Health and Population Perspectives and Issues 36 (1 & 2), 1- 11, 2013

AWARENESS AND PRACTICE OF INFECTION CONTROL

AMONGST DOCTORS AND NURSES IN TWO ICUs OF A
TERTIARY CARE HOSPITAL IN DELHI
Hema Gogia* and Jayanta K. Das**
ABSTRACT
With the objective of assessing the awareness and practices
of Hospital Acquired Infection (HAI) control measures amongst
doctors and nurses, this study was undertaken in an Intensive
Care Unit (ICU) of Dr. Ram Manohar Lohia Hospital, New Delhi,
a tertiary care hospital. The sample population comprised 26
doctors and 55 nurses, and the study used a questionnaire-based
approach combined with in-depth interviews to achieve the
objectives. Overall, the findings showed that although there was
a high level of awareness of hospital-acquired infection control
measures amongst doctors (79.81%) and nurse (79.55%); infection
control practices were found to be lower amongst them, 70.43
per cent for doctors and 63.86 per cent for nurses. Overall, the
p value for awareness versus practices amongst the doctors was
found to be significant (p-value = 0.02239 and 0.0432 for doctors
and nurses respectively) at 95 per cent confidence interval. It was
also found that proper protocols related to hospital management
were not adhered to, and staff responsible for the lack of correct
practices despite high awareness amongst doctors and nurses. It is
evident from the study findings that several other factors are also
responsible for low infection control practices in hospital settings
despite high awareness amongst doctors and nurses. HAIs need to
be notified and records should also be maintained for surgical site
infections, catheter-associated urinary tract infections, ventilator
associated pneumonia, blood stream infections and pyrexia
of unknown origin. Infection-control guidelines should include
standard operating procedures (SOPs) for management of common
HAIs. Authors have the view that standard operating procedures
and guidelines for management of surgical site infections, device
related infections, ventilator associated pneumonia, blood stream
infections, sterilization procedures, visitor precautions, periodic
*MD- CHA Student, E-mail: [email protected]; **Director, National Institute of Health
and Family Welfare, Munirka, New Delhi-110067.

trainings, no-antimicrobial use policy, isolation practices, practices

for dealing with outbreaks, bio-medical waste management were
not readily available. Mandatory trainings on infection control,
which are not found in the ICUs of the hospital, are a must for all
ICU staff irrespective of whether they are contractual, temporary
or full-time. Hence, it must be made mandatory to have such
procedures and guidelines to contain and minimize all types of
hospital acquired infections.
Key words: Hospital acquired infection (HAI), Nosocomial, Infection
control practices, Awareness, Tertiary care.

Nosocomial infections or Hospital Acquired Infections (HAI) are a major global

safety concern for both patients as well as healthcare professionals. Many factors
promote infection among hospitalized patients decreased immunity among
patients; increasing variety of medical procedures and invasive techniques
creating potential routes of infection; and the transmission of drug-resistant
bacteria among crowded hospital populations, where poor infection control
practices may facilitate transmission. Despite progress in public health and
hospital care, infections continue to develop in hospitalized patients, and may
also affect hospital staff. The burden of HAI is substantial in developed countries,
where it affects from 5 per cent to 15 per cent of hospitalized patients in regular
wards and as many as 50 per cent or more of patients in intensive care units. In
developing countries, the magnitude of the problem remains underestimated or
even unknown largely because diagnosis of hospital acquired infection is complex
and surveillance activities to guide interventions require expertise and resources.
Studies also show that patients hospitalized in ICUs are 5 to 10 times more likely
to acquire nosocomial infections than other hospital patients.
OBJECTIVES
The objectives of this study were to:

assess the factors responsible for non-compliance of infection control

measures amongst doctors and nurses, and

suggest measures for enhancing the practice of HAI control measures

amongst them.

