1

CHAPTER I
INTRODUCTION

In the Philippine setting, nosocomial infection has caused a great impact in the
country’s health care system. There were reports of unexplained incidence of
nosocomial infection in several hospitals particularly government hospitals; not only
that, it has been reported in the latest statistics that the incidences are remarkably
increasing.

This information may bring an alarming effect in the health care system but
nothing can be compared to the burden that is placed to the patient. Substantial
burden received by the individual causes increased morbidity, including delayed
wound healing, delayed rehabilitation, increased exposure to antimicrobial therapy and
its potential adverse effects, prolonged hospitalization thus causing higher health care
cost.

Nosocomial infections also contribute to the emergence and dissemination of

antimicrobial-resistant organisms. Antimicrobial use for treatment or prevention of
infections facilitates the emergence of resistant organisms. Patients infected with
antimicrobial-resistant organisms are then a source of contamination for other
hospitalized patients.

Knowledge and information gathered about these incidences has made the
researchers to conduct a study about the prevalence, characteristics and factors
associated with nosocomial infection in selected hospital in Metro Manila. This study
focuses on the realization that as nursing students and future health care workers in a
hospital, it is important to understand how infection occurs, the modes of bacterial
transmission, and the prevalent microorganisms involved in causing disease. Focused
efforts aimed at treating existing infection and preventing the occurrence of
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nosocomial infection can dramatically improve the care and recovery of hospitalized
patients.

A. Background of the Study

A nosocomial, or hospital-acquired, infection is a new infection that develops in

a patient during hospitalization. It is usually defined as an infection that is identified at
least forty-eight to seventy-two hours following admission, so infections incubating, but
not clinically apparent, at admission are excluded.

Nosocomial infections occur worldwide, both in the developed and developing

world. They are a significant burden to patients and public health. They are a major
cause of death and increased morbidity in hospitalized patients. They may cause
increased functional disability and emotional stress and may lead to conditions that
reduce quality of life. Not only do they affect the general health of patients, but they
are also a huge burden financially. The greatest contributors to these costs are the
increased stays that patients with nosocomial infections require. The increased length
of stay varies from 3 days for gynecological procedures to almost 20 days for
orthopedic procedures. Other costs include additional drugs, the need for isolation,
and the use of additional studies. There are also indirect costs due to loss of work.

Nosocomial infections are most frequently infections of the urinary tract,

surgical wounds, and the lower respiratory tract. A World Health Organization
prevalence study and other studies have shown that these infections most commonly
occur in intensive care units and in acute surgical and orthopedic wards. Infection
rates are also higher in patients with increased susceptibility due to old age, underlying
disease, or chemotherapy.

Patients are exposed to a variety of microorganisms during a hospital stay, but

contact between a patient and an organism does not necessarily guarantee infection.
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Other factors influence the nature and frequency of infections. Organisms vary in
resistance to antimicrobials and in intrinsic virulence. Bacteria, viruses, fungi, and
parasites can all cause nosocomial infections. There are multiple ways of acquiring
such an organism. The organisms can be transferred from one patient to another
(cross-infection). They can be part of a patient’s own flora (endogenous infection).
They can be transferred from an inanimate object or from a substance recently
contaminated by another human source (environmental transfer). The organisms that
cause most hospital acquired infections are common in the general population, in
which setting they are relatively harmless. They may cause no disease or a milder
form of disease than in hospitalized patients. This group includes Staphylococcus
aureus, Coagulase-negative staphylococci, Enterococci, and Enterobacteria. Factors
that increase a patient’s susceptibility to nosocomial infections include young or old
age, decreased immune resistance, underlying disease, and therapeutic and
diagnostic interventions.

B. Statement of the Problem

The study aims to determine the prevalence, characteristics and factors

associated with nosocomial infection in Ospital ng Maynila.
Specifically, this research study sought to answer the following questions:
1. What is the prevalence rate of nosocomial infection in the selected
government hospital from the year 2006 to 2007?
2. What are the factors that contribute to the prevalence of nosocomial
infection?
3. What are the patient’s characteristics associated with the acquisition of
nosocomial infection?
4. Is there a significant relationship among prevalence, factors and
characteristics regarding nosocomial infection?
5. What programs can be developed to improve the hospital practices in the
occurrence of nosocomial infection based on the results of the study?
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C. Hypothesis

There is no significant relationship among prevalence, factors and

characteristics regarding nosocomial infection.

D. Significance of the Study

Adhering to recommended infection prevention practices, diseases can be

prevented. This study will serve as a basis of formulating new ideas and will also serve
as a source of information which researchers may use for future studies concerning
nosocomial infection.

E. Conceptual and Theoretical Framework

Conceptual Framework:

Characteristics
Prevalence Prevalence
Nosocomial
Infection
Clinical Physical
Practices Environment

Prevalence
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Physical environment concerning nosocomial infection includes ventilation,

contaminated water systems, staffing, nurse-patient ratio and open beds close
together. On the other hand, the clinical practices include inadequate sterilization of
equipment, invasive procedures, cohorting, isolation of patients with communicable
diseases, hand washing, and improper handling and disposal of bodily secretions and
soiled linens. Characteristics of the patients can be measured through age, length of
stay, low birth weight on neonates, and initial and final diagnoses of the patient. With
those variables interrelated, prevalence of nosocomial infection may take place.

As a conclusion, more factors associated with nosocomial infection greatly

affect the poor state of health of the patients that leads to higher prevalence rate of
nosocomial infection, or vice versa.

