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Hospital Topics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vhos20
Nosocomial Infections: In the Elderly a
Antonina M. Brem PH.D. & Emily M. Torok M.S.
a
a
St. John Hospital , 22101 Moross Road, Detroit, Michigan, 48236, USA Published online: 13 Jul 2010.
To cite this article: Antonina M. Brem PH.D. & Emily M. Torok M.S. (1979) Nosocomial Infections: In the Elderly, Hospital Topics, 57:6, 10-40, DOI: 10.1080/00185868.1979.9954725 To link to this article: http://dx.doi.org/10.1080/00185868.1979.9954725
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
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NOSOCOMIAL INFECTIONS BY ANlONlNA M. BREM, PMD. EM11 Y M. TOROK, M.S. St. hhn Hospital 22101 Moross Road Detroit, Michigan 48236
Antonina M. h e m , Ph.D. earned her BS and MS In Biology at Wayne State Untverdty and her Ph.D. In Mlcroblology at the University of Michlgan. for ten years she has served a t the St. John Hospltal, Detroit, Michigan as the Microbiologist, Epidemiologist, and Infectlon Control Coordinator. She i s also consultant to Metropolitan Hospitals in Detrolt and Westland, and Is on the faculty of Wayne State Unlversiy teaching cllnlcal mlcrobloiogy to medical students.
10
osocomial infections are tion because of changes in the infections that occur in skin, respiratory, and immunoinstitutional m e e t i n g s logical defense mechanisms. (hospitals, extended care facil- Elderly patients are frequently ities, convalescent centers, nurs- debilitated and often require ing homes) diagnosed and con- utilization of supportive/therafirmed by clinical / laboratory peutic procedures which inevidence. The term nosocomical crease their risk of infection. is preferable to hospital acquired The data presented was comso that a culpability i s not piled from a 600 bed middle erroneously implied. class community teaching hosDescriptive studies of noso- pital. The overall nosocomial comial infections exclude infec- infection rate for this hospital tions that are incubating at the has averaged 3.5% since 1969. time of admission to the institu- The incidence of nosocomial intion-those that become clini- fection for a 12-month period cally apparent within 48-72 commencing in January 1977 hours after admission. There are and ending in December of additional nosocomial infections 1977 has been examined. The that are not apparent until after intent was to compare the discharage (surgical wound in- geriatric patient (65 years and fections) and are not included over) with the younger patient in standard nosocomial infec- with regard to number and type tion statistics. of nosocomial infection. An on-going study since During 1977 there were 24,1969 by the Center for Disease 625 admissions to this hospital; Control (CDC) indicates that 4,541 ,patients were 65 years or approximately 5% of patients older. The length of stay of all admitted to institutions develop patients was 8.0 days; patients an infection during their stay. over 65 years of age were hosOur hosDital has participated pitalized and average of 13.1 in the CDC National Nosoco- days. A total of 898 (3.6%) mial study since its commence- patients acquired nosocomial ment in 1969 utilizing their infections; nosocomial infecstrict criteria for determining tions in patients under 65 years of age was 2.1%; the geriatric our nosocomial infections.' Nosocomial infections are a nosocomial infection rate was serious problem for all patients; 10%. however, the situation i s cornTable 1 shows, by number pounded with increasing age. and percentage, the type of With advancing age there is a nosocornial infections according diminution in the patient's to month, in patients over 65 ability to resist microbial infecContinued on page 41
N
HOSPITAL TOPICS
Nosocomial Infections in the Elderly, Continued from page 10 TABLE ONE Monthly Distributions of Nosocomial Infections of Hospitalized Patients 4,541 Patients > 65 Years and Older
2,087 Patients < 65 Years
Jan. Feb.
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March April May
June July Aug. Sept.
Oct.
Nov. Dec.