METHODOLOGY
The study was conducted in two of the intensive care units of Dr. Ram Manohar
Lohia Hospital, New Delhi in the month of July 2013. Out of the four ICUs at the

Hospital, only ICU-I (Main Medical ICU) and Swine Flu ICU were included in the
study. ICU-II which is functional at the resuscitation unit and the Medical ICU of
the Nursing Home that admits patients from the Nursing Home only and not from
the general population were excluded to avoid bias and for obtaining appropriate
results.
The study was primarily conducted to assess the three factors responsible for noncompliance of infection control measures awareness, practices and management
support. Primary data were collected through questionnaire on awareness and
practices about hospital acquired infection (HAI). All the 26 doctors (senior
residents, post-graduates, junior residents) and 55 nurses (sisters-in-charge, staff
nurses and additional nursing superintendent) posted in the two ICUs in the month
of July 2013 were included in the study. In-depth interviews were conducted of
the ICU staff and personnel involved in the control of hospital-acquired infections
including the ICU in-charge; Head of the Department of Microbiology, Infection
control and CSSD in-charge; Sister in-charge of Infection Control and Assistant
Nursing Superintendent of the ICU. The tools were prepared based on the
hospital-acquired infection guidelines provided by the World Health Organization
(WHO) and Centre for Disease Control (CDC). The tools were pre-tested before
data collection and proper approval was obtained from the appropriate authority
prior to the study. The limitation of the study was that the HAI control practices
could not be observed but evaluated based on a self designed questionnaire and
interview schedule.
FINDINGS AND DISCUSSION
Awareness of HAI amongst Doctors and Nurses
The questions on awareness were categorized under the following heads: Common
HAIs, Mode of Transmission, Categories of Exposure, Standard Precautions, Staff
Precautions, Antibiotic Use and Biomedical Waste Management. The responses
on awareness of doctors and nurses on HAI show that 88.46 per cent of the
doctors knew that it spreads through cross-transmission while 83.64 per cent
of the nurses stated that it spreads through environment. Most of the doctors
(96.15%) as well as nurses (98.18%) informed hand hygiene is the single most
important measure for preventing HAI. Similarly, 84.62 per cent of the doctors
and 87.27 per cent of the nurses stated UTI as the common HAI in a hospital
(Table 1). Findings show that there was a high level of awareness amongst doctors
(79.81%) and nurses (79.55%) in the intensive care unit of the hospital.

TABLE 1

AWARENESS OF DOCTORS AND NURSES ON HAI

Statements on Awareness of HAI (True/False)

Percentage
of Correct
Responses
(Doctors)

Percentage
of Correct
Responses
(Nurses)

Mode of Transmission
HAI can spread through self-transmission

76.92

60.00

HAI can spread through cross transmission

88.46

96.36

HAI can spread through environment

Standard Precautions
Single most important measure for preventing HAI
is hand hygiene

76.92

83.64

96.15

98.18

Single most important measure for preventing HAI

is wearing personal protective equipments

76.92

47.27

Single most important measure for preventing HAI

is using urinary catheter only when indicated

76.92

52.73

Common HAI in hospital is UTI

84.62

87.27

Common HAI in hospital are Ventilator associated

pneumonia

76.92

83.64

Common HAI in hospital are blood stream

infections

76.92

74.55

categories of exposure of infection to the staff

includes needle stick injuries

84.62

92.73

Categories of exposure of infection to the staff

includes non-intact skin exposure

73.08

85.45

Common HAI Sites

Categories of exposure

Statements on Awareness of HAI (True/False)

Staff Precautions

Percentage Percentage
of Correct
of Correct
Responses Responses
(Doctors)
(Nurses)

