح يؼشػ ثشكم

زؼشػ خبص نؼذ انغزشفبد ثغجت لبثهزى نهؼذ كزنك إخشاء انؼهبد انزشؼ انز

نب زا انحبل ثشكم خبص لنئك انز نذا لجم الا أ اخفبع انص ػذ الدرى .

:تػيى انذساسخ

دساعخ رذخهخ )شج انزدشجخ: لجم ثؼذ االخزجبس(.

األهذاف:

ح رمى أثشانجشبيح انزؼه نهشػبد نهؼشفخ انبسعبد انزؼهمخ ثكبفحخ انؼذ ف حذ

انؼبخ انشكضح نحذث انالدح ف يغزشفبد الؽفبل ف الخ انخشؽو ي أخم خفغ يؼذالد

االػزالل انفبد ي الؽفبل حذث انالدح ػ ؽشك رحغ ػخ انشػبخ انزشؼخ ف حذح

انؼبخ انشكضح نحذث انالدح.

:ـشق اجشاء انجحج

نألؽفبل ف الخ انخشؽو، يغزشف خؼفش ث ػف انشخؼ أخشذ ز انذساعخ ف يغزشف

يشػخ . لذ رى خغ 5:نالؽفبل يغزشف يغزشف انالدح أيذسيب. ركذ ػخ انذساعخ ي

انجببد ثبعزخذاو االعزجب )نمبط انؼشفخ( انشخؼخ )نمبط انبسعخ(. رى رحهم انجببد

(.SPSSخ نهؼهو االخزبػخ )ثبعزخذاو انحضو اإلحظبئ

انتبئج:

% اػط 5.:7( فب زؼهك ثزؼشف انزؼمى)P <0.05خد فشق كجشح ف يؼشفخ انشػبد )

% غجخ االخبثبد انظححخ ثؼذ حؼس 19.5اخبثخ طححخ لجم حؼس انجشبيح انزؼه ثب

انشػبد كبذ اخبثز طححخ % ي61.9انجشبيح انزؼه( فب زؼهك ثزؼشف انطشاد)

% غجخ االخبثبد انظححخ ثؼذ حؼس انجشبيح انزؼه( 17.7لجم حؼس انجشبيح انزؼه ثب

اإلحزشاط انمبع، إعزؼبل اداد انحبخ انشخظخ ف حذح حذث انالدح ، انشػبد انهار

انجببد ثشكم طحح كبذ غت يئخ الم لجم حؼس انجشبيح انزؼه يمبسخ انغت أخج

أخثزى ثؼذ انجشبيح. انمخ انزعطخ الخبثبد انشػبد ثخظص ثبى انئخ الػه ي

( (، يب 4.78± 4.71( ، انز صاد ف ثؼذ رفز انجشبيح انزؼه إن )4.87± 8:.4الل كب

ؼشفخ .ظش رحغ اػح نه

رحغذ انؼشفخ انبسعبربنؼهخ انظححخ ي لجم انشػبد ثشكم يهحظ ثغجت رطجك

.(P < 0.05)انجشبيح انزؼه

:انخالغخ

ادبثخ ف انؼشفخ انبسعخ انؼهخ دالنخ احظبئخاظشد انذساعخ فؼبنخ اػحخ راد

نهشػبد ثؼذ رطجك انجشبيح انزؼه .

IX

List of Abbreviations

CDC Center of Disease Control

HBV Hepatitis b virus

CCIH Committee of Control Infection in hospitals

HCV Hepatitis c virus

HCAI Healthcare Associated Infections

HCWs Health Care Workers

HIV Human Immune Virus

HLD High Level Disinfection

ICU Intensive Care Unit

MH Maternity hospital

NI Nosocomial Infection

NICU Neonatal Intensive Care unit

PCIHs Program to Control Infection in Hospitals

SPSS Statistical Package for Social Science

PPE Personal Protective Equipment

US United State

UTI Urinary Tract Infection

Chapter one

Introduction

Problem statement

Justification

Objective

1

Chapter (One)

Introduction

1.1 background

NICU patients are at high risk for infection because of their illnesses,

immature immune systems, and exposure to invasive procedures and devices.

The way NICU is designed can enhance (or interfere with) infection control

precautions, such as hand washing and disposal of soiled items Consultation

with an infection control specialist during the planning stages of a new NICU

with regard to both the design itself and the care practices that will be utilized

can positively affect outcomes for babies and functionality for staff (1)

..

Everyone who is in contact with infant, including parent and personnel must

assume this responsibility. Infection control refers to policies and procedures

used to minimize risk of infection in the nursery or in the community.

Neonatal infection currently causes about 106 million deaths annually in

developing countries sepsis and meningitis is responsible for most of those

deaths. Resistance to the commonly used antibiotics is emerging and

constitutes an important problem worldwide to reduce global neonatal death

strategies of proven efficacy. Such as hand washing, barriers restriction to

neonate (2)

.

2

1.2 Problem Statement

Infection control is known to be the most important issue in caring for the

newborn infants their immunity is limited for the first week. After birth the

infant needs protection from infection. Protecting infant from infection is a

major responsibility of nurses who care for them (3)

.Neonatal infection

currently cases about 106million deaths annually in developing countries

sepsis and meningitis are responsible for most of those deaths. Resistance to

the commonly used antibiotic is emerging and constitutes an unimportant

problem worldwide to reduce global neonatal death strategies of proven

efficacy. Such as hand washing .barriers restriction to neonatal units need to

be implemented hand washing has been shown to be effective even since 19th

century. .For this reasons the researcher want to make educational program

regarding infection control for those nurses who work in this very sensitive

area to prevent all neonate admitted in neonatal intensive care unit from

nosocomial infection(4)

.

3

1.3 Justification and rational

The pathogenic organism and various form of illness they produce can

easily spread in an environment such as neonatal intensive care unit. First of

all newborn infants are especially liable to nosocomial infection because of

their intrinsic susceptibility to infection as well as the invasive procedure to

which they are subjected this is particularly so for those born prematurely or

low birth weight(5)

.Secondly gaffer Ibn Ouf hospital and maternity hospital

admitted about600 newborn every month generally there is feeling among

health worker that the rate of infection in the hospital is high health personal

require education continuous reminding and feedback if compliance is to be

maintained. Finally because the nurses has a major role to infection control in

intensive care so educational programs is needed theoretically and

practically, this might lead to control of infection and reduce the mortality

and morbidity of neonate who admitted in neonatal intensive care unit(6)

.

4

1.4 Objectives of study

1.4.1 General objectives

To evaluate the effect of educational program for nurses knowledge

&practice regarding infection control in neonatal intensive care units in

pediatric hospital in Khartoum state.

1.4.2 Specific objectives

1- To assess basic knowledge of the nurses about infection control in

neonatal intensive care unit, regarding e.g. (sterilization, disinfection,

standard precaution, use of Personal Protective Equipments ……..etc)

2- To assess basic practice of the nurses about infection control e.g. (hand

washing, sterilization of incubators and how to use Personal Protective

Equipments).

3-To evaluate the effect of implementing program for the nurses' knowledge

and practice about infection control in neonatal intensive care unit.

4- To evaluate the effect of implementing program of the nurses' practice

about infection control in neonatal intensive care unit.

1

Chapter Two

Literature review

5

Chapter (two)

Literature review

2.1 Chapter (two) Literature review

Healthcare Associated Infections (HCAI) are major problems for the safety

and quality of life of patients Besides, their impact may result in death,

prolonged hospitalization, long term disability, considerable financial impact

on healthcare institutions and high cost for patients and their family

members(7)

.Due to the high incidence of HCAI in Brazil, it is estimated that

3% to 15% of hospitalized patients develop Nosocomial Infection (NI)(8)

, the

Ministry of Health there created the Nosocomial Infection Control Program

which is a set of actions carried out deliberately and systematically, in order

to reduce to a minimum the incidence of these infections. Ordinance No

2.616/98in brazil regulates the National Infection Control Program and the

establishment of the Committee of Nosocomial Infection Control. Among the

various duties of the CCIH was continuing education with the purpose of

prevention and control of these HCAI(9)

.Despite all the efforts of the WHO

and the Ministry of Health, a recent publication in an international journal

reveals that one important challenge faced by Brazil is reducing healthcare

acquired infections. The authors consider this problem of a great magnitude,

once many hospitals count on poorly-structured PCIHs and do not prioritize

sanitary surveillance (10)

. There is also evidence that these infections are a

major cause of neonatal morbidity and mortality in developing countries

(11).The HCAI in the Neonatal Intensive Care Units (NICU) are those

acquired in the intra partum period (of maternal origin and occurring in the

first 48 hours of life), during hospitalization, or 48 hours after discharge,

except for transplacental infections(12)

. Newborns need special attention and

6

care, because their skin is the main port of entry for these infections (13)

.

Thus, the nursing team of neonatal intensive care units and CCIH must work

together to detect possible failures in order to improve the quality of life of

the newborn (14)

.There are several risk factors in a NICU, including: invasive

procedures, length of stay, low birth weight, early contact with parents. All

these factors can trigger a higher proliferation of HCAI, impairing the

recovery and the quality of life of the newborn (15).

Infection control is the discipline concerned with nosocomial or healthcare-

associated infection. It is a practical sub-discipline of epidemiology it is an

essential part of the infrastructure of health care. Infection control and

hospital epidemiology are akin to public health practice, practiced within the

confines of a particular health-care delivery system rather than directed at

society as a whole(16)

.People receiving health and medical care, whether in a

hospital or clinic, area risk of becoming infected unless precautions are taken

to prevent infection. Nosocomial (hospital-acquired) infections are a

significant problem throughout the world and are increasing For example,

Nosocomial infection rates range from as low as 1% in a few countries in

Europe and the America to more than 40% in parts of Asia, Latin America

And sub-Saharan Africa

(2.1.2) Most of these infections can be prevented with readily available,

relatively inexpensive strategies by:

Adhering to recommended infection prevention practices, especially

hand-Hygiene and wearing gloves .Paying attention to well-established

processes for decontamination and-Cleaning of soiled instruments and other

items, followed by either Sterilization or high-level disinfection; and

Improving safety in operating rooms and other high-risk areas where the-

Most serious and frequent injuries and exposures to infectious agents occur.

7

2.2 Infection control in healthcare facilities

2.2.1 Aseptic technique

Is a key component of all invasive medical procedures Similarly,

infection control measures are most effective when Standard Precautions

(health care) are applied because undiagnosed infection is common(17)

.

Asepsis and aseptic technique: Combination of efforts made to prevent enter

of microorganisms into any area of the body where they are likely to cause

infection. The goal of asepsis is to reduce to a safe level, or Eliminate, the

number of microorganisms on both animate (living) Surfaces (skin and

mucous membranes) and inanimate objects (surgical Instruments and other

items).Antisepsis. Process of reducing the number of microorganisms on

skin, Mucous membranes or other body tissue by applying an antimicrobial

(Antiseptic) agent. Decontamination. Process that makes inanimate objects

safer to be Handled by staff before cleaning (i.e., inactivates HBV, HCV and

HIV And reduces, but does not eliminate, the number of other contaminating

Microorganism).Ideally, soiled surgical instruments, gloves and other items

should always Be handled by staff wearing gloves or using forceps. Because

this is not always possible, it is safer first to soak these soiled items for 10

minutes In 0.5% chlorine solution, especially if they will be cleaned by

hand). Metal objects should then be rinsed to prevent corrosion Before

cleaning Other objects that should be Decontaminated, by wiping with the

0.5% chlorine solution, include large Surfaces and equipment that Come in

contact with patients’ blood or body fluids, secretions or Excretions (except

sweat).

