A RESEARCH PROPOSAL PRESENTED IN PARTIAL FULFILLMENT FOR

THE AWARD OF A DEGREE IN BACHELOR OF SCIENCE IN NURSING OF

THE UNIVERSITY OF NAIROBI.

FACTORS CONTRIBUTING TOWARDS POST SURGICAL

INFECTIONS IN KENYATTA NATIONAL HOSPITAL,

NAIROBI KENYA.

ByWACHIRA ALEX KAMAU

BSC (N) IV

H32/6694/2001

SUPERVISOR

MR. WAITHAKA PETER MUCHINA

Bse N, MPH (UON)

LECTURER SCHOOL OF NURSING SCIENCE

UNIVERSITY OF NAIROBI.

DATE (AUGUST 2006 )

TABLE OF CONTENTS

TABLE OF CONTENTS ,. 11

DECLARATION IV

CERTIFICATE OF APPROVAL V

ACKNOWLEDGEMENT VI

DEDiCATION VII

ABBREVIATION VIII

OPERATION DEFINITIONS IX

EXECUTIVE SUMMARY ,. X

CHAPTER ONE 1

1.0 INTRODUCTION [1.1 PROBLEM STATEMENT 31.2 JUSTIFiCATION 51.3 OBJECTiVES 7

1.3.0 MAIN OBJECT/VE 71.3.1 SPECIFIC OBJECT/VE. 7

1.4 RESEARCH QUESTIONS 71.5 HyPOTHESiS 81.6 EXPECTED BENEFIT 8

CHAPTER TWO 9

2.0 LITERATURE REVIEW 9

2.1 INTRODUCTION 92.2 KNOWLEDGE ATTITUDE AND PRACTICE [02.3 FACTORS AFFECTING POST SURGICAL INFECTIONS [ [2.4 EFFECTS OF POST SURGICAL INFECTION [2

CHAPTER THREE ,. 14

3.0 METHODOLOGY ,. 14

3.1 STUDY DESIGN [43.1 STUDY AREA [43.2 STUDY POPULATION [43.3 SAMPLING [5

3.3. 1Sampling criteria 153.3.1.1 Inclusion Criteria 153.3. 1.2 Exclusion Criteria 15

3.4 SAMPLE SIZE DETERMINATION 163.5 SAMPLING METHOD [73.6 STUDY INSTRUMENTS [73.7 STUDY INSTRUMENT PRE TESTING 17

ii

3.8 DATA RECORDING AND PROCESSiNG 183.9 DATA ANALYSIS AND PRESENTATION 183.10 RECRUITMENT AND TRAINING OF RESEARCH ASSISTANTS 183.11 STUDY liMITATIONS 183.12 ETHICAL CONSIDERATION 19

TIME FRAME 20

GHANT CHART 21

STUDY BUDGET 22

REFERENCES ; 23

APPENDiCES 25

ApPENDIX I: OBSERVATION CHECKLIST FOR PATIENTS 25APPENDIX II: QUESTIONNAIRE FOR HEALTH CARE WORKERS 28ApPENDIX III: OBSERVATION CHECKLIST 31ApPENDIX IV: RESEARCH PARTICIPANTS CONSENT FORM 33ApPENDIX V: LETTER TO THE ETHICAL AND RESEARCH COMMITTEE .. 34

ApPENDIX VI: LETTER TO THE DIRECTOR KENYATTA NATIONALHOSPiTAL 35ApPENDIXVII: LETTER TO THE MINISTER MINISTRY OF EDUCATION 36ApPENDIX VII: MAP SHOWING KENYATTA NATIONAL HOSPITAL 37

. III

DECLARATION

I Wachira Alex Kamau do hereby declare that this research proposal is my

original work and has not been submitted for an award of degree or Diploma in

any University.

s;9natudx---- d Date: 1+11- Sf'$''''''=D,( 'l--0-O to,. / ~

IV

CERTIFICATE OF APPROVAL

This research proposal has been submitted for examination for the award of

the degree of Bachelor 0 cience in Nursing with my approval as a university

supervisor.

Mr. Waithaka P. Muchina. Ssc N, MPH (UON)

Lecturer, School of Nursing Sciences. University of Nairobi.

v

ACKNOWLEDGEMENT

I wish to express my sincere gratitude and appreciation to all those people who

helped me in one way or the other in the development of this proposal.

