Universal precautions: costs for protective equipment.

BACKGROUND: The amount and costs of protective equipment used to implement universal precautions in Thailand have not previously been studied. METHODS: A cross-sectional study was done to determine the frequency of clinical and laboratory procedures requiring universal precautions and the amount of protective equipment needed for each. RESULTS: The study was performed in 24 government hospitals in Thailand in December 1993. Totaling 6549 beds, these hospitals had provided service to 357,391 inpatients and 3,411,122 outpatients during the previous year. The annual number of procedures performed in these hospitals was estimated at 17.5 million, with expenditures for protective equipment of $2.4 million (U.S.) per year. The average overall cost for protective equipment was U.S. $5.37 for one inpatient stay and U.S. $0.15 for one outpatient visit. The projected national expense for these barriers was U.S. $41.5 million per annum. The cost for these barriers after the implementation of universal precautions was 2.5 times the cost before implementation. CONCLUSIONS: Overuse of sterile and examination gloves and gowns and underuse of heavy-duty gloves, masks, aprons, goggles, and boots were discovered during the study. Appropriate use of disposable and reusable universal precautions equipment would free health care dollars for other purposes.

Efficacy of hospital infection control in Thailand 1988-1992.

Hospital infection control in Thailand was initiated in 1971, but it was not until 1987 that active infection control activities actually started. To evaluate the efficacy of the infection control programme, two national prevalence studies of hospital acquired infection (HAI) were undertaken. The HAI prevalence rate in 1988 was 11.7%; this was reduced to 7.3% four years later. The reduction of HAI was found in hospitals of all sizes, in all types of infection and almost all services. This reduction happened despite a shortage of infection control personnel. Co-operation of administrators, doctors and nurses is essential for success in HAI control. Such co-operation has been successfully created by the Nosocomial Infection Control Group of Thailand.

Universal precautions: knowledge, compliance and attitudes of doctors and nurses in Thailand.

A study on the knowledge, compliance and attitudes of doctors and nurses on "universal precautions" (U.P.) was done by questionnaire in April 1993. Four hundred and sixty-nine doctors and 4,554 nurses from 35 hospitals throughout Thailand responded. Almost all doctors and nurses understood the definition of U.P.. The latter were correctly applied in less than half of the personnel. A significant number of doctors and nurses required HIV screening tests and isolation of patients with HIV infections. Most doctors and nurses knew that sharp injuries were the most important cause of acquiring HIV infection in health-care settings. Those who are more vulnerable to injury would take more precautions. Up to a quarter of doctors and nurses did not fully understand how to use protective barriers properly. The practice of handwashing needs to be improved. Both doctors and nurses were willing to take care of HIV infected patients. They supported the application of U.P. as a safety measure. Welfare support for health-care workers who have contacted HIV at work is also expected.

PIP: Medical personnel and patients are at risk of acquiring HIV in health care settings. Special measures have therefore been introduced to reduce the risk of HIV transmission in such settings. These recommendations, known as "universal precautions", have been accepted and implemented in many countries. The essence of the recommendations is accident prevention, the application of protective barriers, and proper disinfection. Universal precautions have been applied in Thailand since 1991. This study investigates the knowledge, compliance, and attitudes of doctors and nurses in Thailand with regard to such measures. Questionnaires were sent to doctors and nurses working in government hospitals in 1993; 468 doctors and 4539 nurses responded. 94.9% of physicians and 85.5% of nurses were knowledgeable of universal precautions, but only 47.1% of the doctors and 27.9% of nurses reported that they would take precautions with all patients. The rest would apply universal precautions with patients known to be infected with HIV. 71.9% of doctors and 81.6% of nurses knew that sharp injuries is the main cause of HIV transmission to health care personnel. Only 75% of doctors and 47% of nurses washed their hands after caring for patients, and 16% of doctors and 50% of nurses rubbed their hands with alcohol after washing them with an antiseptic. These health practitioners had positive attitudes about their careers and stated their willingness to continue working even with the specter of HIV/AIDS.

The Second Thai National Prevalence Study on Nosocomial Infections 1992.