Cleaning. Process that physically removes all visible dust, soil, blood or other

body fluids from inanimate objects as well as removing sufficient numbers of

microorganisms to reduce risks for those who touch the skin or handle the

8

object. (It consists of thoroughly washing with soap or detergent and water,

rinsing with clean water and drying. (18)

.

High-level disinfection (HLD): The process that eliminates all

microorganisms accepts some bacterial endospores s from inanimate objects

by boiling, steaming or the use of chemical disinfectants.

Sterilization. Process that eliminates all microorganisms (bacteria viruses,

fungi and parasites) including bacterial end spores from inanimate objects by

high-pressure steam (autoclave), dry heat (oven), chemical sterilants or

radiation (19)

.

2.2.2 Hand washing and antisepsis (hand hygiene)

Appropriate hand hygiene can minimize micro-organisms acquired the

Hands during daily duties and when there is contact with blood, body fluids,

secretions, excretions and known and unknown contaminated equipment or

surfaces (20)

.

2.2.3 Wash or decontaminate hands:

After handling any blood, body fluids, secretions, excretions and-

contaminated items between contact with different patients;-

-between tasks and procedures on the same patient to prevent cross

contamination between different body sites;-immediately after removing

gloves; and using a plain soap, antimicrobial agent, such as an alcoholic hand

rub or waterless antiseptic agent. The hospital setting is a good setting for

communication about personal hygiene, such as informing visitors and the

general public about hygiene rules such as washing hands (21)

.

9

2.3 Infection Control in the NICU

Focuses on the following area:

I. Physical Setup

II. Administrative arrangement

2.3.1 Physical Setup

Space

1. Each infant care space in the Neonatal Intensive Care Unit shall preferably

contain a minimum of 11.2 square meters (120 square feet), excluding sinks

and aisles.

2. There shall be an aisle adjacent to each infant care space with a minimum

width of 0.9 meters (3 feet).

3. Traffic to other services shall not pass through the unit. (22)

.

2.3.2 Ventilation:

• Positive pressure airflow from a ceiling entry to a floor return pulling

dust downwards and out is recommended

• Filters with efficiency of at least 90-100% must be used

• Minimum of 10-15 air charges per hour

• Access to at least one isolation room with negative air pressure

discharging air vented to the outside to accommodate newborns with

airborne infection (23)

.

2.3.3 Scrub Areas

1. In the NICU, there should be at least 1 hands-free hand washing sink for 4

beds.

2. In single bedroom, a hands-free hand washing sink shall be provided with

in each infant care room.

3. Hand washing facilities that can be used by children and people in

wheelchairs shall be available in the NICU.

10

4. Sinks for hand washing should not be built into counters used for other

purposes.

5. Sink location, construction material and related hardware (paper towel,

covered trash receptacle, and soap dispensers) should be chosen with

durability, ease of operation and noise control in mind.

6. Minimum dimensions for a hand washing sink are 61 cm wide X 41 cm

front to back X 25 cm deep (24 in. X 16 in. X 10 in.) From the bottom of the

sink to the top of its rim; so as to minimize splashing.

7. Pictorial hand washing instructions should be provided above all sinks.

8. Sinks should be designed so as to control splashing and avoid standing or

retained water.

9. Faucet aerators may be useful to reduce water splashing in sinks, but they

are notoriously susceptible to contamination with a variety of hydrophilic

bacteria. They should not be used.

10. Sinks should be scrubbed clean daily with a detergent

2.4 Standard Infection Control Precautions (Universal) - to be

observed

2.4.1 Isolation Rooms:

• Appropriately designed isolation rooms should be available in all

hospitals with a nursery.

• A suitable area should be designated for hand scrubbing in preparation

for procedures that require aseptic technique.

• Adequate space of 13.94 square meters (150 square feet) should be

available excluding the entry work area.

• Ideally single multi-bedded corners are appropriate?

• Ventilation in isolation rooms to have negative pressure with our 100%

exhausted to the outside.

11

• A hands free emergency communication system is required within the

isolation room to minimize in and out movement.

• Choice and placement of windows and blinds should allow for care of

operation and cleaning.

• All babies with Septicemia should be isolated.

• Babies transferred from other hospitals or admitted from home must

have swabs taken and sent for culture.

• Transfers must be nursed in an isolation unit (24)

.

2.5 Administrative arrangement

2.5.1 Nosocomial infection

A hospital-acquired infection, also called a nosocomial infection, is an

infection that first appears between 48 hours and four days after a patient is

admitted to a hospital or other health-care facility About 5–10% of patients

admitted to acute care hospitals and long-term care facilities in the United

States develop a hospital-acquired, or nosocomial, infection, with an annual

total of more than one million people. Hospital-acquired infections are

usually related to a procedure or treatment used to diagnose or treat the

patient's initial illness or injury. The Centers for Disease Control (CDC) of

the U.S. Department of Health and Human Services has shown that about

36% of these infections are preventable through the adherence to strict

guidelines by health care workers when caring for patients. What can make

these infections so troublesome is that they occur in people whose health is

already compromised by the condition for which they were first hospitalized.

Hospital-acquired infections can be caused by bacteria, viruses, fungi, or

parasites. These microorganisms may already be present in the patient's body

or may come from the environment, contaminated hospital equipment, health

care workers, or other patients. Depending on the causal agents involved, an

infection may start in any part of the body. A localized infection is limited to

12

a specific part of the body and has local symptoms. For example, if a surgical

wound in the abdomen becomes infected, the area around the wound

becomes red, hot, and painful. A generalized infection is one that enters the

bloodstream and causes systemic symptoms such as fever, chills, low blood

pressure, or mental confusion. This can lead to sepsis, a serious, rapidly

progressive multi-organ infection, sometimes called blood poisoning that can

result in death. Hospital-acquired infections may develop from the

performance of surgical procedures; from the insertion of catheters (tubes)

into the urinary tract, nose, mouth, or blood vessels; or from material from

the nose or mouth that is aspirated (inhaled) into the lungs. The most

common types of hospital-acquired infections are urinary tract infections

(UTIs), ventilator-associated pneumonia, and surgical wound infections. The

University of Michigan Health System reports that the most common sources

of infection in their hospital are urinary catheters, central venous (in the vein)

catheters, and endotrachial tubes (tubes going through the mouth into the

stomach). Catheters going into the body allow bacteria to walk along the

outside of the tube into the body where they find their way into the

bloodstream. A study in the journal Infection Control and Hospital

Epidemiology shows that about 24% of patients with catheters will develop

catheter related infections, of which 5.2% will become bloodstream

infections. Death has been shown to occur in 4–20% of catheter-related

infections. (24)

.

2.6 Chain of infection

Infection Control recognizes the chain of infection as a model that

easily describes how infection may enter the body, and by the development

of that model how infection may be prevented from entering the body and

establishing, and from being spread to other contacts (25)

.

13

2.7 Prevention and Control of Infections

2.7.1 Staff Health

1. Health care workers should be immune to rubella, measles and chicken

pox.

2. Yearly influenza vaccination is available.

3. Ideally, individuals with a respiratory, cutaneous, mucocutaneous or

gastrointestinal infection should not have direct contact with neonates.

2.7.2 Hand washing

1. Medical and hospital personnel must follow careful hand-washing

techniques to minimize transmission of disease.

2. Personnel should remove rings, watches, and bracelets before washing

their hands and entering the neonatal nursery.

3. Fingernails should be trimmed short and no false fingernails or nail polish

should be permitted.

14

4. Antiseptic preparations (e.g. chlorhexidine 4 %) should be used for

scrubbing before entering the nursery, before providing care for neonates,

before performing invasive procedures, and after providing care for neonates.

5. Before handling neonates for the first time, personnel should scrub their

hands and arms to a point above the elbow thoroughly with an antiseptic

soap. After vigorous washing, the hands should be rinsed thoroughly and

dried with paper towels.

6. A 10-second wash without a brush, but with soap and vigorous rubbing,

followed by thorough rinsing under a stream of water, is required before and

after handling each neonate and after touching objects or surfaces likely to be

contaminated with virulent microorganisms or hospital pathogens.

7. Hand washing is necessary even when gloves have been worn in direct

contact with the infant. Hand washing should immediately follow removal of

gloves, before touching another infant.

8. Alcohol-containing foams kill bacteria satisfactorily when applied to clean

hands and with sufficient contact (in accordance with manufacturers

'recommendations). They can be used in areas where no sinks are available or

during emergency but they are not sufficient in cleaning physically soiled

hands, because transient organisms are not removed. (1)

.

2.7.3 Protective Attire:

• A short sleeved gown should be worn over special clothing designated

for nursery by the health care personnel and lodger mothers- this gown

to be exclusively for one named neonate and hand hygiene strictly

practiced before moving on to others

2.7.4 Patient Care Equipment

Cleaning and disinfection:

Important to follow the manufacturer’s instructions, swabs for culture

should be taken from ventilators of the infected babies/ neonates.

15

• Terminal disinfection of equipment done using soap and water and

hypochlorite solution.

• Ventilator tubing used in babies with negative bacilli to be discarded as

medical waste.

• Ventilators used for infected babies to be left standing for 96hours after

terminal disinfection before re-use.

• Incubators and bassinets should have the detachable parts removed and

scrubbed meticulously.

• Incubator fans, where applicable should be cleaned and disinfected

• Air filters in the incubator should be maintained as recommended by the

manufacturer.

• Waterproofed mattresses replaced when waterproof covering is broken

• Porthole cuffs are easily and often heavily contaminated, therefore need

for daily cleaning with detergent and daily cleaning with disinfectant

(1).

• Babies admitted in the nursery for prolonged periods, need to be transferred

into cleaned and disinfected incubators after seven days and the used

incubator be exposed to thorough cleaning and disinfection (26)

.

2.7.5 Traffic Control / Visitation

1. Parents are educated about visitation policies prior to the birth of the

infant.

2. The parents, grandparents, or a designated support person and siblings of

infants will be admitted to that area following NICU visiting protocols.

3. Visitors are screened for infection.

4. Visitors with active infections should be excluded from the area with the

following two exceptions:

16

a. Fathers with respiratory symptoms may wear a mask at the delivery but

may not visit the baby in NICU. Other visitors with respiratory symptoms are

excluded from visiting under any circumstances.

b. Parents and siblings may visit in the NICU with a mask IF the infant is in

critical condition.

c. A mother (not father or sibling) with active (non-dried) herpes simplex

infection may have contact with the infant. She is to wear a mask and be

educated on the importance of hand hygiene before contact with the infant.

No facial contact should occur.

2.7.6 Dress Requirements:

1. Those assigned to the care of babies will wear a clean uniform.

2. Hair which is shoulder length or longer must be tied back off the collar.

3. Long-sleeved cover gowns will be worn by those working with babies with

drainage or infectious disease process, or whenever soiling may be likely.

Disease process, or whenever soiling may be likely.

4. Gowns are to be worn once and discarded. Health Maintenance

1. Sick calls are mandatory for:

a. symptoms of diarrhea or upper respiratory infection.

B. cold sores or fever blisters.

C. any lesion on the genitals or irritating vaginal discharge.

D. skin infection or pustule acne.

2. All of the above must be reported to Employee Health.

3. Associates may not return to work until the condition is resolved or is no

longer infectious (27).

17

2.7.7 linens

Handle, transport and process used linen that is soiled with blood, body

fluids, secretions or excretions with care to ensure that there is no leaking of

fluid.

2.7.8 Prevention of needle stick/sharps injuries

Take care to prevent injuries when using needles, scalpels and other sharp

instruments or equipment. Place used disposable syringes and needles,

scalpel blades and other sharp items in a puncture-resistant container with a

lid that closes and is located close to the area in which the item is used.

Take extra care when cleaning sharp reusable instruments or equipment.

Never recap or bend needles. Sharps must be appropriately disinfected and/or

destroyed.

