A Study to Evaluate the Effectiveness of Planned

"A STUDY TO EVALUATE THE EFFECTIVENESS OF PLANNED

TEACHING PROGRAMME ON THE KNOWLEDGE OF

RECORDING AND INTERPRETATION OF

ELECTROCARDIOGRAM(ECG) AMONG STAFF NURSES

WORKING IN SELECTED INTENSIVE CARE UNITS (I.C.U) OF

SELECTED HOSPITALS IN TUMKUR .”

PROFORMA FOR REGISTRATION OF SUBJECT FOR THE

DISSERTATION

SUBMITTED BY

NIDIGANTLA SUBRAHMANYAM

MEDICAL SURGICAL NURSING

2012-2013

SRI SIDDHARTHA COLLEGE OF NURSING

AGALKOTE, B.H. ROAD

TUMKUR

1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 NAME OF THE Mrs. N.SUBRAHMANYAM CANDIDATE & I YEAR M.Sc NURSING ADDRESS SRI SIDDHARTHA COLLEGE OF NURSING, AGALKOTE, TUMKUR 2 NAME OF THE SRI SIDDHARTHA COLLEGE INSTITUTION OF NURSING,B.H ROAD,TUMKUR 3 COURSE OF THE DEGREE OF MASTER OF STUDY & SUBJECT NURSING MEDICAL SURGICAL NURSING 4 DATE OF ADMISSION 13-08-12

5 TITLE OF THE TOPIC "A STUDY EVALUATE THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON THE KNOWLEDGE OF RECORDING AND INTERPRETATION OF ELECTROCARDIOGRAM(ECG) AMONG STAFF NURSES WORKING IN SELECTED INTENSIVE CARE UNITS (I.C.U) OF SELECTED AREAS IN TUMKUR DISTRICT"

2 6 BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

“Cardiovascular disease (CVD) is the world's leading killer, accounting for 17 million or 30 per cent of total global deaths in 2010.1 CVD alone accounts for one-quarter of all deaths in low mortality low-income countries. Non-communicable diseases such as cancers, neuropsychiatric and cardiovascular diseases now kill greater numbers of people in the lower-income countries than they do in high-income countries.2 While deaths from heart attacks have declined more than 50 per cent since the 1960s in many industrialized countries, 80 per cent of global cardiovascular diseases related deaths now occur in low and middle-income nations, which covers most countries in Asia. In India in the past five decades, rates of coronary disease among urban populations have risen from 4 per cent to 11 per cent.1

Introduced in 1902 by Einthoven, electrocardiography is the graphical display of electrical potential differences of an electric field originating in the heart as recorded at the body surface.3 As a record of electrical activity of the heart; it is a unique technology that provides information not readily obtained by other methods. The procedure is safe, simple, and reproducible; the record lends itself to serial studies; and the relative cost is minimal.

There are numerous potential clinical uses of the 12-lead ECG. The ECG may reflect changes associated with primary or secondary myocardial processes (e.g., those associated with coronary artery disease, hypertension, cardiomyopathy, or infiltrative disorders), metabolic and electrolyte abnormalities, and therapeutic or toxic effects of drugs or devices Electrocardiography serves as the gold standard for the noninvasive diagnosis of arrhythmias and conduction disturbances, and it occasionally is the only marker for the presence of heart disease. As a research tool, it is used in long-term

3 population-based surveillance studies and in experimental trials of drugs with recognized or potential cardiac effects.4

The technological development of powerful personal computers enabled the development of extremely sophisticated signal processing algorithms, introducing another dimension in the usefulness of ECG recordings. Analysis of RR intervals; QRS and T-wave morphology, including late potentials; QT dispersion; and T-wave alternans are currently being evaluated as prognostic markers in patients with structural heart disease. In addition, transtelephonic monitoring of implanted devices has become a standard technique of evaluating and following patients5.

Electrocardiograms are interpreted by Physicians and Nurses in many specialties, including cardiology, internal medicine, family practice, and emergency medicine.

Interpretative skills vary among specialists .An adequate knowledge base should include the ability to define, recognize, and understand the basic pathophysiology of certain electrocardiographic abnormalities6.

Ensuring correct recording of ECG is imperative on the part of Nurses and technicians.