UTI*
URI**
Wound
Mix***
Total
UTI
URI
Wound
Misc
Total
0.075 15 0.070 14 0.050 10 0.050 10 0.050 10 0.030 6 0.055 11 0.030 6 0.075 15 0.065 13 0.065 13 0.055 11
0.060
0.015 3 0.085 17 0.060 12 0.055 11 0.040 8 0.025 5 0.050 10 0.040 8 0.075 15 0.015 3 0.065 13 0.040 8
0.040 8 0.015 3 0.025 5 0.030 6 0.020 4 0.015 3 0.015 3 0.025 5 0.050 10 0.030 6 0.050 10 0.015 3
0.189 38 0.194 39 0.204 39 0.204 41 0.174 35 0.100 20 0.144 29 0.129 26 0.269 54 0.169 34 0.239 48 0.119 24 2.140 429
0.200 9 0.330 15 0.286 13 0.352 16 0.264 12 0.242 11 0.573 26 0.418 19 0.595 27 0.352 16 0.661 30 0.264 12
0.176 8 0.374 17 0.264 12 0.308 14 0.154 7 0.198 9 0.264 12 0.396 18 0.176 8 0.220 10
0.154 7 0.066 3
0.154 7 0.066 3 0.066 3 0.044 2
0.683 31 0.837 38
206
12 0.025 5 0.070
14 0.070 14 0.065 13 0.030 6 0.025 5 0.035 7 0.070 14 0.060 12 0.060 12 0.010 2
Total 134 116 113 66 * UTI = Urinary Tract Infection ** URI Upper Respiratory Tract Infection *** Misc. All infections not UTI, URI, Wd
--
and patients under 65. The percentage of nosocomial infections was significantly higher in patients over 65 than those under 65 in all months and of all types. Nosocomial infections prior to and during the 1950's were synonymous with Staphylococcus. While Staphylococcus and Streptococcus retained their potential to complicate many recoveries, commencing in the 1960's and continuing into the NOVEMBER/DECEMBER 1979
1970's, they have declined as etiologic agents of nosocomial infections and a striking and progressive increase in the frequency of gram negative bacilli and fungi has occurred. Nosocomial infections may be exogenous, acquired from - a source outside the patient but within the hospital environment. The source could be personnel, other patients, hospital air, water, medication, fluids,
0.044
20 0.418 19
2 0.132 6 0.132 6 0.066 3 0.154 7 0.132 6 0.154 7 0.286 13 0.176 8 0.088 4
0.044 2 0.044 2 0.044 2 0.066 3 0.044 2 0.066 3 0.110 5 0.066 3
154
72
37
0.440
o.ai
30 0.837 38 0.595 27 0.551 25 1.035 47 1.013 46 0.969 44 0.925 42 1.387 63 0.837 38 10.330 469
needles, catheters, and disposables. Endogenous infections are caused by microbes from the patients' personal microflora. Usually infections of this type reflect an alteration of the existing balance between the patients' microflora and their defense mechanisms. Many nosocomial infections are in the category of exogenous acquisition followed by endogenous infections. The patients 41
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first acquire the multi-drug resistant microbes of the institution as part of their personal microflora. Then when events or processes alter their defense mechanisms, an endogenous nosocomial infection occurs. Infections in the elderly frequently conditioned in occurrence by some existing abnormality of the host are referred to as obligatory infections. Abnormalities that oblige infections are many, ranging from anatomic (urethral stricture), metabolic (diabetes mellitus), neoplastic (branchogenic carcinoma), collagen vascular (lupus eryt hematosis),therapeutic (ioniZing radiation), devitalized t i S sue (ischemic necrosis), to the “unknown”. Obligatory infections may be abrupt in Onset, run an acute course, and even result in death. More commonly, however, a smoldering, chronic truce between the patients and their microbes is the outcome. Mi(-robes involved are usually of the endogenous microbiata or bear a quasi-commensal relationship to the patients.2 Bacteria constituting the resvoirs of nosocomial infedions are widely distributed in nature; however, their pathogenicity is clinically displayed only in the institutionalized
compromised
patient. Antimicrobial therapy selectively enriches the institutional biosphere and profoundly shapes the character of nosocomial infections by suppressing microflora of the patient that are susceptible to the drug and allowing proliferation of microbes resistant to the drug. These effects are clinically most evident in the gastrointestinal tract, respiratory tract, 42
the vagina, and the skin. Most Use of these techniques i s not microbes regularly associated without risk, for they have adwith nosocomial infections are verse effects on the patient’s capable of acquiring resistance defense mechanism. Anatomic to drugs easily; multi-drug re- risk factors impede normal sistant microbes have a survival clearance or drainage, such as advantage in hospitalized pa- in the genitourinary or broniens receivting antimicrobic chopulmonary tract abnormalitherapy. ties. Foreign metal/plastic bodies, Approximately 2/3 Of the patients in this study acquired in- as urinary, intravenous, oral, fections with the Pse~~domo-and nasal catheters, impair local nadst Enterobacter, Serratia, tissue defenses and provide a and/or Flavobacteri~m. These direct portal of entry for orinfections were most likely e m - ganisms, for prolonged time genous as these bacteria are periods Protheses and sutures to survive and multiply interfere with cellular defenses i d o n rf~ost inanimate objects by providing inaccessible to such as nebulizers, humidifierst phagocytes. minimal nutrient liquids, and The host plays the determiantiseptic agents- Infections with nant role in the overt clinical E* colit Proteus, Candida, and manifestations of a microbe. AsEnterococci are endogenous in sociated with aging is a decline source*Staphylococci and Strep- in the immunological defense tOCOCCi infections were rare in processes. The total number of this study; when they occur, the circulating