A prevalence study on N.I. in Thailand was repeated in 1992 to evaluate the efficacy of the ongoing control programme. The survey included 10,373 patients in 33 hospitals throughout Thailand. The prevalence rate of N.I. in this study was 7.3 per cent. When compared with a previous study done in 1988, it was found that the prevalence rate had decreased by 4.4 per cent. The reduction of N.I. occurred in all types of hospitals, and in all services. Major reduction was found in the age groups 5-14, 15-24 and 25-34 years, in orthopaedics, paediatrics and surgical departments. Lower respiratory tract infections were the commonest infection in this study while urinary tract infection was the commonest in 1988. Overuse of antimicrobials was discovered in this survey. The success in reduction of N.I. was attributed to the increase in N.I. activities. Campaigns against N.I. since 1988 seem effective and should be intensified.

A national study on surgical wound infections 1992.

A study on SWI was done in 33 hospitals in Thailand between March 16 and May 15, 1992 involving 15,319 surgical wounds. The average incidence rate of SWI as 2.7 per cent. It was highest in provincial hospitals. Patients aged under 10 years and 51-60 years had higher rates of SWI. It was most prevalent in the surgical department followed in rank by accident and orthopaedic departments respectively. Wound types were the most important denominator of SWI; the incidence of SWI in dirty, contaminated, clean-contaminated and clean wounds were 9.7, 5.1, 1.5 and 1.3 per cent respectively. Antimicrobial prophylaxis were used in 76.7 per cent of the wounds. Ampicillin, gentamicin and cloxacillin were the commonly used drugs. Prevention of SWI needs to be improved in provincial hospitals and in the use of prophylactic antimicrobials.

An outbreak of methicillin-resistant Staphylococcus aureus (M.R.S.A.) in a burn unit.

An outbreak of methicillin-resistant Staphyllococcus aureus (MRSA) in the burn unit of Siriraj Hospital from August 1990 to July 1991 was reported. Temporary decrease in the incidence of MRSA was observed during a period when no new cases were admitted. The incidence rose again after normal service resumed. Surveillance cultures in 29 patients from May to July 1991 grew MRSA in 19 patients (65.5 per cent). Infection by MRSA was found in 14 patients (48.3 per cent). Methicillin-resistant Staphylococcus aureus first appeared in these patients mainly during the first and second weeks of admission. Wound infections were the only manifestation in 14 patients. Four of the MRSA infected patients died of infection by organisms other than MRSA. Nasal carriage was found in 2 of 25 ward staff members. The cost of treatment for each episode of MRSA infection was as high as 19,322.90 baht. The epidemic of MRSA infections persisted despite all control measures resulting in temporary closure of the ward.

Use of antiseptics and disinfectants in Thailand 1990.

A survey by questionnaire was done in March and April 1990 on the use of antiseptics and disinfectants (A/D). Twenty-seven hospitals with 675 wards were enrolled. Results showed that the cost of A/D was 3.3 to 8.1 per cent of the total expenses for drugs. Essential A/D were available and used in most places. Many low level A/D, which have been excluded from modern hospitals, were still employed. Contamination of A/D was a real threat due to improper preparation, unclean containers and refill practices in many wards. Improper applications of A/D, namely: overuse, underuse, and wrong choices were found in many places. Textbooks and written guidelines were available but it is unlikely that they were referred to in practice. A national policy on the use of A/D and proper education to medical personnel are clearly needed.

Basic elements for the control of nosocomial infection in Thai hospitals.

A survey on the basic elements for the control of N.I. was done in 38 hospitals in Thailand in 1991. Manpower shortage was found in one half of them. Service by the microbiological laboratory was under-utilized. Good guidelines on N.I. control needed to be more widely adopted. Capacity of C.S.S.D. lagged behind demands in most hospitals. Water supply was of most concern and needed to be improved in all. Waste-water treatment plants were needed in about one half of the hospitals. Personnel working in catering did not receive adequate screening for communicable diseases in one-half. Workers in the laundry department needed education on infection prevention in about one-third of hospitals. Improper disposal of infectious waste was found in one-quarter. The results of the study indicated that a comprehensive programme is needed for improving the efficacy of N.I. control in Thailand.