Because it helps the Physician and Nurse to correctly interpret recordings and take appropriate measures. Operators recording ECGs should ensure that chest leads are placed in the proper position and electrodes make good skin contact to minimize artifacts. Incorrect placement of pericardial leads may lead to a false diagnosis of infarction. The reversal of limb leads and the switching of precordial leads have been well-documented to cause alterations in ECGs 7

Several studies have examined the accuracy of computer ECG interpretation programs and have suggested that computer analysis cannot substitute for physician interpretation of ECGs. A systematic study of computerized ECG interpretation performed in 1991 demonstrated that computer programs were 6.6% less accurate, on average, than cardiologists at identifying ventricular hypertrophy and myocardial infarction (MI) 8.

4 Eectrocardiographic interpretation requires a basic knowledge of electrocardiographic technology, cardiac anatomy, and cardiac physiology as well as the ability to recognize diagnostic patterns on a 12-lead tracing

.Correctly recorded and interpreted ECGs will undoubtedly unearth the hidden changes associated with primary or secondary myocardial processes, metabolic and electrolyte abnormalities, and therapeutic or toxic effects of drugs or devices and aid the Physician and the Nurse to intervene promptly and save many precious lives

6.2 Need for the study:

According to world health organization (WHO), at least twenty million people survive heart attacks and strokes around the world every year; many require continuing costly clinical care9.

British Heart Foundation’s 2009 statistics revealed Cardio Vascular Disease (CVD) accounted for more than 276,000 deaths in the United Kingdom (UK) in 2009. Thirty- nine percent of deaths are from CVD, and 36 percent of premature deaths in men and 27 percent in women are from CVD10

European Cardio Vascular statistics of 2008 showed that each year CVD causes over

4.85 million deaths in Europe and over 2.1 million deaths in the European Union (EU).

It causes nearly half of all deaths in Europe (51 percent) and in the EU (44 percent). It is the main cause of death in women in all countries of Europe and is the main cause of death in men in all countries except France and San Marino. It is the main cause of years of life lost from early death in Europe and the EU – around a third of years of life lost

11 are due to CVD

Heart and Stroke Foundation of Canada web site revealed that every seven minutes, a

5 Canadian dies of heart disease and stroke. CVD accounts for more deaths than any other disease that is, 36 percent of male deaths and 38 percent of female deaths. It costs the

Canadian economy about $18.4 billion annually12

The World Health Organization (WHO) estimates that 60 per cent of the world's cardiac patients will be Indian by 2010. Dr Timothy Gill, an Asia-Pacific specialist with the International Obesity Task Force, a medical NGO that coordinates with the WHO on obesity issues feels that of all Asians, South Asians have by far the worst problems when it comes to heart disease Nearly 50 per cent of CVD-related deaths in India occur below the age of 70, compared with just 22 per cent in the West. This trend is particularly alarming because of its potential impact on one of Asia's fastest- growing economies. In 2008, for example, India lost more than six times as many years of economically productive life to cardiovascular disease than did the U.S., where most of those killed by heart disease are above retirement age1.

In India it is estimated that at least 800,000 people die of heart attacks every year. About 5 out In India it is estimated that at least 800,000 people die of heart attacks every year. About 5 out of every 11 patients die after getting heart attacks,

13 mostly within 1 hour before medical aid can reach them

Coronary artery disease has progressively increased among urban Indians during the last half a century and it affects people at younger age. India has the highest incidence of

CAD in the world and the incidence is expected to reach epidemic proportions in the next few decades14.

The electrocardiogram (ECG) is one of the most widely used and useful investigations in contemporary medicine. It is essential for the identification of disorders of the cardiac rhythm, in various general conditions like head injury, poisoning, accidents, drowning, surgical complications, electrolyte disturbance etc. But it is specifically useful for the

6 diagnosis of abnormalities of the heart such as Myocardial infarction (M.I), Coronary artery disease etc Nurse working in an ICU is one of the most trained personnel who possess specialized skills to provide care for these critically ill patients. Out of the many procedures she performs, she is required to have a working knowledge on electrocardiogram (ECG) i.e. correct recording and interpretation of ECG. She is in a unique position to provide 12 lead ECG and initiate an appropriate response. Key elements of 12 lead ECG interpretations and their application to established guidelines are essential skills for nurses working in ICU’s frequented by patients with serious problems15.