lymphocytes, parexogenous SOurce k frequently ticularly the T cells, dehospital carriers with no clinical c r e a ~ e s . ~ * ~ , ~ disease. A Klebsiella pneumoThe inflammatory response i s niae infection i S USUally an exofunctionally impaired and the genous-endogenous infection. capacity of phagocytes to inCurrent and PrOgreSSiVely intracellularly destroy microbes i s creasing technological advances destroyed.e In many diseases in the Physical, chemical, and biological modalities at the cli- common to the elderly such as shock, congestive heart failure, nicians’ disposal permit their inrenal disease, and vascular intervention very decisively in the sufficiency, leucocyte function fight against disease and allow i s impaired because of local and them to accomplish extraordi- systemic acidosis; infection risk nary medical feats. increases with decreased pH. There are immunosuppressive Age associated skin rhanPe!s drugs, invasive diagnostic technics, cytotoxic drugs, ionizing increase infection risk in the hasradiation, prolonged complex pitalized elderly patient* As One surgical procedures like cardio- Of its Physiological functions pulmonary bypass with the re- skin is a protective barrier placement of malfunctioning against the invasion Of microbes parts with artificial or biological into underlying tissues* valves, grafts, shunts, dialysis, Aging skin loses some of its and hormonal therapy (adreno- layers. Protein depletion imcorticosteroids) for joint dis- pairs protein synthesis and increases vulnerability to mieases. HOSPITAL TOPICS
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crobes. Decreased biotin and vitamin A causes breaks in the epithelium continuity. D e creased skin and mucous membrane secretions decrease the lipids, fatty acids, and lactic acids which alleged to have bactericidal effects. Decreased tissue and body fluid result in decreased lysozyme, the enzyme that splits sugars from the peptidoglycan polymer of bacterial cells. The chronically ill geriatric patients who are unable to move/shift their weight frequently develop a decubitus ulcer or pressure sore when the soft tissue of the skin breaks down over a bony prominence such as the heel, coccyx, or hip.' Nosocomial infections involving pressure sores are commonly seen as open ulcerated areas easily contaminated and subsequently infected with normal flora/pathogenic microorganisms. Surgical wounds are also focuses of post-operative infection because the elderly skin i s penetrated by instruments that introduce organisms from the surface to its underlying tissues which has decreased vascular responses to mobilize adequate inflammatory reactions, inefficient phagocytes, and a decreased ability to respond to trauma. Nosocomial pneumonia is a common infection in the elderly because of phvsioloeical changes in their lungs predisposing them to such complications. The number of bronchiole cilia decreases and mucous glands atrophy. The cough reflex i s depressed as is the phagocytic capacity of the alveo I a r polymorphonuclear leucocytes. NOVEMBER/DECEMBER 1979
Patients are unable to clear their lungs of aspirated secretions during respiration; thus nosocomial infections of the respiratory tract are complications in comatose, stuperous, or anesthesia/drug altered sensorium patients.* Elderly patients with severe chronic pulmonary disease often require mechanical respiratory assistance through the use of therapy equipment. This equipment may become colonized with gram negative bacteria and become a major source of nosocomial respiratory infections. As age advances, the likelihood of chronic disease increases. Greater percentages of the elderly have diseases like carcinomas, leukemia, diabetes mellitus, uremia, emphysema, atherosclerosis, hypertension and other cardiovascular malfunctions. These diseases compromise the blood flow to the kidney so renal circulation i s reduced and the system becomes highly vulnerable to infection. Nosocomial urinary tract infections are frequent in geriatric patients (especially catheterized ones) and can be a fatal complication of their disease/traumatic wound. The psychological state of mind of the geriatric patient, his family, and hospital personnel may influence the rate of nosocomial infection. Society in the United States gives a low priority to "non-productive persons" such as the elderly. There is an attitudinal problem reflecting a general lack of interest in and neglect of the aged. Unfortunately this attitude of benign neglect i s often extended to the hospital, some-
times resulting in minimal staffing and poor clinical workups on the geriatric floor.e Aged -patients are generally not expected to survive their illnesses and, sensing this, they may develop a fatalistic attitude of depression which helps lower their resistance to microorganisms and increase their susceptibility to infection.
Summary Physiological changes which are part of the aging process, and the frequent presence of chronic underlying diseases are factors that debilitate patients over 65 and render them more susceptible to microorganisms of their endogenous flora/hospita1 environment which are usually non-pathogenic. In a community teaching hospital of 600 beds, the nosocomial infection rate of patients over 65 was five times that of patients under 65. A large number of aged persons who acquired nosocomial infections were diagnosed upon admission to suffer from such chronic diseases as hypertension, diabetes, cardiovascular diseases, and renal abnormalities.