Contamination of mercurochrome and chlorhexidine-cetrimide in a teaching hospital.

A study on the contamination of antiseptics was done in a teaching hospital, during March and April 1989. Ninety-five samples of 9 antiseptics from 23 wards were cultured. Results showed that 2 of 12 and 3 of 5 samples of mercurochrome and chlorhexidine-cetrimide compound were contaminated. This led to a wider scale study on the two products. It was found that over one-half of the samples of mercurochrome and 6 of 54 samples of chlorhexidine-etrimide compound were contaminated. Mercurochrome was contaminated by gram-positive and chlorhexidine-cetrimide compound by gram-negative bacteria. Contamination of mercurochrome was found in samples taken from the pharmacy and wards, and of chlorhexidine-cetrimide compound from wards only. Mercurochrome was removed from the hospital formulary and the use of chlorhexidine-cetrimide compound was more restricted.

Blood culture: comparison of outcomes between switch-needle and no-switch techniques.

BACKGROUND: Because blood culture is a common test at our institution, we hoped to save money and reduce the risk of needlestick injury by modifying our current technique for the preparation of culture specimens without increasing the risk of contamination. OBJECTIVE: To compare the contamination rates of blood culture specimens obtained by the conventional method of switching to another sterile needle before inoculation with those of specimens obtained by a method without switching. DESIGN: Cross-over study. SETTING: Department of Medicine of university hospital. PARTICIPANTS: Nursing personnel working in seven acute care medical wards in Siriraj Hospital, Bangkok, Thailand. INTERVENTIONS: From March to June 1991, participating nurses prepared blood culture specimens by means of both switch-needle and no-switch techniques in a cross-over study. All blood culture specimens were submitted to microbiology laboratory to determine the growth of microorganisms. MEASUREMENT: Growth in a culture was considered to be "true positive" or "contamination" by predetermined criteria. RESULTS: Total number of blood culture specimens was 1619; of these, 813 were prepared by switch-needle technique and 806 were prepared by no-switch technique. The contamination rates were 7.6% and 8.3% for switch-needle and no-switch techniques, respectively (p = 0.61). CONCLUSIONS: The switch-needle technique may not be necessary for obtaining blood culture specimens unless the needle is obviously contaminated. The no-switch technique for the preparation of blood culture specimens is more convenient and less expensive; it also poses less risk of needlestick injury.

Does indication sheet reduce unnecessary urethral catheterization?

The study on the effect of indication sheet on the decision of doctors in ordering urethral catheterization was done in thirteen hospitals randomly selected from all regions of Thailand. 16,959 patients in medical and surgical wards were included between April and May 1989. The rates of urethral catheterization did not change by the influence of indication sheet. However, urethral catheterization without proper indications was reduced from 27.0 per cent in the control group to 14.3 per cent in the experiment group. The indication sheet was accepted in 96.5 per cent of the occasions when doctors prescribed urethral catheterization. The indication sheet changed the doctors' decision and hence reversed the order in 3 events (0.8%). It is concluded that indication sheet was well accepted by doctors and could reduce urethral catheterization without proper indications.

A national prevalence study on nosocomial infections 1988.

A National survey of N.I. in Thailand was done in April 1988. Twenty-three hospitals throughout the country were enrolled. Of the 6,805 patients studied, 52 per cent were males and 48 per cent were females. The prevalence rate of nosocomial infections was 11.7 per cent. The highest rate was found in the second biggest (regional) hospitals (18.8%). There were minor variations in the rates of infection in each age group. The infection rate was highest in intensive care units (35.1%) followed by orthopaedic (20.4%) and paediatric (15.7%) departments respectively. Urinary infections were the commonest (25.8%). Surgical wound infections ranked second (19.6%). Skin infections were as high as 11.8 per cent. P. aeruginosa were the commonest bacterial isolates (22%) followed by E. coli (18.1%) and Klebsiella species (14.0%). Antimicrobials were prescribed in 52 per cent of patients, and, in a large number, for prophylactic purposes. It is concluded that N.I. are the main health problems affecting more than 200,000 patients annually in Thailand. Urgent studies and interventions are clearly needed.