The investigators during their clinical experience in TUMKUR Hospital noticed deficit in the levels of knowledge of recording and interpretation of ECG by nurses in

ICUs. In view of this need, the investigators strongly felt that every nurse working in the

ICU should have adequate knowledge on the recording and interpretation of ECG so that precious lives could be saved. Planned teaching programme is a logical solution for this problem and would greatly help these nurses to equip them in the correct recording and interpretation of ECG.

6.3 REVIEW OF LITERATURE:

This chapter deals with review of literature which helps to gain an insight into various aspects of the problem under study, its objectives, appropriate research design, methods, instrument measures and techniques of data collection that may prove useful in the proposed project.

The review of literature provides a basis for future investigations, justifies the need for replication, throws light on the feasibility of the study, indicates constraints of data collection and helps to relate findings of one study to another. It also helps to establish a

7 comprehensive body of scientific knowledge in a professional discipline from which valid pertinent theories may be developed.16

In the present study, the research investigator has carried out different types of Literature review at different stages of his research process and presented under the following headings:

1. Studies supporting recording of electrocardiogram (ECG).

2. Studies supporting interpretation of electrocardiogram (ECG)

3. Studies supporting planned teaching programme

Studies supporting the recording of electrocardiogram

An observational study was done on a randomly selected sample of 185 patients in an emergency setting on the appropriate recording of the electrocardiogram, it was found that moving location of electrodes from the standard limb lead position to the trunk, by placing the arm leads on the anterior ‘acromial region’ and the leg leads in the ‘anterior superior iliac spine’ resulted in difference in amplitudes within 5% of the values of standard recordings in 99.6 of all wave forms. It is prudent that a uniform approach for placing the limb leads needs to be adopted with the provision that when a modification is used for special reasons (patients with tremors), some information is entered on the ECG record and included as part of the ECG’s interpretive report 17

A Comparative study was done on a convenient sample of 184 patients in Kingston hospital, New Jersey. The purpose of the study was to compare the proposed new method using a 6-lead ECG BELT for precordial application to the standard 12 lead

ECG method to determine the level of agreement among automated interpretations. The results indicated that BELT and standard automated interpretations disagreed significantly more frequently than repeat standard recording automated interpretations of

8 the cardiac rhythm. The study suggested that the ECG BELT is not adequate for clinical application in its current form 18

An Evaluative study was done on the usefulness of leads aVR and −aVR as well as on the history of the frontal leads in electrocardiography. Results revealed that Lead aVR and particularly, lead −aVR, provide useful information when systematically analyzed.

In addition, if lead −aVR is examined in its anatomically logical sequence, ie, aVL, I,

−aVR, II, aVF, and III, the frontal plane of the 12-lead ECG is more easily understood.

The study showed that ECG interpretation would be enhanced by displaying the limb leads in an orderly arrangement that starts with lead aVL and ends with lead III, and many ECG changes would be ideally displayed by a lead −aVR at 30° 19.

An evaluative study was done on one hundred forty-nine consecutive patients admitted to neurology department of an University Hospital Geneva, Geneva, Switzerland with an acute stroke or TIA. The purpose of the study was that 7-day ambulatory ECG monitoring using an event-loop recording (ELR) device would detect otherwise occult episodes of atrial fibrillation and flutter (AF) after acute stroke or transient ischemic attack (TIA). The results revealed that Standard ECG identified AF in 2.7% of the cases at admission (4/149 patients) and in 4.1% of remaining patients within 5 days (6/145).

Holter disclosed AF in 5% of patients with a normal standard ECG (7/139 patients), whereas ELR detected AF in 5.7% of patients with a normal standard ECG and normal

Holter (5/88 patients). The study concluded that ELR identified patients with AF, who remained undetected with standard ECG and with Holter. ELR should, therefore, be considered in every patient in whom a cardioembolic mechanism is suspected. 21

A randomized clinical trial on 174 patients in general practice was done in Amsterdam

Netherlands. The objective of the study was to test the diagnostic yield of Patient- activated memo event recorders in diagnosing episodes of cardiac arrythmias in patients with palpitations or light-headedness. The results revealed that there were fewer patients

9 without a diagnosis in the intervention group (17% vs. 38%; RR = 0.5, 95% CI 0.3 to

0.7) and more patients with a cardiac diagnosis (67% vs. 27%: RR 2.5, CI 1.8 to 3, 5).