Urinary catheterizations and inhalation therapy were found to be associated often with their infections. These supportive procedures, while often necessary to prolong life, are also hazardous; they can become sources of potential pathogens which cannot be destroyed or controlled effectively by compromised elderly patients and become a source of their infections. The occurrence of nosocomial infections in the geriatric Contlnuod on pogo 40
43
Contlnued from previous page
Nosocomial Infections Continu4edfrom page 43
Kritek, Phyllis 6. The Generation and Classificotion of Nursing Diagnosis: Toward a Theory of Nursing. Image, Val. 10 No. 2, June 1978.
patient may be only an incon- of the clinicians of geriatric pavenience or a catastrophe. The tients. 0 frequency of n o s o c o m i a l infecREFERENCES t i o n s will further increase as the 1. Center for Disease Control: Natlonal percentage of p a t i e n t s Over 65 Nosocomlol infections Study. Atlanta, increases and their defenses Ga. against infection being grossly 2. Hoeprich, Paul D.: infectlous DIs.
Morram, G., Schlegei, M., and Bovlr, 8. Primary Nurslng: A Model for Indlvlduallred Care. St. Louis: C. V. Mosby, Co. 1974.
Downloaded by [Monash University Library] at 05:14 07 January 2015
Morram, G. and Fiynn, K. Abaravlch, W., and Carey, S. Cost-Effertlvenesr of Primary and Team Nurrlng. Contemporary Publlshlng, Inc., 1976. Mauksch, I., Marlom, D. Prescription for 5urvival. Amerlcan Journal of Nursing, December 1972, 2189-2193. McCaln, Faye K. Nurslng by AssessmentNot Intuition. Amerlcan Journal of Nurslng, 6514) 82-84, 1965. Ohno, M. 1. The Eye-Patched Patlent Amerlcan Journal of Nursing, 71, [February 1971) 271-274. Schorr, T.M., Lets Hoar it for Primary Nursing. [Edltorial) American lournal of Nursing Voi. 77, No. 11 [November 1977). Yuro, H., Waish, M.B. The Nurslng Process. New York: Meredith Corporation, 1973. Zlmmerman, Donna, Gohrke, Carol, The GoalDirected Nursing Approach: i t Doer Work. American Journal of Nursing, Vol. 70, No. 2 [February 19701, 306-310. OTHER: Morram, G., Abavarich, W.,Carey, 5. end Fiynn, K. A Comparlson of the Cast Effectiveness of Team and Prlmary Nursing Car. Modalltles. Eoston: New England Deaconess Hospltal, 1975.
i n s u l t e d by d i s e a s e h h e r a p y increases. Microbial p o p u l a t i o n s a r e continuous~y ,-hanging; when one microbe is e x t e r m i n a t e d , new microbes avail themselves of the ecological niche created in the i n s t i t u t i o n . The problem has no easy solution*A good of microbiology, infectious diseases, and an appreciation of the host/parasite r e l a t i o n s h i p will help. The constantly-changing constituenrs Of the t i o n s will continue to challenge the diagnostichreatment skills
eases. Harper L
ROW,
1977.
3. American Hospital Association: Proceedings of rhe lnternatlonal Conference on Nosocomial infections. Waverly Press, Boitlmore, MD., 1977. 4. Dlas-Jouannn, E,.
et. a!.: Studles of Human Lymphocytes on the Newborn and the Aged. The American Journpi Of Medicine 58:620-628, 1975. 5. MacKinney, A.: Effect of A g h g on rho Perlpheral Blood Lymphocyte Count. Journal of Gerontology 33:
213-216,1978. 6. Greenfield, lazar J.: Surgery of the Aged. w. Swnden Philadelphia, 1975. 7. Reichel, Wllliam: Cllnlcal Aspecrs of Amins. The Willlams and Wiikinr Company, Baltimore, MD., 1978.
- -
Design, Development, Future, of Unit Service Management Continued from page 48 4. Support Services-liaison: a) Responsible for translating the needs of the patient unit(s) for all hospital support services by effective verbal and written communication and follow-up with the appropriate supervisor of each department. b) Provides input and works with support service department supervisors in planning for future needs affecting- the .patient unit(s). 5. Emergency Procedures: a) Coordinates telephone communications, obtains needed services and supplies and directs “traffic” both to and from all CAC’s as appropriate. b) During codes 5 and 7 the Unit Manager will coordinate communications and direct “traffic” on the patient unit(s). 6. Promotes and maintains harmonious relationships with patients, visitors and all hospital personnel. 7. Makes patient rounds at the beginning of each shift for the purpose of assessing needs relative to 1 through 6 above.
POSITION QUALIFICATIONS 1. Individual Characteristics: (a) Dedicated to quality patient care. (b) Capable of independent judgement. (c) Intelligent. (d) Mature. (el Positive and responsive attitude. (f) Good problem-solving skills. (g) Good communication skills. (h) Flexible. (i) People-oriented. (j) Neat and well-groomed.
2. Experience: Preferably 1-2 years of hospital experience or relevant business experience. A supervisory background is desirable, but not essential.