2.7.9 Management of health-care waste:

Uncollected, long stored waste or waste routing within the premises must be

avoided. A sound waste management system needs to be developed and

closely monitored (28)

.

2.8. Daily Routines duties and responsibilities for nurses in

NICU

1. Cord care will be given using water.

2. A bath is given every third day using a mild soap. The face, bottom, and

hair are washed daily.

3. Strict asepsis will be maintained during all invasive procedures.

4. Infants should be held away from the face and hair of the care provider.

5. Personnel (Nursery or float staff) who have worked part of a shift in

another area of the hospital are not to enter the patient care area unless they

change into a clean uniform or don a clean cover gown and perform a three-

minute scrub.

18

2.8.1 Infant Feeding

1. Formula

a. Mothers will be instructed to cleanse hands before receiving baby for

formula feeding.

b. Formula products should be selected based on nutritional needs;

alternatives to powdered forms should be chosen when possible.

c. Sterile water is used for reconstituting powdered forms.

d. Trained personnel prepare powdered formula under aseptic technique in

the designated nutrition room.

e. Manufacturer’s instructions are followed; product should be refrigerated

immediately (35-50 F] and discarded if not used within 24 hours after

preparation

f. The administration or "hang time" for continuous enteral feeding should

not exceed 4 hours.

g. Formula recalls are handled in a manner consistent with hospital policy for

Product recalls .Breast feeding will be instructed on nipple care as well as

hand care mother.

2.8.2 General Housekeeping

1. Cleaning should be performed in the following order – patient areas,

accessory areas and then adjacent halls.

2. In the cleaning procedure, dust should not be dispersed into the air.

3. Standard types of portable vacuum cleaners should not be used in the

neonatal ICU or because particulate matter and microbial contamination in

the room may be disturbed and distributed by the exhaust jet. Vacuum

cleaners that discharge outside the patient care area (i.e., 9central vacuum

cleaning systems or portable vacuums) should be used so that only the

cleaning wand, floor tool, and high-efficiency, particulate air filtered vacuum

hose are brought into the patient care area.

19

4. Once dust has been removed, scrubbing with a mop and a

disinfectant/detergent solution should be performed. Mop heads should be

machine laundered and thoroughly dried daily.

5. Cabinet counters, work surfaces, and similar horizontal areas should be

cleaned once a day and between patient use with a disinfectant/detergent and

clean cloths; as they may be subject to heavy contamination during routine

use. Friction cleaning is important to ensure physical removal of dirt and

contaminating microorganisms.

6. Surfaces that are contaminated by patient specimens or accidental spills

should be carefully cleaned and disinfected.

7. Walls, windows, storage shelves and similar non-critical surfaces should

be scrubbed periodically with a disinfectant/detergent solution as part of the

general housekeeping program.

8. Sinks should be scrubbed clean at least daily with a detergent (1)

.

2.8.3 Laundering

1. The chemicals trichlorocarbanilide or sodium salt of pentachlorophenol

should not be used in hospital laundering because they may be harmful.

2. To avoid the hazards associated with the use of such chemicals or enzymes

in the hospital laundry, the physician in charge should be aware of all agents

in use and should be informed before any changes are made in laundry

chemicals or procedures. Caution should be exercised when new laundry or

cleaning agents are introduced into the nursery or when.

Procedures are changed

2.9 Outbreak Control

• The infection control committee should define the status referred to as an

outbreak when there is a significant change from the baseline infection

rate at a certain site or with a particular microbe.

20

• Microbiological intervention measures should be taken to identify

involved micro-organisms.

• Emphasis on compliance to infection control practices should be the main

focus prompt outbreak response measures (29)

.

Prevention is better than cure: The nurses must follow the following

practices to protect children from entering the neonatal unit

2.10 Routine Practices in Perinatology:

Routine Practices are based on the premise that all patients are potentially

infectious, even when asymptomatic, and that the same safe standards of

practice should be used routinely with all patients to prevent exposure to

blood, body fluids, secretions, excretions, mucous membranes, non-intact

skin or soiled items and to prevent the spread of microorganisms. Routine

Practices refer to the infection prevention and control practices that are to be

used with all patients during all care, to prevent and control transmission of

microorganisms in all health care settings(30)

.

The basic elements that comprise Routine Practices are: risk assessment

hand hygiene environmental controls administrative controls personal

protective equipment (PPE) (31)

.

A. Risk Assessment and Screening The first step in the effective use of

Routine Practices is to perform a risk assessment. In perinatology, the risk

assessment must include both mother and newborn, as well as primary care

givers and others who have close contact with the newborn. There are three

types of risk assessment in perinatology:

1. Interventions and preventive practices that are dealt with prior to birth

2. Screening protocols for infectious illnesses

21

3. point-of-care risk assessment to guide use of personal protective

equipment and patient placement. A point-of-care risk assessment is

applied before every interaction with the mother or newborn, throughout

the continuum of care (antenatal, care at birth, postnatal and newborn

care). Infection risk is assessed based on symptoms of infection(32)

in order

to determine which interventions or avoidance procedures are required to

minimize risk and prevent transmission of infection during the interaction.

The risk assessment is performed prior to every interaction because the

mother’s/ newborn’s status can change. See Figure 1 for questions to be

asked as part of a point-of-care risk assessment. A point-of-care risk

assessment must be applied before every interaction with a mother or

newborn, throughout the continuum of care. Based on the results of the

risk assessment, interventions and barriers may be put into place to reduce

one’s risk of acquiring or transmitting infection (33)

. While hand hygiene

and the Four Moments are always required, the risk assessment may

indicate that extra barriers be put into place. For example: exposure of

hands wear gloves exposure of clothing or forearms wear a gown

exposure to mucous membranes of the eyes, nose, mouth wear a mask

and eye protection exposure to contaminated equipment or surfaces

wear gloves and possibly gown for each interaction with each mother/

newborn .point-of-care risk assessment where there is a risk of

transmission of infection based on the risk assessment, appropriate controls

must be put into place and appropriate PPE must be used to protect the

health care provider, other staff, other mothers, newborns and visitors.

perform a risk assessment individual risk assessment (1) individual risk

assessment (2) decision (1): do I need protection for what I am about to do

because there is a risk of exposure to blood and body fluids, mucous

membranes, non-intact skin or contaminated equipment? rationale for

22

action intervention and interaction (1): must follow routine practices

because there is a risk that i might expose myself to an infection that is

transmitted via this route, or expose the mother/newborn to my

microorganisms decision (2): do I need protection for what I am about to

do because the mother/newborn has undiagnosed symptoms of infection?

Intervention and Interaction #2: I must alert someone about the

mother/newborn who has symptoms so that a diagnosis may be made, and

I must determine what organizational requirements are to be put in place to

protect myself and others. Decision #3: What are the organizational

requirements for this mother/newborn who has an identified infection?

Intervention and Interaction #3: must follow the procedures prescribed for

this infection to protect others and Organizational Risk Assessment

.Health care providers must assess their risk of exposure to body

substances, such as: - blood - body fluids, including breast milk -

secretions, including vaginal secretions - excretions, including meconium

and identify the strategies that will decrease exposure risk and prevent the

transmission of microorganisms. B. Hand Hygiene Hand hygiene relates to

the removal of visible soil and removal or killing of transient

microorganisms from the hands while maintaining good skin integrity.

Hand hygiene is the single most important and effective measure to

prevent the spread of health care-associated infections. In the neonatal

intensive care unit (NICU) setting, improved adherence to hand hygiene

practice has been shown to reduce infection rates (34)

health care setting

should have in place a hand hygiene program that includes easy access to

alcohol-based hand rub at point-of-care, dedicated hand washing sinks in

patient care areas, a hand care program and a program to monitor hand

hygiene compliance with feedback to staff and management. To make it

possible for health care providers to clean their hands at the right time, (35)

There should also be adequate sinks with soap and water to allow for hand

23

washing. ABHR is the preferred method to routinely decontaminate hands

in clinical situations when hands are not visibly soiled,4 as it provides for a

rapid kill of most transient microorganisms, is less time-consuming than

washing with soap and water and is easier on skin(36)

Hand washing with

soap and running water must be performed when hands are visibly soiled.4

Hand hygiene is the single most important and effective infection

prevention and control measure to prevent the spread of health care-

associated infections. Effective hand hygiene is reflected by the four

moments that are part of Ontario’s Just Clean Your Hands program: 1.

BEFORE initial contact with each patient or their environment 2.

BEFORE performing an aseptic procedure 3. AFTER care involving body

fluid exposure risk 4. AFTER contact with a patient or their environment.

Hand Hygiene in the Neonatal Intensive Care Unit (NICU) For the

purposes of hand hygiene, there are three distinctive environments in the

NICU Neonate Environment: the environment inside an isolate/ warmer

that includes the neonate 2. Immediate Care of Environment: the

environment immediately outside the isolate/ warmer that includes

equipment used in the care of the neonate (e.g., monitors, ventilators,

supplies) 3. NICU Environment: the remainder of the NICU (e.g., nursing

station, hallways, lounges, storage rooms, preparation rooms, utility

rooms). Effective hand hygiene in the NICU environment necessitatesthe

addition of an extra hand hygiene ‘moment’ on each entry to the isolette/

warmer that holds the neonate. For the purposes of the 4 moments for hand

hygiene, the Immediate Care Environment and the Neonate Environment

may be considered to be distinct , presenting an additional opportunity for

hand hygiene. Hand hygiene in the NICU would then be performed: 1.A

BEFORE contact with the Immediate Care Environment 1.B BEFORE

contact with the neonate or the Neonate Environment 2. BEFORE

performing an aseptic procedure 3. AFTER care involving body fluid

24

exposure risk 4. AFTER contact with the Immediate Care Environment

Hospital Environment NICU Environment Immediate Care Environment

Neonate Environment Immediate Care Environment Clean hands on each

entry into the space and on leaving the space Neonate Environment Clean

hands at each entry to the space NICU Environment Clean hands at initial

entry Figure 2: The Environment of the Neonatal Intensive Care Unit and

Adaptation of Hand Hygiene Moments Jewellery is hard to clean and hides

bacteria and viruses from the action of the hand hygiene agent(37)

Rings

increase the number of microorganisms present on hands(38)

although this

has not been linked to increases in infections. Rings may increase the risk

of tears in gloves It is recommended that rings and bracelets not be worn

by those with direct contact with mothers or newborns. If the health care

setting policy allows health care providers to wear hand and/ or arm

jewellery, it must be limited to a smooth wedding band without projections

or mounted stones(39)

and/ or a watch. In the NICU setting, for provision of

direct patient care, arms should be bare below the elbows, i.e., no

bracelets, rings, or watches. Impediments to effective hand hygiene: -

jewellery - nail conditions - nail polish - artificial nails In the NICU

setting, for provision of direct patient care, arms should be bare below the

elbows. Nails, Nail Polish and Artificial Nails Long nails are difficult to

clean, can pierce gloves41 and harbor more microorganisms than short

nails. Natural nails should be kept clean and short(40)

The nail should not

show past the end of the finger.43 Studies have shown that chipped nail

polish or nail polish worn longer than 4 days can harbor microorganisms

that are not removed by hand washing, even with surgical hand

scrubs(41)

Freshly applied nail polish does not result in increased numbers

of bacteria around the nails. Fingernail polish, if worn, must be fresh and

in good condition. Acrylic nails harbour microorganisms and are more

difficult to clean than natural nails.46 Artificial nails and nail

25

enhancements have been implicated in the transfer of microorganisms such

as Pseudomonas species(42)

Klebsiella pneumoniae48 and yeast and in

outbreaks, particularly in neonatal nurseries. Artificial nails and nail

enhancements are also associated with poor hand hygiene practices and

result in more tears to gloves. (43)

For these reasons, artificial nails and nail

enhancements must not be worn by those having direct contact with

mothers/ newborns. Artificial nails and nail enhancements must not be

worn by those having direct contact with mothers or newborns. C. Personal

Protective Equipment (PPE) Personal protective equipment (PPE) is worn

to prevent transmission of microorganisms from patient-to-patient, from

patient-to-staff and from staff-to-patient, by placing a barrier between a

potential source of infection and one’s own mucous membranes, airways,

skin and clothing(44)

The selection of PPE is based on the nature of the

interaction with the mother or newborn and/ or the likely mode(s) of

transmission of infectious agents, according to the risk assessment. PPE

includes gloves, gown and facial protection. PPE should be put on just

prior to the interaction with the mother/ newborn. When the interaction for

which the PPE was used has ended, PPE should be removed immediately

and disposed of in the appropriate receptacle. The process of PPE removal

requires strict adherence to a formal protocol to prevent recontamination.