More relevant cardiac arrhythmias were detected (22% vs 7%) with event recording than with usual care (RR 3.2, 95% CI 1.5 to 6.8). The study concluded that the Patient- activated loop recorders are feasible and effective diagnostic tools in patients with palpitations or light-headedness in primary care22.

Studies supporting interpretation of electrocardiogram

A cluster randomized controlled trial on 14, 802 patients aged 65 or over was conducted in 50 primary care centers in England. The purpose of the study was to assess whether screening improves the detection of atrial fibrillation (cluster randomisation) and to compare systematic and opportunistic screening. The results revealed the detection rate of new cases of atrial fibrillation was 1.63% a year in the intervention practices and

1.04% in control practices. Systematic and opportunistic screening detected similar numbers of new cases. The study concluded that Active screening for atrial fibrillation detects additional cases over current practice. The preferred method of screening in patients aged 65 or over in primary care is opportunistic pulse taking with follow-up electrocardiography23

An experimental study was done on 117 persons consecutively admitted to a coronary care unit in a community hospital, Toronto, Canada. The objective of the study was to find out the usefulness of three additional electrocardiographic chest leads (V7, V8, and

V9) in the diagnosis of acute myocardial infarction. The results of the study revealed that among the 46 (39%) with a proven acute myocardial infarction the electrocardiograms

(ECGs) of 9 (20%) showed ST-segment elevation or abnormal Q-waves, or both, in the three additional leads. In six of the nine, such changes were associated with signs of anterolateral or inferior wall infarction (in three each) on the standard 12-lead ECG.

10 Thus the study showed that additional chest leads are helpful in detecting myocardial injury of necrosis in areas of the heart not properly reflected on the standard 12-lead

ECG. this study was performed to evaluate the sensitivity of ST-segment elevation of standard and extended ECG leads in a cohort of patients with angiographically confirmed diagnosis of AMI 25.

A Cohort study conducted on 47 patients with end stage renal failure undergoing hemodialysis sessions with the objective to evaluate the responses of P-wave, R waves, and host of other electrocardiogram (ECG) changes to the procedure. The results showed after hemodialysis (HD), significant ECG changes precipitated by hemodialysis included an increase in the  P,  QRS, mean, QRS duration, maximum P-wave duration, measured in lead II. Lead II was the lead with the longest P-wave duration in 36 patients

(76.5%) 26.

An evaluative study on 2112 randomly selected standard 12-lead ECGs was done in

Nelson’s hospital, England. The purpose of this study is to determine the accuracy of

ECGC rhythm interpretation in a typical patient population. The results revealed that the

ECG-C correctly interpreted the rhythm in 1858 and incorrectly identified the rhythm in

254 (overallaccuracy, 88.0%). Sinus rhythm was correctly interpreted in 95.0% of the

ECGs (1666/1753) with this rhythm, whereas nonsinus rhythms were correctly interpreted with an accuracy of only 53.5% (192/359) (P < .0001). Thus the study concluded that ECG-C demonstrates frequent errors in the interpretation of non sinus rhythms. In addition, incorrect rhythm interpretation by the ECG-C was frequently further compounded by additional major inaccuracies. Expert over reading of the ECG remains important in clinical settings with a high percentage of non sinus rhythms 27.

An evaluative study on the Value of Troponin-T Test in the Diagnosis of

11 Acute Myocardial Infarction was conducted at Dr. SN Medical College and associated group of Hospitals in 156 patients of acute myocardial infarction reaching within 24 hours of onset of symptoms. Serial ECG changes were considered as gold standard for the diagnosis of myocardial infarction. The results of the study revealed that, sensitivity

(64.7%) and specificity (71.4%) of troponin-T test was higher than CPK-MB (54.9% and

42.8%) and SGOT (31.3% and 57.0%) respectively. The study concluded that bedside troponin-T test is highly sensitive and specific in the diagnosis of acute myocardial infarction and can be used in emergency and ambulatory settings33.

An observational study on a randomized sample of 84 was done at All India Institute of

Medical Sciences. The objective of the study was to determine the role of ECG in the recognition of Left septal fascicular block. The study concluded that Left septal fascicular block is a polymorphic conduction defect which may explain some previously inadequately understood electrocardiographic abnormalities34.

