Nghiên cứu thực trạng nhiễm khuẩn bệnh viện do acinetobacter baumannii và hiệu quả áp dụng một số biện pháp dự phòng tại bệnh viện bệnh nhiệt đới trung ương, 2011 2013 tt tiếng anh

MINISTRY OF EDUCATION
AND TRAINING

DEPARTMENT OF DEFENSE

MILITARY MEDICAL UNIVERSITY

DOAN QUANG HA

RESEARCH SITUATION OF HOSPITAL NOSOCOMIAL
INFECTIONS BY ACINETOBACTER BAUMANNII AND
EFFICIENCY APPLICATION OF SOME PREVENTION
MEASURES AT THE CENTRAL HOSPITAL OF TROPICAL
DISEASES, 2011 - 2013
Majors: Preventive medicine
Code: 9720163

UMMARY OF MEDICAL DOCTORAL THESIS

HA NOI - 2019


THE DISSERTATION WAS MADE IN VIETNAM MILITARY
MEDICAL UNIVERSITY

Science instructor:
1. Prof.PhD. Nguyen Van Kinh
2. Assoc.Prof.PhD. Nguyen Vu Trung

Reviewer 1: Assoc.Prof.PhD. Le Thi Anh Thu - Cho Ray Hospital
Reviewer 2: Assoc.Prof.PhD. Tran Viet Tien - Vietnam Military

Medical Academy.
Reviewer 3: Assoc.Prof.PhD. Dinh Van Trung - 108 Military Cental
Hospital.

The dissertation is protected before the school's thesis dissertation
council at Military Medical University at: …

Can learn the dissertation at
1. National Library
2. VMMU Library
3. …………………………...


1
ABSTRACT
Hospital nosocomial Infections (HNI) are infections that patients
suffer during hospitalization are one of the main causes of high
morbidity and mortality rates for patients in hospitals around the
world. HNI is often caused by multi-antibiotic resistant bacteria.
When bacteria are resistant to an antibiotic, the treatment will face
many difficulties, prolong the time of disease, the risk of death
increases, new generation antibiotics have higher costs causing great
economic losses.
Hospital nosocomial Infections occur in the Emergency
Department at a higher rate than other departments in the hospital,
usually 2-3 times. In Vietnam, there is no research on the situation of
HNI, in the Emergency Department of infectious diseases hospitals, so
it is difficult to compare and assess the quality of implementing
preventive measures. HNI, as well as insufficient analysis of risk
factors associated with HNI, to take appropriate and timely measures

to reduce the risk of HNI.
1. Objectives of the study:
1. Describe the current situation and factors related to HNI caused
by Acinetobacter baumannii at the Emergency Department, Central
Hospital of Tropical Diseases, 2011.
2. Evaluation of results of application of some measures and
techniques to improve HNI control activities at the Central Hospital
for Tropical Diseases.
2. Summary of new main scinetific contributions of the thesis
- Assessing the status of HNI at the emergency care department,
Hospital for Tropical Diseases, discovering bacteria Acinetobacter
baumannii is the most common pathogenic bacteria.
- Find some risk factors for HNI by Acinetobacter baumannii at
emergency resuscitation department, Tropical Diseases Hospital. This
is the basis for making preventive measures.
- The study has shown that the basic interventions are the
organization of infection control network, improving the knowledge
and skills of HNI control for medical staff and closely monitoring the
hygiene compliance. Hand and surface cleaning, this is the core key to
minimize the risk of HNI.


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3. Thesis layout: The thesis consists of 137 pages, including sections
and 4 chapters:
Problem: 02 pages
Chapter 1. Document overview: 34 pages
Chapter 2. Subjects and research methods: 20 pages
Chapter 3. Research results: 42 pages
Chapter 4. Discussion: 36 pages

Conclusion: 02 pages
Recommend: 01 page
Reference 1267 documents (44 Vietnamese documents, 82 English
documents).
CHAPTER 1
OVERVIEW DOCUMENT
1.1. Current situation of HNI
Developed countries: General HNI 8.7%. HNI at ICU 30%.
Developing countries: 1 out of 10 patients admitted to hospital is
patients with HNI. At the Faculty of Active Treatment, there were
35.2% (4.4% - 88.9%) patients with HNI.
1.2. Risk of HNI caused by Acinetobacter baumannii
Factors related to the patient's condition: Chronic disease,
immunodeficiency caused by HIV / AIDS, the use of
immunosuppressive drugs or anti-mitotic drugs, ... Patients over 60
years old, or newborns.
Factors related to invasive techniques: Mechanical ventilation,
pacemaker, central vascular catheter placement or other invasive
procedures, ... are risk factors for A.baumannii infection.
Factors related to the emergence of antibiotic resistant
A.baumannii strains: Located in the department of high-risk infection
such as positive resuscitation, Neonatology, Burns, ... are at risk of
infection potential A.baumannii and are favorable conditions for the
emergence of resistant A.baumannii strains.
1.3. Solution to control HNI
Research indicates that at least 20% of all HNI can be prevented
through a number of interventions. Some basic measures in HNI
prevention: Hand hygiene, sterility, patient isolation, policy solutions,
training and supervision.
The role of hand hygiene in HNI prevention: WHO recommends