I wish to thank Mr. P.M. Waithaka who is my lecturer and my supervisor in all

his efforts to see me through.

I would like to thank the several institutions and librarians who have helped me

to obtain the necessary data.

Your kindness is highly appreciated.

God bless you all.

VI

DEDICATION

I dedicate this proposal to my parents Mr and Mrs. William Wachira for their

continued support and for having educated me up to this level I say thank you

and God bless you.

And to my late Grandfather Joseph Muriuki Mathenge who loved to see me

graduate. Rest in Peace.

VII

ABBREVIATION

AIDS

BSC (N)

CDC

CSSD

OMSHAl

HCW

HIV

I.C.P

K.A.P

KNH

MOH

NNIS

SPSS

SSI

U.O.N

WHO

Acquired Autoimmune Deficiency Syndrome

Bachelor of Science Nursing

Centre for disease control and prevention

Central Sterilizing Services Department.

Director of Medical Services

Hospital acquired infections

Health care workers

Human Immunodeficiency Syndrome

Infection control and prevention practice.

Knowledge attitude and practice

Kenyatta National Hospital

Ministry of Health

National Nosocomial infection surveillance

Statistical Package for Social Sciences

Surgical site infection

University of Nairobi

World Health Organization

viii

OPERATION DEFINITIONS

Clean Contaminated wound: clean contaminated wounds are from clean

operations in which the gastrointestinal or respiratory track was entered but no

significant spillage occurred.

Clean wound: They are wounds from operations in which the gastrointestinal,

genitals urinary or respiratory tract is not entered, no apparent information is

encountered and no break in aseptic technique occurs, however the following

operations are excluded from this category cholecystectomy, appendicectomy

in passing and hysterectonomy are excluded if no acts inflammation occurs.

Contaminated wound: Contaminated wounds are from operations in which

acute inflammation without pus formation is encountered or in which gross

spillage from a hollow viscous occurs, fresh traumatic wounds and operation

wounds in which a major break in aseptic technique occurs are included in this

category.

Dirty wound: They are created by operation in which pus is encountered or a

perforated viscous is found, traumatic wounds more than fours hours old are

included in this group.

Infected wound: All wounds and clinical evidence of infection such as pus

discharge, abscess formation or indurations, including wound rupture (or

wound gaping) or oozing of the main wound (whether serous or bloody).

Possible infected wound: if it develop the signs of inflammation or a serous

discharge wound classification

Uninfected wound: if it heals per primes without discharge.

IX

EXECUTIVE SUMMARY

This is a cross sectional survey focusing on the infection control and

prevention practices by the health care workers in Kenyatta National Hospital

Nairobi and how these practices contribute to post surgical infections. The

main objective of the study is to assess the ICP practices by HCW in KNH

surgicar units and to establish the causes of post surgical infections in patients

who have had their surgery done in KNH.

The study will involve observation of patients who have had surgery done in

theatres of KNH.A sample size of a total of 276 patients will be observed and a

follow up done in the wards and clinics to see the outcome of the operation.

The study tools will include a questionnaire for HCW, whose main items

include CME attendance by HCW, their ICP practices and activities of the

Hospital's ICP committee. There will be an observation check list which will

focus on among others ICP practices by HCW in theatre this includes gloving,

scrubbing, gowning. An observation check list for the patients will be filled

separately and will focus on the patient condition pre and postoperatively. Bsc.

N Interns will be recruited and trained on study tools implementation.

Before commencing on the study authority will be sought from the research

and ethical committee of KNH as well as from the OMS in MOH.

The findings are expected to generate useful information on any existing "gaps"

if any in the practice of ICP among the HCW and secondarily offer suggestions

on the way forward with regard to this issue.

The study is expected to take a total of 27 weeks at a cost of Kshs 292,000

x

CHAPTER ONE

1.0 INTRODUCTION

Post operative and hospital acquired infections have been a problem for as long

as there have been hospitals, attempts to prevent their occurrence and spread

began hundreds of years ago when separate hospitals were built for patients

with communicable diseases fever hospitals, small pox hospitals, tuberculosis

sanitoria and "pest houses" were established in efforts to separate the infected

patients from other patients and from the community [America College of

surgeons, 1998].