3. Education: High School Diploma, preferably a Bachelors degree in a related area. 0
8. Duties as assigned by the Director of USM. 40
HOSPITAL TOPICS
Hospital Topics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vhos20
Nosocomial Infections: In the Elderly a
Antonina M. Brem PH.D. & Emily M. Torok M.S.
a
a
St. John Hospital , 22101 Moross Road, Detroit, Michigan, 48236, USA Published online: 13 Jul 2010.
To cite this article: Antonina M. Brem PH.D. & Emily M. Torok M.S. (1979) Nosocomial Infections: In the Elderly, Hospital Topics, 57:6, 10-40, DOI: 10.1080/00185868.1979.9954725 To link to this article: http://dx.doi.org/10.1080/00185868.1979.9954725
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Downloaded by [Monash University Library] at 05:14 07 January 2015
NOSOCOMIAL INFECTIONS BY ANlONlNA M. BREM, PMD. EM11 Y M. TOROK, M.S. St. hhn Hospital 22101 Moross Road Detroit, Michigan 48236
Antonina M. h e m , Ph.D. earned her BS and MS In Biology at Wayne State Untverdty and her Ph.D. In Mlcroblology at the University of Michlgan. for ten years she has served a t the St. John Hospltal, Detroit, Michigan as the Microbiologist, Epidemiologist, and Infectlon Control Coordinator. She i s also consultant to Metropolitan Hospitals in Detrolt and Westland, and Is on the faculty of Wayne State Unlversiy teaching cllnlcal mlcrobloiogy to medical students.
10
osocomial infections are tion because of changes in the infections that occur in skin, respiratory, and immunoinstitutional m e e t i n g s logical defense mechanisms. (hospitals, extended care facil- Elderly patients are frequently ities, convalescent centers, nurs- debilitated and often require ing homes) diagnosed and con- utilization of supportive/therafirmed by clinical / laboratory peutic procedures which inevidence. The term nosocomical crease their risk of infection. is preferable to hospital acquired The data presented was comso that a culpability i s not piled from a 600 bed middle erroneously implied. class community teaching hosDescriptive studies of noso- pital. The overall nosocomial comial infections exclude infec- infection rate for this hospital tions that are incubating at the has averaged 3.5% since 1969. time of admission to the institu- The incidence of nosocomial intion-those that become clini- fection for a 12-month period cally apparent within 48-72 commencing in January 1977 hours after admission. There are and ending in December of additional nosocomial infections 1977 has been examined. The that are not apparent until after intent was to compare the discharage (surgical wound in- geriatric patient (65 years and fections) and are not included over) with the younger patient in standard nosocomial infec- with regard to number and type tion statistics. of nosocomial infection. An on-going study since During 1977 there were 24,1969 by the Center for Disease 625 admissions to this hospital; Control (CDC) indicates that 4,541 ,patients were 65 years or approximately 5% of patients older. The length of stay of all admitted to institutions develop patients was 8.0 days; patients an infection during their stay. over 65 years of age were hosOur hosDital has participated pitalized and average of 13.1 in the CDC National Nosoco- days. A total of 898 (3.6%) mial study since its commence- patients acquired nosocomial ment in 1969 utilizing their infections; nosocomial infecstrict criteria for determining tions in patients under 65 years of age was 2.1%; the geriatric our nosocomial infections.' Nosocomial infections are a nosocomial infection rate was serious problem for all patients; 10%. however, the situation i s cornTable 1 shows, by number pounded with increasing age. and percentage, the type of With advancing age there is a nosocornial infections according diminution in the patient's to month, in patients over 65 ability to resist microbial infecContinued on page 41
N
HOSPITAL TOPICS
Nosocomial Infections in the Elderly, Continued from page 10 TABLE ONE Monthly Distributions of Nosocomial Infections of Hospitalized Patients 4,541 Patients > 65 Years and Older
2,087 Patients < 65 Years
Jan. Feb.
Downloaded by [Monash University Library] at 05:14 07 January 2015
March April May
June July Aug. Sept.
Oct.
Nov. Dec.