hand washing is the cheapest and most effective measure to prevent


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HNI. Many studies show that good hand hygiene reduces the
incidence of HNI. Infection rate can be reduced from 33% to 12% and
from 33% to 10% immediately after two times of intervention to
promote routine hand washing.
The role of surface sanitation in HNI prevention: Many studies
show that contaminated surface environment is an important cause of
the spread of pathogens causing hospital outbreaks. Proper sanitation
and disinfection of surface environments contribute to reducing HNI
and controlling outbreaks that may occur in medical facilities.
CHAPTER 2
STUDY SUBJECT AND METHODOLOGY
2.1. Subjects, locations, study time
2.1.1. Research subjects
* Descriptive study
- The patient was treated at the Emergency Department of the
Central Hospital of Tropical Diseases from January 1, 2011 to
December 31, 2011.
* Intervention study
- Patients who are treated at the Emergency Department from
January 1, 2012 - December 31, 2013.
- Medical staff: Doctors, nurses, infection control staff working at
the departments of the Central Hospital of Tropical Diseases.
- Organizational system, infrastructure related to HNI prevention
of Central Hospital of Tropical Diseases.
2.1.2. Study location: Central Hospital of Tropical Diseases.
2.1.3. Research time:

- The study describes: January 1, 2011 to December 31, 2011.
- Intervention study: January 1, 2012 to December 31, 2013.
2.2. Research methods
2.2.1. research design
Research design includes 2 studies:
- Research to assess the status of HNI and factors related to HNI
in the Department of Emergency Medicine.
- Intervention study: Develop, implement and evaluate the
effectiveness of a number of measures and techniques to improve
infection control activities at the Central Hospital for Tropical Diseases.
2.2.2. Sample size and sampling method
* Descriptive study


4
- Sample size: All patients with HNI in the Emergency
Department are from January 1, 2011 to December 31, 2012.
- Sampling: Choose samples without probability, successively. All
patients qualify for research into the Emergency Department.
- Criteria to select patients: The patient is in the Emergency
Department for 48 hours or more.
- Exclusion criteria: The patient had a HNI before entering the
Emergency Department; The patient showed signs of HNI within the
first 48 hours after entering the Emergency Department; The patient
died within 48 hours after entering the Emergency Department.
* Intervention study
- Patients with HNI at the Emergency Department: All patients
with HNI in the Department of Emergency Medicine from January 1,
2012 to December 31, 2013.
- Sample size of medical staff: All doctors, nurses, sanitation

workers, infection control staff working in the departments of the
Hospital.
2.3. Content, research variables and data collection methods
2.3.1. Descriptive study
2.3.1.1. Research variables
* The main variable
- Determination of HNI: Based on WHO 2002 standards. Time is
counted as a case from 48 hours after admission to the Emergency
Department to 48 hours after leaving the Emergency Department.
- Date of onset of HNI: The time of determining the case
according to WHO standards. For patients with multiple HNI, the
time of onset is calculated from the first HNI. If bacterial isolation is
performed, the time is calculated at the time of sampling.
* The secondary variable
+ Duration of treatment in the Department of Emergency
Medicine: Calculated from the time of arrival to the exit of the
Emergency Department.
+ Full treatment period: The time the patient is in the hospital.
+ Treatment costs: The entire cost of treatment for the patient
during the hospital stay.
+ Pathogen: Is an isolated agent from a patient's sample
corresponding to a specific HNI.
* Independent variable
- Epidemiological factors: Age, gender
- Factors: (1) Background disease: Select the main disease type
for this admission; (2) Comorbidities: The disease is accompanied by


5
the main disease and affects the current medical condition at many

levels.
- Intervention factor
+ Invasive intervention: Intubation, peripheral intravenous
clearance, central venous catheterization, catheterization, gastric
emptying, pleural drainage, peritoneal membrane ...
+ Drug treatment:
Antibiotic treatment: When antibiotics are used in patients with
evidence of infection.
Other drugs: Corticosteroids, H2 inhibitors, vasomotor, muscle
relaxants, sedation are calculated when appointing patients for at least
24 hours.
+ Blood transfusion: patients receive blood transfusions and blood
products.
+ Intravenous feeding: When the patient is nourished by infusing a
solution containing protein or fat for at least 24 hours.
- Time to put the device: Calculated from the time of intervention
to the detection of HNI. If the patient does not have a HNI, it will be
calculated from the time of placing the device to the end of the
intervention or when leaving the Emergency Department..
2.3.1.2. The method of data collection
* Initial assessment of patients
Patients who meet the criteria for study will be examined, perform
diagnostic tests and record information filled in the collection form.
* Monitor and evaluate patients
All patients are cared for, monitored and treated according to the
regimen appropriate to the condition and have the same conditions for
HNI control.
Interventions on patients and treatments are recorded on the date
of implementation and duration of use. Monitor and evaluate signs of
HNI of each location.

