Rajiv Gandhi University of Health Science, Karnataka, Bangalore PROFORMA SYNOPSIS FOR REGISTRATION FOR DISSERTATION

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NAME OF THE CANDIDATE AND ADDRESS

MRS. DHANYA.P.NAIR. D/O MR. K.R.PURUSHOTHAMAN NAIR KALAPPURACKAL HOUSE UZHAVOOR EAST POST KOTTAYAM DISTRICT KERALA-686634 M.S RAMAIAH INSTITUTE OF NURSING EDUCATION AND RESEARCH M.S.R.I.T.POST BANGALORE-560054

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NAME OF THE INISTITUTION

3. COURSE OF STUDY AND SUBJECT

M.Sc NURSING (1ST YEAR) MEDICAL SURGICAL NURSING DISSERTATION PROTOCOL

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DATE OF ADMISSION TO COURSE

31-5-2007

TITLE OF THE TOPIC: EFFECTIVENESS OF STRUCTURED TEACHING MODULE FOR NURSES ON KNOWLEDGE REGARDING PREVENTION AND MANAGEMENT OF MRSA (METHYLINE RESISTANT STAPHYLOCOCCUS AUREUS) INFECTIONS.

6. BRIEF RESUME OF INTENDED WORK

INTRODUCTION: "Every human being is the author of his own health . Buddha As long as one is healthy, he or she is safe. Health deteriorates due to various reasons, and sometimes it requires hospitalization. Hospitalization disrupts normal routine functioning of client and his family. Hospital is a place, which harbours germs, or organisms, which leads to infections among the clients health care providers.1 Staphylococcus aureus is one of the most versatile nosocomial pathogens. The wide spread use of penicillin in the early 1950s saw the spread of penicillin resistant in Staphylococcus aureus hospitals, after which time methicillin and its derivatives become the drug of choice for the treatment of infections 2. Even before methicillin was widely used Jevons identified strain of Staphylococcus aureus with natural resistance to this antibiotic in 1961.Thereafter, methicillin resistant S.aureus emerged as a major pathogen world wide2. Several survey has confirmed that the incidence of MRSA ( Methyline Resistant Staphylococcus Aureus) varies form region; during last 20 years, the proportion of isolates resistant to methicillin less than 1%in Scandinavia and more than 30% in India, France ,Italy and Spain. In the 1990s, a type of the few antibiotics began to showing up in the wider community. Today, that form of Staphylococcus known as CA-MRSA (Community Acquired Methyline Resistant Staphylococcus Aureus) is responsible for many serious skin and soft tissue Infections and for serious form of pneumonia. MRSA (Methyline Resistant Staphylococcus Aureus) infection can be fatal. Media as super bug because of its multiple drug resistance.3 has referred it In recent years, MRSA (Methyline Resistant Staphylococcus Aureus) has become a particularly significant problem in Indian hospitals. In one study conducted in tertiary care hospital in India, Methyline Resistant Staphylococcus

Aureus) MRSA (carriage rate ranged between 28.4%in out patients to 35 % in inpatients. MRSA is often seen in units such as trauma, burns, surgical, pulmonary and intensive care. These units are fertile environment for MRSA because of open wounds, frequent dressing changes requiring handling by multiple health care workers, use of intra luminal devices, and inherent immuno-compromised state of patients.3 Staphylococcus bacteria are commonly found in the skin or in the nose of about one third of population. Staphylococcus bacteria are generally harmless unless they enter the body through a cut or other open wound. Healthy people can be carriers and they pass germ to others. But in older adults and people who are ill or have weakened immune systems it causes serious illness called Methicillin-resistent Staphylococcus Aureus. MRSAs resistance to commonly used antibiotics has developed over time as a result of the widespread use of antibiotics, individuals who do not complete the prescribed course of medications, improper prescribing of antibiotics, and the sharing of medications. For many years, prescribing antibiotics was the standard of practice whether it was appropriate or not. Over time, the bugs have adapted to the drugs in their efforts to survive, and drugs that were once effective can no longer kill the organisms.4

The first documented MRSA outbreak in the United States occurred at a Boston hospital in 1968 but the disease was confined to hospitals and nursing homes for many years. Over the last decade it has started to emerge drastically in critical care units, operation theatres, etc. In 1990s, a type of MRSA began showing up in the wider community. Today, that form of staphylococcus known as CA-MRSA (Community Acquired Methiline Resistant Staphylococcus Aureus) is rapidly evolving bacteria and resistant to most of the antibiotics.5