UTI*
URI**
Wound
Mix***
Total
UTI
URI
Wound
Misc
Total
0.075 15 0.070 14 0.050 10 0.050 10 0.050 10 0.030 6 0.055 11 0.030 6 0.075 15 0.065 13 0.065 13 0.055 11
0.060
0.015 3 0.085 17 0.060 12 0.055 11 0.040 8 0.025 5 0.050 10 0.040 8 0.075 15 0.015 3 0.065 13 0.040 8
0.040 8 0.015 3 0.025 5 0.030 6 0.020 4 0.015 3 0.015 3 0.025 5 0.050 10 0.030 6 0.050 10 0.015 3
0.189 38 0.194 39 0.204 39 0.204 41 0.174 35 0.100 20 0.144 29 0.129 26 0.269 54 0.169 34 0.239 48 0.119 24 2.140 429
0.200 9 0.330 15 0.286 13 0.352 16 0.264 12 0.242 11 0.573 26 0.418 19 0.595 27 0.352 16 0.661 30 0.264 12
0.176 8 0.374 17 0.264 12 0.308 14 0.154 7 0.198 9 0.264 12 0.396 18 0.176 8 0.220 10
0.154 7 0.066 3
0.154 7 0.066 3 0.066 3 0.044 2
0.683 31 0.837 38
206
12 0.025 5 0.070
14 0.070 14 0.065 13 0.030 6 0.025 5 0.035 7 0.070 14 0.060 12 0.060 12 0.010 2
Total 134 116 113 66 * UTI = Urinary Tract Infection ** URI Upper Respiratory Tract Infection *** Misc. All infections not UTI, URI, Wd
--
and patients under 65. The percentage of nosocomial infections was significantly higher in patients over 65 than those under 65 in all months and of all types. Nosocomial infections prior to and during the 1950's were synonymous with Staphylococcus. While Staphylococcus and Streptococcus retained their potential to complicate many recoveries, commencing in the 1960's and continuing into the NOVEMBER/DECEMBER 1979
1970's, they have declined as etiologic agents of nosocomial infections and a striking and progressive increase in the frequency of gram negative bacilli and fungi has occurred. Nosocomial infections may be exogenous, acquired from - a source outside the patient but within the hospital environment. The source could be personnel, other patients, hospital air, water, medication, fluids,
0.044
20 0.418 19
2 0.132 6 0.132 6 0.066 3 0.154 7 0.132 6 0.154 7 0.286 13 0.176 8 0.088 4
0.044 2 0.044 2 0.044 2 0.066 3 0.044 2 0.066 3 0.110 5 0.066 3
154
72
37
0.440
o.ai
30 0.837 38 0.595 27 0.551 25 1.035 47 1.013 46 0.969 44 0.925 42 1.387 63 0.837 38 10.330 469
needles, catheters, and disposables. Endogenous infections are caused by microbes from the patients' personal microflora. Usually infections of this type reflect an alteration of the existing balance between the patients' microflora and their defense mechanisms. Many nosocomial infections are in the category of exogenous acquisition followed by endogenous infections. The patients 41
Downloaded by [Monash University Library] at 05:14 07 January 2015
first acquire the multi-drug resistant microbes of the institution as part of their personal microflora. Then when events or processes alter their defense mechanisms, an endogenous nosocomial infection occurs. Infections in the elderly frequently conditioned in occurrence by some existing abnormality of the host are referred to as obligatory infections. Abnormalities that oblige infections are many, ranging from anatomic (urethral stricture), metabolic (diabetes mellitus), neoplastic (branchogenic carcinoma), collagen vascular (lupus eryt hematosis),therapeutic (ioniZing radiation), devitalized t i S sue (ischemic necrosis), to the “unknown”. Obligatory infections may be abrupt in Onset, run an acute course, and even result in death. More commonly, however, a smoldering, chronic truce between the patients and their microbes is the outcome. Mi(-robes involved are usually of the endogenous microbiata or bear a quasi-commensal relationship to the patients.2 Bacteria constituting the resvoirs of nosocomial infedions are widely distributed in nature; however, their pathogenicity is clinically displayed only in the institutionalized
compromised
patient. Antimicrobial therapy selectively enriches the institutional biosphere and profoundly shapes the character of nosocomial infections by suppressing microflora of the patient that are susceptible to the drug and allowing proliferation of microbes resistant to the drug. These effects are clinically most evident in the gastrointestinal tract, respiratory tract, 42
the vagina, and the skin. Most Use of these techniques i s not microbes regularly associated without risk, for they have adwith nosocomial infections are verse effects on the patient’s capable of acquiring resistance defense mechanism. Anatomic to drugs easily; multi-drug re- risk factors impede normal sistant microbes have a survival clearance or drainage, such as advantage in hospitalized pa- in the genitourinary or broniens receivting antimicrobic chopulmonary tract abnormalitherapy. ties. Foreign metal/plastic bodies, Approximately 2/3 Of the patients in this study acquired in- as urinary, intravenous, oral, fections with the Pse~~domo-and nasal catheters, impair local nadst Enterobacter, Serratia, tissue defenses and provide a and/or Flavobacteri~m. These direct portal of entry for orinfections were most likely e m - ganisms, for prolonged time genous as these bacteria are periods Protheses and sutures to survive and multiply interfere with cellular defenses i d o n rf~ost inanimate objects by providing inaccessible to such as nebulizers, humidifierst phagocytes. minimal nutrient liquids, and The host plays the determiantiseptic agents- Infections with nant role in the overt clinical E* colit Proteus, Candida, and manifestations of a microbe. AsEnterococci are endogenous in sociated with aging is a decline source*Staphylococci and Strep- in the immunological defense tOCOCCi infections were rare in processes. The total number of this study; when they occur, the circulating