Effect of Educational Program about Infection Control Precautions for Nurses in Pediatric Hemodialysis Units

Introduction

Hemodialysis remained the most common treatment modality with approximately 1,929,000 patients undergoing hemodialysis, for 89% of all dialysis patients In Egypt the total prevalence of patients on dialysis is 264 per million (CDC,2014). Nurses are directly responsible for patients undergoing hemodialysis and they administer care to reduce the complications (Jane & Ruth, 2012).

The patient and the dialysis apparatus should be under supervision of nurses consistently, so that different potential complications can be detected. Dialysis nurses must have knowledge and skills, because they considered important features of quality nursing care in the hemodialysis (Judith& Karen, (2013).

Hemodialysis places children at high risk for infection because of patient comorbidities and numerous human, environmental, and procedural factors. Establishing an infection prevention and control program which includes a bundle of strategies and interventions that are consistently performed will reduce the infection risk for both employees and patients (Hassona, Winkelman, El-Wahab, Ali & Abdeen, (2012).

Patients who undergo hemodialysis have a higher risk of infection, due to the following factors: Frequent use of catheters or insertion of needles to access the bloodstream, weakened immune systems, frequent hospital stays and prolonged hospital stay, and increased medical treatment costs. Infectious complications are a serious clinical problem and they are associated with high rates of morbidity and mortality (Elsayed, El-Soreety, Elawany & Nasar,2012).

Infection is reported as the second most common cause of death in hemodialysis patients (20.2%), after cardiovascular disease. by the United States National Nosocomial Infection Surveillance, the admission rate for pneumonia rose 7.3%, for bacteremia/septicemia 31%, and for cellulitis 20.3%. There were 103 admissions per 1000 patient years with the diagnosis of bacteremia/septicemia and 129 per 1000 patient years with the diagnosis of vascular access-associated infection (Judith, Guzman & Karen, 2013).

Infection prevention is essential to understand the transmission of a pathogen resulting in colonization or infection requires the following six vital links, causative agent infectious reservoir, portal of exit from the reservoir, mode of transmission, portal of entry into host and susceptible host. Each link must be present for infection or colonization to proceed and breaking any of the links can prevent the infection. The aim of isolation precautions is to interrupt these links (CDC, 2011).

Recent guidelines for the prevention of transmission of infection published in the United States and Canada are based on the principles that certain precautions are required for the care of all patients, regardless of diagnoses, and are determined by the task performed and that further measures are required for patients with certain infections, and are determined by the route of transmission of the infection (CDC. 2010b).

The nurse is considering the first line to seek to improve clinical practice in the hemodialysis units. It was important to assess the ability of nurses to create positive change in the practice. The continuous advances in technology increased the complexity of hemodialysis treatment and put patients at a higher risk for infection due to several etiologies related to chronic disease (Abdelsatir, 2013).

Healthcare associated infections (HAIs) are preventable through Implementation of best infection prevention and control practices.  This will facilitate the delivery of high quality health care for patients and a safe working environment for our healthcare workers. These national  guidelines  are  developed  to  provide  a  coordinated  approach to  the  prevention  and  management  of  HAIs (Abou El-Enein &EL Mahdy,2011).

Dialysis centers are not hospital-based and therefore they frequently do not have access to the trained infection perfectionists that provide infection control expertise in hospitals. Dialysis technicians, who provide a large amount of care in dialysis settings, generally receive limited formal training in infection control and aseptic technique (CDC, 2013).

Key Infection Prevention Practices: Perform hand hygiene frequently and change gloves, Maintain separate clean areas for supplies and medications and separate contaminated areas for used items, Practice proper handling and delivery of patient supplies and medications Perform effective cleaning and disinfection of dialysis equipment and environmental surfaces, Carefully handle medications and the patient’s vascular access to avoid contamination (Chenoweth,Hines,Hall,Saran,Kalbfleisch, et al, 2015).

 The role of the Nurse in Infection Prevention and Control Specialist is straight forward: identify, prevent, and control outbreaks of infection in health care settings and the community; however, the activities, knowledge and skills required are exceptionally advanced and complex. While the role is straight forward, the span of activities to meet the responsibilities of the role is broad, and the methods are varied (Emily& Trish, 2011(.

Significance of the study

Chronic kidney disease (CKD) is an emerging global public health problem. The disease is a component of a new epidemic of chronic conditions that replaced malnutrition and infection as leading causes of mortality during the 20th century (Ahamed & Sallam, 2018)).