A CDC (Centre for disease control) reports published in October 2007 issue of the Journal of American Medical association suggested that MRSA infections are more prevalent than previously thought. A strategy for National Health Service trusts (NHS) recommends options for specific patient groups and is drawn from approaches found to be practical and effective across various NHS clinical settings. There is good evidence and /or strong consensus that screening should be

applied to almost all patients including pre-operative patients, emergency, orthopaedic, trauma, critically ill patients, and patients on dialysis.6 Other patients include, all patients previously known to be MRSA positive, all elective surgical patients, oncology/chemotherapy patients, patient admitted from high-risk settings etc. Practising strict aseptic techniques, including hand washing, use of personal protective equipments and isolating the patients who are found to be MRSA positive helps to reduce the infection level at hospitals.6 6.1 NEED FOR THE STUDY

Hospitalisation can be an experience for the patients as being comforted and cared for. However it can be also an experience for anxiety and depression. There may be pain, disability and uncertainty for the patients; along with added up infection from the hospitals.

MRSA is usually introduced into an institution by a colonised or infected patient or health care worker. It is well known that colonisation with MRSA precedes infection. Several modes of transmission exist, including transient colonisation of hospital staff and contact with heavily contaminated fomites and environmental surface of the infected patients. Factors contributing to the transmission and perpetuation of this organism include prolonged hospital stay and use of several broad-spectrum antibiotics. Carriage of the pathogen by healthcare workers who can transmit the pathogen to the patients with whom they have contact also directly contributes to the continuance of the problem.4 As above-mentioned, the main mode of transmission includes hands of healthcare workers, environment, and air (less frequent). Major risk factors include, surgical and traumatic wounds, superficial skin lesions such as pressure sores ulcers and dermatitis, colonisation of nose or skin with MRSA, presence of invasive devices, prolonged hospital stay, extreme age, excessive use of antibiotics, patients at high units, immune response/immunosuppressive therapy, overcrowding and

staff shortage, inadequate facilities for hand washing, frequent transfer of patients and staff between units and hospitals.4 The National Nosocomial Infections Surveillance (NNIS) System of the Centre for Disease Control and Prevention (CDC) performed a survey from October 1986 to April 1998. They ranked hospital wards according to their association with central-line bloodstream infections. The highest rates of infection occurred in the burn ICU, the neonatal ICU, and the pediatric ICU. Nosocomial infections are estimated to more than double the mortality and morbidity risks of any admitted patient and probably result in as many as 70,000 deaths per year in the United States. This is the equivalent of 350,000 years of life lost in the United States. 7 The National Statistics department said that there is a sudden rise in the death rates due the people suffering from MRSA, the so-called hospital super bug. According to the latest figures MRSA is now six times more likely to be a factor in the deaths of people in National Health Service (NHS) hospitals. A total of 1,168 people had MRSA recorded on their death certificate as a principal cause of death or a contributory factor in 2004, a rise of 213 from 2003. Fears of lethal hospital infections such as MRSA are driving a record 50,000 patient a year abroad for treatment. Despite billions being poured into the Health Service, patients are now spending 163 million a year on medical services overseas. India, Hungary and Turkey are among the most popular destinations for medical tourists. So the health tourism also one factor, which invites infection, forms other countries to India.6 Incidence of MRSA infections is increasing due to unsanitary conditions in hospitals and over crowding. According to a survey conducted by Indian Medical Association, it shown that the incidence of MRSA in 1990s, as 0.5% is now has been increased to 3-4 % in tertiary hospitals. A study conducted in Hinduja Hospital about programme of MRSA surveillance in India, 739 culture swabs were taken from patients form different cities, 235 (32%) were found to be multiply resistant with the individual figures for resistance being (47%) Bangalore, 42.5 %( Delhi) and in 27 % (Bombay). MRSA is emerging to be a significant problem pathogen in the surgical setting with vancomycin probably the only reliable choice for these infections.10