+ Urinary catheterization: Urine testing every 72 hours until
urination is withdrawn, urine urine + (+) and leukocytes (+) will be
considered suspected urinary infection.
+ Intubation: When clinically there is a fever or changes in sputum
or hearing of the lungs with a new burst will appear for chest X-ray.
+ Intravenous catheter placement: When there is a change in place
of the injection site, or the presence of an infection syndrome for
carrying out infection determination tests.
- The test identifies the case:
+ Blood culture: Conducted when the patient has the symptoms of
infection syndrome:


6
1) There are 2 of the following 4 criteria: fever> 38.50C; Rapid pulse;
Fast breathing; white blood cells increase or decrease compared to Band
neutrophil age> 10%.
2) Evidence of infection or suspicion through examination and
examination. Blood was taken from the periphery, inserted into Bactec
Peds plus / F blood culture bottle and implanted with an automatic
implant.
+ Implant urine on the third day after catheterization and repeat
when there are signs of: Urine pain, dysuria, pain on the pubic bone
when pressed, or opaque urine; If no urinary catheterization is available,
a urine culture will be performed when there are symptoms on or with
leukocytes or nitrites (+) in the total urine analysis. The inoculum is
considered to be positive when there is at least 105 cfu/mm3.
+ Transplant from the wounds and secretions of the drainage pipes to
find the pathogen. The specimen will be inoculated with bacteria on
aerobic environment and fungal environment if it is suspected to be

fungus.
Interpretation of transplanting results: If there is an isolated agent,
it will be considered as the cause of the disease. In the case of a
specimen that has two or more agents, the predominant agent is
considered to be the cause of infection. In cases where the
microbiological result is negative but suspicion can still be replanted.
- Determination of case: the patient was followed up 48 hours
after leaving the Emergency Department, if there was a HNI during
this period, it was also considered a HNI associated with the
Emergency Department. The end result of the patient is calculated
until discharge, the time in the Emergency Department, the length of
hospital stay and the patient's treatment cost are recorded..
2.3.2. Intervention study
2.3.2.1. Intervention content
Building a HNI control system, establishing an Infection Control
Council, an infection control network, developing rules and operation
mechanism of the council and a network of HNI monitoring.
Develop training programs and contents for ongoing HNI
Develop programs, content and implement training on knowledge
and skills to practice HNI control for health workers.
2.3.2.2. Research variables
HNI control system.
Reality of hand hygiene before and after intervention.


7
Reality of surface hygiene before and after intervention.
Knowledge and practice of HNI control by medical staff.
Efficacy index for HNI control capacity.
2.3.3. Data processing

Data are statistically processed by SPSS 22.0 software.
CHAPTER 3
RESEARCH RESULTS
3.1. Current situation, factors related to HNI caused by
Acinetobacter baumannii at the Emergency Department, Central
Hospital of Tropical Diseases, 2011
3.1.1. Situation and factors related to HNI caused by Acinetobacter
baumannii at the Emergency Department

Figure 3.1. The cause of HNI in the Emergency Department
The cause of HNI at the Department of Emergency is the highest
due to Acinetobacter baumannii (34.1%). Other causes of other HNI are
P.aeruginosa (18.2%), K.pneumoniae (11.4%) and Providencia spp (9.1%).
Table 3.1. Distribution of HNI by A.baumannii according to
accompanying diseases
HNI
Total
Diseases
p
Yes
No
n = 682
n = 102 (%) n = 580 (%)
Alcoholism
13(12.75) 67(11.55) 80(11.73)
> 0.05
COPD
9(8.82)
53(9.14)
62(9.09)

> 0.05
Diabetes
7(6.86)
478.10)
54(7.92)
> 0.05


8
immunodeficiency
7(6.86)
17(2.93)
24(3.52)
< 0.05
Cancer
4(3.92)
21(3.62)
25(3.67)
> 0.05
Hepatitis progresses
2(1.96)
15(2.59)
17(2.49)
> 0.05
HIV
1(0.98)
10(1.72)
11(1.61)
>0.05
TNMMN

1(0.98)
5(0.86)
6(0.88)
>0.05
renal impairment
33(32.35) 174(30.00) 207(30.35) > 0.05
Heart disease
25(24.51) 171(29.48) 196(28.74) > 0.05
The rate of HNI by A.baumannii in patients with renal impairment is
highest (32.35%), followed by heart disease (24.51%), alcoholism
(12.75%), COPD (8.82%), diabetes (6.86%), immunodeficiency (6.86%).
Table 3.2. Time of HNI by A.baumannii appearance
Time appears
Type of HNI by A.baumannii
Averaged ± SD (day)
General HNI by A.baumannii
6.25 ± 2.26
Hospital pneumonia by A.baumannii
7.12 ±1.65
Sepsis by A.baumannii
6.20 ± 2.23
Urinary
tract
infections
by
4.56 ± 1.12
A.baumannii
The onset of HNI averaged 6.25 ± 2.26 days. Urinary tract infections
have the earliest time of occurrence 4.56 ± 1.12, the longest is hospital
pneumonia is 7.12 ±1.65.