lymphocytes, parexogenous SOurce k frequently ticularly the T cells, dehospital carriers with no clinical c r e a ~ e s . ~ * ~ , ~ disease. A Klebsiella pneumoThe inflammatory response i s niae infection i S USUally an exofunctionally impaired and the genous-endogenous infection. capacity of phagocytes to inCurrent and PrOgreSSiVely intracellularly destroy microbes i s creasing technological advances destroyed.e In many diseases in the Physical, chemical, and biological modalities at the cli- common to the elderly such as shock, congestive heart failure, nicians’ disposal permit their inrenal disease, and vascular intervention very decisively in the sufficiency, leucocyte function fight against disease and allow i s impaired because of local and them to accomplish extraordi- systemic acidosis; infection risk nary medical feats. increases with decreased pH. There are immunosuppressive Age associated skin rhanPe!s drugs, invasive diagnostic technics, cytotoxic drugs, ionizing increase infection risk in the hasradiation, prolonged complex pitalized elderly patient* As One surgical procedures like cardio- Of its Physiological functions pulmonary bypass with the re- skin is a protective barrier placement of malfunctioning against the invasion Of microbes parts with artificial or biological into underlying tissues* valves, grafts, shunts, dialysis, Aging skin loses some of its and hormonal therapy (adreno- layers. Protein depletion imcorticosteroids) for joint dis- pairs protein synthesis and increases vulnerability to mieases. HOSPITAL TOPICS
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crobes. Decreased biotin and vitamin A causes breaks in the epithelium continuity. D e creased skin and mucous membrane secretions decrease the lipids, fatty acids, and lactic acids which alleged to have bactericidal effects. Decreased tissue and body fluid result in decreased lysozyme, the enzyme that splits sugars from the peptidoglycan polymer of bacterial cells. The chronically ill geriatric patients who are unable to move/shift their weight frequently develop a decubitus ulcer or pressure sore when the soft tissue of the skin breaks down over a bony prominence such as the heel, coccyx, or hip.' Nosocomial infections involving pressure sores are commonly seen as open ulcerated areas easily contaminated and subsequently infected with normal flora/pathogenic microorganisms. Surgical wounds are also focuses of post-operative infection because the elderly skin i s penetrated by instruments that introduce organisms from the surface to its underlying tissues which has decreased vascular responses to mobilize adequate inflammatory reactions, inefficient phagocytes, and a decreased ability to respond to trauma. Nosocomial pneumonia is a common infection in the elderly because of phvsioloeical changes in their lungs predisposing them to such complications. The number of bronchiole cilia decreases and mucous glands atrophy. The cough reflex i s depressed as is the phagocytic capacity of the alveo I a r polymorphonuclear leucocytes. NOVEMBER/DECEMBER 1979
Patients are unable to clear their lungs of aspirated secretions during respiration; thus nosocomial infections of the respiratory tract are complications in comatose, stuperous, or anesthesia/drug altered sensorium patients.* Elderly patients with severe chronic pulmonary disease often require mechanical respiratory assistance through the use of therapy equipment. This equipment may become colonized with gram negative bacteria and become a major source of nosocomial respiratory infections. As age advances, the likelihood of chronic disease increases. Greater percentages of the elderly have diseases like carcinomas, leukemia, diabetes mellitus, uremia, emphysema, atherosclerosis, hypertension and other cardiovascular malfunctions. These diseases compromise the blood flow to the kidney so renal circulation i s reduced and the system becomes highly vulnerable to infection. Nosocomial urinary tract infections are frequent in geriatric patients (especially catheterized ones) and can be a fatal complication of their disease/traumatic wound. The psychological state of mind of the geriatric patient, his family, and hospital personnel may influence the rate of nosocomial infection. Society in the United States gives a low priority to "non-productive persons" such as the elderly. There is an attitudinal problem reflecting a general lack of interest in and neglect of the aged. Unfortunately this attitude of benign neglect i s often extended to the hospital, some-
times resulting in minimal staffing and poor clinical workups on the geriatric floor.e Aged -patients are generally not expected to survive their illnesses and, sensing this, they may develop a fatalistic attitude of depression which helps lower their resistance to microorganisms and increase their susceptibility to infection.
Summary Physiological changes which are part of the aging process, and the frequent presence of chronic underlying diseases are factors that debilitate patients over 65 and render them more susceptible to microorganisms of their endogenous flora/hospita1 environment which are usually non-pathogenic. In a community teaching hospital of 600 beds, the nosocomial infection rate of patients over 65 was five times that of patients under 65. A large number of aged persons who acquired nosocomial infections were diagnosed upon admission to suffer from such chronic diseases as hypertension, diabetes, cardiovascular diseases, and renal abnormalities.