A study was conducted in August1997, St Johns Medical college hospital, Bangalore in the burns unit, to determine the prevalence of MRSA in colonisation in health workers. 34 health care workers screened for the same using swab from hairline, nostril, axilla, and hands. 17 out of 34 screened were MRSA positive; 16 people tested positive for the methicillin- sensitive strain of, 7 of Staphylococcus Aureus them were also MRSA-positive at different site. In total, over two third of all healthcare workers were colonised by Staphylococcus Aureus.3 Treatment of MRSA is mainly by the drugs such as Mupirocin, Vancomycin, Teicoplanin etc, in which mupirocin is not even started available in India and the cost of vancomycin and teicoplanin is not affordable for poor people to have a complete course of particular medication. It is always prevention is better that cure. So its a high time for nurses to have knowledge about basic preventive measures of MRSA infection and its management. Also, student researchers own experiences from working with the isolation wards in an oncology unit, motivated need of giving awareness to the nurses regarding the knowledge of prevention and management of MRSA infections. 6.2 REVIEW OF LITERATURE Review of literature is the key step in research process. Literature review of present study has been collected and presented under following headings, 6.2.1 6.2.3 6.2.4 General information about MRSA infections. Role of health care professional in prevention and management of MRSA infections. Effectiveness of teaching programme/awareness of prevention and management of MRSA infections for nurses.

6.2.2 Incidence associated with MRSA infections

Literature related to;

6.2.1 General information about MRSA Staphylococcus aureus is a gram positive organism, usually found as normal flora of skin and mucous membrane of human. Pathogenic ones can cause severe infections. Staphylococcus bacteria are generally harmless unless they enter the body through a cut or other open wounds. It has been shown that because of gene mutation and long-term antibiotic use, some of the strains are become resistant to the penicillins and it is called MRSA (Methicillin resistant staphylococcus aureus). Experts so far uncovered 17 strains of MRSA, with differing degrees of immunity to the effects of various antibiotics. Two particular strains, clones 15 and 16, are thought to be more transmissible than the others, and accounts for 96%of MRSA bloodstream infections in UK.4 The main mode of transmission includes hands of healthcare workers, environment, and air (less frequent). Major risk factors include, surgical and traumatic wounds, superficial skin lesions such as pressure sores ulcers and dermatitis, colonisation of nose or skin with MRSA, presence of invasive devices, prolonged hospital stay, extreme age, excessive use of antibiotics, patients at high units, immune response/immunosuppressive therapy, overcrowding and staff shortage, inadequate facilities for hand washing, frequent transfer of patients and staff between units and hospitals.6 In 1990s, a type of MRSA began showing up in the wider community. Today, that form of staphylococcus known as CA-MRSA (Community Acquired Methyline Resistant Staphylococcus Aureus) is rapidly evolving bacteria and resistant of most of the antibiotics. The risk factors of CA-MRSA is young age especially children, participating in contact sports, sharing towels and athletic equipments, having a weakened immune system, living in crowded unsanitary conditions, recent hospitalisation and antibiotic use and association with healthcare workers etc.6 MRSA infections can cause a broad range of symptoms depending on the part of the body is infected. These may include surgical wounds, burns, catheter sites, eye, skin, and blood. Infection often results in redness, swelling and tenderness at the site of infection. Generally symptoms starts as small red bumps

that resemble pimples, boils or painful abscess that require surgical drain. Healthy individuals act as the carries of infections.6 Sample for screening is collected from anterior nares (nose).This is the most common carriage site for MRSA. Other sites include swabs from axilla, perineum and any skin lesions, if present. Three testing methods are in use in laboratories in UK: direct culture on an MRSA-selective agar, broth enrichment with sub culture, and PCR rapid test. In India broth enrichment with sub culture is widely used.6 Treatment is given with antibiotics such as mupirocin, vancomycin, teicoplanin, and other drugs are used as per sensitivity to the particular organism and per clinicians order. Chlorhexidine bath is also used for external decolonization. Three consecutive negative screening is done weekly, are required to declare MRSA negative.6 6.2.2 Incidence associated with MRSA The first epidemics caused by MRSA occurred in eastern Australia in the late 1970s and this, or a closely related organism, first became a clinical problem in England in 1980-1981, in the northeast Thames region. A survey conducted over a six-month period by the Staphylococcus Reference Laboratory revealed that by 1987-1988 this strain (Methyline Resistant Staphylococcus Aureus -1) was affecting 50 different hospitals. Eleven other epidemic strains were also identified during the survey, each affecting up to eight hospitals. In one year a single strain of MRSA, prevalent in south-east England, produced 40 infections, including bacteraemia, pneumonia, surgical wounds, and skin and urinary tract infections, and three attributable deaths in one acute hospital.6 The National Statistics department said that there is a sudden rise in the death rates due the people suffering from MRSA, the so-called hospital super bug. According to the latest figures MRSA is now six times more likely to be a factor in the deaths of people in National Health Service (NHS) hospitals. A total of 1,168 people had MRSA recorded on their death certificate as a principal cause of death or a contributory factor in 2004, a rise of 213 from 2003.6