The hospital staff should be vaccinated for Hepatitis

100.00
B and Tetanus at the time of joining to the hospital
BMW

Biomedical Waste should be segregated at source

76.92
Colour coded bins should be used for BMW
100.00
disposal
Antibiotic Use

There is no role for routine antibiotic prophylaxis

30.77
in patients with urinary catheters
Disinfection

Sodium Hypochlorite is used in laboratories for

80.77
disinfecting liquid waste

100.00

100.00
98.18

36.36

76.36

Infection Control Practices amongst Doctors and Nurses

The questions on practices were categorized under the following heads: Notifying
HAIs, Site of exposure, Biomedical Waste Management, Spill Management,
Linen Management, Catheter related precautions and patient safety. The data
given in Table 2 reveal that infection control practices were found to be lower
amongst doctors (70.43%) and nurses (63.864%) in the intensive care units of
the hospital. Overall, the p-value for awareness versus practices amongst the
doctors was found to be significant (p-value = 0.02239 and 0.0432 for doctors and
nurses respectively) at 95 per cent confidence interval. Only 61.54 per cent of the
doctors and 81.82 per cent of the nurses responded that they inform the higher
authorities about HAI when only it led to a death. Similarly, only 61.54 per cent
of the doctors and 69.09 per cent of the nurses stated that they generally recap
or bend the needles prior to disposing those off. On the query of washing the
area with detergent in case of a blood-spill, only 42.31 and 41.82 per cent of the
doctors and nurses respectively were responded assertive.

TABLE 2

INFECTION CONTROL PRACTICES BY DOCTORS AND NURSES

Parameter for Practices

Notifying HAI
Do you inform the higher authorities about HAI
only if it has led to death?
Do you inform HAI only if it has deteriorated the
condition of the patient?
Do you always inform the higher authorities in
case of occurrence of HAI?
Site of Exposure
Do you wash the site of exposure with soap
and water?
BMW Management
Do you recap or bend the needles before
discarding them?
Do you discard disposable needles and other
sharps into puncture resistant containers at the
site of procedure?
Spill Management
Do you cover spills of blood or body fluids with
1% of freshly prepared sodium hypochlorite for
10 minutes and then mop dry?
Do you get the area washed with detergent
and water in case of a blood spill?
Do you ensure second decontamination if
required in case of blood spills?
Linen Management
Do you ensure that the used linen is not shaken
in order to prevent dissemination of microorganisms into the environment?

Percentage
of Correct
Response
(Doctors)

Percentage
of Correct
Response
(Nurses)

61.54

81.82

73.08

65.46

61.54

47.27

92.31

90.91

61.54

69.09

92.31

90.91

88.46

72.73

42.31

41.82

57.69

18.18

84.62

81.82

Parameter for Practices

Do you ensure that soiled linen is put in bleach,

washed, dried and then sent to the department
of laundry?
Catheter Related Precautions
Do you remove catheter within 24-48 hours
unless indicated?
Are you able to adhere to documentation of
catheter insertion and removal dates?
Do you ensure placement of the urinary
bag below the level of the bed to prevent
transmission of infection?
Standard Precautions
Do you continue wearing ICU slippers when
entering the bathroom?
Do you always wash hands or use hand rub
after removing gloves?

Percentage
of Correct
Response
(Doctors)
84.62

Percentage
of Correct
Response
(Nurses)
98.18

84.62

52.73

88.46

96.36

92.31

83.64

11.54

1.82

50.00

29.09

The study findings reveal that records on HAI were not maintained properly and
HAI events were not notified. The infection control guidelines were not readily
available at a centralized repository that is easily accessible to all. The Infection
Control Guidelines were not updated regularly. There should be standard
operating procedures and guidelines for management of the following hospital
acquired infections as those were not readily available during the course of this
research. Standard operating procedures for insertion of urinary catheter, central
venous catheters and peripheral venous catheters with specific focus on limiting
duration of catheter and frequency at which the catheter must be changed were
not available at the time of study. Though systemic antibiotic prophylaxes were
usually used in patients with urinary catheter, these have been proven by the
World Health Organization as not-effective measures.
No regular standard operating procedures were in practice for management of
surgical site infections, with regular monitoring and surveillance; and reporting
of infection rates back to individual surgeons. No standard operating procedures
were found to be in place for management of VAP, with appropriate disinfection
and in-use care of tubing respirators and humidifiers to limit contamination. No

