SYNOPSIS
ST.JOHN’S COLLEGE OF NURSING
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGLORE.
KARNATAKA, INDIA.
ANNEXURE - II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / NAME OF CANDIDATE AND ADDRESS / MS. NISHANTHINI RST. JOHN’S COLLEGE OF NURSING, SARJAPUR ROAD, BANGALORE- 34.
2. / NAME OF THE INSTITUTION / ST. JOHN’S COLLEGE OF NURSING, BANGALORE.
3. / COURSE OF STUDY, SUBJECT / MSc. (NURSING),
MEDICAL SURGICAL NURSING
4. / DATE OF ADMISSION TO COURSE / MAY 2ND 2011
5. / TITLE OF THE TOPIC / STERILE VERSUS CLEAN CATHETER CARE TECHNIQUE FOR PATIENTS WITH INDWELLING CATHETERS IN RELATION TO COST EFFECTIVENESS.
6. BRIEF RESUME OF INTENDED WORK
6.1. NEED FOR THE STUDY
Health care associated infection is also referred to as nosocomial infection. It is defined as “an infection occurring in a patient during the process of care in a hospital or other health care facility which was not present or incubating at the time of admission”.1 Health care associated infection occurs worldwide and affects both developed and developing countries. It is estimated that in developed countries 5-10% of patients admitted to acute care hospitals acquire an infection; the attack rate for developing countries can exceed 25% certain factors increase the risk of infection among hospitalised patients: underlying disease and decreased immunity, the increasing use of invasive diagnostic and therapeutic techniques, the transmission of drug resistant pathogens, and poor infection control measures. However, the available studies indicate that health care associated infections are likely to be more frequent and serious in developing countries where the lack of resources and basic facilities for infection control combine with patients being more susceptible to infection because of malnutrition, multiple co-morbidities, immunosuppression, and poor personal hygiene1.
Four types of infections account for more than 80% of hospital acquired infection and are generally linked to specific and well known risk factors. They are urinary tract infection, surgical site infection, lung infection and blood infections. Out of this catheter associated urinary tract infections are the most frequent, accounting for about 35%of health care associated infection1.
Long term catheterised patients are at greater risk for catheter associated urinary tract infections 2. Risk of infections in hospitals relates to the quality of care given by the nurses. Here the catheter associated urinary tract infections relates the quality of catheterization and catheter care. About 80-90% of hospital acquired urinary tract infections originate from urinary catheters. Urinary catheter should be used only if necessary and should be removed as soon as practicable. Early removal of urinary catheters can reduce urinary tract infections up to 40%. About 15% of catheter associated urinary tract infection has been linked to improper hand washing and poor aseptic techniques in cleaning the urethral meatus area and inserting and maintaining the urinary catheters 3.
Despite this controversy, there are acceptable reasons for the use of indwelling catheters. But nosocomial catheter associated urinary tract infections continues to be a common and serious problem in health care setting. The prevalence of urinary tract infection in patients with long term (for >28 days) indwelling catheter is about 100 percent 4. According to Hospital infection control committee of St. Johns Medical College Hospital(SJMCH), Bangalore, the incidence of catheter associated urinary tract infections is 7 percent (August 2011). Catheter care being a procedure under nursing domain some strategies related to the technique for catheter care need to be devised, to reduce such type of nosocomial infection. In SJMCH general wards follow sterile technique for catheter and they provide twice daily, where as in ICU catheter care in given with soap and water (clean technique).
Women are more susceptible to urinary tract infection due to the close proximity of the orifices of the intestinal tract and the urinary tract and they have extremely short urethral conduit 5.
As the investigator worked in the intensive care unit, where patients had long term urinary catheter requiring catheter care and that definitely is the responsibility of the nurses to take all measures to prevent urinary tract infection. Hence, owing to the detailed background mentioned above, it is in the interest of the investigator to compare the effect of sterile versus clean catheter care technique for preventing catheter associated urinary tract infection.
6.2. REVIEW OF LITERATURE
In this study the review of literature is classified into 2 parts.
· Studies related to catheter care and catheterisation.
· Studies related to catheter associated urinary tract infection.