(45)

Gloves Gloves are worn for contact with mucous membranes, non-intact

skin, blood, body fluids, secretions, excretions or equipment and

environmental surfaces contaminated with any of these.2 Gloves are not a

substitute for hand hygiene, which must be performed before putting on

gloves and after glove removal. Appropriate glove use: Perform hand

hygiene before putting on gloves. Put on gloves immediately before the

activity for which they are indicated. Remove gloves and discard

26

immediately after the activity for which they were used. Change gloves

between care for each patient, including the mother and her newborn.

Wear gloves when handling the newborn after delivery prior to bath or

adequate removal of the mother’s body substances. Wear gloves for all

diaper changes. Wear gloves for contact with an undiagnosed rash, lesion

or non-intact skin. Do not re-use or wash gloves. Perform hand hygiene

after gloves are removed. Gowns A gown is worn when a procedure or

care activity is likely to generate splashes or sprays of blood, body fluids,

secretions or excretions.2 Long-sleeved gowns protect the forearms and

clothing from contamination with potentially infectious material, for

example, holding newborns outside of the isolate or bassinet.9 Gowns are

not required for parents holding their newborn. A gown should be worn or

other appropriate barrier used when holding a newborn against the chest.

Appropriate gown use by staff2 : Wear a gown when providing care that

may contaminate skin or clothing. Put gown on immediately before the

activity for which it is indicated. Remove gown immediately after the

activity for which it is used. Change gown between care for each mother

or newborn. Wear gown properly, i.e., appropriately tied at neck and

waist. Discard gown into an appropriate receptacle after each use and do

not re-use. Perform hand hygiene after gown is removed. Facial

Protection A mask and eye protection are used to protect the mucous

membranes of the eyes, nose and mouth from care activities likely to

generate splashes or sprays of blood, body fluids, secretions or excretions,

or within two metres of a coughing mother(46)

A mask is also used when

performing some aseptic procedures, such as central line insertions and

wound dressings. A mask should be worn by a coughing mother, if

tolerated, when she goes outside her room. Eye protection may be

disposable or, if reusable, should be cleaned and disinfected after each use.

27

Prescription eye glasses are not acceptable by themselves as eye

protection, but they may be worn underneath face shields and some types

of eye protection. Appropriate use of eye protection2 : Put on eye

protection immediately before the activity for which it is indicated.

Remove eye protection immediately after the activity for which it is used.

Discard eye protection after use or place into an appropriate receptacle for

cleaning and disinfection. Ensure eye protection is comfortable. Ensure

eye protection does not interfere with vision. Ensure eye protection fits

securely(47)

. Appropriate mask use2: Put on mask immediately before the

activity for which it is indicated. Remove mask immediately after the

activity for which it is used. Secure mask over the nose and mouth.

Change mask if it becomes wet. Do not touch mask while being worn.

Do not allow mask to hang around the neck. Do not fold mask or store in

a pocket. Do not re-use mask. Perform hand hygiene after removing

mask. Appropriate use of N95 respirator2 : Put on respirator immediately

before the activity for which it is indicated. Remove respirator as soon as

it is safe to do so. Use only a fit-tested respirator. Perform a seal-check

each time a respirator is applied. Change respirator if it becomes wet or

soiled. Remove respirator correctly and discard immediately after use.

Perform hand hygiene after removing the respirator(48)

.. D. Environmental

Cleaning in Perinatal Care Maintaining a clean and safe health care

environment is an essential component of IPAC and is integral to the

safety of mothers, newborns, staff and visitors. Some studies have shown

that environmental strains of microorganisms are identical to those of the

patient occupying the environmental space In some instances, outbreaks

have been brought under control when the intensity of environmental

cleaning was increased. Frequency of Cleaning Environmental cleaning

and disinfection should be performed on a routine and consistent basis to

28

provide for a safe and sanitary environment: Clean labour and birthing

rooms after each patient AND additionally as required. Clean well baby

observation areas at least daily according to a fixed schedule AND

additionally as required. Clean mother’s room at least once daily AND

additionally as required. Clean NICU at least twice per day AND

additionally as required. Clean isolettes/ warmers according to a schedule

AND additionally as required. Terminally clean NICU isolette/ warmer

and environment on discharge of the newborn. Terminally clean transport

equipment after each newborn transport. Frequent audits of practice should

be included as part of the organization’s responsibility for maintaining a

clean environment.7 Isolates' and Warmers When choosing isolates or

warmers, the ability to clean the equipment should be considered. There

should be a written policy and procedure for cleaning isolates'/ warmers

that includes frequency of cleaning (e.g., weekly and when visibly soiled)

and methodology for cleaning. Cleaning should follow the manufacturer’s

instructions for the equipment being cleaned. When cleaning an isolates or

warmer, all detachable parts should be removed and scrubbed. If the

isolates has a fan, it should be cleaned and disinfected according to the

manufacturer’s instructions. The air filter should be maintained as

recommended by the manufacturer. Mattresses should be replaced when

the surface covering is broken. Isolates portholes, cuffs and sleeves are

easily contaminated and should be cleaned and disinfected frequently.

Disposable cuffs should be replaced according to a regular schedule. (50)

.

Milk Preparation Areas Milk preparation areas should be separate and not

used for other purposes. Milk preparation areas may become contaminated

and must be cleaned daily and between the preparations of milk from

different mothers. Refrigerators and freezers used for breast milk should

have a regular cleaning schedule and must not be used for preparing or

29

storing other items such as food, specimens or medications. Cleaning and

Disinfecting Products Cleaning and disinfecting products used in the

health care setting must be approved by .Low level disinfectants such as

quaternary ammonium compounds, peroxides, iodophors and hypochlorite

(‘bleach’) may be used for general disinfection. Phenolics should not be

used in nurseries or the NICU because absorption through the skin can

cause hyperbilirubinemia. (51)

Cleaning and disinfecting agents may be

combined into a single product, thus saving a step in the process. Cleaning

and disinfecting protocols should allow for the full contact time specified

for the product used. Products that leave no toxic residues should be

selected for cleaning and disinfecting newborn areas and equipment.

Birthing Pools, Tubs and Tanks Health care-associated infections have

been linked to the use of birthing tanks, whirlpools and whirlpool spas for

birthing. (52)

Potential routes of infection include incidental ingestion of the

water, sprays and aerosols, and direct contact with wounds and non-intact

skin. There should be stringent policies and procedures for cleaning and

disinfection of hydrotherapy equipment that include: Remove parts in

contact with contaminated water for cleaning and disinfection (e.g., jets).

Drain equipment after each use. Thoroughly clean all surfaces and

removable parts of the equipment. Disinfect surfaces and removable parts

with a chemical germicide and disinfection method recommended by the

equipment manufacturer. Equipment manufactured for home use (e.g.,

whirlpool spas, hot tubs) is not designed or constructed for birthing

purposes and manufacturers are not obligated to provide cleaning and

disinfecting instructions to the same standard that is required for medical

equipment. There should be a careful evaluation of this equipment and its

use in a health care setting before purchase. Linen Newborn care items

(e.g., mattress covers, positioning aids) should be cleanable or disposable.

Items that are laundered in-house must be laundered according to

30

established standards and best practices, including63 clear separation of

clean and soiled laundry during transportation, sorting, folding and storage

written procedures for washing, conditioning, rinsing and drying each

type of material(53)

There is a defined washing formula that controls the

steps in the washing process, including the timing and amount of

chemicals added to the load and includes flushing, washing, bleaching,

rinsing, finishing (e.g., souring) and extraction of water. Linen is washed

at a high temperature (>71C) with a hot water detergent for a complete

wash cycle (≥ 25 minutes). If low temperature(54)

.

2.11 Previous Studies:

Among educational program, Cairo university hospital study done by

( Galal YS1, Labib JR, Abouelhamd WA 2012)to evaluate the impact of

educational program on nurses knowledge and attitude in pediatric intensive

care unit , The result of this study show A significantly higher level of

knowledge was revealed in the post intervention phase as compared with the

pre intervention phase with regards to the types of nosocomial infections

(94.4 vs. 76.8%, P<0.001), the at-risk groups for acquiring infection (95.2 vs.

86.4%, P=0.035) and the measures applied to control nosocomial infections

(89.6 vs. 68%, P<0.001). Nurses in the post intervention phase had

significantly more knowledge about the types of hand washing (99.2 vs.

91.2%, P=0.006). A significantly higher percent of nurses significant higher

total knowledge and attitude scores were revealed in the post intervention

phase as compared with the pre intervention one (P<0.001). The percentage

practice score of observed units was the highest among nurses in the neonatal

intensive care unit at the Japanese Hospital (88%), whereas it was the lowest

in the emergency pediatric unit (65%).This study concluded and

recommended there is scope for improvement in knowledge and attitude after

educational program was offered to the nursing staff. Educational training

31

programs should be multidisciplinary interventions in the era of quality

control to help healthcare workers realize the importance of basic infection-

control measures in reducing pediatric morbidity and mortality and

improving the quality of care(55)

.Other study done in Mysore University,

Mysore - 570 006, Karnataka, India to evaluate the Impact of education on

knowledge, attitudes and practices among various categories of health care

workers on nosocomial infections, Various levels of HCWs were enrolled in

the study. Doctors (n=50) comprised of consultants, senior doctors and junior

doctors. The nurses (n=50) comprised of senior and junior nurses and ward

aides (n=50) comprised of senior and junior cadre staff. A questionnaire on

knowledge, attitudes and practices on prevention of nosocomial infections,

skin disinfection and hand washing, waste disposal, universal precautions and

nosocomial infections was administered to the subjects enrolled for the study,

From this results of the study we have drawn conclusions that a yearly

education program on nosocomial infections and its prevention will help in

the retention of knowledge, attitudes and practices among the various

categories of HCWs. This will help in better adherence to barrier protection

such as hand washing, use of gloves and hand disinfection. We also

recommend written guidelines in every institution for HCWs. A regular

system of monitoring infection rates as well as dissemination of the data will

form a link between the management and the HCWs and thus help in

implementing and improving strategies for prevention of nosocomial

infections .(56)

A study conducted on Hacettepe University Ihsan Dogramaci Children

Hospital, Infection Control Unit. The aim of the study is to assess the effect

of ring wearing and ring types on hand contamination and efficacy of

alcohol-based hand disinfection among nurses working in intensive care

settings. The study methods Hand cultures were obtained from

32

84 nurses providing direct patient care in intensive care units of

a pediatric hospital. Colony counts were compared depending on ring

wearing and the type of ring worn. Twenty-eight nurses were asked to a wear

plain wedding ring, 28 to wear rings with stones and 28 not to wear any

rings, starting 15 days before and continuing throughout the study. Cultures

were obtained by using sterile gloves containing phosphate-buffered-saline

solution (PBS) after an alcohol-based hand disinfectant was used and

bacteria were identified with standard laboratory tests. study results

the nurses wearing rings had more gram-positive, Gram-negative and total

bacterial colonization on their hands than the nurses without rings despite

using an alcohol-based rub (p=0.001). When comparing the two groups with

rings (plain wedding rings and rings with stones), colony counts of Gram-

positive, Gram-negative and total bacteria did not differ (p>0.05).this study

concluded that Ring wearing increases the bacterial colonization of hands

and alcohol-based hand disinfection might not significantly reduce

contamination of the ring-wearing hands. The type of ring did not cause any

significant difference on the bacterial load. Wearing rings could increase the

frequency of transmission of potential nosocomial pathogens. (57)