Urinary catheterizations and inhalation therapy were found to be associated often with their infections. These supportive procedures, while often necessary to prolong life, are also hazardous; they can become sources of potential pathogens which cannot be destroyed or controlled effectively by compromised elderly patients and become a source of their infections. The occurrence of nosocomial infections in the geriatric Contlnuod on pogo 40
43
Contlnued from previous page
Nosocomial Infections Continu4edfrom page 43
Kritek, Phyllis 6. The Generation and Classificotion of Nursing Diagnosis: Toward a Theory of Nursing. Image, Val. 10 No. 2, June 1978.
patient may be only an incon- of the clinicians of geriatric pavenience or a catastrophe. The tients. 0 frequency of n o s o c o m i a l infecREFERENCES t i o n s will further increase as the 1. Center for Disease Control: Natlonal percentage of p a t i e n t s Over 65 Nosocomlol infections Study. Atlanta, increases and their defenses Ga. against infection being grossly 2. Hoeprich, Paul D.: infectlous DIs.
Morram, G., Schlegei, M., and Bovlr, 8. Primary Nurslng: A Model for Indlvlduallred Care. St. Louis: C. V. Mosby, Co. 1974.
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Morram, G. and Fiynn, K. Abaravlch, W., and Carey, S. Cost-Effertlvenesr of Primary and Team Nurrlng. Contemporary Publlshlng, Inc., 1976. Mauksch, I., Marlom, D. Prescription for 5urvival. Amerlcan Journal of Nursing, December 1972, 2189-2193. McCaln, Faye K. Nurslng by AssessmentNot Intuition. Amerlcan Journal of Nurslng, 6514) 82-84, 1965. Ohno, M. 1. The Eye-Patched Patlent Amerlcan Journal of Nursing, 71, [February 1971) 271-274. Schorr, T.M., Lets Hoar it for Primary Nursing. [Edltorial) American lournal of Nursing Voi. 77, No. 11 [November 1977). Yuro, H., Waish, M.B. The Nurslng Process. New York: Meredith Corporation, 1973. Zlmmerman, Donna, Gohrke, Carol, The GoalDirected Nursing Approach: i t Doer Work. American Journal of Nursing, Vol. 70, No. 2 [February 19701, 306-310. OTHER: Morram, G., Abavarich, W.,Carey, 5. end Fiynn, K. A Comparlson of the Cast Effectiveness of Team and Prlmary Nursing Car. Modalltles. Eoston: New England Deaconess Hospltal, 1975.
i n s u l t e d by d i s e a s e h h e r a p y increases. Microbial p o p u l a t i o n s a r e continuous~y ,-hanging; when one microbe is e x t e r m i n a t e d , new microbes avail themselves of the ecological niche created in the i n s t i t u t i o n . The problem has no easy solution*A good of microbiology, infectious diseases, and an appreciation of the host/parasite r e l a t i o n s h i p will help. The constantly-changing constituenrs Of the t i o n s will continue to challenge the diagnostichreatment skills
eases. Harper L
ROW,
1977.
3. American Hospital Association: Proceedings of rhe lnternatlonal Conference on Nosocomial infections. Waverly Press, Boitlmore, MD., 1977. 4. Dlas-Jouannn, E,.
et. a!.: Studles of Human Lymphocytes on the Newborn and the Aged. The American Journpi Of Medicine 58:620-628, 1975. 5. MacKinney, A.: Effect of A g h g on rho Perlpheral Blood Lymphocyte Count. Journal of Gerontology 33:
213-216,1978. 6. Greenfield, lazar J.: Surgery of the Aged. w. Swnden Philadelphia, 1975. 7. Reichel, Wllliam: Cllnlcal Aspecrs of Amins. The Willlams and Wiikinr Company, Baltimore, MD., 1978.
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Design, Development, Future, of Unit Service Management Continued from page 48 4. Support Services-liaison: a) Responsible for translating the needs of the patient unit(s) for all hospital support services by effective verbal and written communication and follow-up with the appropriate supervisor of each department. b) Provides input and works with support service department supervisors in planning for future needs affecting- the .patient unit(s). 5. Emergency Procedures: a) Coordinates telephone communications, obtains needed services and supplies and directs “traffic” both to and from all CAC’s as appropriate. b) During codes 5 and 7 the Unit Manager will coordinate communications and direct “traffic” on the patient unit(s). 6. Promotes and maintains harmonious relationships with patients, visitors and all hospital personnel. 7. Makes patient rounds at the beginning of each shift for the purpose of assessing needs relative to 1 through 6 above.
POSITION QUALIFICATIONS 1. Individual Characteristics: (a) Dedicated to quality patient care. (b) Capable of independent judgement. (c) Intelligent. (d) Mature. (el Positive and responsive attitude. (f) Good problem-solving skills. (g) Good communication skills. (h) Flexible. (i) People-oriented. (j) Neat and well-groomed.
2. Experience: Preferably 1-2 years of hospital experience or relevant business experience. A supervisory background is desirable, but not essential.
3. Education: High School Diploma, preferably a Bachelors degree in a related area. 0
8. Duties as assigned by the Director of USM. 40
HOSPITAL TOPICS