Table 3.3. Rate of HNI by A.baumannii to location (n = 102)
Type of HNI
Number of cases
Rate (%)
Hospital pneumonia
46
45.10
Sepsis
26
25.49
Bacterial infection of vascular
catheter placement
22
21.57
Urinary tract infections
6
5.88
Other infections
5
4.90
Hospital pneumonia was highest (45.10%), septicemia (25.49%),
infection of vascular catheter placement (21.57%) and urinary tract
infection (5.88%).
Table 3.4. The duration of treatment in the Emergency
Department and the hospital stay of HNI locations by
A.baumannii
Type of HNI by
HNI by A.baumannii Difference
p

9
A.baumannii
Yes
No
HNI Time for
Resuscitation
10,2 ± 3,5 4,6 ± 1,6 5,6 (3,5 – 10,7) <0,01
Time in hospital
12,8 ± 2,8 7,2 ± 2,5 5,6 (3,3 – 10,9) <0,01
Hospital pneumonia
Time for Resuscitation 11,7 ± 3,2 5,5 ± 3,0 6,2 (4,0 – 12,4) <0,01
Time in hospital
14,5 ± 3,5 8,2 ± 3,2 6,3 (4,4 – 13,0) <0,01
Septicemia
Time for Resuscitation 11,5 ± 3,6 6,8 ± 3,2 4,7 (3,1 – 11,5) <0,01
Time in hospital
15,4 ± 3,4 8,8 ± 4,2 6,6 (4,0 – 14,2) <0,01
Urinary tract
infections
Time for Resuscitation 10,7 ± 3,2 6,5 ± 3,2 4,2 (2,2 – 11,5) <0,05
Time in hospital
13,4 ± 3,2 9,3 ± 4,4 4,1 (2,5 – 11,7) <0,05
Bacterial infection of
vascular catheter
placement
Time for Resuscitation
9,6 ± 3,5 6,9 ± 3,5 2,7 (1,3 – 9,7) <0,05
Time in hospital
12,4 ± 3,5 9,4 ± 4,5 3,0 (1,0 – 11,0) <0,05

The duration of treatment in the Emergency Department and the
hospital stay of hospital-acquired cases are longer than 5.6 days.
Hospital pneumonia has a longer duration of treatment and hospital
stay than 6.2 and 6.3 days.
Table 3.5. Treatment cost of group with and without HNI by
A.baumannii (million VND)
HNI by A.baumannii
Type of HNI by
Difference
p
A.baumannii
Yes
No
HNI by A.baumannii 23.5 ± 6.5 16.5 ± 4.6 7.0 (5.1 – 22.1) <0.01
Hospital pneumonia 25.6 ± 6.7 15.7 ± 6.7 9.9 (3.5 – 23.3) <0.01
Septicemia
24.8 ± 6.2 16.5 ± 6.9 8.3 (4.8 – 21.4) <0.01
Urinary tract
22.3 ± 4.9 16.5 ± 7.2
infections
Bacterial infection of
vascular catheter
22.5 ± 5.5 16.7 ± 7.5
placement

5.8 (6.3 – 17.9)

<0.05

5.8 (7.2 –18.8)

<0.05

The total cost of treatment for cases of HNI increased by more
than 7.0 million VND. The cost of treatment increased for the case of
hospital pneumonia more than 9.9 million VND, the cost of treatment
increased for sepsis more than 8.3 million VND.


10
3.1.2. Factors related to HNI by A.baumannii in the Emergency
Department
Table 3.6. The relationship between intervention techniques and
HNI by A.baumannii
No
Yes
(n = 580)
(n = 102)
Intervention
p
n
%
n
%
Gastric catheterization
241 41.55
50
49.02 0.057
Intubation - Breathing
0.000

machine
68 11.72
54
52.94
Put the central venous
0.000
catheter
18
3.10
41
40.20
Reveal veins
0
0.00
26
25.49 0.000
Put arterial catheter
9
1.55
21
20.59 0.000
Put urine catheter
168 28.97
36
35.29 0.015
Pleural drainage
80 13.79
11
10.78 0.219
Peritoneal drainage