STUDIES RELATED TO CATHETER CARE AND CATHETERISATION
A comparative study was conducted in Nehru hospital, PIGMER, Chandigarh, on the effectiveness of sterile versus clean technique for indwelling catheter care. A total of 53 subjects were studied, 27 subjects were in group I (sterile technique) and 26 were included in group II (clean technique). Data analysis was done using independent t test and chi square tests. The findings of the study are both the techniques were effective in preventing catheter associated bacteriuria, as the difference in both groups was statistically insignificant. It was concluded that both the techniques are equally effective if carried out correctly 6.
A prospective study on sterile versus non sterile urethral catheterisation was conducted at Kent, London in the year 1995. 156 patients who underwent preoperative urethral catheterisation were randomly allocated to sterile (74) or clean/ non sterile (82) technique groups. Data analysis was done using chi square test. The findings revealed that there was no statistical difference between the two groups with respect to the incidence of urinary tract infection. However, there was considerable cost difference between the two groups, the sterile method being over twice as expensive as the clean method7.
In New Delhi a descriptive study was conducted in the year 2010 to determine the frequency of unsterile and non indicated catheterisation in medical wards and the reasons for doing it. 63 out of 125 patients were catheterised by unsterile method. Data analysis was done using chi-square test. The results showed that females are at risk for catheterisation in unsterile method. 52.8% developed Bacterial colonization on foley’s catheter and 22.4% were diagnosed to have catheter associated urinary tract infection 8.
STUDIES RELATED TO CATHETER ASSOCIATED URINARY TRACT INFECTION
A descriptive study was conducted in New Delhi in November 2005 to recognize the urinary tract infection in spinal cord injury patients. 73 patients were interviewed. Data was analysed using descriptive statistics. The results showed that total of 54 (74%) patients reported pain in the supra pubic region and 50 (68.4%) of them had leakage of urine after clean intermittent catheterization 9.
A retrospective cohort study conducted in 2008 to describe the frequency and duration of perioperative catheter use in Denver. The sample size was 35,904. Data analysis was done using ANOVA and chi square test. The findings showed that patients who had indwelling catheters for more than 2 days are twice as likely to develop urinary tract infections. This in turn will increase the nosocomial infection rates 10.
A prospective study was conducted in the year 1997 in university college of medical sciences, New Delhi, India to assess the prevalence of urinary tract infection in patients with chronic renal failure (CRF) patients. The results indicated that 12% out of 100 samples had urinary tract infections. Asymptomatic urinary tract infection was also common in CRF patients. The incidence of UTI increased with severity of CRF. Gram negative organisms were isolated most commonly (80%) 11.
A case control study conducted in Saudi Arabia in the year 2003 to estimate the overall nosocomial and urinary tract infections. 206 patients with UTI were included as cases and 618 patients without UTI was considered control group. The statistical analysis was done using SPSS. This study showed that the mean incidence rate of UTI 0.85 per 100 discharged patients. Noscomial infection was significantly associated with hospital stay for more than 3 weeks. Urinary tract infection represents approximately 31.7%of overall nosocomial infection throughout the study period 12.
A descriptive study conducted in Mahidol University, Bangkok, in the year 2003 to determine the incidence, risk factors, clinical outcomes and antibiotic cost of catheter associated urinary tract infection. There were 101 subjects from neurology and neurosurgery ward. The results revealed that incidence of CAUTI was 73.3% and high incidence was found in patients with indwelling catheter for more than 2 weeks. The incidence in female patients was 43.6% and in males it was 29.7%. The cost of patients with CAUTI was 6 times higher13.
6.3. PROBLEM STATEMENT
A comparative study to assess the effect of sterile versus clean catheter care technique in relation to urinary tract infection and cost effectiveness among patients with indwelling catheter in a selected hospital, Bangalore.
6.4. OBJECTIVES
- To compare the incidence of urinary tract infection in sterile technique and in clean catheter care technique.
- To assess the cost effectiveness of sterile catheter care technique and clean catheter technique.
- To determine the association of urinary tract infection with selected baseline variable.
6.5. OPERATIONAL DEFINITION
· Sterile catheter care technique
In this study, sterile catheter care technique refers to use of normal saline, povidine iodine solution and sterile articles for cleaning the catheter and insertion site.
· Clean catheter care technique
In this study, clean catheter care refers to use of soap, warm water and clean cotton and clean articles for cleaning the catheter and insertion site.