routine procedures were being followed for the management of blood stream
infections and pyrexia of unknown origin developing 48 hours after admission.
Similarly, standard operating procedures for sterilization, with steps for regular
disinfection and periodic cleaning of air-conditioning ducts, clearly defined
autoclaving procedures, procedures for training of doctors and nurses for quality
check of sterilized/autoclaved equipment, and clear-written guidelines for
cleaning and disinfection of the toilets, ICU floors, beds, mattresses and blankets
were not in place at the ICUs. Proper visitor precautions for the usage of personal
protective equipment inside the ICU, screening of visitors for any infectious
disease or limiting number of visitors per patient entering the ICU at any given
time were not seen at the studied ICUs of the hospital.
All staff members were not trained on infection control measures and practices
at the time of induction to the hospital and periodically thereafter. Trainings on
infection-control were mostly imparted to junior residents and full-time regular
employees but not to other contractual staff. This loophole calls for an urgency
to provide compulsory induction trainings on infection control for all ICU staff
irrespective of contractual, temporary or full-time. There is no formal, written
antimicrobial use policy to be followed across the hospital. So, the antimicrobial
use policy should be made compulsory at a centralized repository that is easily
accessible to all. The trends of antibiotic use and resistance patterns were not
being regularly prepared and monitored. The antimicrobial use policy should
be regularly updated. Proper isolation practices such as separate cubicles for
infected-patients, negative air pressure for isolated infected-patients to prevent
spread of infectious agents through airborne route were not seen in the hospital.
The frequency of outbreaks at the hospital ICU was 2-3 months. However, there
were no defined HAI outbreak management measures in place. No established
terms of reference for the outbreak investigation were available. Also, no outbreak
investigation report was ever prepared in the hospital detailing the reasons
and causes of outbreak, interventions, effectiveness, and recommendations to
prevent future occurrence. Although proper management of bio medical waste at
the hospital was existing, no training was provided to all the staff on bio-medical
waste management and handling, and proper placement of the waste bins with
proper lids at the bedside. Besides, no clear-cut instruction was given to the
ICU staff regarding proper segregation of waste at the site of generation in the
colour-coded bags, and training of all staff on bio-medical waste management
and handling.
Adhering to Hygiene by Doctors and Nurses for Infection Control
The researchers found that 50 per cent of the doctors and 70.90 per cent of the
8

nurses always used hand rub or washed hands before and after touching the
patient. However, remaining 50 per cent of the doctors and 29.09 per cent of
the nurses mostly did hand wash or used hand rub. 38.5 and 12.5 per cent of the
doctors and nurses respectively stated the lack of hand-sanitisers at the bed-side
as the reason for not rubbing the hands with hand-sanitisers. While no doctor
was of the view that patient over-load hindered them from using hand-wash/
hand-rub, 37.5 per cent of the nurses reasoned that high patient-staff ratio barred
them from adhering to proper hand-hygiene. From Figure 1, it is also observed
that 7.7 per cent of the doctors and 12.5 per cent of the nurses did not use handwash due to allergic to hand-wash products as well as laziness.
FIGURE 1
REASONS FOR NOT WASHING HANDS OR USING HAND RUB ALWAYS
Hand Hygiene Practices:
Reasons for not Washing/Rubbing Hand Always
Doctors
Nurses
Lack of
appropriate
accessible
equipment
at every bed

High
patient-tostaff ratios

Allergies to
hand
washing
products

Laziness

In case of
emerency

Doctors

38.50%

0.00%

7.70%

7.70%

46.20%

Nurses

12.50%

37.50%

12.50%

12.50%

25.00%

All the doctors and nurses stated that they wear ICU slippers and caps while
entering the ICU. The ICU slippers are washed daily in the night. The doctors took
the slippers from the ICU daily but the sisters had kept their slippers permanently
at the ICU. Though 36.36 per cent of the sisters washed their slippers daily, the
remaining 63.63 per cent of sisters washed them once in 2-3 days. Only 11.54
per cent of the doctors and 1.82 per cent of nurses change into their personal
slippers while entering into the bathroom during duty hours. The rest wore the
ICU slippers for the same. 57.69 per cent of the doctors and 63.63 per cent of
the nurses said that they wore gloves always for all the required events. However,
42.31 per cent of the doctors and 36.36 per cent of the nurses mostly wore gloves
on the required events. The reasons for sometimes not wearing gloves included
lack of gloves by 5 per cent of the nurses whereas 9.1 per cent of the doctors
reasoned work-load, lack of motivation/laziness and allergic to gloves (Figure 2).