 Age standardized death rates due to CKD have increased during the last 23 years. CKD has shifted from the 36th cause of death in 1990 to the 19th cause in 2013 (Association for professionals Infection center, (2014).

 A change in the global approach to CKD from the treatment of end stage renal disease (ESRD) to intensive primary and secondary prevention is therefore considered an absolute public health priority(Abd ElHafeez,Bolignano,D’Arrigo, Dounousi, Tripepi, and Zoccali, 2018).

 Infection is the most common cause of hospitalization in hemodialysis patients and has become the second major cause of death. Lack of hygiene by staff increases the chance of infection (E Bagheban, SLakdizaji & Zamanzadeh, 2018).

 The increasing risk of pediatric infections because of poor of infection control practices which causes significant children morbidity and mortality as well as increased hospitalization. pediatric patient  admitted  to hemodialysis  unit  as  the last end  stage of  renal failure,  routinely  as  two to  three  time  at a weak.  Are routinely subjected to many procedures that invades (enters) the body (Abdelsatir, 2013).

The prevalence of HCV infection among dialysis patients in developed countries ranges from 3.6 to 20%, with higher rates in developing countries.  It was estimated to be 52.1% in Egypt. There is a high prevalence of HCV among HD patient (Lotfy, Sakla& El-Naggar ,2015).

 So the  pediatric  nurses  need  theoretical  and   technical  information  about  infection control  precautions  in hemodialysis  units. There for developing and applying nursing intervention for nurses about infection control of some procedure in the   hemodialysis units, is very important and beneficial in terms of quality of care (Mabrouke ,2015).

Aim of the study

The aim of the current study was to evaluate the effect of educational program about infection control precautions for nurses in pediatric hemodialysis units; this is through the following.

1)       Assess the nurses' knowledge and practices about infection control measures in the hemodialysis units before applying educational program.

2)       Develop and apply an educational program about infection control precautions for nurses in pediatric hemodialysis units.

3)       Evaluate the effect of the educational program on the nurses' knowledge and practices about infection control precautions in pediatric hemodialysis.

Research hypothesis

Pediatric hemodialysis nurses knowledge and practices' mean scours will increase about infection control precaution after receiving an educational program than before. 

Subjects and Methods

Research design:  Pre/post quasi experimental design was used in this study. A quasi experimental design is one type of experimental design that very similar to the true experimental design except there is loss one criteria which is control, manipulation or randomization (Burns & Grove , 2012). 

Research Setting: The study was conducted in pediatric hemodialysis units at Minia University and Minia General Hospitals.

Subject:   A convenient sample of all nurses in hemodialysis units (36) nurses; from Minia University Hospital and Minia General Hospital.

Tools for Data Collection: Tool 1:- A structured interview questionnaire sheet in Arabic language was used for the studied nurses as pre/posttest. It was designed by the research investigator after extensive review of the related literature. It composed of the following parts.

• Part I- Demographic data related to the nurses' age, sex, qualification, years of experience and previous attending courses in infection control.
• Part II- Nurses, knowledge related to infection control in pediatric hemodialysis unites that involve 31 items of closed -ended questions were divided into knowledge about infection control in general, which consisted of 26 items and 5 items about infection in hemodialysis units, the total score of knowledge equal 93 degree.
• Part III:An observational checklists that was adopted from Control Diseases Center (CDC, 2014) National Center for emerging and zoonotic infectious diseases division of health quality promotion) to assess the nurses, practices about infection control procedures in hemodialysis unites  which include (hand washing(10 steps), wearing gloves(5 steps), administration intramuscular injection (7 steps), hemodialysis injectable medication administration preparation ( 7 steps), hemodialysis injectable medication administration (8steps), arteriovenous (AV) fistula graft cannulation (10 steps) and AV fistula graft decannulation (8 steps), hemodialysis catheter connection (9 steps ) and hemodialysis catheter disconnection (10 steps), hemodialysis catheter exit site care (10 steps) and dialysis station routine disinfection before(8 steps) and after receiving patient (6 steps).

The nurses' actual practices were assessed by the research investigator using the checklists by direct and indirect observation. The nurses, practices evaluated as done or not done where a score of 1 was given for done correctly, score of zero was given for not done practice these scores were converted in to a percentage score.  The nurses, practice was considered satisfactory if the percent score is 60% or more and unsatisfactory if less than 60%. It was done during actual routine work in the morning shift.