47
8.10
5
4.90
0.075
Invasive interventions were associated with HNI, including:
gastric catheterization, intubation-mechanical ventilation, central
venous catheterization, venous disclosure, arterial catheterization and
put arterial catheter.
Table 3.7. Compare the index of instrument use between 2 groups
with and without HNI by type of intervention

Intervention
Gastric
catheterization
Intubation
Put the central
venous catheter
venous disclosure
Put arterial catheter
Put urine catheter
Pleural drainage

Not HNI by
A.baumannii
(n = 580)
Time set Index
(n = 2843) SDDC

HNI by

A.baumannii
(n = 102)
Time set
Index
(n = 3384) SDDC

651

0.229

1.412

0.364

232

0.082

1.836

0.473

49

0.017

1.187

0.306

0
15
350
115

0.005
0.123
0.04

212
171
299
103

0.055
0.044
0.091
0.027

P
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
0.004


11

Peritoneal drainage
70
0.025
45
0.012 < 0.001
Medium
185.3
0.065
664.8
0.171 < 0.001
Index of instrument use = Time of tooling/ Treatment time

Chart 3.2. Correlation between
the time at which the device was
placed and the use index of the
instrument in the group with HNI
by A.baumannii

Chart 3.3. Correlation between
the time to place the device and
the index using the device of the
group without the HNI by
A.baumannii

The average use index in patients with HNI by A.baumannii was
higher than for patients without HNI (p <0.001). The index of
instrument use is used to assess the exogenous risk and the patient's
risk of endogenous infection. When patients have a high index of
instrument use, the risk of HNI is higher.
There is a correlation between the time to put the tool and the

index to use the tool. The length of time to place the device increases
the index of instrument use and increases the risk of HNI. Time and
index of instrument use of endotracheal procedure, central venous
catheterization and catheterization were markedly different between
the group with HNI and no HNI by A.baumannii.


12

Chart 3.4. Correlation between the number of HNI by
A.baumannii and the number of days treated at the Emergency
Department
The number of HNI increased gradually in patients treated after 5
days. The number of HNI is highest in patients with 10-15 days of
treatment. The number of HNI decreased gradually in the treatment
group after 15 days. Thus, the group of patients hospitalized for 10-15
days has the highest risk of HNI by A.baumannii.
Table 3.8. Relationship between some risk factors with hospital
pneumonia by A.baumannii
Hospital pneumonia
by A.baumannii
Research
OR
Total
p
information
(95% CI)
Yes
No
(n = 46) (n = 636)

203
3.0
Intubation
30(14.78) 173 (85.22)
0.001
(29.8)
(2.5 –3.6)
Intubation > 5 181
3.9
46(25.41) 135 (74.59)
0.001
day
(26.5)
(3.1 – 5.1)
H2 receptor
216
1.3
29(13.43) 187(86.57)
0.215
inhibition
(31.7)
(0.9 – 1.9)
Gastric
305
25 (8.20) 280 (91.80)
1.2
0.386


13

catheterizatio
n
Sedative
Muscle
relaxants

(44.7)
198
(29.0)
107
(15.7)

(0.8 – 1.7)
1.3
(0.9 – 1.9)
1.4
26(24.30) 81 (75.70)
(0.8 – 2.2)
25(12.63) 173 (87.37)

0.244
0.234

For multivariate analysis, the risk factors for hospital pneumonia
were intubation with OR: 3.0 (2.5 - 3.6), intubation time with OR: 3.9
(3.1 - 5.1). Using sedative, H2 receptor inhibition, muscle relaxation
and gastric catheterization are not risk factors in multivariate analysis
(p> 0.05).

14
Table 3.9. Multivariate analysis of risk factors for sepsis by
A.baumannii
Sepsis by
A.baumannii
Research
OR
Total
p
information
(95% CI)
Yes
No
n = 26 (%) n = 625 (%)
Central venous
2.3
133 (19.5) 25 (18.80) 108 (81.20)
0.001
catheter
(1.9 – 2.8)
Central venous
2.3
132 (19.4) 25 (18.94) 107(81.06)
0.001
catheter > 3 day
(1.9 – 2.8)
Number of
1.8
intravenous
70 (10.3) 12 (17.14) 58 (82.86)

0.104
(0.9 – 3.5)
lines ≥ 3
Feeding by
75 (11.0) 25 (33.33) 50 (66.67)
0.001
intravenous
Blood
1.0
155 (22.7) 17 (10.97) 138 (89.03)
1.00
transfusion
(0.6 – 1.8)
By multivariate analysis showed that the risk factors for sepsis
were: Place the central venous catheter with OR: 2,3 (1,9 - 2,8); The
venous catheter is centered over 3 days with OR: 2,3 (1,9 - 2,8).
Table 3.10. Single analysis of risk factors for urinary tract infections
by A.baumannii
Urinary tract infections
by A.baumannii
Research
OR
p
information
(95% CI)
Yes
No
n = 6 (%) n = 676 (%)
1.08
Put urine catheter

6 (2.83) 206 (97.17)
0.001
(1.04 – 1.12)
Put urine catheter > 3
1.08
6 (2.83) 206 (97.17)
0.001
day
(1.04 – 1.12)
Univariate analysis showed that the risk factors of urinary tract
infection were: Set catheterization with OR: 1.08 (1.04 - 1.12) and
time to urinate> 3 days with OR: 1, 08 (1.04 - 1.12).