A study conducted on Sydney Children's Hospital, Randwick, NSW. It

has been estimated that there may be as many as 150,000 healthcare

associated infections (HCAI) in Australia each year, contributing to 7,000

deaths, many of which could be prevented through the implementation of

appropriate infection control practices. Contact with contaminated hands is a

primary source of HCAI. Intensive care staff have been identified as one of

the least adherent groups of health care professionals with hand washing;

they are less likely to practice hand antisepsis before invasive procedures

than staff working in other patient care specialties. The study examined the

self-reported clean and aseptic hand washing practices of nurses working

in pediatric intensive care units (PICUs) across Australia and New Zealand,

33

the patterns in variation between nurses' reported hand washing practices and

the local policies, and patterns in the duration of procedural hand washing for

specific procedures. A survey was undertaken in 2001 in which participating

tertiary pediatric hospitals provided copies of their infection control policies

pertaining to central venous catheter (CVC) management; five nurses on each

unit were asked to provide information in relation to their hand washing

practices. Seven hospitals agreed to participate and 30 nurses completed the

survey. The study found an enormous level of variation among and

between nurses' reported practices and local policies. This variation extended

across all aspects of hand washing practices - duration and extent of hand

wash, type of solution and drying method used. The rigor of hand washing

varied according to the procedure undertaken, with some evidence

that nurses made their own risk assessments based on the proximity of the

procedure to the patient. In conclusion, this study's findings substantiate the

need for standardization of practice in line with the current Centers for

Disease Control and Prevention Guidelines, including the introduction of

alcohol hand rub. (58)

A study conducted on Division of Cardiac Intensive Care, Department

of Cardiology, Children's Hospital Boston, USA. Our goal was to determine

whether an intervention involving staff education, increased awareness, and

practice changes would decrease central line-associated

bloodstream infection rates in a pediatric cardiac ICU. The Study methods a

retrospective, interventional study using an interrupted time-series design

was conducted to compare central line-associated bloodstream infection rates

during 3 time periods for all patients admitted to our pediatric cardiac ICU

between April 1, 2004, and December 31, 2006. During the pre intervention

period (April 2004 to December 2004), a committee was convened to track

and prevent nosocomial infections. Results is The estimated mean pre

34

intervention central line-associated bloodstream infection rate was 7.8

infections per 1000 catheter-days, which decreased to 4.7 infections per 1000

catheter-days in the partial intervention period and 2.3 infections per 1000

catheter-days in the full intervention period. The pre intervention central line-

associated bloodstream infection rate was significantly higher than the

median rate of 3.5 infections per 1000 catheter-days for multidisciplinary

PICUs reporting to the National Healthcare Safety Network. During the full

intervention period, our central line-associated bloodstream infection rate was

lower than this pediatric benchmark, although statistical significance was not

achieved. This study concluded a multidisciplinary, evidence-based initiative

resulted in a significant reduction in central line-associated bloodstream

infections in our pediatric cardiac ICU. (59)

A study conducted on Nosocomial Infections in a Pediatric Intensive

Care Unit.”. To assess the changing epidemiology of nosocomial infections

(NI) in a pediatric intensive care unit (PICU). Prospective surveillance for NI

was performed in a pediatric acute care hospital with a 14-bed PICU. Data on

PICU device use was collected for the most recent year. The findings are

there were 697 NI in PICU (20.7 per 1000 patient-days). 61% of NI was

related to invasive devices and 6% to surgery. Major sites were: urinary tract

(UTI) 26% (92%), bloodstream 23% (91%), lower respiratory tract (LRI)

14% (71%) and upper respiratory tract (URI) 11%. For 1998-99, infections

per 1000 device days were 6.3 for BSI, 19.8 for UTI and 1.3 for pneumonia.

Microbial agents were identified in 82% of NI. Over the 10 years numbers of

PICU NI increased, as did the proportions of total hospital NI (regression

coefficient) 0.83, (Chi square for trend p 0.005) and total hospital patient

days (r 0.43, p < 0.0001) attributed to the PICU. There was no significant

change in PICU NI rate or in the proportion of NI that were device related.

There was an increase in the rate of UTI (r 0.60 p < 0.0001). Researcher

35

concludes that this study was that use of invasive devices is an important

factor in PICU NI, and reduction of NI rates will require improved device

management. (60)

A study conducted at neonatal unit in Maulana Azad Medical College

and hospital in New Delhi. Nosocomial infection profile and risk factors. The

aim was to determine the incidence of neonatal nosocomial infections with

the help of cohort study and using tertiary care teaching hospital set up. The

method was hospital born neonates transferred to the neonatal unit after birth

and available in the unit 48 hours later comprised the cohort for the

surveillance. The final result was 134 neonates were enrolled in the cohort.

The overall nosocomial infection rate was 16.8/1000 patients days. Device

associated infection rate was 11.9/1000devices days. Multidrug resistant

Klebsiella species was the commonest organism causing nosocomial

septicemia and pneumonia followed by pseudomonas aeruginosa. The risk

factors detected to be significantly associated with infection on multiple

logistic regression analyses were a birth weight<1500g and assisted

ventilation >72h. It is finally concluded very low birth neonates are at the

greatest risk for nosocomial infection and death. (61)

A study conducted on School of Nursing, Columbia University, New

York, USA. Attitudes toward practice guidelines among intensive care unit

personnel: a cross-sectional anonymous survey. The study assessed attitudes

of intensive care unit (ICU) staff members toward practice guidelines in

general and toward a specific guideline, The Centers for Disease Control and

Prevention's Guideline for Hand Hygiene in Healthcare Settings; correlated

these attitudes with staff and hospital characteristics; and examined the

impact of staff attitudes toward the Hand Hygiene Guideline on self-reported

implementation of the Guideline. We performed a cross-sectional survey

of staff in 70 ICUs in 39 U.S. hospitals, members of The National

36

Nosocomial Infection Surveillance System. A survey, "Attitudes Regarding

Practice Guidelines," was administered anonymously to all

willing staff during a site visit at each hospital. A total of 1359 ICU personnel

responded: 1003 nurses (74%), 228 physicians (17%), and 128 others

(10%).the study results is Significantly more positive attitudes toward

practice guidelines were found among staff in pediatric compared with adult

ICUs (P < .001). Nurses and other staff when compared with physicians had

more positive attitudes toward guidelines in general but not toward the

specific Hand Hygiene Guideline. Those with more positive attitudes were

significantly more likely to report that they had implemented

recommendations of the Guideline (P < .001) and used an alcohol product for

hand hygiene (P = .002). This study concluded the majority of staff members

were familiar with the Centers for Disease Control and Prevention Hand

Hygiene Guideline. Staff attitudes toward practice guidelines varied by type

of ICU and by profession, and more positive attitudes were associated with

significantly better self-reported guideline implementation. Because

differences in staff attitudes might hinder or facilitate their acceptance and

adoption of evidence-based practice guidelines, these results may have

important implications for the education and/or socialization of ICU staff. (62)

A prospective study was conducted at the Department of Pathology,

Pediatrics and Gynae/obstetrics Combined Military Hospital, Gujranwala.

Regarding infection control practices in the delivery room and nursery.

Situation analysis was carried out, according to which a total of 56 cases of

neonatal sepsis were diagnosed on the basis of clinical and lab criteria during

a six month period from November 2005 to April 2006. The routine being

followed in relation to neonates was observed by a team of doctors in the

delivery room and the nursery. Certain observations were made regarding

breach of infection control practices and specimens were collected from

37

suspected sources of infections for cultures. Recommendations were made in

the light of observations and the results of cultures of the specimens to

interrupt the chain of infection and to eradicate the source/reservoir of

infections in the delivery room and the nursery environment. The

gynecologists and the pediatrician in charge of the delivery room and the

nursery respectively remained involved during the whole process and the

paramedical staff was given necessary training in the light of

recommendations. Findings suggested that After the implementation of the

control measures, the rate of neonatal sepsis was drastically reduced from

63/1000 to 14/1000 live births over the next 3 months. So researcher

conclude that Survey of the delivery room and nursery regarding infection

control practices and training of the paramedical staff helped in reducing the

nosocomial neonatal sepsis. (63)

Studies conducted on infection control practices reduce nosocomial

infections and mortality in preterm infants in Bangladesh. The skin is a

potential source for invasive infection in neonates from developing countries

such as Bangladesh. A randomized controlled trial was conducted from1998

to 2003 in the special care Nursery of a tertiary hospital in Bangladesh to test

the effectiveness of topical emollient therapy in enhancing the skin barrier of

preterm neonates less than 33 weeks of gestational age. In the initial months

of the study, the infection and morality rates were noted to be unacceptably

high. Therefore, an infection control program was introduced early in the trial

to reduce the rate of nosocomial infection. The study was used a simple but

comprehensive infection control program was introduced that emphasized

education of staff and caregivers about measure to decrease risk of

contamination, particularly hand washing, proper disposal of infectious waste

and strict asepsis during procedure, as well as prudent use of antibiotics.

Infection control efforts resulted in declines in episodes of suspected sepsis

(47%), cases of culture-proven (61%) sepsis, patients with a clinical

38

diagnosis of sepsis (79%) and deaths with clinical (82%) or culture-proven

sepsis (50%).(64)

A study conducted on hand washing program for the prevention of

nosocomial infections in a neonatal intensive care unit. The objective was to

evaluate the effects of a hand hygiene program on compliance with hand

hygiene and thereat of nosocomial infections in a neonatal intensive Care unit

(NICU). Design is: open trial. Setting is a level-III NICU in a teaching

hospital. Participants are Nurses, physicians, and other health care workers in

the NICU. The final results are was over all compliance with hand hygiene

improved from 438 at 80% during the promotion program. The rate of

nosocomial infections decreased from 15.13 to 10.69 per 1,000 patient-days

(p=.0003) with improved hand washing compliance. In particular, respiratory

tract infections decreased from 3.35 to 1.06 per 1,000 patient-days during the

Hand washing campaign (p=.0002). Furthermore, the correlation between

nosocomial infection of the respiratory tract and hand washing compliance

also reached statistical significance (r=-0.385; p=.014). (65)

1

Chapter Three

Material and method

39

Chapter (Three)

Materials and method

3.1 Materials

3.1.1 study design:

A Quasi-experimental study: pretest and posttest for the same group was used

to evaluate the effect of an educational program on nurses Knowledge

&practice regarding the infection control in neonatal intensive care unit.

3.1.2 Study duration:

The study started 2013 ----2015

3.1.2.1 the Study setting

The study was conducted in two pediatric hospitals in Khartoum state:

Khartoum is the capital and the second largest city of the Republic of Sudan

and of Khartoum State. It is located at the confluence of the White Nile

flowing north from Lake Victoria and the Blue Nile flowing west from

Ethiopia. The location where the two Niles meet is known as "Almogran",

meaning the Confluence. The main Nile continues to flow north towards

Egypt and the Sea. Divided by the Niles, Khartoum is a tripartite metropolis

with an estimated overall population of over five million people consisting of

Khartoum proper and linked by bridges to Khartoum North called AlKhartūm

Bahrī and Omdurman to the west.

40

3.1.2.2 Gaffer Ibn Ouf specialized pediatric hospital

The largest pediatric hospital in Khartoum state is located near the Mk

Nemer Street behind nursing college Khartoum University formed 4 floors.

