| Objective To prevent nosocomial infections for childhoodcancer patients by risk management process(Risk identification、Risk assessment、Risk control and Evaluation)Methods1. Risk identificationSeven hundred and seventeen cases of 124 childhood cancer patients hospitalized from 2013 to 2014 were retrospectively analyzed to collect data on nosocomial infections. Relevant factors and the direct ecomonic losses of nosocomial infections were analyzed in a case-control study.2. Developing risk assessing process and risk control measuresOn the basis of previous studies, combined with literature review and panel discussion, risk factorsof nosocomial infectionswere initially chosen. Then based on these factors, a questionnaire was developed,and 2 rounds of expert consultations were implemented among 24 experts(8 doctors,8 nurses, and 8 professionals of infection control) from 8 hospitals allocated in 6 provinces in China. Each item in the questionnaire was ranked on a 0-6 scale with 0 for total disagreement and 6 for total agreement. These items were revised and confirmed bylevel of agreement of experts.Criteria of consensus were defined as Means≥3.0 or Coefficient of variation(CV)≤0.5. Based on the items that remained after two rounds of consultation, risk assessment processes and risk control measures were initially formulated by panel discussion and literature review.3. Risk managing and evaluation of effectivenessRisk management of nosocomial infection was implemented in a prospective interventional study. A total of350 cases of 75 childhood cancer patients hospitalized in 2015 were enrolled as intervention group, while 717 cases hospitalized in 2013 and 2014 as control group. The effectiveness of risk management was evaluated by comparing the two groups’data on nosocomial infection and economic losses caused by nosocomial infections.Results1. Results of risk identification1.1Data on nosocomial infection of childhood cancer patients hospitalized in 2013-2014 Sixty-one in 124 patients occurred nosocomial infection at least once during times of hospitalization, and the proportion was 49.19%. There were 125 cases of nosocomial infection in 717 cases, and the infection rate is 17.43%. Daily point infection rates increased day by day during the hospital stay, with a range of 1.67%-46.15%. Periodical infection rates were 19.55%-46.15%.Infection occurred mainly at sites of blood system (26.40%), upper respiratory tract (24.00%) and lower respiratory tract (16.00%). As to pathogens of infections, Gram-negative bacilli were detected mostly and accounted for 47.27%, fungi for 29.09%, and Gram-positive bacteria for 23.64%, respectively. Antibiotics were administrated for 16 days during nocosomial infections, and the time of administrating only one kind of antibioticwas 4.5 days, two kinds of antibiotics 4 days,3 kinds of antibiotics 1 days, and special antibiotics 9 days, respectively.1.2Relevant factors of nosocomial infections in childhood cancer patients Age, gender, season of hospitalization had no correlationship with nosocomial infection. Diagnosis was validated as a relevant factor. The infection rates of leukemia, lymphoma, and other types of malignant tumors were 20.00%,14.84%, and 10.54%, respectively. Frequencies of chemotherapy, blood transfusion, and stem cell infusion differed between the infected group and non-infected group, and the differences were statistically significant.Binary Logistic regression showed that diagnosis type, chemotherapy, blood transfusion and stem cell transplantation came into the regression equation, the OR values of them were 1.48,1.63,2.13 and 18.18, respectively.1.3 Direct economic losses caused by nosocomial infectionThe hospitalization expense of infected group was 2.43 times of non-infected group, Infected group paid more 20072.76 Yuan than non-infected group, in which 13545.29 Yuan for drugs, 3320.00 Yuan for blood transfusion, and 1365.50 Yuan for laboratory tests. The average length of hospital stay was 24.79 days for infected group and 15.68 days for non-infected group. So infected group stayed inhospital for more 9.11 days than non-infected group.2. Results of developing risk assessing process and risk control measures2.1 Preliminarylychosen of risk factors of nosocomial infections in childhood cancer patients Based on results of the first part, literature review and summary of clinical experience,37 items of seven domains were chosen out through panel discussion.2.2 Results of experts consultation2.2.1 Authority coefficients, positive coefficients and coordination coefficientsof experts The means of authority coefficients of experts was 0.79, the