Theoretical Framework:
Florence Nightingale’s theory encloses three major relationships which are the
environment to patient, nurse to environment, and nurse to patient. Environment is the
focus of Nightingale’s theory and that environment is the main factor that contributes to
patient’s illness. Harmfulness of the environment is recognized as well as the benefit
of good environments in preventing disease. The concepts of this environmental
theory used are the ventilation, warmth, light, diet, cleanliness and noise. Furthermore,
healthy surroundings were crucial for proper nursing intervention; but, concern about
healthy surroundings included not only the hospital settings, but also the private
homes of patients and the physical living conditions of the poor. (Tomey and Alligood,
2002).

Proper ventilation as one of the essential components of environmental health

seemed to be identified as a source of disease and recovery. As Nightingale’s greatest
concern, nurses must “keep the air he (patient) breathes as pure as the external air,
without chilling him”. (Tomey and Alligood, 2002). Basically, infection may be spread
through the air and breathed in, but with weakened defenses. Thus, contaminated air
 6

conditioning systems can be the risk for the invasion of the colonizing pathogens
resulting to increased chances of respiratory tract infection. Various sterilization
measures are helpful ranging from simple acts like sterilizing ventilators to full scale air
filtering systems in the hospital. Added to that, hospitals must have specially ventilated
isolation wards for patients with highly contagious diseases such as tuberculosis.

Another critical component of the environmental theory is the cleanliness, which

is addressed to the patient, the nurse and the physical environment. It is said that a
dirty environment is a source of infection through the organic matter it contained; and
so, to prevent contamination, proper handling and disposal of bodily secretions and
sewage are required. There is also a strong advocacy on hand washing in this theory
since nurses are obliged to wash hands frequently. Likewise, not only the nurses are
subjected to cleanliness but the patients as well, because taking a bath frequently is
strongly recommended to improve health status. (Tomey and Alligood, 2002). On the
other hand, as with the nosocomial infection, health care workers could be the source
of infectivity through contact transmission. Physical contact of health care providers
with other patients that are colonized or infected with pathogenic organisms increases
the likelihood of infection. Therefore, hand washing, which is being failed to follow
most of the time, should be strictly implemented.

A further component of Nightingale’s theory is the description of petty

management. The health care provider is indeed in control of the environment both
physically and administratively. The health care provider must manage the
environment so as to protect the patient from both physical and psychological harm.
(Tomey and Alligood, 2002). Regarding nosocomial infection, the health care workers
must give such value on the characteristics of the patient as they are
immunocompromised or have poor state of health and as such. Their management
like proper disposal of infectious wastes, isolation of patients with communicable
diseases, cohorting and hand washing must not be neglected. Petty management
must be the one that needs further improvement to prevent nosocomial infection.
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As a result, any deficiency in one or more of these factors could lead to

impaired functioning of life processes or diminished health status.

F. Scope and Limitations

The study population includes only nurses. It focuses on the prevalence,

characteristics and factors associated with nosocomial infection in Ospital ng Maynila.
By itself, the foremost limitation of the study is the lack of verification of honesty of the
subjects while answering the checklist. Their response could determine if there is a
significant relationship among the three variables regarding nosocomial infection.

G. Definition of Terms

a) Prevalence - the total number of cases in the population at a given time, or

the total number of cases in the population, divided by the number of individuals in the
population.
b) Factors - elements that contribute or lead to the development of nosocomial
infection specifically clinical practices and physical environment.
c) Clinical Practices – procedures done by the health care practitioner in a
hospital setting.
d) Physical Environment – the client’s surroundings and its nature and
characteristics, and equipment being used, which may cause good quality of care or
the opposite.
e) Characteristics – conditions of the patients like age, length of stay, initial and
final diagnoses that predispose them to have nosocomial infection
f) Nosocomial Infection - classified as infections that are acquired with the
delivery of health care services in a health care facility.
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g) Government Hospital – a public institution founded for reception and cure of

persons diseased in body or mind, or disabled, infirm, and in which they are treated
either at their own expense, or more often by charity.
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CHAPTER II
REVIEW OF RELATED LITERATURE

This chapter presents the related literature and studies with relevant implication
to the research study. This chapter is very essential because the researchers believe
that an effective research must be based upon past knowledge. These past knowledge
served as their basis for coming up to a more efficient study; thus, further improving
their knowledge and be able to come up with a good solution to the problem.

A. Related Literature

Nosocomial infection is any infection acquired while in the hospital. Nosocomial

infections can be transmitted from person to person by health care workers who do not
wash their hands properly between treating patients or by improper procedures, such
as inadequate disinfection or sterilization of equipment. Approximately 1.9 million such
infections occur each year in the United States, contributing to more than 88,000
deaths yearly. The Department of Health, through the environmental health services,
has the authority to act in all issues and concerns in environmental health including the
code on sanitation of the Philippines (PD 856, 1978) DOH 2000 pp 314-321).

Hospital patients are particularly susceptible to nosocomial infections because

their immune systems are often suppressed or compromised due to age,
immunosuppressive medication, or other underlying causes, such as acquired
immunodeficiency syndrome (AIDS). Nosocomial infections, which progress rapidly
and are frequently resistant to antibiotics, generally involve bacteria such as
Staphylococcus, Enterobacter, or Pseudomonas or fungi such as Candida. In addition,
some microorganisms that reside in a person's body and that normally cause little or
no harm may start a nosocomial infection if the individual is treated with an antibiotic
that destroys beneficial organisms, thus allowing disease-causing organisms to take
over. (Microsoft® Encarta® Reference Library 2003. © 1993-2002).
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Within the patient’s stay at the hospital, bacteria or other micro-organisms will
stay or colonize and invade the skin, respiratory tract, and genitourinary tract leading
to the development of so many infections from different areas or system of the body.
Of course, there are factors why this incidence takes place. These said risk factors are
categorized into 3 areas: iatrogenic, organizational, and patient-related. The iatrogenic
risk factors include pathogens on the hands of medical personnel, invasive procedures
(intubation and extended ventilation, indwelling vascular lines, urine catheterization),
and antibiotic use and prophylaxis. The organizational risk factors include
contaminated air-conditioning systems, contaminated water systems, and staffing and
physical layout of the facility (nurse-to-patient ratio, open beds close together). Lastly,
the patient risk factors include the severity of illness, underlying immunocompromised
state, and length of stay.