The NICU located on the 4th floor containing 25 incubators.

3.1.2.3 Omdurman Maternity Hospital

• This hospital located in Omdurman west .It is biggest Maternity

Hospital in Sudan. The daily admission rate About 400 delivery, and

had biggest NICU which contain 65 incubators.

3.1.3 study subject

-A sample is 61 of nurses from previously mentioned setting

-All nurses (either diploma nurses or faculty of nursing graduates, regardless

to experience year, age, qualification level and previous training program)

who were caring for neonate that admitted in a neonatal intensive care unit at

a pediatric hospital (total number of nurses who agreed to participate).

3.1.4 Data collection tools

Two tools were used to collect the needed data to achieve the aim of the

study, they were:

3.1.4.1 Structured Interview questionnaire

.This tool is developed by researcher after reviewing the literature to assess

the nurses' knowledge regarding infection control in a neonatal intensive care

unit. This tool was divided to two parts, one demographic data include (age,

educational level, experience years) the second part included the knowledge

of nurses about infection control (use of protective equipments, definitions of

sterilization and disinflation).

41

3.1.4.2 Observational Checklist

it was developed by the researcher to assess the nurses performance regarding

infection control in neonatal intensive care unit .it was include (hand washing,

using of protective equipments)

3.2 Method:

The study was designed to be accomplished as the following:

- An official letters that were obtained from faculty of nursing and sent to

the directors of Gaffer Ibn Ouf hospital and Maternity hospital to take the

permission and facilitate the research implementation.

- The tools of study were developed by the researcher after review of

literature. The pilot study was done on 10% of the study sample (who were

excluded from participation) to test the visibility and reliability of study tools

and modification was done and the tools were found to be understandable and

applicable.

Research team:

The research team composed of 2 nurses was trained by researcher to use the

data collection tools for one week for 4 sessions.

The study took place in three phases:

Phase One:

Pre interventional phase, the nursing staff's base line level of knowledge,

and the practice concerning infection-control measures were tested by using a

self-administered pre-test questionnaire and an observation checklist.

42

Phase Two:

Include orientation about the Health Educational Program. An educational

program to study group designed by the researcher based on actual

assessment. Different teaching methodologies as lectures, discussion,

demonstration, and re demonstration, and used. different assisting learning

methods were used in the program as small books, show pictures, posters,

and real equipments. The intervention was implemented to nurses in small

groups (not more than 5 nurses)

Phase Three:

The post interventional phase a post the implementation of the education

program, the same questionnaire was administered to reassess the nurse's

knowledge regarding infection control. It was made mandatory that all the

fields should be filled. Each of the fields was given a score 0=poor 1= fair,

2= good. The knowledge score according to WHO category of knowledge

75% as good 50-75 as fair less than 50% as poor all the subjects in the study

were graded based on scores as, good, fair and poor. The practice

performance reassesses using similar checklist.

3.3 Data Management and Analysis:

3.3.1 Data Management:

Data was collected by researcher herself, coded manually and tabulated

before analysis.

3.3.2 Data Analysis:

The collected data as pretest and post test organized, categorized,

tabulated using numbers and percentage, Chi-square (x²) test used. The

43

statistical package for social sciences (SPSS version 20) used for statistical

analysis.

3.4 Ethical Considerations:

They were considered before study phases as the following:

– Approval from the National Al Ribat University Graduate

College was taken.

– Permission was taken from hospital health authority and verbal

from participant.

– The study participants were informed about the research and

their rights to withdraw is considered and their information was

treated confidentially.

39

Chapter Four

Results

44

Chapter (four)

Results

The results of the present study showed in tables and figures as fallow:

Socio demographic data

Figure (1) Distribution of the study sample according to age

Figures (4.1) age among study group showed a majority of age from 20-

30(45.9%) years while minority age less than 20 years old (1.6%).

1.6%

45.9%

39.3%

13.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

<20 years 20-30 years 31-40 years > 40 years

45

Figure (2) Distribution of the study sample according to qualifications

Figures (4.2) showed that most of the study group has BSc degree 67.2 while

only 11.5 have MSc degree.

21.3%

67.2%

11.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

Diploma BSc MSc

46

Figure (3) Distribution of the study sample according to the years of

experience.

Figures (4.3) showed that 42. 6 % have 2-5 years while 13.1% more than 10

years.

14.8%

42.6%

29.5%

13.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

2 years 2-5 years 6-10 years > 10 years

47

knowledge questions regarding infection control

Table (4.1) Distribution of the study sample according to their

knowledge regarding the definition of sterilization N = 61

Item Pre Post Total

Correct

answer

Incorrec

t answer

Correct

answer

Incorrec

t answer

Pre Post

No % No % No % No % No % No %

Definition of

sterilization

22

36.1

39

63.9

58

95.1 3 4.1 61 100.0 61 100.0

The method

of

sterilization

9 14.8 52 85.2 57 93.4 4 6.6 61 100.0 61 100.0

48

Table (4.2) Comparison of knowledge of the study sample regarding the

definition of sterilization

Variables

Pre Post SE CI 95%

t Df P

Mean SD Mean SD Lower Upper

Definition of

sterilization 0.69 0.47 0.89 0.32 0.07 -0.34 -0.05 -2.7 60 0.005

The method of

sterilization 0.57 0.50 0.93 0.25 0.07 -0.50 -0.22 -5.1 60 0.002

Table (4.1) illustrates the answers of the nurses about their knowledge

regarding sterilization at ICU care: 36.1% of the nurses gave correct answer

about the definition of sterilization before attendance of the program, while,

correct answer was mentioned by 95.1% of them after attendance, the nurses

who correctly answered the method of sterilization were 14.8% before the

program compared to 93.4% of them after the program. The mean value of

nurses answers regarding the definition of sterilization was (0.69±0.47) at

pretest measurement, which increased at posttest measurement to

(0.89±0.32), T value was (-2.7), indicating significant differences (P=0.005 <

0.05) in their knowledge between pretest and posttest period (Table 4.2).

49

Table (4.3) Distribution of the study sample according to their

knowledge regarding the definition of disinfectant N = 61

Item Pre Post Total

Correct

answer

Incorrec

t answer

Correct

answer

Incorrec

t answer

Pre Post

No % No % No % No % No % No %

Definition of

disinfection 18 29.5 43 70.5 48 78.7 13 21.3 61 100.0 61 100.0

Micro organism

live in

disinfectant

fluid 5 8.2 56 91.8 57 93.4 4 6.6

61 100.0 61 100.0

Baby

breastfeeding as

disinfectant

43

43

53 86.9 58 95.1

3

4.9 61 100.0 61 100.0

50

Table (4.4) Comparison of knowledge of the study sample regarding the

definition of disinfectant

Variables

Pre Post SE CI 95%

t Df P

Mean SD Mean SD Lower Upper

Definition of

disinfection 0.51 0.50 0.97 0.18 0.07 -0.59 -0.32 -6.7 60 0.001

Some microorganism

live in disinfectant

fluid 0.64 0.48 0.95 0.22 0.07 -0.45 -0.18 -4.6

60

0.002

Baby breastfeeding

as disinfectant 0.54 0.50 0.85 0.36 0.08 -0.47 -0.16 -3.9 60

0.001

Table (4.3) illustrates the answers of the nurses about their knowledge

regarding disinfectant at ICU care: 29.5% of the nurses gave correct answer

about the definition of disinfectant before attendance of the program, while,

correct answer was mentioned by 78.7% of them after attendance, the nurses

who correctly answered that some microorganisms may live in disinfectants

were 8.2% before the program compared to 93.4% of them after the program,

the nurses who correctly answered that baby breastfeeding may serve as

disinfectants were 13.1% before the program compared to 95.1% of them

after the program. The mean value of nurses answers regarding their

definition of disinfectant was (0.51±0.50) at pretest measurement, which

increased at posttest measurement to (0.97±0.18), T value was (-6.7),

indicating significant differences (P=0.001 < 0.05) in their knowledge

between pretest and posttest period (Table 4.4).

51

Table (4.5) Distribution of the study sample according to their

knowledge towards standard precaution, use of PPE N = 61

Item

Pre Post Total

Correct

answer

Incorrec

t answer

Correct

answer

Incorrect

answer Pre Post

N

o %

N

o % No % No % No % No %

Investigation

that will be

done when

detect

infection

9 14.8 52 85.2 56 91.8 5 8.2 61 100.0 61 100.0

when

incubator

should be

sterilized

10 16.4 51 83.6 52 85.2 9 14.8 61 100.0 61 100.0

when

incubator

should be

disinfected

8 13.1 53 86.9 55 90.2 6 9.8 61 100.0 61 100.0

The space

between

incubators in

NICU

13 21.3 48 78.7 54 88.5 7 11.5 61 100.0 61 100.0

Umblical

cord care for

newborn

baby is

important

11 18.0 50 82.0 58 95.1 3 4.9 61 100.0 61 100.0

Eye care for

newborn is

important

5 8.2 56 91.8 57 93.4 4 6.6 61 100.0 61 100.0

prephral IV

cannula

should be

replace

7 11.5 54 88.5 57 93.4 4 6.6 61 100.0 61 100.0

disposable

of the west

product

should be

replaced

10 16.4 51 83.6 57 93.4 4 6.6 61 100.0 61 100.0

After

replace the

baby diaper

advice the

mother

about

13 21.3 48 78.7 57 93.4 4 6.6 61 100.0 61 100.0

52

Table (4.6) Comparison of knowledge of the study sample regarding

standard precaution, use of PPE

Variables Pre Post

SE CI 95%

t Df P Mean SD Mean SD Lower Upper

Investigation that will

be done when detect

infection

0.64 0.48 0.87 0.34 0.08 -0.38 -0.08 -

3.0 60 0.003

when incubator should

be sterilized 0.67 0.47 0.92 0.28 0.07 -0.38 -0.11

-

3.5 60 0.008

when incubator should

be disinfected 0.67 0.47 0.98 0.13 0.06 -0.44 -0.19

-

5.0 60 0.001

The space between

incubators in NICU 0.59 0.50 0.98 0.13 0.07 -0.52 -0.26

-

6.0 60 0.006

Umblical cord care for

newborn baby is

important

0.84 0.37 0.97 0.18 0.05 -0.24 -0.03 -

2.5 60 0.003

Eye care for newborn

is important 0.75 0.43 0.98 0.13 0.06 -0.34 -0.11

-

4.0 60 0.001

prephral IV cannula

should be replace 0.36 0.48 0.98 0.13 0.06 -0.75 -0.50

-

9.7 60 0.002

disposable of the west

product should be

replaced

0.25 0.43 0.89 0.32 0.07 -0.78 -0.50 -

9.2 60 0.001

After replace the baby

diaper advice the

mother about

0.67 0.47 0.98 0.13 0.08 -0.44 -0.19 -

5.0 60 0.003

Table (4.5) illustrates the answers of the nurses about their knowledge regarding standard

precaution, use of PPE at NICU care: 14.8% of the nurses gave correct answer about the

investigation that will be done when detecting infection before attendance of the program,

while, correct answer was mentioned by 91.8% of them after attendance, the nurses who

correctly answered the when the incubator to be sterilized were 16.4% before the program

compared to 85.2% of them after the program, the nurses who correctly answered the

statements about the standard precaution, use of PPE at NICU care were lower

percentages before the program compared to the higher percentages of their answers after

the program. The mean value of nurses answers regarding their first statement was

(0.64±0.48) at pretest measurement, which increased at posttest measurement to

(0.87±0.34), T value was (-3.0), indicating significant differences (P=0.003 < 0.05) in

their knowledge between pretest and posttest period (Table 4.6).