15
Table 3.11. Multivariate analysis of infectious risk factors where
vascular catheters are placed by A.baumannii
Bacterial infection
where blood vessels
are placed by
Research
OR
p
A.baumannii
information
(95% CI)
Yes
No
n = 22 (%) n = 660 (%)
Place the central

7.2
22 (16.54) 111 (83.46)
0.001
venous catheter
(4.2 – 12.4)
Intravenous infusion
0.9
21 (30.0) 49 (70.0)
0.692
≥2
(0.5 – 1.5)
Use vasomotor
0.8
13 (7.8) 153 (92.17)
0.540
medicine
(0.4 – 1.5)
Risk factors for vascular infection are: Place the central venous
catheter with OR: 7.2 (4.2 - 12.4). The number of intravenous lines
and the use of vasomotor drugs is not a risk factor for infection due to
vasculature.
3.2. Results of applying some measures and techniques to improve
HNI control activities at the Central Hospital for Tropical Diseases
3.2.1. Results of building HNI control model
Intervention to establish an infection control system consists of
three levels: the control committee for infection of infection and
infection control network in each department.
Infection Control Council
The council consists of the CHNIrman, 01 Vice CHNIrman, 01
permanent member and members. CHNIrman of the Infection Control

Council is the Deputy Director of the Hospital. Vice CHNIrman of the
Council is Head of infection control department. Commissioner of the
Infection Control Council is representative of clinical and subclinical
departments.
The task of the Infection Control Council
+ Proposing and advising the Director of the hospital to develop,
amend and supplement professional technical regulations on infection
control in accordance with the actual hospital.
+ Advise the Director about the plan to develop infection control
related to medical care; Consultation on repair, design and


16
construction of new medical facilities in hospitals in accordance with
the principles of infection control.
+ Organize training, scientific research on infection control.
Infection control network
Infection control network includes hospital level, department
level.
Infection control network organization: Each department at least
one doctor with a nurse participating in the infection control network
operates under the specialized guidance of the infection control
department. Members are often trained to update their expertise on
infection control.
The mission of infection control network
+ Coordinate to organize the implementation of infection control
in hospitals.
+ Check, supervise and urge hospital staff to implement
professional regulations and procedures related to infection control.
3.2.2. Evaluate the effectiveness of improving HNI in the intervening

aspects
* Effective for hand hygiene
Table 3.12. Effective intervention for hand hygiene conditions
Maximum
PreScore after
interventio
Evaluation criteria
point
∆
intervention
n points
(WHO)
The infrastructure

100

35

95

60

Training

100

35

100

65

Compliance monitoring

100

50

92,5

42,5

The media

100

65

85

20

Safe environment

100

55

80

25

∆: Points difference before - after intervention.
Assessment of infrastructure for hand hygiene: Increase 60 points
after intervention. The hospital has a separate budget for hand
hygiene, plans to improve the infrastructure for hand hygiene, fully
equipped with hand sanitizing solutions in departments and rooms.
Training on hand hygiene: Increased by 65 points after
intervention. The hospital has built a training system and has teaching


17
staff on hand hygiene; Strengthen training, hand hygiene training and
regulations on hand hygiene training for medical staff.
Monitoring of hand hygiene compliance: Increasing 42.5 points
after intervention. The hospital has strengthened most of the activities
of supervising hand hygiene in departments and rooms and informed
hand hygiene status to all employees in the hospital..
Hand hygiene communication activities: Increase 20 points
compared to before intervention. The hospital has strengthened
posters to guide the use of hand sanitizing solutions at departments
and rooms.
Degree of improvement of safe environment on hand hygiene:
Increased by 35 points compared to before intervention. The hospital
has established an official program for patients to participate in hand
hygiene programs and has organized monitoring and evaluation of
personal responsibility in implementing hand hygiene at departments.
Table 3.13. Knowledge of research subjects, on hand hygiene, before after intervention
Before
After

intervention
intervention
Efficiency
Level
p
(n = 259)
(n = 259)
index (%)
n
%
n
%
Achieved
82
31,7
223
86,1
< 0,001
171,6
Not
36
13,9
achieved
177
68,3
Total
259
100
259
100

Overall assessment of hand hygiene knowledge of the subjects
showed that the proportion of subjects with knowledge gained after
the intervention increased from 31.7% to 86.1%. Performance index
171.6%. The difference is statistically significant with p <0.001.
Table 3.14. The rate of compliance with hand hygiene by time of day,
before - after intervention
Time
Before intervention
After intervention
PV