Based on the survey performed by the National Nosocomial Infections

Surveillance (NNIS), System of the Centers for Disease Control and Prevention
(CDC), from October 1986 to April 1998, the highest rates of infection occurred in the
burn ICU, the neonatal ICU, and the pediatric ICU.

Acquiring nosocomial infection has no relationship with sex factor, however;

neonates having low birth weight and male sex (male-to-female ratio is 1.7:1) are
associated with an increased risk of nosocomial infection. And in terms of age,
bacteremias and surgical site infections were more common in infants younger than 2
months than in older children. However, urinary tract infections were reported more
frequently in children older than 5 years than in younger children.

Dr. Linda S. Efferen (2000) tackled about nosocomial infection in her article
entitled “Impact of Nosocomial Infections in the ICU”, which focuses primarily on
issues related to ventilator-associated pneumonia (VAP), but also includes discussions
on nonpulmonary nosocomial infections. She tackled the risk factors and pathogenesis
which has 3 types: classical approach, pathogen targeted, and dynamic concept. She
 11

discussed also the prevention and treatment (Bacterimia and Urinary Tract Infection)
and also the cost of nosocomial infections.

In the article entitled “Public Health Focus: Surveillance, Prevention, and

Control of Nosocomial Infections” (1998), it discussed and explained how protocols,
procedures, and organizations were brought about to understand, control, plan,
implement and prevent nosocomial infection. It discussed greatly on how nosocomial
affects the world and examines knowledge about the effectiveness of nosocomial
infection surveillance, prevention, and control and their cost-benefits. It stated that
SENIC (Study on the Efficacy of Nosocomial Infection Control Project) has enhanced
the practice of infection control in the United States by providing a scientific basis for
determining the effectiveness of infection surveillance and control programs. This
basis may be unique among programs addressing complications of hospitalization. It
further explained that the findings of SENIC have also suggested the need for
physician training in infection control. As a result, they have provided a training course
in hospital epidemiology for physicians. In addition, the results of SENIC affirmed
interest in surveillance of nosocomial infections and demonstrated the importance of
using selected outcome measures (nosocomial infection rates) from targeted
surveillance. Here, it was said that SENIC found that hospitals reduced their
nosocomial infection rates by approximately 32% if their infection surveillance and
control program included four components: 1) appropriate emphasis on surveillance
activities and vigorous control efforts, 2) at least one full-time infection-control
practitioner per 250 beds, 3) a trained hospital epidemiologist, and 4) for surgical
wound infections, feedback of wound infection rates to practicing surgeons. However,
questions regarding the efficacy and cost-effectiveness of these programs have
persisted.

Dr. Robert Weinstein (1998) discussed in his article, “Nosocomial Infection

Update”, important people under Infection control like Jenner, Semmelweis,
Nightingale, Oliver Wendell Holmes, and Thomas Crapper who happens to be the
father of indoor plumbing. Modern infection control is grounded in the work of Ignaz
 12

Semmelweis, who in the 1840s demonstrated the importance of hand hygiene for
controlling transmission of infection in hospitals. However, infection control efforts
were spotty for almost a century. It said that in 1976, the Joint Commission on
Accreditation of Healthcare Organizations published accreditation standards for
infection control, creating the impetus and need for hospitals to provide administrative
and financial support for infection control programs. In 1985, the Centers for Disease
Control and Prevention's (CDC's) Study on the Efficacy of Nosocomial Infection
Control reported that hospitals with four key infection control components—an
effective hospital epidemiologist, one infection control practitioner for every 250 beds,
active surveillance mechanisms, and ongoing control efforts—reduced nosocomial
infection rates by approximately one third. Over the past 25 years, CDC's National
Nosocomial Infections Surveillance (NNIS) system has received monthly reports of
nosocomial infections from a nonrandom sample of United States hospitals; more than
270 institutions report. The nosocomial infection rate has remained remarkably stable
but because of progressively shorter inpatient stays over the last 20 years, the rate of
nosocomial infections per 1,000 patient days has actually increased 36%, from 7.2 in
1975 to 9.8 in 1995. In the article, it is estimated that in 1995, nosocomial infections
cost $4.5 billion and contributed to more than 88,000 deaths—one death every 6
minutes. This article also explained why nosocomial infection is present, who are the
candidates or rather who can be affected, and the prevention and the control.

B. Related Studies

In a study entitled “Practice of Epidemiology…” (Hugonnet, Villaveces, and

Pittet, 2006), the authors compared a case-crossover design, a case-time-control
design, and a cohort design to evaluate the effect of nurse staffing level on the risk of
nosocomial infections. They evaluated two strategies, conditional logistic regression
and generalized estimating equation, to analyze the case-crossover study. The study
was performed among critically ill patients in the medical intensive care unit of the
University of Geneva Hospitals, Geneva, Switzerland. Of 366 patients who stayed
more than 7 days in the intensive care unit between 1999 and 2002, 144 developed an
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infection. The main reasons for admission were infectious (35.3%), cardiovascular
(32.5%), and pulmonary (19.7%) conditions. A comparison of the three study designs
showed that lower nurse staffing was associated with an approximately 50% increased
risk of nosocomial infections. All analyses yielded similar estimates, except that the
point estimate obtained by the conditional logistic regression used in the case-
crossover design was biased away from unity; the generalized estimating equation
yielded unbiased results and is the most appropriate technique for case-crossover
designs. The case-crossover methodology in hospital epidemiology is a promising
alternative to traditional approaches, but selection of the referent periods is
challenging.