53

Nurses performance practice regarding infection control in NICU

Table (4.7a) Distribution of the study sample according to their practices

regarding incubators care (hand washing) N = 61

Item Pre Post Total

Correct

answer

Incorrec

t answer

Correct

answer

Incorrec

t answer

Pre Post

No % No % No % No % No % No %

1_ wash hand

before any

procedure

10 16.4 51 83.6 50 82.0 11 18.0 61 100.0 61 100.0

.2.Wash hand

after procedure 9 14.8 52 85.2 55 90.2 6 9.8 61 100.0 61 100.0

3.Use aseptic

technique during

vein puncture and

taking sample-

5 8.2 56 91.8 59 96.7 2 3.3 61 100.0 61 100.0

Table (4.7a) illustrates the answers of the nurses about their practices

regarding prevention of infection at NICU care: 16.4% of the nurses correctly

done hand washing before procedure at pretest, while the percentage of the

nurses who does this procedure correctly at posttest was 82%, the nurses who

correctly done the second procedure were 14.8% at pretest measure compared

to 90.2% of them at posttest measure, the nurses who correctly done the other

procedures were lower percentages at pretest measure compared to the higher

percentages of the nurses who correctly done these procedures at the posttest

measure.

54

Table (4.7b) Comparison of practices of the study sample infection

control according to their practices regarding incubators care (hand

washing) N = 61

Variables Pre Post SE CI 95%

t Df P Mean SD Mean SD Lower Upper

1_ wash hand

before any

procedure 0.26 0.44 0.97 0.18 0.06 -0.83 -0.58 -11.51 60 0.005

.2.Wash hand after

procedure 0.25 0.43 0.93 0.25 0.06 -0.82 -0.56 -10.74 60 0.006

3.Use aseptic

technique during

vein puncture and

taking sample- 0.16 0.37 0.92 0.28 0.06 -0.87 -0.64 -12.68 60 0.005

The mean value of nurses correct practices scores regarding the first

procedure was (0.26±0.44) at pretest measurement, which increased at

posttest measurement to (0.97±0.18), t value was (-11.51), indicating

significant differences (P=0.005 < 0.05) in their practices between pretest and

posttest period (Table 4.7b).

55

Table (4.7c) Distribution of the statistical significance of the study

sample according to their practices regarding incubators care

(equipment) N = 61

Item Pre Post Total

Correct

answer

Incorrec

t answer

Correct

answer

Incorrec

t answer

Pre Post

N

o

% No % No % No % No % No %

4.Wearing

gloves when

suctioning

neonate

17 27.9 44 72.1 49 80.3 12 19.7 61 100.0 61 100.0

5.Wear gloves

when replaced

diaper

6 9.8 55 90.2 48 78.7 13 21.3 61 100.0 61 100.0

7.Use

Protective

equipment

when

handling

newborn baby

1 1.6 60 98.4 51 83.6 10 16.4 61 100.0 61 100.0

9.Using

correct

technique in

sterilization

after finish

procedure

3 4.9 58 95.1 49 80.3 12 19.7 61 100.0 61 100.0

10.Adequate

spacing

between cote

and incubator

3 4.9 58 95.1 50 82.0 11 18.0 61 100.0 61 100.0

11.Use

special

equipment for

each infant

35 57.4 26 42.6 55 90.2 6 9.8 61 100.0 61 100.0

19.Disinfecte

d oxygen

mask

18 29.5 43 70.5 54 88.5 7 11.5

56

Table (4.7d) Comparison of the statistical significance of the study

sample according to their practices regarding incubators care

(equipment) N = 61

Variables Pre Post SE CI 95%

t Df P Mean SD Mean SD Lower Upper

1.Wearing gloves

when suctioning

neonate 0.21 0.41 0.95 0.22 0.06 -0.86 -0.62 -12.34 60 0.001

2.Wear gloves when

replaced diaper 0.26 0.44 0.97 0.18 0.06 -0.83 -0.58 -11.51 60 0.005

3.Use Protective

equipment when

handling newborn

baby 0.20 0.40 0.95 0.22 0.06 -0.87 -0.64 -12.91 60 0.002

4.Using correct

technique in

sterilization after

finish procedure 0.20 0.40 0.92 0.28 0.06 -0.84 -0.60 -11.57 60 0.001

5.Adequate spacing

between cote and

incubator 0.15 0.36 0.95 0.22 0.05 -0.91 -0.70 -14.98 60 0.002

6.Use special

equipment for each

infant 0.16 0.37 0.92 0.28 0.06 -0.87 -0.64 -12.68 60 0.005

7.Proper disposable

of sharp instruments 0.39 0.49 0.97 0.18 0.07 -0.71 -0.44 -8.55 60 0.003

8.Disinfected

oxygen mask 0.38 0.49 0.93 0.25 0.07 -0.70 -0.42 -7.93 60 0.009

The mean value of nurses correct practices scores regarding the first

procedure was (0.21±0.41) at pretest measurement, which increased at

posttest measurement to (0.95±0.22), t value was (-12.34), indicating

significant differences (P=0.001 < 0.05) in their practices between pretest and

posttest period (Table 4.7d).

57

Table (4.7e) Distribution of the study sample according to their practices

regarding infection control (sharp tools) N = 61

Item Pre Post Total

Correct

answer

Incorrec

t answer

Correct

answer

Incorrec

t answer

Pre Post

No % No % No % No % No % No %

6.Recapped

needle after

use

2 3.3 59 96.7 53 86.9 8 13.1 61 100.0 61 100.0

8.Proper

handling of

sharp

needle

2 3.3 59 96.7 57 93.4 4 6.6 61 100.0 61 100.0

17.Replaced

disposable

west

product

every 8

hour

14 23.0 47 77.0 56 91.8 5 8.2 61 100.0 61 100.0

18.Proper

disposable

of sharp

instruments

29 47.5 32 52.5 51 83.6 10 16.4 61 100.0 61 100.0

58

Table (4.7 f) Comparison of the study sample according to their practices

regarding infection control (sharp tools) N = 61

Variables Pre Post SE CI 95%

t Df P Mean SD Mean SD Lower Upper

1.Recapped needle

after use 0.26 0.44 0.97 0.18 0.06 -0.83 -0.58 -11.51 60 0.005

2.Proper handling of

sharp needle 0.36 0.48 0.87 0.34 0.08 -0.66 -0.36 -6.71 60 0.003

3.Replaced

disposable west

product every 8 hour 0.41 0.50 0.93 0.25 0.07 -0.67 -0.38 -7.38 60 0.002

4.Proper disposable

of sharp instruments 0.39 0.49 0.97 0.18 0.07 -0.71 -0.44 -8.55 60 0.003

The mean value of nurses correct practices scores regarding replaced

disposable west product was (0.41±0.50) at pretest measurement, which

increased at posttest measurement to (0.93±0.25), t value was (-7.38),

indicating significant differences (P=0.002< 0.05) in their practices between

pretest and posttest period (Table 4.7f).

59

Table (4.7g) Distribution of the study sample according to their practices

regarding infection control (daily routine practice) N = 61

Item Pre Post Total

Correct

answer

Incorrec

t answer

Correct

answer

Incorrec

t answer

Pre Post

N

o

% No % No % No % No % No %

12.Health

education of

mother

about

infection

control

7 11.5 54 88.5 53 86.9 8 13.1 61 100.0 61 100.0

13.Doing

eye care 11 18.0 50 82.0 47 77.0 14 23.0 61 100.0 61 100.0

14.Doing

umbilical

care

4 6.6 57 93.4 54 88.5 7 11.5 61 100.0 61 100.0

15.Enough

clean linen

available

1 1.6 60 98.4 51 83.6 10 16.4 61 100.0 61 100.0

16.Restricte

d visitor 3 4.9 58 95.1 52 85.2 9 14.8 61 100.0 61 100.0

60

Table (4.7h) Comparison of the study sample according to their practices

regarding infection control (daily routine practice) N = 61

Variables Pre Post SE CI 95%

t Df P Mean SD Mean SD Lower Upper

1.Health education

of mother about

infection control 0.36 0.48 0.95 0.22 0.07 -0.72 -0.46 -8.68 60 0.002

2.Doing eye care 0.43 0.50 0.97 0.18 0.07 -0.68 -0.41 -7.97 60 0.003

3.Doing umbilical

care 0.62 0.49 0.95 0.22 0.07 -0.46 -0.19 -4.79 60 0.004

4.Enough clean

linen available 0.56 0.50 0.95 0.22 0.07 -0.53 -0.25 -5.63 60 0.007

5.Restricted visitor 0.54 0.50 0.95 0.22 0.07 -0.55 -0.27 -5.84 60 0.008

The mean value of nurses correct practices scores regarding health education

of mother about infection control was (0.36±0.48) at pretest measurement,

which increased at posttest measurement to (0.97±0.18), t value was (-8.68),

indicating significant differences (P=0.002< 0.05) in their practices between

pretest and posttest period (Table 4.7h).

44

Chapter Five

Discussion

Conclusion

Recommendations

61

Chapter (five)

Discussion

Routine Practices are based on the premise that all patients are potentially

infectious, even when asymptomatic, and that the same safe standards of

practice should be used routinely with all patients to prevent exposure to

blood, body fluids, secretions, excretions, mucous membranes, non-intact

skin or soiled items and to prevent the spread of microorganisms. Routine

Practices refer to the infection prevention and control practices that are to be

used with all patients during all care, to prevent and control transmission of

microorganisms in all health care settings. A study conducted at two pediatric

hospitals in Khartoum state to evaluate the effect of an educational program

regarding infection control for nurses when dealing with incubator care in the

neonatal intensive care units. Demographic data of study group showed the

mean age was 30 years old the majority of age group is between 20 to 30

years (45.9%), while minority is less than 20 years (1.6%).The educational

level showed most nurses participated in the study had BSc (67.2%) degree

while only (11.5 %) had MSc degree. As experience years most nurses had

between 2 to 5 years .42.6% years while only more than 10 years (13.1%).

General knowledge regarding sterilization at NICU, the program increased

knowledge of the study sample (nurses), where the mean value of nurses

answers regarding the definition of sterilization was (0.69±0.47) at pretest

measurement, which increased at posttest measurement to (0.89±0.32),

indicating significant differences (P=0.005) in their knowledge between

pretest and posttest period. This was agreed with the findings of previous

study conducted in Cairo university hospital to evaluate the impact of

educational program on nurses knowledge and attitude in pediatric intensive

care unit , showed that there is scope for improvement in knowledge and

62

attitude after educational program was offered to the nursing staff

sterilization in NICU care (P<0.001). (55)

. Other study done in Mysore

University, Mysore - 570 006, Karnataka, India proved that early education

program on nosocomial infections and its prevention will help in the

retention of knowledge, attitudes and practices among the various categories

of HCWs..(56)

In this study, it was clear from the findings that knowledge of the nurses was

significantly improved after attendance of the program this study result

was agree with this study, where the mean value of nurses answers regarding

their definition of disinfectant was (0.51±0.50) at pretest measurement, which

increased at posttest measurement to (0.97±0.18), t value was (-6.7),

indicating significant differences (P =0.001) in their knowledge between

pretest and posttest period. This is similar to a study conducted on Hacettepe

University Ihsan Dogramaci Children Hospital, Infection Control Unit

showed that improvement of nurses in their knowledge regarding disinfectant

was significantly high (p=0.001).(57)

Concerning the knowledge of the nurses regarding the standard precaution,

use of PPE at NICU care, it was found to be clearly increased after

attendance of the program, where the mean value of nurses answers regarding

their first statement was (0.64±0.48) at pretest measurement, which increased

at posttest measurement to (0.87±0.34), t value was (-3.0), indicating

significant differences (P=0.003) in their knowledge between pretest and

posttest period. This is similar to previous study from USA showed that pre

intervention central line-associated bloodstream infection rate was

significantly higher than the median rate of 3.5 infections per 1000 catheter-

days for multidisciplinary PICUs reporting to the National Healthcare Safety

Network. (59)

63

In this study, correct practices of the nurses was significantly improved

due to application of the program, where the mean value of nurses correct

practices scores regarding the first procedure was (0.26±0.44) at pretest

measurement, which increased at posttest measurement to (0.97±0.18), t

value was (-11.51), indicating significant differences (P=0.005) in their

practices between pretest and posttest period. This similar to previous studies

showed that Nurses and other staff when compared with physicians had more

positive attitudes (P < .001). Toward guidelines in general but not toward the

specific Hand Hygiene Guideline. Those with more positive attitudes were

significantly more likely to report that they had implemented

recommendations of the Guideline (P < .001) and used an alcohol product for

hand hygiene (P = .002). This study concluded the majority of staff members

were familiar with the Centers for Disease Control and Prevention Hand

Hygiene Guideline. Staff attitudes toward practice guidelines varied by type

of ICU and by profession, and more positive attitudes were associated with

significantly better self-reported guideline implementation. Because

differences in staff attitudes might hinder or facilitate their acceptance and

adoption of evidence-based practice guidelines, these results may have

important implications for the education and/or socialization of ICU Staff.(62)

Another study across Australia and New Zealand, found an enormous level of

variation among and between nurses' reported practices and local policies.