Studies supporting planned teaching programme:

A Pre experimental study was conducted on a purposive sample of 45 to assess the effectiveness of structured teaching program on the knowledge and practice of hand washing technique among food handlers at CMC, Ludhiana, and Punjab. A co- relational approach was adopted to assess the knowledge and practice. Post-test scores of 83.1% in knowledge and 92% in practice as against the pre-test scores of 44% in knowledge and

49.3 % in practice showed a remarkable gain in both areas thus proving the effectiveness of structured teaching program35.

An evaluative study to identify the “effectiveness of a need based planned teaching programme on care of infants for mothers in selected areas of Udupi district” was conducted on a Purposive sampling size of 50 mothers. The study results revealed a statistically significant difference between pre-test and post-test mean knowledge scores

12 that is (t (49) = 25.86, p<0.05) indicating a significant gain in knowledge. The study concluded that a planned teaching programme on Care of infants was an effective teaching strategy37

.A pre experimental study was done on the “Effectiveness of planned health education on control and prevention of diarrhoea among mothers having children below five years at selected rural areas, Tirupathi, Andhrapradesh”. The sample size was 100 mothers selected by using convenient sampling technique. The mean post- test knowledge scores of 7.27 in knowledge, and 12.53 in practice were higher than the mean pre-test knowledge scores of 3.82 in knowledge and 6.21 in practice. Also the t - test scores of

14.43 in knowledge and 21.55 in practice showed significant improvement in the knowledge on control & prevention of diarrhoea & hygienic health practices at P< 0.01 level38.

6.4 STATEMENT OF PROBLEM:

13 “A study to evaluate the effectiveness of planned teaching programme on the knowledge of recording and interpretation of electrocardiogram (ECG) among staff nurses working in selected Intensive Care Units (I.C.U) of selected hospitals in Tumkur..

6.5 OBJECTIVES OF THE STUDY:

1. To assess the level of knowledge of recording and interpretation of

electrocardiogram (ECG) among subjects.

2. To prepare and administer planned teaching programme on the recording and

interpretation of Electrocardiogram (ECG)

3. To evaluate the effectiveness of planned teaching programme in terms of gain in

knowledge scores.

4. To determine the association between pre-test and post test levels of knowledge

with elected demographic variables.

6.6 RESEARCH HYPOTHESIS:

. H1 :The mean post test scores of subjects exposed to PTP will be greater then their mean pretest scores as measured by structured knowledge questionnaire at 0.05 level of significance.

H2 : There will be a significant association between the pretest and post test scores knowledge score and inselected demographic varibles

6.7 OPERATIONAL DEFINITIONS:

1. Effectiveness: Refers to determining the extent to which the information in the PTP has achieved the desired effect as expressed by gain in knowledge score.

2. Planned teaching programme (PTP) :

14 Refers to a written material used for teaching which is prepared by researcher and content validated by experts. It is intended to provide information / knowledge regarding

: a. Anatomy and physiology of heart b. Electrophysiology of the heart

c. Wave forms, intervals, segments and complexes of ECG

d. Analyzing ECG rhythm strip 3.

Knowledge:

Refers to the correct response of nurses to items on cognitive aspects of ECG and is expressed in terms of knowledge score.

4. Level of knowledge - refers to the scores obtained on knowledge items of recording and interpreting ECG and interpreted as good, average, and poor.

5. Recording - refers to the knowledge of applying leads and tracing the electrical activity on the ECG paper.

6. Electrocardiogram (ECG): Refers to the pattern of electrical activity traced on electrocardiographic paper.

7. Staff Nurses - Refers to registered nurses with a B.Sc (Nursing) or GNM qualification, working in ICUs

8. Intensive Care Units - Refers to wards where critically ill patients are admitted for receiving intensive nursing and medical care.

6.8 ASSUMPTIONS:

The study assume that Staff nurses working in ICU have some knowledge in recording and interpreting ECG.