“Nosocomial Bloodstream Infection and Clinical Sepsis” states that primary

bloodstream infection (BSI) is a preventable infectious complication in critically ill
patients and have a negative impact on patients’ outcome. Surveillance definitions for
primary BSI distinguish those that are microbiologically documented from those that
are not. The latter is known as clinical sepsis, but information on its epidemiologic
importance is limited. Prospective on-site surveillance data of nosocomial infections in
a medical intensive care unit was analyzed. Of the 113 episodes of primary BSI, 33
(29%) were microbiologically documented. The overall BSI infection rate was 19.8
episodes per 1,000 central-line days (confidence interval [CI] 95%, 16.1 to 23.6). The
rate fell to 5.8 (CI 3.8 to 7.8) when only microbiologically documented episodes were
considered. Exposure to vascular devices was similar in patients with clinical sepsis
and patients with microbiologically documented BSI. The laboratory-based
surveillance alone will underestimate the incidence of primary BSI and thus jeopardize
benchmarking (Nosocomial Bloodstream …, Hugonnet, H. Sax., Eggimann, J
Chevrolet, and D. Pittet, 2000).

In the study entitled, “Results of a Matched Case-control Study of ICU Patients”

(Girou, E., Stephan, F., Novara, A., Safar, F., & Fagon, J., 1998) a pairwise,
retrospective case-control study with 1:1 matching was used. The study was
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conducted in the Service de Réanimation Médicale of Broussais University Hospital in

Paris, a 10-bed ICU that receives patients from all departments in the hospital and from
ICUs of other hospitals. The study period ran from January 1, 1992, to December
31, 1992, during which time 281 patients were admitted in the unit. The study suggests
that a persistent high level of therapeutic activity and persistently depressed
consciousness on the third day after ICU admission are associated with the acquisition
of nosocomial infection by critically ill patients hospitalized in a medical ICU. Such
nosocomial infections are responsible for excess mortality, prolonged stay, and
increased therapeutic activity independently of the initial severity of illness. Thus,
nosocomial infections exact a heavy charge on all concerned such as, the patient, the
medical staff, and economic resources, especially in cases of multiple infections.

A study entitled, “Relationship Between Under Nutrition and Nosocomial

Infections in Elderly Patients” shows that elderly patients hospitalized in rehabilitation
units were at particularly high risk of nosocomial infections and that 20% of them
presented multiple infections. These latter patients were older, presented an altered
nutritional status, had lower food intake, had more urinary catheters, showed a
prolonged recovery, increased mortality and had more discharge placement. A better
understanding of the predisposing factors for nosocomial infection in elderly
hospitalized patients may allow some preventing strategies to reduce the risk. A
reduction in the number of invasive procedures, particularly urinary catheterization, a
nutritional assessment on admission and if necessary, a nutritional intervention, may
help to reduce the incidence of nosocomial infections. (Paillaud, E., Herbaud, S.,
Caillet, P., Lejonc,J., Campillo, B., & Bories, P., 2005).

The prevalence of ICU-acquired infection is common and often associated

with microbiological isolates of resistant organisms, wherein most frequently reported
micro-organisms were Enterobacteriaceae (34.4%), Staphylococcus aureus (30.1%;
[60% resistant to methicillin], Pseudomonas aeruginosa (28.7%), coagulase-negative
staphylococci (19.1%), and fungi (17.1%). Based on the studies done on Intensive
 15

Care Units in 17 countries in Western Europe, there were seven risk factors identified,
such as, increasing length of ICU stay (> 48 hours), mechanical ventilation, diagnosis
of trauma, central venous, pulmonary artery, and urinary catheterization, and stress
ulcer prophylaxis. ICU-acquired pneumonia, clinical sepsis, and bloodstream infection
increased the risk of ICU death. (Vincent JL, et. al.) While with regard to the study
made by Toufen Junior C, et. al., with patients over 16 years old occupying an
intensive care unit bed over a 24-hour period, multivariate regression analysis
revealed 3 risk factors for intensive care unit-acquired infection, which are age > or =
60 years, use of a nasogastric tube, and postoperative status. As an example, there
was a study, done by Michalopoulos A. et. al, focusing on acquiring an infection after a
cardiac surgery. Results revealed that there were a hundred and seven of 2122
patients developed microbiologically documented nosocomial infection after open
cardiac surgery. The majority of nosocomial infections were respiratory tract infections
and central venous catheter-related infections. Risk factor associated with this are
those with history of immunosuppression, transfusion of more than five red blood cell
units in both the operating room and during the first ICU postoperative day, and
development of acute renal failure within the first two days after operation.
(http://www.ncbi.nlm.nih).

C. Synthesis

Articles and journals regarding prevalence, characteristics and factors

associated with nosocomial infections are not hard to find. The following articles
especially the one entitled “Public Health Focus: Surveillance, Prevention, and Control
of Nosocomial Infections” (1998) discussed greatly on how nosocomial affects the
world and examines knowledge about the effectiveness of nosocomial infection
surveillance, prevention, and control and their cost-benefits. Also, these articles
tackled about the factors associated in nosocomial infections and some preventable
infectious complication in critically ill patients that have a negative impact on patients’
outcome.
 16

In the study entitled, “Results of a Matched Case-control Study of ICU Patients”

the authors concluded that nosocomial infection is one of the major factor that
contributes to the enlarged mortality, prolonged stay, and increased therapeutic
activity independently of the initial severity of illness at Intensive Care Unit.
Furthermore, one of the study, noted that elderly patients are at high risk in acquiring
nosocomial infections.
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CHAPTER III
METHODOLOGY

A. Design

The researchers explored the “Prevalence, Characteristics and Factors

Associated with Nosocomial Infection in Selected Hospital in Metro Manila.” Thus, in
order to answer the research questions, this research used a Descriptive Correlational
Research Design. Under this research design, the study will be able to know and to
describe relationships among prevalence of nosocomial infection, factors contributing
to nosocomial infection, and patient’s characteristics contributing to nosocomial
infection.