FIGURE 2
REASONS FOR NOT ALWAYS WEARING GLOVES WHEN INDICATED
Reasons for Not Wearing Gloves Always

Lack of
gloves

lack of
If too much motivation or In case of
of work
emergency
out of
laziness

Due to
all ergy with
gloves

Doctors

0.00%

9.10%

9.10%

54.50%

9.10%

Nurses

5.00%

20.00%

0.00%

45.00%

0.00%

Uniform trousers and short-sleeved gowns were available in the ICUs for both
men and women. It was seen that no doctor or nurse entered the ICU without
wearing the uniform. The doctors took clean/fresh uniform from the ICU store on
a daily basis while all the nurses had their dedicated uniform which they washed
themselves. 89.09 per cent of the nurses wore the same uniform twice before
washing whereas the rest of the nurses washed the uniform after wearing the
same only once. But it was observed that the doctors from other departments did
not wear uniforms during their rounds while entering the ICUs. Also, the patients
attendants rarely wore gowns on entering into the ICUs.
CONCLUSION AND RECOMMENDATIONS
On the basis of the findings, it is evident that though the awareness of HAIs
amongst doctors and nurses was high, infection control measures and practices
were not up to the mark because of the so many factors discussed above.
These factors must be considered seriously by policy-makers while framing
the guidelines and policies for better and more effective management of HAIs.
According to the Centres for Disease Control and Prevention (CDC), Healthcare
Associated Infections (HAI) that patients acquire while receiving treatment for
other conditions are estimated to be one of the top ten causes of death. Therefore,
it is imperative to revisit, reform and rewrite and replace the existing guidelines
and policies to improve the infection control practices in the hospital setting.
While most of the existing measures to prevent and control nosocomial infections
in the intensive care unit at Dr. R. M. L. Hospital are largely effective, modifications,
enhancements and refinements to these existing measures may only help in further
improving the overall ICU infection rate. HAIs need to be notified and records
should also be maintained for surgical site infections, catheter-associated urinary
10

tract infections, ventilator associated pneumonia, blood stream infections and

pyrexia of unknown origin. Infection-control guidelines should include Standard
Operating Procedures (SOPs) for management of common HAIs. There should
also be posters, charts, handouts and snippets of these guidelines displayed on
strategic places/points of the hospital for ready reference in every department
and ward. Moreover, these infection-control measure guidelines must be updated frequently as an essential procedure.
As standard operating procedures and guidelines for management of surgical
site infections, device related infections, ventilator associated pneumonia, blood
stream infections, sterilization procedures, visitor precautions, periodic trainings,
no-antimicrobial use policy, isolation practices, practices for dealing with
outbreaks, bio-medical waste management were not readily available. Hence,
it must be made mandatory to have such procedures and guidelines to contain
and minimize all types of hospital acquired infections. Mandatory trainings on
infection control, which are not found in the ICUs of the hospital, are a must for
all ICU staff irrespective of whether they are contractual, temporary or full-time.
Proper isolation practices such as separate cubicles for infected patients, negative
air pressure for isolated infected-patients to prevent spread of infectious agents
through airborne route
REFERENCES
1.

Weber, D.J., Raasch, R. and Rutala W. A. (1995, March). Nosocomial infections

in the ICU: The growing importance of antibiotic resistant pathogens. CHEST
Journal of the Amercian College of Chest Physicans, 115 (Suppl_1).

2. World Health Organization. (2002). Prevention of hospital acquired

infections: A practical guide. Geneva: WHO.
3. CDC. (2008). Health-care-associated infections in hospitals. GAO-08-283.

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