A study conducted in department of Microbiology and Immunology, Choithram Hospital & Research Centre, Indore. MRSA prevalence increased from 12% in 1992 to 80.83% in 1999. Indian literature shows that MRSA incidence was as low as 6.9% in 1988 and reached to 24% and 32.6% in Vellore and Lucknow in 1994 and was of the same order in Mumbai, Delhi and Bangalore in 1996 and in Rohtak and Mangalore in 1999. However, in some of the centres it was as high as 87%.9 Sir Dorabji Tata Centre for Research in Tropical Diseases, Society for Innovation and Development, Indian Institute of Science Campus, Malleswaram, Bangalore, conducted a study on genotyping of methicillin-resistant Staphylococcus aureus strains from two hospitals in Bangalore, South India. Methicillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial pathogen in India, and up to 70% methicillin resistance has been reported from hospitals in various parts of India.11 6.2.3 Knowledge of nurses regarding prevention and management of MRSA A Study conducted by B.S.Coopler and B.S.Gibbler on Isolation measures in hospital management of MRSA shows that intensive control measures including patient isolation is effective in controlling MRSA. No well designed studies exist to that allows the role of isolation measures alone to be assessed. None the less, there is evidence that concerted efforts that include isolation can reduce MRSA even in endemic settings. Current isolation measures recommended in national guidelines should continue to be applied until further research establishes otherwise. A study conducted in Ninewells Hospital and Medical School, Dundee, UK, on infection control and management of MRSA: assessing the knowledge of staff in an acute hospital setting .The aim of this study was to assess the knowledge and perceived practice of staff regarding MRSA and its management in an acute hospital setting. A further aim was to determine what staff felt was needed in terms of information or education on the risks, management and treatment of MRSA. A questionnaire survey was carried out through group administration during a study day 9

and by face-to-face interviews. Subjects included in the questionnaire were regarding infection and colonization, treatment, and the availability of local support and advice. There were 174 responses, divided equally between doctors and nurses. Knowledge on many aspects of MRSA and its management was deficient, although the majority of participants who felt that they required additional information about MRSA acknowledged this.8 A study conducted in USA, at Society for health care Epidemiology of America (SHEA) on preventing nosocomial transmission of multi drug-resistant strains of Staphylococcus aureus. In spite of infection control practices followed in the hospital they noted that there is a steady rise of MRSA infections, a task force was appointed draft the evidence based guidelines in preventing nosocomial transmission of pathogens. This study has recommended contact precautions for patients colonized or infected with this type of pathogens. They recommend facilities should require this as a policy.12 6.2.4. Effect of teaching programme/awareness of MRSA infections for nurses. A study conducted on Contact precautions for Clostridium dificile and Methicillin-Resistant Staphylococcus aureus (MRSA) in School of Nursing and Midwifery, University of Southampton , and implications emerging from a single case study designed to explore a group of nurses' and healthcare assistants' infection control practice, and to introduce interventions aimed at implementing best practice. The study was undertaken on one hospital ward and the sample comprised all permanently employed nurses and healthcare assistants (n=18). Guidelines on Contract Precautions were developed and informed by an expert panel of infection control nurses (n=100) from across the UK. Analyses of the data from all three phases of the study revealed that participants experienced great difficulty comprehending infection control recommendations and varied in the extent to which they adopted them. Their capacity to understand and implement these recommendations was hampered, not only by a lack of knowledge, but also by irrational beliefs, inaccurate perceptions of risk, both in relation to themselves and patients, and a lack of ability or willingness to exercise clinical judgment, particularly in relation to glove use. It has shown that a structured protocol on contact precautions was effective in many