B. Sampling method

The researchers used Convenience Sampling in order to get available people

as study participants. Within the selected hospital, nurses, at 7am-7pm shift, within
the day of the survey, were given questionnaires, in the form of checklist, for them to
answer. The survey was done within two days. One day is allotted for gathering
hospital records, and the other day is for distributing questionnaires.

B.1. Inclusion Criteria

Nurses permanently employed in the said hospital and are assigned to

ICU areas like MICU, SICU, PICU are included.

B.2. Exclusion Criteria

Doctors, medical residents and consultants are not included.

C. Setting

This study was conducted at Ospital ng Maynila located in Roxas Boulevard,

Malate, Manila. It is a government hospital in Metro Manila. Specifically, the study was
 18

conducted in areas (e.g. MICU, SICU and PICU) that the hospital have where most
patients, if not all, acquire nosocomial infection. The said hospital has made certain to
give their consent before the study can pursue.

D. Data Collection Method

To obtain all necessary information the study needs, the researchers reviewed
hospital records with nosocomial infection incidence from year 2006 to 2007. These
hospital records showed the prevalence and trend of nosocomial infection for the last
two years and patients’ characteristics in acquiring nosocomial infection. A
questionnaire in a form of checklist was also given to staff nurses to answer. This
questionnaire yields to know the factors or health practices of nurses in the hospital
and how it can affect in the prevalence of nosocomial infection. The questionnaire
included items regarding practice in using Personal Protective Equipments (PPE), care
of patient’s equipment, linen care, wound care, infective waste disposal, and invasive
medical devices and technology used.

E. Data Collection Protocol

Permission to the director of the selected hospital was first obtained. The
researchers explained and briefed the nurses about the study on nosocomial infection.
Questionnaire in the form of checklist was then distributed to each of them. Other
researchers were tasked to retrieve all the questionnaires to enhance return rate that
will greatly affect the result of the study. Frequency percentage ranking was done to
know and describe the leading factor that contributes to nosocomial infection. Records
review from 2006 up to 2007 was also done by the researchers to get the prevalence
of nosocomial infection and characteristics of patients that could have affect in
nosocomial infection.
 19

F. Statistical Treatment

The Chi-square test of independence is designed to test whether or not the two

variables are independent (not related). If we reject the null and say the variables are

not independent of one another, then we have established that the two variables are

related. This test would be used to determine whether there exists a significant

relationship between the prevalence of nosocomial infection and the characteristics of

the patients.

The formula is shown below. The null hypothesis is rejected when the chi-

square value is greater than the critical value.

df = (R - 1) (C- 1) where R= number of rows

C = number of columns
xi = observed frequencies
Ei = expected frequencies

H0: There is no relationship between the prevalence of nosocomial infection

and the characteristics of the patients. (variables are independent).

H1: There is a relationship between the prevalence of nosocomial infection and

the characteristics of the patients. (variables are not independent).

 20

Scale Weighted Mean Range Interpretation

5 4.20 – 5.00 100% Performed
4 3.40 – 4.19 75% Performed
3 2.60 – 3.39 50% Performed
2 1.80 – 2.59 25% Performed
1 1.00 – 1.79 0% Performed

The scale above would be utilized by the researchers to determine the extent of

the nurses’ responses to the factors that affect the risk of Nosocomial Infection. Each

range has a corresponding interpretation so as to further analyze and understand the

extent of the clinical practices and maintenance of the physical environment.

 21

CHAPTER IV
RESULTS AND DISCUSSION

The following tables aim to answer the research questions previously raised by
the researchers.

Table 4.1 Prevalence of Nosocomial Infection in Ospital ng Maynila for the Year
2006-2007

Living Dead
Patients Patients
who had who had
other other
Admitting Diagnosis Diagnose Diagnose
conditions conditions
(Affected System of the Body) d d
developed developed
(Discharge (Discharge
Diagnosis) Diagnosis)
Respiratory System 14 3 19 2
Reproductive System 6 1 8 3
Skeletal System 4 0 1 0
Nervous System 60 0 33 2
Cardiovascular system 188 0 78 7
Digestive System 2 0 9 2
Lymphatic System 0 0 0 1
Endocrine System 96 0 15 5
Muscular System 2 0 0 0
Injury 1 0 5 0
Multiple Organ 0 0 4 0
Circular System 0 0 6 2
TOTAL 373 4 178 22
Percentage 1.07% 12.36%

The preceding table summarizes the patient records for the year 2006-2007.

Out of the 373 patients admitted to the hospital differently diagnosed, 4 of which or

equivalent to 1.07% of the admitted patients where diagnosed with a discharge

diagnosis of having other complications developed. For the year 2006-2007, the

nosocomial infection prevalence is about 1.07% for those living and 22 out of 178 or
 22

12.36% of those who have died. In total, the prevalence rate is about 13.43% for the

year 2006-2007.