This variation extended across all aspects of hand washing practices -

duration and extent of hand wash, type of solution and drying method used

before and after training program. (58)

64

Conclusion

According to the study findings the researcher concluded that:

o There was significant statistical improvement in knowledge and

practical skills after the educational program was offered to the

nursing staff.

o Also the researcher concluded that the importance of education

regarding infection control held in neonatal intensive care unit

enhance the nurses knowledge.

o There was a statistically significant difference between pre and

post test after the application of the educational program (P <

0.05) in all aspects.

o In addition, there was a scope of improvement in the

performance of practical skills of nurses post application of the

program ((P < 0.05) among all participants.

65

Recommendations

According to the study results the researcher recommended that:

o It is important to design, plans, strategies and protocols in all

NICU through which improvement and the quality of care to

healthy and sick neonate will be achieved.

o Hospitals administrators should strive to create an organizational

atmosphere in which adherence to recommended all infection

control practice is considered an integral part of providing high-

quality care in NICU in order to decrease the mortality and

morbidity of neonate that was increased in last few years,

o In Order to reach a successful goal, hospitals must provide

visible support and sufficient resources for continuous

educational programs to grant the importance of basic infection-

control measures in reducing pediatric morbidity and mortality

and improving the quality of care.

o Supervisory system should be created to ensure best practice.

o It is recommended that the availability of recourses, training of

staff members, staff motivation and teamwork contributes in

promotion in infection control and prevention.

o This study should stimulate further researches in infection control

in neonatal intensive care unit.

66

Chapter Six

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66

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66

Appendices

73

جبيعخ انشثبـ انىـي

كهيخ انذساسبد انعهيب

استجيب حىل:

أحش ثشبيج تعهيي نهشؾبد ثطأ يكبفحخ انعذوي في األـفبل حذيخي انىالدح ف وحذح انعبيخ انشكضح

انمسى) أ(ا نجيببد االجتبعيخ وانذيىغشافيخ:

:انعش .5

74 -64 ة( ) عخ 64الم ي )أ(

عخ 84 -74 )د( عخ 84اكثش ي )ج(

انستىي انتعهي .2

يبخغزش )ج(ثكبنشط ة( ) دثهو ( )أ

سىاد انخجشح .3

54اكثش ي د( ) عخ 54-: )ج( عخ 9-6 ة( ) الم ي عز أ()

عاد

هم نذيك دوسح تذسيجيخ ف يكبفحخ انعذوي .4

ال ة( )ؼى ( أ)

انمسى) ة( نعشفخ انشؾبد حىل يكبفحخ انعذوي في وحذح حذيخ انىالدح:

في انسبئم انطهش و انػبثى ؟ ثعؽ انكبئبد انذليمخ تعيص .1

ال ة( ) ؼى أ( )

انشؾبعخ انطجيعيخ تح االـفبل ي انعذوي؟ .2

ال اػشف ج( ) ال ة( ) ىؼ ( أ)

نهكطف ع انعذويانفحىغبد انت يتى انميبو ثهب ( ة)

ظبئف انكه )ج( صساػخ انذو ة( ) رحهم انذو كبيم ( أ)

ال اػشف (ـ ) رحهم انجل (د )

انتعميى يعي إصانخ جيع انكبئبد انحيخ وتطم جشاحيى انتطيف ؟ ( ة)

فاػشال ( )ج ال ة( ) ؼى ( أ)

74

ـشق انتعميى؟

االشؼخ )د( االعهة اندبف ج( ) انغهب ة( ) انجخبس رحذ انؼغؾ ( أ)

ال اػشف .................. اخش ...................... )( انحبنم (ـ)

تطهيش يعي إصانخ جيع انكبئبد انحيخ انتطيف ونك ال تطم جشاحيى؟ ( د)

الاػشف ج( )ال ة( )ؼى ( أ

يجت تعميى حبؾخ؟ ( ث)

ف حبنخ انؼشسح ج( )نكم دخل خذذ ة( )ثؼذ كم خشج ( أ)

انطفم رفا را) ( ا كب انطفم يؼذراال ا ( د)

يجت تطهيش انحؿبخ ؟ ( ر)

ف حبنخ انؼشسح ج( )نكم دخل خذذ ة( ) ثؼذ كم خشج )أ(

ارا رف انطفم ا كب انطفم يؼذ راال ا )د(

يجغي أ تكى انسبفخ ثي انحبؾبد في ف وحذح حذيخ انىالدح؟ ( س)

يزش6) ج( عى 14) ة( عى 94 ( أ)

انظبفخ وانعبيخ ثبنعي يهخ نحذيخ انىالدح؟ ( ص)

ال اػشف )ج( ال ة( ) ؼى ( أ)

يهخ نحذيخ انىالدح؟ حجم انسشيانظبفخ وانعبيخ ثبن ( ط)

اػشف ال ج( )ال ة( )ؼى ( أ)

يجت تغيش انفشاضخ كم ؟ ( ش)

48ػذ انخشج )ج(عبػخ 16 ة( ) عبػخ ( أ)

انتخهع ي انفبيبد ف حذيخ انىالدح الثذ ا يكى كم؟ ( ظ)

حغت انحبخخ ج( ) عبػبد 68 ة( ) عبػبد 7 ( أ)

يكبفحخ انعذوي انسئىنيخ انشئيسيخ ل؟ ( ؼ)

االث يؼب ج( ) انشع ة( ) انطجت ( أ)

اػشف ال د( )

؟عذ تغيش انحفبؾخ اػح االو ة )ـ(

ال اػشف ج( ) حانزؼبيم انغهى يغ انحفبع انمضس ة( )غغم انذ ( أ)

75

؟هم تعتمذ أ انعىائك انتي تحىل دو تفيز االحتيبـبد انعبنيخ ي يكبفحخ انعذوي هي

ؼى ال أ( ػذو يؼشفخ)

ؼى ال خلد انزكهفخ انبد ة ( ػذو رفش)

ال ؼى ج ( نى رك يزلؼخ ف لغى انجشركل)

ؼى ال ( مض االططبفد)

ؼى ال رذست نالططبف( ػذو خد )

)( اخش..............................................................................................

؟يكبفحخ انعذوي هي فهم تعتمذ أ انسبهي في تفيز االحتيبـبد انعبنيخ ( ؽ)

ال ؼى اناسد ( رفش )ا

ال ؼى االططبف ( رذست ة(

ال ؼى االططبف( رحفض ج )

ال ؼى ( انؼم اندبػد )

ال ؼى رحذث ثشركل يكبفحخ انؼذ ()ـ

.............................اخش.................................................................................................

76

ALREBAAT NATIONAL UNIVIRSITY

POSTGRADUTE COLLEGE

Questionnaire about:

Impact of educational program for nurses regarding infection control

in neonatal intensive care unit

section (A)sociodemographic data

Serial no: ………………………………………………………

1-Age

(a) <20 years (b) 20-30years (c) 31-40 (d) >40years

2-Educational level

(a)Diploma (b) BSc (c) MSc

3-Exepriance years

(a)<2 years (b) 2-5years (c) 6-10years (d)>10 years

Section (B):knowledge of nurses about infection control in NICU:

5-some microorganism live in disinfectant fluid and soap

(a)YES (b) NO (c) DON’T KNOW

6-baby breast feeding affords some protection against infection?

(a)YES (b) NO (c) I DON’T KNOW

7-Investigation that will be done when detect infection?

(a)Complete blood count

(b)Blood culture

(c)Renal function test

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(d)Urine analysis

(e)Don’t know

8-Sterilization mean removal of all livening organism include spores?

(a)YES (b) NO (c) DON’T KNOW

9-The method of sterilization

(a)Steam under pressure

(b)Boiling

(c)Dry method

(d)Radiation

(e)Solution

(f)Others……………………………………………………………………………

(g)Don’t know

10-Disinfection means removal of all livening organism but not include spores

(a)YES (b) NO (c) DON’T KNOW

11-when incubator should be sterilized

(a) After any discharge (b) for every new admission

(c) Every week (d) when necessary

(e) Only if baby infectious (f) if the baby die

(g) Don’t know

12-when incubator should be disinfected

(a) After any discharge (b) for every new admission

(c) Every week (d) when necessary

(e) Only if baby infectious (f) if the baby die

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(g) Don’t know

13-The space between incubators in NICU should be

(a) 90CM (b) 50CM (c) 2meters

14-Umblical cord care for newborn baby is important

(a)YES (b) NO (c) DON’T KNOW

15-Eye care for newborn is important

(a)YE (b) NO (c)DON’T KNOW

16-prephral IV cannula should be replace

(a)Every 48 hour (b) every 72 hour (c) on baby discharge

17-disposable of the west product should be replaced

(a)Every 8 hour (b) every 24 hour (c) as needed

18-infection controls the main responsibilities of:

(a)Nurses (b) doctor (c) both

(d)Don’t know

19-After replace the baby diaper advice the mother about

(a) Hand washing (b) proper handling of dirty diaper

(c) Others (d) don’t know

20-did you think the barriers to the implementation of universal precaution of

infection control are:

(a ) lack of knowledge YES NO

(b ) Unavailability of material cost constraints YES NO

(c) unforeseen in department protocol YES NO

(d) Shortage of staff YES NO

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(e) Lack of training of staff YES NO

(a) Others …………………………….

21- Did you think the contributors to the implementation of universal precaution of

infection control are?

(b) Availability of resources Yes NO

(c) Training of staff members Yes NO

(d) Staff motivation and compliance Yes NO

(e) Team work Yes NO

(f) Updated infection control protocol Yes NO

(g) Others …………………………….

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ALREEBAT UNIVIRSITY

GRADUTE COLLEGE

Observation check list about educational program regarding infection

control for nurses in NICU:

Serial

NO……………………………………………………………………….

Name……………………………………………………………………

Procedure Done Not

Done

1_ wash hand before any procedure

.2.Wash hand after procedure

3.Use aseptic technique during vein puncture and

taking sample-

4.Wearing gloves when suctioning neonate

5.Wear gloves when replaced diaper

6.Recapped needle after use

7.Use Protective equipment when handling newborn

baby

8.Proper handling of sharp needle when use

9.Using correct technique in sterilization after finish

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procedure

10.Adequate spacing between cote and incubator

11.Use special equipment for each infant

12.Health education of mother about infection control

13.Doing eye care

14.Doing umbilical care

15.Enough clean linen available

16.Restricted visitor

17.Replaced disposable west product every 8 hour

18.Proper disposable of sharp instruments

19.Disinfected oxygen mask

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