Scoring system:

For knowledge; the total  score ( 92)  was categorized into three levels unsatisfactory if  score less 60%, average for 60% -70%, and good for more than 70%. For practice; the total score (96) was categorized into two levels unsatisfactory if scoreless 60%, and satisfactory for more than 60%.    For each part, the score of the items were summed up and the total divided by number of items, giving a mean score for the area. These scores were converted into a percent score and mean and standard deviations were computed. These scores were converted into a percent score. The nurse's practice was considered satisfactory if the percent score is 60% or more and unsatisfactory if scored less than 60% (Mohamed, 2018).

Tool Validity and Reliability

Data collection tools related to nurses practices were adopted from Control Diseases Center (CDC.2014) National Center for emerging and zoonotic infectious diseases division of health quality promotion) to assess the nurses, practices about infection control procedures in hemodialysis, the tools are valid and reliable.

Pilot study

 A pilot study was carried out on (4) nurses from the selected units using the previously mentioned tools, to evaluate their applicability and clarity and to estimate time for each tool. According to results of the pilot study the necessary modification was done. Nurses involved in the pilot study were included from the main study subjects.

The program

The study work was conducted in the period from November 2016 to April 2017, the research investigator was available daily by rotation at each study setting, each group was given the freedom to choose their optimal time for receiving the program whenever they have minimal work load. Each session usually started by a summary of what has been taught   during the preceding session. Giving praise / recognition to the studied nurses were used as motivation during program implementation.

The session started by meeting the nurses throughout the morning shift, the research investigator first introduced herself to them and gave them a complete background about the study, its aim, and then the pretest format was distributed in order to collect the required data. The research investigator was available for more clarification whenever needed. Then, the content of the program was designed based on actual educational need assessment of the studied nurses. Consequently, the subject content has been sequenced through theoretical and practical sessions.

Method of teaching involved modified lecture, group discussion, pictures, and data show on my personal computer and demonstration and re-demonstration. Suitable teaching aids were used especially for the program such as real equipment and facilities.

It was designed in Arabic form of educational program by the research investigator based upon the actual need assessment of nurses. It was also supplemented with information based on review of relevant literature (nursing textbook, journals and internet resources) about infection control in pediatric hemodialysis

Data collection procedure

Administrative approval was obtained from ethics committee; Faculty of Nursing, Minia University. An official permission was obtained from the concerned hospital authorities to conduct the study. The aim, and expected out comes of the study was explained to the administrators, as well as participants nurses.

Application of the program sessions was organized according to the time available to the nurses in each hemodialysis units, the time required for the program implementation was in six months, and the nurses will be interviewed two days /week from 9am: 12am.  Nurses were divided in to nine small groups.

The program was conduct over two sessions per day to cover all information in knowledge and practices about infection control in hemodialysis. Different teaching methods were used to motivate and reinforce techniques. A copy of the program booklet was given to each participant. "Post-test" was carried out immediately and after six months after implementation of training program to assess the effect of the program on nurse's knowledge and practices about infection control in hemodialysis units.

The educational program for nurses working in hemodialysis unit included a guidance book which covered theoretical and Practical parts through the following items: Theoretical part included: definition of infection , cycle if infection ,  rout of transmission, high risk group and general precaution; Practical part: it composed of the application of procedures(hand washing, wearing gloves, administration intramuscular injection, hemodialysis injectable medication administration preparation  ,hemodialysis injectable medication administration, arterio-venous fistula graft cannulation and arterio-venous fistula graft decannulation, hemodialysis catheter connection and hemodialysis catheter disconnection, hemodialysis catheter exit site care and dialysis station routine disinfection before and after receiving patient.

Ethical consideration

The purpose of the study was explained to the nurses and oral consent was obtained from them to participate in this study. They were given an opportunity to withdraw from the study without given a reason and they were assured that anonymity and confidentiality of information was protected. Ethics, values, culture, and beliefs were respected.