Most of the admitted patients were diagnosed to have cardiovascular disorders

with 188 out of 373 of the patients or 50.40%. Next highest count is that of endocrine

disorders with 96 or 25.74% of the patients, followed by nervous system disorders with

16.09% and respiratory system disorders with 3.75%. Out of the 14 patients

diagnosed to have respiratory ailments, 3 of them were discharged to have developed

other conditions other than their primary sickness, 1 out of the 6 reproductive system

patients were diagnosed to have acquired nosocomial infection.

To the deceased, 7 out of the 78 cardiovascular patients were diagnosed to

have acquired nosocomial infection, 5 from the 15 endocrine patients also developed

the infection. 3 out of the 8 reproductive ailments have discharge diagnosis, 2 from the

19 respiratory patients and another 2 from those with digestive ailments.

Table 4.2 Age of Patients at Risk of having Nosocomial Infection

Age Living Dead Infected

Adolescent (12y/o to 20
2 2
y/o) 1
Young Adulthood (20y/o to
56 29
40y/o) 3
Middle Adulthood (40y/o to
201 68
64y/o) 14
Late Adulthood (65y/o and
114 79
above) 12
TOTAL 373 178 30
 23

The preceding table gives the patients’ age characteristics which are exposed

and prone to nosocomial infection. There are 2 adolescents for both the living and

dead, with 56 young adults for the living and 29 counts for those who have died.

There are 201 in the middle adulthood living and 68 of those who have died. For the

late adults, the count is 114 for the living and 79 of which died. There are more

patients in the middle adulthood admitted in the hospital, 53.89%, and at risk of having

nosocomial infection, next are those in the late adulthood compromising 30.56% of the

living patients. The least to be exposed and at risk are the adolescents and young

adults with 0.54% and 15.01% of the total number of living patients.

Table 4.3 Length of Hospital Stay of Patients at Risk of having Nosocomial

Infection

Living Dead Infected

Less than a week 309 154 20
Less than a month 64 22 8
More than a
0 2
month 0
TOTAL 373 178 28

Most of the patients’ records, both for the living and those who have died, show

that there are a lot more patients who are in the hospital for only less than a week.

There are 82.84% of the living patients who have stayed in the hospital for only less

than a week, 17.16% of the total admissions have stayed for less than a month and

none of the living yet has stayed for more than a moth. As for the patients who have

died, there are 154 out of 178, equivalent to 86.52% of the total number of deceased

patients.
 24

Table 4.4 Factors that Contribute to the Prevalence of Nosocomial Infection

Factor Mean Range Interpretation

Clinical Practices 4.27 5 100% Performed
Physical
4.00 4 75% Performed
Environment

The above table summarizes the nurses’ responses on the factors that

contribute to the prevalence of Nosocomial Infection. For the Clinical Practices, their

responses fall on the 5th scale meaning that the clinical practices are almost 100%

performed as shown by the mean response of 4.27. For the Physical environment, the

mean of 4.00 fell on the 4th scale which determines that the physical environment is

maintained at 75% efficiency.

If according to the nurses, the cleanliness of the hospital and its environment

are properly maintained, therefore these factors do not have a relationship to the

prevalence of nosocomial infection of the patients.

Table 4.5 Chi-square Test for Significant Relationship Between Prevalence and
Characteristics of Patients

Characteristic Chi-square Critical Value Significance

Admission 18.307
44.208 Significant
Diagnosis
Age of Patient 3.830 7.815 Not Significant
Length of Hospital
3.840 5.991 Not Significant
Stay

The chi-square test was utilized by the researchers to determine whether there

exists a significant relationship on the prevalence of nosocomial infection with the

patients’ characteristics. At 0.05 level of significance, the critical value for the

admission diagnosis is 18.307 which is less than the computed chi-square value of
 25

44.208, giving the researchers sufficient evidence to conclude that the admission

diagnosis plays a big part as to whether the patient will be prone to nosocomial

infection or not.

The age of the patient and length of hospital stay were shown to have no

significant relationship to the prevalence of nosocomial infection among the patients

studied.
 26

CHAPTER V

SUMMARY, CONCLUSION AND RECOMMENDATION

Summary

In the Philippine setting, nosocomial infection has caused a great impact in the

country’s health care system. There were reports of unexplained incidence of

nosocomial infection in several hospitals particularly government hospitals; not only

that, it has been reported in the latest statistics that the incidences are remarkably

increasing.

This information may bring an alarming effect in the health care system but

nothing can be compared to the burden that is placed to the patient. Substantial

burden received by the individual causes increased morbidity, including delayed

wound healing, delayed rehabilitation, increased exposure to antimicrobial therapy and

its potential adverse effects, prolonged hospitalization thus causing higher health care

cost.

Nosocomial infections also contribute to the emergence and dissemination of

antimicrobial-resistant organisms. Antimicrobial use for treatment or prevention of

infections facilitates the emergence of resistant organisms. Patients infected with

antimicrobial-resistant organisms are then a source of contamination for other

hospitalized patients.
 27

Knowledge and information gathered about these incidences has made the

researchers to conduct a study about the prevalence, characteristics and factors

associated with nosocomial infection in selected hospital in Metro Manila. This study

focuses on the realization that as nursing students and future health care workers in a

hospital, it is important to understand how infection occurs, the modes of bacterial

transmission, and the prevalent microorganisms involved in causing disease. Focused

efforts aimed at treating existing infection and preventing the occurrence of

nosocomial infection can dramatically improve the care and recovery of hospitalized

patients.

A nosocomial, or hospital-acquired infection is a new infection that develops in

a patient during hospitalization. It is usually defined as an infection that is identified at

least forty-eight to seventy-two hours following admission, so infections incubating, but

not clinically apparent, at admission are excluded.

