Duong Minh Cuong, McLaws Mary-Louise
School of Public Health and Community Medicine, UNSW Medicine, UNSW Australia, Level 3 Samuels Building, Sydney, NSW, 2052, Australia.
BMC Infect Dis. 2017 Mar 1;17(1):181. doi: 10.1186/s12879-017-2290-3.
Non-compliance with infection control practices poses a serious risk to patients receiving chronic hemodialysis. We aimed to identify the type and frequency of non-compliance with infection control practices in a hemodialysis unit in Vietnam where a large outbreak of hepatitis C infection had occurred.
Mixed methods approach included observations and discussions of non-compliance with all 12 nurses at the Hemodialysis Unit, District-6 Hospital in Ho Chi Minh City. Observations of nursing care activities were made between September 2013 and January 2014. Compliance with hand hygiene and glove use during nursing care activities were classified according to the potential for a serious risk of transmission of infection and reported as percentages. Each nurse was expected to provide 11 nursing care activities to three patients assigned per hemodialysis sessions. Activities were to be given on an individual patient-centered care basis, that is, one patient was to receive all 11 activities by their assigned nurse. On completion of the observations all nurses were enrolled in a focus group where observed non-compliance was discussed and transcripts were examined for themes.
Hand hygiene compliance rate was low (27%, 95%CI 25%-28%, 1633/6140) regardless of classification of seriousness of risk from this breach. Although glove use (76%, 95%CI 74-78%, 1211/1586) and other personal protective equipment use (81%, 95%CI 78%-83%, 773/959) were high gloves were observed to be reused with multiple patients during a single nursing care activity provided to consecutive patients. Nurses explained the breakdown of providing nursing care activities on an individual patient-centered basis was a response to limited supply of gloves and hand hygiene facilities and was exacerbated by nursing being co-opted by overly demanding patients to provide services without delay.
The adaption by the nurses to provide 11 single care activities to multiple consecutive patients in the absence of changing gloves and low hand hygiene compliance was potentially the central risk factor that facilitated the hepatitis C outbreak. Patient-centered care needs to be enforced to minimize multiple nurse-patient contacts that are associated with non-compliance classified as serious risk of infection transmission. Nurse empowerment to resist unreasonable patient demands may also be pivotal to assisting their compliance with hand hygiene and single patient-centered care. An audit program to measure infection control resources and practices may facilitate enforcement of the guidelines.
不遵守感染控制措施会给接受慢性血液透析的患者带来严重风险。我们旨在确定越南一家血液透析单位中不遵守感染控制措施的类型和频率，该单位曾发生大规模丙型肝炎感染疫情。
采用混合方法，包括对胡志明市第六区医院血液透析科的12名护士进行观察，并就不遵守规定的情况进行讨论。在2013年9月至2014年1月期间对护理活动进行观察。根据感染传播严重风险的可能性，对护理活动期间手部卫生和手套使用的合规情况进行分类，并以百分比报告。预计每位护士在每次血液透析疗程中为分配的三名患者提供11项护理活动。活动应以个体患者为中心进行，即一名患者由其指定护士提供所有11项活动。观察结束后，所有护士参加了一个焦点小组，讨论观察到的不遵守规定的情况，并检查记录以找出主题。
无论这种违规行为导致的风险严重程度如何分类，手部卫生合规率都很低（27%，95%可信区间25%-28%，1633/6140）。虽然手套使用（76%，95%可信区间74%-78%，1211/1586）和其他个人防护设备使用（81%，95%可信区间78%-83%，773/959）比例较高，但在为连续患者提供的单次护理活动中，观察到手套被多名患者重复使用。护士们解释说，以个体患者为中心提供护理活动出现问题，是因为手套和手部卫生设施供应有限，而且过度要求的患者要求护士立即提供服务，这使情况更加恶化。
在不更换手套且手部卫生合规率低的情况下，护士们采用为多名连续患者提供11项单独护理活动的方式，可能是导致丙型肝炎疫情爆发的核心风险因素。需要加强以患者为中心的护理，以尽量减少与被归类为感染传播严重风险的不遵守规定行为相关的护士与患者的多次接触。赋予护士抵制患者不合理要求的权力，对于帮助他们遵守手部卫生和以患者个体为中心的护理也可能至关重要。一项衡量感染控制资源和措施的审计计划可能有助于执行这些指南。