18
Opportunitie Number of Rate Opportunities Number of Rate
s need hand opportunitie %
need hand opportunities %
hygiene
s with hand
hygiene
with hand
hygiene
hygiene

3.072
1.831 59,6
3.083
2.820
91,5 53,5
2.654
1.479 55,7

2.769
2.511
90,7 62,8
5726
3310 57,81
5852
5331
91,10 57,59
The table above shows that the health workers' hand hygiene
compliance rate over time is similar. However, the number of
opportunities needed to clean the hands of the morning is much more
than in the afternoon. After the intervention, the rate of hand hygiene
compliance of health workers increased markedly, the preventive
value reached 53.5% and 62.8%.
* Effective for surface disinfection at hospital
Table 3.15. Effective interventions for hygienic surface disinfection
conditions

Shining

Pm
Total

Evaluation criteria

Rating
score

Before
intervention

After
intervention

∆

Means and chemicals for
hygiene and surface
100
55
100
45
disinfection
Training and guidance on
surface disinfection at
100
50
90
40
hospitals
Frequency of disinfection
by surface position,
100
55
85
30
according to the time of
day at the hospital
After the intervention, the hospital has facilities, chemicals for
disinfection hygiene and personal protective equipment. Score

increased 45 points. The hospital has its own budget and has a plan to
improve adequate sanitation and disinfection.
Training and guidance on hygiene and surface disinfection at
hospitals increased by 40 points after intervention. The hospital has
full training materials and regular training and guidance for medical
staff. However, the training plan only reached 30/40 points.
The frequency of cleaning and disinfecting surfaces at the hospital
increased by 30 points after the intervention. The hospital has planned
and implemented strict monitoring of surface disinfection and
evaluation of 85/100 points.
Evaluating the effectiveness in compliance with hygiene practices
of surface disinfection after intervention increased by 23 points.
Table 3.16. Evaluate knowledge of research subjects


19
on hygiene and surface disinfection, before-after intervention
Level

After
intervention

Before
intervention
(n = 259)

Efficiency

p
(n = 259)

index (%)
n
%
n
%
Achieved
130
50,2
224
86,5
<0,001
Not achieved
129
49,8
35
13,5
72,3
Total
259
100
259
100
The percentage of research subjects who gained knowledge about
surface hygiene and sanitation increased from 50.2% to 86.5% after
intervention. Efficiency index after intervention reached 72.3%. The
difference is statistically significant with p <0.001.
* Effect of minimizing HNI
Table 3.17. Effect of minimizing infection
Type of HNI
Hospital pneumonia

Sepsis
Bacterial infection of
vascular catheter placement
Urinary tract infections
Other infections
Number of HNI patients

Before
intervention

After
intervention

(n = 682)
n
%

(n = 2480)
n
%

PV

135
75

19,8
11,0

223

136

9,4
5,5

52,5
50,1

63

9,2

124

5,0

45,9

16
14
299

2,3
2,1
43,8

32
30
555

1,3
1,2
22,4

45,0
41,1
49,0

The reserve value of HNI is 49.0%. In particular, the highest
preventive value of hospital pneumonia was 52.5%, the lowest was
the other measures of infection prevention (41.1%).
CHAPTER 4
DISCUSSION
4.1. Current situation and factors related to HNI caused by
Acinetobacter baumannii at the Emergency Department, Central
Hospital of Tropical Diseases
4.1.1. Situation of HNI caused by Acinetobacter baumannii at the
Emergency Department, Central Hospital of Tropical Diseases


20
The rate of HNI in the Department of Emergency Medicine,
Central Hospital of Tropical Diseases is relatively high (43.8%),
34,1% HNI by A. baumannii. The consequences of HNI by A.
baumannii are quite severe, increasing treatment time 5.6 days and
increasing treatment costs by 7.0 million VND.
Compared with other research results, the rate of HNI in the
Department of Emergency Medicine, Central Hospital of Tropical
Diseases is higher than that of other domestic research results. The
study of Huynh Van Hue at the Department of Positive and AntiPoisoning at Sa Dec General Hospital in 2012 showed that the rate of

HNI was 14.48%. Ha Manh Tuan's study at the Emergency
Department, Children's Hospital in 2006 was 24.4%. Like some other
research results, the incidence of HNI in the Emergency Department
is higher than that of other departments.
Regarding the position of HNI, the rate of pneumonia accounts for
the highest rate (45.10%), followed by septicemia (25.49%), infection
of blood vessels (21.57%) and the lowest is urinary tract infections
(5.88%). This result is consistent with the research results of Huynh
Van Hue (hospital pneumonia 49.33%) and Ha Manh Tuan (hospital
pneumonia accounts for 49.3%).
The cause of the rate of HNI in the Department of Emergency
Medicine, Central Hospital of Tropical Diseases is higher than that of
other domestic research results, possibly due to one of the following
reasons: High patient density At the Emergency Department of the
Central Hospital of Tropical Diseases currently 5m2 / 1 patient,
compared with the standard of infection of 7.4 - 9m2 / patient; The
ratio of nursing to patients at the time of the survey was 1/4 lower
than the standard of 1/1 of the Emergency Department. The lack of
nursing makes compliance with HNI control measures inadequate.
From the above analysis to reduce the risk of HNI in the Emergency
Department in addition to implementing routine HNI prevention
measures, attention should be paid to: Reducing patient density and
strengthening direct care nursing patients.