Nosocomial infections occur worldwide, both in the developed and developing

world. They are a significant burden to patients and public health. They are a major

cause of death and increased morbidity in hospitalized patients. They may cause

increased functional disability and emotional stress and may lead to conditions that

reduce quality of life. Not only do they affect the general health of patients, but they

are also a huge burden financially. The greatest contributors to these costs are the

increased stays that patients with nosocomial infections require. The increased length

of stay varies from 3 days for gynecological procedures to almost 20 days for
 28

orthopedic procedures. Other costs include additional drugs, the need for isolation,

and the use of additional studies. There are also indirect costs due to loss of work.

Nosocomial infections are most frequently infections of the urinary tract,

surgical wounds, and the lower respiratory tract. A World Health Organization

prevalence study and other studies have shown that these infections most commonly

occur in intensive care units and in acute surgical and orthopedic wards. Infection

rates are also higher in patients with increased susceptibility due to old age, underlying

disease, or chemotherapy.

The study aims to determine the prevalence, characteristics and factors

associated with nosocomial infection in Ospital ng Maynila.

Specifically, this research study sought to answer the following questions:

1. What is the prevalence rate of nosocomial infection in the selected

government hospital from the year 2006 to 2007?

2. What are the factors that contribute to the prevalence of nosocomial

infection?

3. What are the patient’s characteristics associated with the acquisition of

nosocomial infection?

4. Is there a significant relationship among prevalence, factors and

characteristics regarding nosocomial infection?

 29

5. What programs can be developed to improve the hospital practices in the

occurrence of nosocomial infection based on the results of the study?

Out of the 373 patients admitted to the hospital differently diagnosed, 4 of which

or equivalent to 1.07% of the admitted patients were diagnosed with a discharge

diagnosis. For the year 2006-2007 the nosocomial infection prevalence is about

1.07% for those living and 22 out of 178 or 12.36% of those who have died. In total,

the prevalence rate is about 13.43% for the year 2006-2007.

Most of the admitted patients were diagnosed to have cardiovascular disorders

with 188 out of 373 of the patients or 50.40%. Next highest count is that of endocrine

disorders with 96 or 25.74% of the patients, followed by nervous system disorders with

16.09% and respiratory system disorders with 3.75%. Out of the 14 patients

diagnosed to have respiratory ailments, 3 of them were discharged to have developed

other conditions other than their primary sickness, 1 out of the 6 reproductive system

patients were diagnosed to have acquired nosocomial infection.

To the deceased, 7 out of the 78 cardiovascular patients were diagnosed to

have acquired nosocomial infection, 5 from the 15 endocrine patients also developed

the infection. 3 out of the 8 reproductive ailments have discharge diagnosis, 2 from the

19 respiratory patients and another 2 from those with digestive ailments.

 30

The patients’ age characteristics which are exposed and prone to nosocomial

infection are summarized as follows: There are 2 adolescents for both the living and

dead, with 56 young adults for the living and 29 counts for those who have died.

There are 201 in the middle adulthood living and 68 of those who have died. For the

late adults, the count is 114 for the living and 79 of which died. There are more

patients in the middle adulthood admitted in the hospital, 53.89%, and at risk of having

nosocomial infection, next are those in the late adulthood compromising 30.56% of the

living patients. The least to be exposed and at risk are the adolescents and young

adults with 0.54% and 15.01% of the total number of living patients.

Most of the patients’ records, both for the living and those who have died, show

that there are a lot more patients who are in the hospital for only less than a week.

There are 82.84% of the living patients who have stayed in the hospital for only less

than a week, 17.16% of the total admissions have stayed for less than a month and

none of the living yet have stayed for more than a moth. As for the patients who have

died, there are 154 out of 178, equivalent to 86.52% of the total number of deceased

patients.

The factors that contribute to the prevalence of Nosocomial Infection are

Clinical Practices and Physical Environment. For the Clinical Practices, their

responses fall on the 5th scale meaning that the clinical practices are almost 100%

performed as shown by the mean response of 4.27. For the Physical environment, the
 31

mean of 4.00 fell on the 4th scale which determines that the physical environment is

maintained at 75% efficiency.

If according to the nurses, the cleanliness of the hospital and its environment

are properly maintained, therefore these factors do not have a relationship to the

prevalence of nosocomial infection of the patients.

The chi-square test was utilized by the researchers to determine whether there

exists a significant relationship on the prevalence of nosocomial infection with the

patients’ characteristics. At 0.05 level of significance, the critical value for the

admission diagnosis is 18.307 which is less than the computed chi-square value of

44.208, giving the researchers sufficient evidence to conclude that the admission

diagnosis plays a big part as to whether the patient will be prone to nosocomial

infection or not.

The age of the patient and length of hospital stay were shown to have no

significant relationship to the prevalence of nosocomial infection among the patients

studied.

Conclusion

The researchers conclude that for the patients admitted in Ospital ng Maynila,

the main factor for the prevalence of nosocomial infection is the admitting diagnosis of

the patients, age and length of hospital stay still needs further study to conclude that
 32

they are also factors. The nurses’ response to hospital hygiene and cleanliness

showed that this also is not a determining factor for the prevalence of nosocomial

infection.

Recommendation
 33

BIBLIOGRAPHY
 34

APPENDIX A

Letter to Ospital ng Maynila

Institute of Nursing
S.Y. 2008 – 2009

August 26, 2008

Dr. Fidel Chua

Hospital Director
Ospital ng Maynila

Dear Sir:

Good day!

We are nursing students from Far Eastern University, Level IV. As part of our nursing research, we are
asking for permission to conduct our study entitled “Prevalence, Characteristics and Factors Associated
with Nosocomial Infection in Selected Hospital in Metro Manila” in your institution. Our study aims to
evaluate hospital trends in prevalence of nosocomial infection and their relationship with the extrinsic
factors and baseline characteristics of patients.