Statistical analysis

Data entry was done using compatible personal computer. The statistical analysis was done using SPSS-19 Statistical Software Package. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables and mean and standard deviations for quantitative variables. The quantitative continuous data were compared by using student t-test in case of comparison between the mean scores of the study group. Qualitative studied variable were compared using chi-square test. Person correlation analysis used for assessment of the inter-relationships between the nurses knowledge and practices about infection control of procedure, statistical significance differences at value<0.05

Results

Table (1): Distribution of the Studied Nurses according To Their Demographics characteristic N=36

Table (1) shows that more than half (55.6%) of the studied nurses are between 20 to less than 30 years old, more than two thirds (72.2%) of the studied nurses were female, while less than one third (27.8%) were male. nearly one third of studied nurses (36.1%) have less than five years of experience, less than half (47.2%) of the them have diploma of secondary nursing school. Regarding to their job description the majority (83.3%) are technical nurses.  All the studied nurses (100%) had previous attendance of training courses affiliated to (ICU), (EMOH) and (WHO), more than half of them (52.8%) were from ruler area.

Table (2) Comparison of Nurses' Knowledge related to Infection Control Pre, Post and after 6 months of the educational Program (N-36)

*                     Significance (p.<0.05)

It is clear from table 2 that there are statistical significance differences between pre, post and after 6 Months of the educational program, regarding the knowledge about infection control (p.0.001).  So there are observed elevation in the knowledge level in post program than in preprogram in relation to hand washing, general precaution measures and precaution in hemodialysis. There is decrease in the knowledge level after six months of educational program.

Table (3): Comparison of Mean Scores of the Nurses' Practice Related to Universal Precaution of   Infection Control Pre/Post Educational Program n= 36

In comparison of means scores of the studied nurses' practice related to universal precaution table (3) illustrates that there are highly statistical significant differences between nurses' practice at pre and post- program (p.<0.05). Regarding to hand washing, wearing gloves, administration of intramuscular injection, hemodialysis injectable medication administration preparation and hemodialysis injectable medication administration.

Table (4): Comparison of Mean Scores of the Nurses' Practice Related to Universal Precaution of   Infection Control Pre/after six months Educational Program n= 36

In comparison of means scores of the studied nurses' practice related to universal precaution table (4) illustrates that there are highly statistical significant differences between nurses' practice at pre and after six months of program (p.<0.05). Regarding to hand washing, wearing gloves, administration of intramuscular injection, hemodialysis injectable medication administration preparation and hemodialysis injectable medication administration.

Table: (5) Comparison of Mean Scores of the Nurses' Practice Related to Hemodialysis Procedure Pre/Post Educational Program N= 36

In comparison of means scores of the studied nurses' practice related to hemodialysis procedure table (5) illustrates that there are highly statistical significant differences between nurses' practices related to hemodialysis procedure at pre and post- educational program (p.<0.05). Regarding to hemodialysis injectable medication administration, arteriovenous fistula graft cannulation, arteriovenous fistula graft decannulation, hemodialysis catheter connection, hemodialysis catheter disconnection, and hemodialysis catheter exit site care and dialysis station routine disinfection.

Table: (6) Comparison of Mean Scores of the Nurses' Practice Related to Hemodialysis Procedure Pre/after six months  of Educational Program N= 36

In comparison of means scores of the studied nurses' practice related to hemodialysis procedure table (6) illustrates that there are highly statistical significant differences between nurses' practices related to hemodialysis procedure at pre and after six months of educational program (p.<0.05). Regarding to hemodialysis injectable medication administration, arteriovenous fistula graft cannulation, arteriovenous fistula graft decannulation, hemodialysis catheter connection, hemodialysis catheter disconnection, and dialysis station routine disinfection. While no statistical significant differences regarding hemodialysis catheter exit site care (p.>0.05).

Table (7): Correlation between Demographic Characteristic and Total Knowledge among the studied nurses.

Table (7) shows that there are no statistical significance correlation between demographic characteristics and total knowledge among the studied nurses at pre, post and after 6 months of the educational program. While regarding occupation there is mild significance correlation (r. 0.36) at post education program. There are significance correlation between nurses' knowledge, residence and occupation (p. 0.001 & 0.03) respectively at pre- program.

Table (8): Correlation between Demographic Characteristic and Total Infection Control Practice among the Studied Nurses.

Table (8) shows that there is no significance correlations between demographic characteristics and infection control practice among the studied participants, while for age and occupation there  are mild correlation at pre, post and after 6 months of the education program. Meanwhile  there are significance correlation regarding to occupation (p. >0.05) at pre- program, as well as regarding to qualification of nurses there  is mild significance correlation at six months post education program.

• There are no significance correlation between demographic characteristics and hemodialysis practice among the studied nurses, while regarding to age and years of experience are mild correlation at pre education.
• There are significance correlation regarding age and years of experience (p.<0.05).
• Regarding to qualification of nurses is mild correlation (r. 0.27) at post education program