The ideal surgical operation results in primary healing an uneventful recovery

and cure of the disease. When an operation fails to achieve these objectives

because of complications it becomes expensive. The price tag includes human

suffering, hospitals utilization as we as the patients loss of income and

productivity. (Ponce-de- Leon, 1991)

In spite of the advances of the twentieth and twenty first century surgical

infection remains the principal course of prolonged and debilitating complications

of surgery (infection in surgical practice, [Erick W. Taylor 1992].

Hospital acquired sepsis is unacceptable given that patients entrust their lives to

the confidence and skills of health care workers, it would be sad to note that

those who should be taking care of the patients are at the fore front of

endangering their lives. [Erick W. Taylor 1992].

The practice of infection control and preventions (ICP) is quite significant in the

prevention of post surgical infections and maintenance of quality of care in

health care facilities. In these facilities some areas are more sensitive to

compromised practice of ICP owing to the nature of procedures performed and

clients involved such as theatre when surgical operations are done.

Apart from reluctance, lack of knowledge, lack of policies and protocols of

infection control in facilities. Lack of resources would also contribute to poor

infection control practices. Lack of administrative and financial has led to

inadequate key ICP personnel training thus time or no standard guidelines on

practice (international federation of infection control, 1997).

The purpose of this study is to assess the factors that contribute to post surgical

infections in Kenyatta National Hospital and secondarily offer suggestions that

would assist in bridging the gaps that may exist on knowledge, attitudes and

practice of ICP among HCW. This is with the hope of reducing maternal

morbidity and mortality

2

1.1 PROBLEM STATEMENT

Hospital acquired infections are one of the main causes of morbidity and

mortality in hospitalized patients at the present time globally (CDC, 2001). The

surgical site infection SSI rate reported from countries with more resources is

often below 5%. In Brazil and Mexico the SSI rates are usually between 10%

and 15% \Santos KRN 1997). Reported rates from African countries range from

19% to 38.7% (Kofiso B 1998).

There's little knowledge on the magnitude, consequences and the related risk

factors of SSI in countries with fewer resources. In countries where there have

been studies, the SSI rates frequently are reported higher than 10% in the USA

it is estimated at 3 %( Nicholos 1990).

In a study done in Ethiopia it was estimated that each patient with postoperative

infection did cost at least 100 US Dollars extra and that 14 of 18 deaths among

surgical patients were attributed to Nosocomial infections (Haste-Gabr E1988).

The infection rate in hospitals in Tanzania is not known. The economic impact of

Nosocomial infections in countries with fewer resources is far greater than in

developed countries due to the larger number of infections and small health

budget (pounce-de -Leons1991).

Nosocomial infections are an important health problem world wide but the efforts

to control them has been initiated only in some developing countries. Lack of

administrative and financial support has led to inadequate key ICP personnel

training thus little or no standard guidelines on ICP practice [International

federation of infection control 1997).

Post operative wounds infections can be disastrous to the patient. It involves

suffering of the patients, a risk to other patients, extra cost because of the need

for more operations, blood, antibiotics nursing and prolonged hospitalization.

(Erickson M, 2001)

Nosocomial infections are too expensive to be tolerated in terms of prolonged

hospital stay, time for treatment, increased use of staff time for treatment,

Increased cost of supplies for would care, loss of man hours may be the largest

but hardest to measure. The informed medical consumer is unlikely to return to a

3

hospital or recommend a hospital where they became more ill while they were

inpatients than they were before being admitted (CDC, 2001).

Some of the effects of hospital acquired infections include loss of life,

incapacitation which leads to less production by the person and to the family at

large psychological trauma, long periods of hospitalization and in other cases

change of lifestyle e.t. c.

Infection control committees should be formed in health care facilities and may

include a simple team of a doctor, infection control nurse and a lab technician

where applicable a record officer: (WHO, 2003)

In other facilities the team may be bigger depending on the size of the facility

and staff availability. In Kenyatta National Hospital the ICP committee has

designated an infection control nurse in each of its department. The hospital

developed a guideline in 1999 titled "handling infectious diseases" on the

guideline they have highlighted precautions on patients' placement, patient

teaching and instructions, visitors' teachings & instruction.

4