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implementing isolation precautions. These findings highlight the need for further study in the drive to improve this crucial aspect of health care services.14 A study was conducted on Impact of education on knowledge, attitudes and practices among various categories of health care workers on nosocomial infections, Department of Microbiology, Mysore University, Karnataka. A total of 150 subjects were included. A scoring system was devised to grade the Knowledge, Attitude and Practice Score. (KAP score). They were further subjected to a series of similar questionnaires at intervals of 6, 12 and 24 months after an education module. Subjects in each category of staff (n=10) were observed for compliance to hand washing practices in the ward in the post-education period. Total compliance was 63.3% and ward aides were most compliant 76.7% Education has a positive impact on retention of knowledge, attitudes and practices in all the categories of staff. There is a need to develop a system of continuous education for all the categories of staff. In order to reduce the incidence of nosocomial infections, compliance with interventions are mandatory.15

6.3 STATEMENT OF PROBLEM A Study to Assess the Effectiveness of Structured Teaching Module for Nurses on Knowledge Regarding Prevention and Management of MRSA (Methyline Resistant Staphylococcus Aureus) Infections at Selected Hospitals of Bangalore.

6.4 THE OBJECTIVES OF THE STUDY

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1. To assess the knowledge of nurses regarding prevention and management of MRSA infections. 2. To determine the effectiveness of structured teaching module among nurses regarding MRSA infections. 3. To find the association between post test knowledge scores and their selected socio demographic variables. 6.5 RESEARCH HYPOTHESES H1: There is significant difference between pre-test and post-test level of knowledge of nurses. H2: There is significant association between knowledge and sociodemographic variables.

6.6 OPERATIONAL DEFINITION: 1. Effectiveness : Refers to gain in knowledge by nurses regarding MRSA infections as determined by significant difference in pre-test and posttest knowledge as measured by a questionnaire. 2. Structured teaching module : It refers to systematically organised teaching strategy for a duration of one hour on prevention and management of MRSA infections. 3. Knowledge : Ability to give correct response to questions asked by investigator measured by structured knowledge questionnaire 4. MRSA prevention and management : It refers to measures to be taken to avoid the occurrence infections in the hospitals and management modalities by nurses by various methods. 5. Nurses : Registered nurses working in different units of

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Hospitals for the study

7. MATERIALS AND METHODS

7.1 Sources of data: Registered Nurses working in different units in selected hospitals for study. 7.2 METHODS OF DATA COLLECTION 7.2.1 Type of study approach : 7.2.2 Research design 7.2.3 Variables under study : : structured teaching module Knowledge of Nurses Age, socio economic status, gender, professional qualification, experience, previous exposure, experience, religion ,habitat. 7.2.4 Sampling technique 7.2.5 Sample size 7.2.6 Follow up : : : Non probability convenient sampling technique 50 nurses. A post test knowledge assessment will be done after administering teaching module after 10 days and subsequent follow up is not done. 7.2.7 Comparison parameters : 7.2.8 Duration of the study 7.2.9 INCLUSION CRITERIA : Comparison between pre-test and post- test knowledge scores. One month. Evaluative study One group pre-test post-test preexperimental design

Independent variable :Dependent variable :Attribute variables :-

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Registered nurses who are working in different units in selected hospitals of Bangalore Nurses who are qualified with diploma/or degree certificate. Nurses who are available during the period of data collection.

EXCLUSION CRITERIA Nurses who are not willing to participate in the study Nurses who have already undergone training programme on management of MRSA Infections. 7.2.10 INSTRUMENTS USED 1. Section A : Socio-demographic variables consisting of age, gender, professional qualification, socioeconomic status, religion, previous exposure, habitat etc. 2. Section B : Structured knowledge questionnaire regarding various aspects of prevention and management of MRSA infections.

7.2.11 Data collection procedure After obtaining permission from the concerned authority, the investigator will take written consent from the participants and explain the purpose of the study and questionnaire will be administered followed by administration of a teaching module and a post-test will be conducted after one week, subjected for data analysis. 7.2.12 Statistical methods used:

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The data obtained will be analysed in terms of objectives of the study using descriptive and inferential statistics. The plan of data analysis is follows: Descriptive statistics - Frequency and percentages will be used to analyse the socio-demographic data, and knowledge scores. Mean, mean statistics, median and standard deviation of pre test and post

test knowledge scores, will be used to assess the knowledge. Inferential statistics: Paired test to assess the effectiveness of structured teaching module on knowledge regarding prevention and management of MRSA infections. Chi-square to determine the association between post test knowledge and selected socio-demographic variables.