To make our research study a success, we are asking to visit your institution for two consecutive days,
12 hours each day. The questionnaires will be administered to nurses assigned in ICU, and review of
the patients’ records admitted in ICU from 2006 to 2007 will also be conducted. We rest assure you that
all information gathered will be treated with much confidentiality.

We are hoping for your kind consideration. Thank you very much and God bless!

Respectfully yours,

Ms. Anna Camille T. de Boda

Research Leader, Group4 - BSN903

Noted:

Dr. Ma. Belinda Buenafe

Research Adviser
 35

APPENDIX B

Checklist (Characteristics)

FAR EASTERN UNIVERSITY

Institute Of Nursing
S.Y 2008-2009

Checklist for characteristics of patients who are prone to have nosocomial infection:

a. Diagnosis of the Patient

Admitting Tally Patients who Tally Total

Diagnosis had other
(Affected conditions
System of the developed
Body) (Discharge
Diagnosis)
Respiratory
System
Reproductive
System
Skeletal
System
Nervous
System
Cardiovascular
system
Digestive
System
Lymphatic
System
Endocrine
System
Muscular
System
 36

b. Age of the patient

Tally Total
Neonate
(1st 28 days of
living)
Infant
(from birth to 1y/o)
Toddler
(1y/o to 3y/o)
Pre-schooler
(4y/o to 5y/o )
Schooler
(6y/o to 12y/o)
Adolescent
(12y/o to 20 y/o)
Young Adulthood
20y/o to 40y/o
Middle Adulthood
(40y/o to 64y/o)
Late Adulthood
(65y/o and above)

c. Length of Hospital Stay

Tally Total
Less than a week
Less than a month
More than a month
More than 3 months
More than 6 months
 37

APPENDIX C

Checklist (Factors)

FAR EASTERN UNIVERSITY

Institute Of Nursing
S.Y 2008-2009

Name:____________________________ Age:____ Sex: Male__ Female__

Civil Status:______ Position:___________ Length of Service:______
Highest Educational Attainment:________________________________________

Instructions: Check the frequency of performing the procedure being practiced at

your daily routine in this hospital.

Legend:
5 – 100 % performed
4 – 75 % performed
3 – 50 % performed
2 – 25 % performed
1 – 0 % performed
Clinical Practices 5 4 3 2 1
Hand washing is followed strictly or religiously.
Washing of hands before and after handling of patient.
Donning of mask and gloves if needed and necessary.
Wearing of gown while entering room of patient who are highly
contagious and removing it before leaving the room.
Wearing of smock gown when going out of the special area.
Visitors are instructed to wear mask and gloves (case to case basis).
Visitors are observed if wearing mask and gloves (case to case
basis).
Remove gloves and soiled gowns promptly after use and as possible.
Clean, disinfect and sterilize instruments immediately after use.
Applying sterile technique for any procedure.
Handle and dispose, with special precautions, waste, blood and blood
 38

products, and sharp items.

Uses a segregation technique in waste disposal.
Changing of linens once soiled.
Handle soiled linens with precautions.
Transport and store clean and sterile linens by methods that will
ensure cleanliness and sterility.
Isolation of patients with chronic diseases.
Educating the patient, as well as the relatives, with the nature of the
disease the patient had, particularly the mode of transmission.
Teaching ways of preventing such transmission.

Physical Environment 5 4 3 2 1
Open windows are maintained in the ICU.

Air-conditioning is maintained and used in the ICU.

Filters of air-conditioners are not allowed to be filled with dirt and dust.

Closing the door upon entering and leaving the ICU is applied.

Observes use of uncontaminated water system to patients.

Restricted nurse-patient ratio is applied.
More than two visitors are allowed to enter the ICU.
Hospital beds in the ICU are arranged with distance to each other.

Cleanliness of the ICU is maintained often.

The ICU is treated by hospital staffs and visitors as strict sterile area.

APPENDIX D

Chi-square Computations
Diagnosis
Infected Not Infected
5 28 33
4 10 14
0 5 5
 39

2 91 93
7 259 266
2 9 11
5 106 111
0 2 2
0 6 6
0 4 4
2 4 6
27 524 551

1.61706 31.38294011 33
0.686025 13.31397459 14
0.245009 4.754990926 5
4.557169 88.44283122 93
13.03448 252.9655172 266
0.53902 10.46098004 11
5.439201 105.5607985 111
0.098004 1.90199637 2
0.294011 5.705989111 6
0.196007 3.80399274 4
0.294011 5.705989111 6
27 524 551

7.077217 0.364665762
16.00878 0.824879717
0.245009 0.012624513
1.434907 0.073936034
2.793742 0.143952356
3.959895 0.204040411
0.035464 0.001827363
0.098004 0.005049805
0.294011 0.015149416
0.196007 0.010099611
9.898949 0.510060358

44.20827

Age
Infected Not Infected
1 3 4
3 82 85
14 255 269
 40

12 181 193
30 521 551

0.217785844 3.782214156 4
4.627949183 80.37205082 85
14.646098 254.353902 269
10.50816697 182.491833 193
30 521 551

2.809452511 0.161772697
0.572655066 0.03297438
0.028501969 0.001641188
0.211793912 0.012195427

3.83098715

Length of Hospital Stay

Infected Not Infected
20 443 463
8 78 86
0 2 2
28 523 551

23.52813067 439.4718693 463

4.370235935 81.62976407 86
0.101633394 1.898366606 2
28 523 551

0.529056312 0.028324238
3.014754207 0.161401755
0.101633394 0.005441176

3.840611082