positive coefficient of experts was 1.00 for the first-round consultation and 0.96 for the second-round consultation. Kendall coefficients of the first and second-rounds were 0.22 and 0.34 respectively, with P value less than 0.01.2.2.2Results of the first round of experts consultation Mean scores of 37 items in the first-round consultation were 2.25-4.96, and coefficients of variation were 0.78-0.04. Nine items were deleted by the criteria of expert consensus,4 new items were developed by the proposalsfrom experts and a total of 32 itmes entered the second-round of consultation.2.2.3Results of the second round of experts consultation Mean scores of 32 items in the second-round consultation were 3.39-4.77, and coefficients of variation were 0.12-0.41. Nine items were deleted by the criteria of expert consensus and 23 items went into the third-round of the consultation.2.3Risk assessment and risk control measures of nosocomial infections in childhood cancer patients Item 1 (Diagnosis), Item 4 (Routine blood test) together with Hospital stay were chosen as classificating factors to screen out early-stage, mid-stage and late-stage high-risk groups of nosocomial infections. Item 2 (Chemotherapy) and Item 5 (Body mass index) were deleted. Item 10,13,14 and 26 wereused to make basic risk control measures. The other 14 items were seen as risk factors of infections, based on which a nursing checklist of risk factors for nosocomial infection in childhood cancer patients was developed.2.3.1 Risk assessment of nosocomial infections in childhood cancer patients Risk assessment measures comprised two parts:Part 1was to screen out high-risk groups and Part 2 to screen out risk factorsof nosocomial infections. The process to screenout high-risk groups was:children with leukemia and children with white blood cell count less than 4×109were seen as early-stage high-risk population.When children’s white blood cell counts were less than 2×109during hospital stay, they were listed as the mid-stage high-risk population. Children hospitalizedfor more than 18 days were all seen as late-stage high-risk population. The nursing checklist of risk factors for nosocomial infection in childhood cancer patients was used daily to screen out risk factors on the early-, mid-, and late-stage high-risk patients.2.3.2Risk control measures of nosocomial infections in childhood cancer patients These measures were summarized as basic measures and targeted measures. The basic risk control measures were applicable to all children with malignant tumors, which included the following three parts:(1) Changing doctors’ behaviors that may put children into dangers of nosocomial infections, (2) Changing nurses’ behaviors that may put children into dangers of nosocomial infections, (3) Improvingchildren and their relatives’ awareness of infection prevention by health education. Targeted measures of risk control were applicable to early-, mid- and late-stage high-risk populations. The targeted measures included:(1) Daily screening risk factors of infection by the nursing checklist as mentioned before; (2) Developing individualized and tailored measuresto diminish risk factors that screened out; (3) Evaluatingand trackingchanges of risk factors, findingout the failure reason, and improving interventions. (4) Protective isolation:It was recommended to living in a laminar flow bed or a single-bed ward for the mid-stage and late-stage high-risk groups. For patients with stem cell transplantation, they nust be admitted in alaminar flow ward.3. Evaluation of the effectiveness of nosocomial infection risk management in childhood cancer patients3.1 Demographics of intervention group There were 350 cases from 75 patients in the intervention group. The proportions of ages, genders and diagnosesof the intervention group had no difference with the control group. In accordance with the established risk assessing process,231 cases were screened out as early-stage high-risk groups,179 cases as mid-stage high-risk groups, and 157 cases as late-stage high-risk groups, respectively.3.2 Comparation of nosocomial infections between the intervention group and control group.3.2.1 Comparation of rates of nosocomial infections between the two groups After intervened with the established measures of risk management,25 of 75 children in the intervention grouphad nosocomial infections.The ratio (33.33%) was lower than the control group (49.12%), and the difference was statistically significant. Nosocomial infections happened in 43 of 350 cases in the intervention group.The ratio(12.29%) was lower than the control group (17.43%), and the difference was