21
4.1.2. Factors related to HNI by Acinetobacter baumannii at the
Emergency Department, Central Hospital of Tropical Diseases
Results of analysis of each type of HNI by A. baumannii: The risk
factor for hospital pneumonia is intubation, prolonged intubation

time> 5 days; Risk factors for hospital sepsis are central venous
catheterization, central venous catheterization for more than 3 days
and intravenous manifestations; Risk factors for urinary tract infection
are urinary catheterization and time for catheterization> 3 days.
The research results of a number of domestic and foreign authors
have shared the same view. Research by Nguyen Viet Hung et al.
(2012), there is an association between HNI and catheterization (OR =
3.5, p <0.01), mechanical ventilation (OR = 2.9). , p <0.05). This result
is also consistent with results from HNI monitoring statistics at US
hospitals: 83% of lung infections related to artificial ventilation, 97%
of urinary infections occur in patients. Catheterization and 87% of
septicemia occur in patients with central venous catheters. This result
shows that it is necessary to focus a lot of resources on the control of
regional infections Emergency care of the hospital, especially the need
to strengthen the sterile practice in caring for patients with roadrelated procedures breathing, blood vessels and urinary tract.


22
4.2. Effective intervention measures
In this intervention, we propose and test some of the following
interventions:
Building HNI control management system: Establishing HNI
control network, developing rules and operation mechanism of the
Council and HNI control network.
Develop programs, contents, documents and organize HNI control
training for nursing such as HNI monitoring procedures and epidemic
management; Preventive isolation measures; Hand washing process;
Instructions for using protective equipment; Process of cleaning,
disinfecting and sterilizing tools; Practical procedure for prevention of
hospital pneumonia; Procedure for practicing hospital sepsis

prevention; Procedures for prevention of primary HNI; Procedures for
prevention of skin and soft tissue infections; Regulating architecture,
organization and environmental standards in clinical departments;
Hospital hygiene process; Hospital solid waste management process
The study results showed that, both before and after the
intervention, the health workers adhere to good hand hygiene at the
time before touching the patient. This can be said that health workers
are conscious of protecting patients from the risks of HNI. After the
intervention, hand hygiene rate increased in all target groups. The
preventive value is highest in the nurse group, reaching 86.3%,
followed by the nursing group 53.4% and the lowest being the doctor
49.7%.
This result shows that the implementation of the training program
at the Central Hospital of Tropical Diseases is effective. The program
contributes to improving the infection control capacity of medical
staff. For other infectious disease hospitals, this training program can
be used to strengthen HNI control capabilities for medical staff.


23
CONCLUSION
1. Situation, factors related to HNI caused by A.baumannii at the
Emergency Department, Central Hospital of Tropical Diseases, 2011
1.1. Situation and factors related to HNI caused by A.baumannii at
the Emergency Department
The rate of HNI in the Emergency Department is 43.8%. In
particular, infection caused by A.baumannii is the highest (34.1%).
Hospital pneumonia by A.baumannii accounted for the highest
proportion (45.10%), septicemia (25.49%), infection of vascular
catheter placement (21.57%), urinary tract infection (5.88% ). The

average onset of HNI was 6.25 ± 2.26 days.
Consequences of HNI by A.baumannii: The duration of treatment
and the length of hospital stay in the Emergency Department of the
HNI cases are longer than 5.6 days. Treatment costs increased by
more than 7.0 million VND.
1.2. Factors related to HNI by A.baumannii in the Emergency
Department
Invasive intervention is associated with HNI by A.baumannii,
including: Gastric catheterization, intubation - mechanical ventilation,
central venous catheterization, venous disclosure, angioplasty and
catheter placement vein. There is a correlation between the duration of
treatment with the risk of HNI by A.baumannii. The group of patients
hospitalized for 10-15 days has the highest risk of HNI by
A.baumannii.
Risk factors for hospital pneumonia by A.baumannii: Intubation,
endotracheal time >5 days; Risk factors for hospital sepsis are central
venous catheterization, central venous circulation > 3 days, revealing
veins; Risk factors for urinary tract infection are urinary
catheterization, time of catheterization > 3 days.
2. Results of applying some measures and techniques to improve
HNI control activities at the Central Hospital for Tropical Diseases