· Incidence
Incidence refers to the number of new cases occurring in a defined population during a specified period of time 14.
· Urinary tract infection
In this study, this refers to an infection that happens anywhere along the urinary tract with symptoms of abnormal urine colour(cloudy), hematuria, foul smell, urge to urinate, pain in suprapubic region, and other associated symptoms like fever, fatigue and flank pain. This is will be measured by urine cultures done on ‘0’ day and 4th day.
· Catheter associated urinary tract infection (CAUTI)
In this study it refers to patient who had an indwelling urinary catheter at the time of or within 48 hours before the onset of urinary tract infection.
· Baseline variables
In this study, baseline variables are age, catheter fastening practice, drainage system, frequency of catheter care and antibiotics administered.
· Effect
This refers to the ability of sterile or clean technique to prevent urinary tract infection.
· Cost effectiveness
This refers to advantage in rupees of one sterile technique over clean technique in relation to time and materials.
· Materials
In this study it refers all the articles used for catheter care procedure viz., povidine iodine solution, normal saline, sterile tray containing an artery forcep, thumb forcep, and a small bowl, sterile cotton, clean tray, clean cotton, soap and warm water.
· Time
In this study time refers to duration taken for a single catheter care procedure as measured by the time in minutes from the start (pre procedure) till the completion of the procedure (after care). Each catheter care procedure will be observed during the study for the duration of 5 days. The mean time was calculated based on the time spend by the staff on each procedure. This will be converted to rupees.
· Cost
In this study cost refers to sum cost for materials and time spend by the nurse in rupees.
6.6. ASSUMPTION
The urinary tract infection can be prevented by using clean catheter care technique.
6.7. DELIMITATIONS
· Study can be generalised only to those patients with indwelling catheter in the selected wards of the hospital.
· The findings are applicable only to female patients.
· Single blind study where implementers will be blind and not the primary investigator.
6.8. PROJECTED OUTCOME
Findings of the study will help to determine which practice i.e.) sterile or clean catheter care technique is more effective practice in reducing infection, cost and time.
6.9. HYPOTHESIS
· There is a significant difference in the incidence of urinary tract infection with sterile and clean catheter care technique.
· There is significant difference in the cost effectiveness of sterile versus clean technique with respect to cost of materials and time.
7. MATERIAL AND METHOD
7.1. SOURCE OF DATA
7.1.1 RESEARCH DESIGN
A single blind experimental design will be used in order to obtain the research objectives.
7.1.2. SETTING
The study will be conducted in the various wards of St. Johns medical college hospital, Bangalore which is a 1250 bedded tertiary care teaching hospital.
The study will be conducted in the intensive care unit, female medicine ward, urology ward, neurology ward, medical and surgical ITU of SJMCH, Bangalore. The ICU is 30 bedded with 27 ventilators and patients with medical and surgical emergencies are admitted. At any given point of time 8 – 12 female patients will require catheter care. In the general wards 10 – 15 female patients will require catheter care.
7.1.3. POPULATION
The population for this study will be females who are with indwelling catheter from intensive care unit, female medicine, urology ward, neurology ward, medical and surgical ITU of SJMCH, Bangalore.
7.2. METHOD OF DATA COLLECTION
7.2.1. SAMPLING PROCEDURE
Purposive sampling method is used to select the eligible female patients with indwelling catheter between the age of 18 years and above and not having any urinary tract infection. There are 2 groups, one group (other wards) will receive catheter care using sterile technique and the other group (ICU) will receive catheter care using clean technique which is followed as a routine care in the hospital.
7.2.2. SAMPLE SIZE
The samples are female patients with indwelling catheter. All the catheter care procedures will be observed for the study. The sample will have 30 new patients with indwelling catheter for sterile technique and 30 new patients for clean technique.
7.2.3. INCLUSION CRITERIA FOR SAMPLING
All female patients with indwelling catheter who are admitted in ICU, female medicine ward, urology ward, neurology ward, medical and surgical ITU of SJMCH, Bangalore.
· Age 18 years and above.
· Indwelling catheters should be in situ for a minimum of 5 days and require catheter care twice daily.
· Patients and care givers who are willing to participate in the study.
7.2.4. EXCLUSION CRITERIA FOR SAMPLING