7.3 Does the study require any investigation or intervention on patients or other humans/ animals. If so please describe briefly? Yes, structured teaching module regarding prevention and management of MRSA infections will be provided and knowledge will be assessed. 7.4 Has ethical clearance been obtained? Ethical clearance will be obtained from concerned authority and the ethical committee. Written consent will be obtained from the subjects. Confidentiality and anonymity of the subject will be maintained.

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8. LISTS OF REFERENCES
1. Spink VW, Ferris V. Quantitative action of penicillin inhibitor from penicillinresistant strain of Staphylococcus. Science 1945; 102: 102-221. 2. Jevons MP. Celbenin-resistant staphylococci. BMJ 1961; 1: 124-25. 3. Krishnan Unny Prabha, Aravind Preetha. Screening of burns unit staff of a tertiary care Hospital for MRSA colonization.Indian J Crit Med 2000; 10: 16-41 4. Vaghela G, L Shah,.M patel,S Mulla. Study of antibiotic sensitivity pattern of Methicillin- resistant Staphylococcus aureus. Indian J Crit Care Med 2007; 11: 99-10.

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5. Barrold SS. Emeregnce of mrsa infections. 1998 jan-mar (cited 1999dec 10):1(2);available in www.cdc.gov/ncidod/dhqp/ar_mrsa_ca_public.html. 6. Griffith A. NHS Scottish Health Technology Assessment Report.2006 (cited in 2006jJune) available in www.dh.gov.uk.reduorgmrsa 7. B S Cooper, S P Stone, C C Kibbler. Isolation measures in the hospital management of methicillin resistant Staphylococcus aureus (MRSA). BMJ 2004 Sep 4; 329(7465): 533 8 P.M. Easton, A. Sarma, F.L.R. Williams. Infection control and management of MRSA: assessing the knowledge of staff in an acute hospital setting. Journal Hosp Infect 2007;66(1): 29-33 9 Verma S, Joshi S, Chitnis V, Hemwani N. Growing problem of methicillin resistant staphylococci--Indian scenario. Indian J Med 1996;42(1):1-3 10 Metha A,Rodrigues C,Kumar R, et al .A pilot programme of MRSA surveillance in India. Journal of PG Med 1996; 42:1-3

11 Gayathri Arakere, Savitha Nadig, Swedberg. Genotyping of MethicillinResistant in Staphylococcus aureus Strains from two Hospitals Bangalore.Journal of clinical microbial 2005;43: 3198202 12 SHEA guigeline for preventing nosocomial transmission of multidrug- resistant strains of Staphyloccus aureus ,Infect Control Hosp Epidemiol 2003; 24(5):362-386 13 Srinivasan S, Sheela D, S, Mathew. Risk factors and associated problems in the management of infections with methicillin resistant Staphylococcus aureus. Indian J Med Microbiol 2006; 24:182-5

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14. Jacqui Prieto. Contact precautions for Clostridium difcile and Methicillin-resistant Staphylococcus aureus (MRSA), Assessing the impact of a supportive intervention to improve practice. Journal of Research in Nursing 2005; 10(5):511-26 15. Suchitra JB, Lakshmi Devi N. Impact of education on knowledge, attitudes and practices among various categories of health care workers on nosocomial infections. Indian J Med Microbiol 2007; 25:181-7

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Signature of the Candidate Remarks of the Guide The study highlights the major responsibilities of nurses during blood transfusion. Very few studies are found in this area. Hence it is feasible study to conduct. Mrs. Prof. PRATIBHA SWAMY PROFESSOR AND HOD

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Name and Designation of: (in Block Letters)

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MEDICAL SURGICAL NURSING 11.1 11.2 11.3 11.4 11.5 11.6 12.1 GUIDE SIGNATURE CO-GUIDE (If any) NIL SIGNATURE Head of the Department. Signature. Remarks of the Chairman and Principal. Signature. 12.2 The synopsis of this study broadened the current nursing practice and it is feasible and relevant.

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