statistically significant. The daily point infection rates of 3-28day in hospital were 0-25.64%, and the periodical infection rates were 15.36%-25.64%. The rates were all lower than the control group, and the differences were statistically significant.3.2.2Comparation of sites of nosocomial infections between the two groups Compositions of sites of nosocomial infectionsof 43 infected cases in the intervention groupwas different withcontrol group, and the difference was statistically significant(x2=32.97, P< 0.01).The intervention group had lower incidencesof different sites of nosocomial infection than the control group, and the incidence of upper respiratory tract infection was reduced from 4.18% to 1.43%(P <0.01).3.2.3 Comparation of pathogens of nosocomial infections between the two groups In the intervention group,15 of 43 cases of hospital infections had positive results of bacterial cultures, among which 2 cases were detected out 2 kinds of pathogens and 2 cases were detected out 3 kinds of pathogens.So the total pathogens detected out were 21 cases. Among these pathpgens,13 wereGram negative bacteria, 5 were Gram positive bacteria and the other 3 were fungi. The rate of fungal infection in the intervention group was 0.86%, lower than 2.23% in the control group, but the difference was not statistically significant.3.2.4Comparation of antibiotics administration in cases of nosocomial infections between the two groups For infected cases in the intervention group, antibiotics were administrated for 16 days totally.The time of administrating only one kind of antibiotic was 4 days, two kinds of antibiotics were adiministrated for 3 days,3 kinds of antibiotics for 2 days, and special antibiotics for 4 days, respectively. There was no difference with the control group except that the time of administrating special antibiotic decreased 5 days.3.2.5Comparation of nosocomial infections in patients with high-risk of infections between the two groups Infection rates of high-risk population in the intervention group were lower than those in the control group, the statistically significant differences were:Early-stage high-risk population of leukemia children’s infection rate was 11.61%, which was lower than the control group (20.00%). intervention group interim infection in mid-stage high-risk groups (WBC<2.0 x 109) infection rate was 27.32%, lower the control group(31.91%).3.3 Direct economic losses of nosocomial infections in the intervention group In the intervention group, the total cost of hospital infection was 46877.80 Yuan, and the non infection cases were 15884.58 Yuan, the former was 2.95 times of the latter, and the difference was 30993.22 Yuan, while the difference between the control group and the non infected group was 20072.76 Yuan. The intervention group increased by nearly ten thousand yuan than the control group(P<0.01).In the intervention group, infected patients stayed in hospital for 26.72 days, while non-infected patients for 16.36 days. Hospitalization was prolongedby 10.36 days when nosocomial infections happened, and this datum was quite similar to9.11 days in the control group.Conclusion1.Nosocomial infection rate of childhood cancer patients was quite high. Nosocomial infections happened mainly in blood system, at upper and lower respiratory tract. Main pathogens of these infections were gram negative bacteria and fungi. Relevant factors of nosocomial infectionsincluded length of hospital stay, diagnosis type, chemotherapy, blood transfusion, stem cell transplantation, white blood cell count and neutrophil cell count, platelet count, erythrocyte count and hemoglobin.2. Based on risk management procedures, prevention of nosocomial infections for childhood cancer patients comprisedrisk assessment and risk control. The risk assessment included:screening out high-risk populationand screening out risk factors.Risk control included:basic risk control measures and targeted risk control measures, basic risk control measures were applicable to all children, and the risk control measures wereapplicable to children at high risk of infection.3. Based on risk management procedures, prevention of nosocomial infections for childhood cancer patientsdecreased the incidence of nosocomial infection, reduced the proportion of upper respiratory tract infection, reduced the infection rates of early-, mid-, and late-stage of high-risk patients.The purpose of this study was basically achieved. But this study did not decrease the administration of antibiotics in infected cases, and it did not reduce the direct economic losses caused by hospital infections too. |
PDF Full Text Request