2. PTP is an effective teaching strategy.

6.9DELIMITATION: The study is delimited to nurses:

15 a. Working in selected hospitals in Tumakur

b. Who are posted to ICU on rotation duty, at the time of data collection and who are

willing to participate in the study

7. 0 MATERIALS AND METHODS OF THE STUDY:

7.1 SOURCE OF DATA:

Data will be collected from Staff Nurses from selected hospitals in

Tumakur

7.2 METHODS OF DATA COLLECTION:

1. RESEARCH DESIGN

The Research design for the study shall be Quasi experimental one group

pretest and post test design

2 .VARIABLES

-Dependent variables-Knowledge of staff nurses.

-Independent variable –Planned teaching program.

-Extraneous variable-Age,sex,marital status,education.

3.SETTINGS

The study will be conducted in selected hospital at Tumkur

4. POPULATION

The population for the study is staff nurse in selected hospitals at Tumkur

5.SAMPLE SIZE

50 Staff Nurse in selected hospitals at Tumkur

7.3CRITERIA FOR SELECTION OF SAMPLE:

16 Inclusion criteria: -

- Staff nurses working in selected ICUs (Medical, Surgical, Neurological along with

ICCU) selected hospital in Tumkur.

- Who are available during the data collection.

-Who can speak and understand English.

Exclusion criteria:

-Nurses on leave.

- Nurses who are in managerial posts. e.g. Floor supervisor

6. SAMPLING TECHNIQUES

Purpose sampling technique shall be used to select the sample .

7. TOOL FOR DATA COLLECTION

Structured Knowledge Questioner method

8.PLAN FOR DATA ANALYASIS

The data analysis shall be done through descriptive and inferential statistics like

frequency ,mean, meanpercentage ,paired ‘t’ test and ‘chisquare’test.

7.4 DOES THE STUDY REQUIRE ANY INTERVENTIONS TO BE

CONDUCT ON PATIENTS OR OTHER HUMAN OR ANIMALS?

No, the study does not require any interventions.

7.5.HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION?

17 Yes, informed consent will be obtained from the institution authorities and subjects.

Privacy ,confidentially and anonymity will be guarded .Scientific objectivity of the study will be maintained with honesty and impartially.

8. LIST OF REFRENCE:

18 1. Kumar N, Rastogi T. Cardiovascular disease in India and the impact of lifestyle and

food habits. Health management 2004 Dec: 44-5

2. Jason T.Campaign for fighting disease. Urbach 2006 Oct: 28-30

3. Einthoven W. Weiteres. über das elektrokardiogramm. Arch Gesamte Physiol.

1908; 172:517

4. Fisch C. Evolution of the clinical electrocardiogram. J Am Coll Cardiol. 1989;

14:1127–1138.

5. Rosenbaum DS, Jackson LE, Smith JM, Garan H, Ruskin JN, Cohen RJ. Electrical

alternans and vulnerability to ventricular arrhythmias. N Engl J Med.

1994;330:235–241

6. Mason JW, Hancock EW, Saunders D. American College of Cardiology report on

ECGEXAM. J Am Coll Cardiol. 1997; 29:466–468.

7. Hurst JW. Images in cardiovascular medicine: "switched" precordial leads.

Circulation. 2000; 101:2870–2871

8. Willems JL, Abreu-Lima C, Arnaud P. The diagnostic performance of computer

programs for the interpretation of electrocardiograms. N Engl J Med. 1991;

325:1767–1773.

9. Cardiovascular Disease: Prevention and Control. WHO; 2006.

10. Coronary Heart Disease Statistics. British Heart Foundation; 2006.

11. European Cardiovascular Disease Statistics. British Heart Foundation Health

Promotion Research Group; 2005.

12. Quick Facts, CVD mortality. Heart and Stroke Foundation of Canada; 2004

76,426;

13. Manchanda SC. Heart Attack – Causes and Prevention. Health Action 2000

19 Aug; 13(8): 35. 14. Kumar H. Emerging new risk factors for coronary artery disease. Indian journal of cardiology 2000 Mar; 3 (14) : 55-6.

15. Pyne CC, Johnson KL, Munro N. Classification of acute coronary syndrome using

the 12 lead Electrocardiogram as guide. AACN 2004 Oct ; 15 (4) : 558-67

16. Polit DF, Beck CT. Nursing research principles and methods.7th ed. Philadelphia: Lippincott Williams & Wilkins; 2004. 17. Madias JE. On the appropriate recording of the electrocardiogram. Jelectrocard. 2006 Nov; [1-4]. Available from: ttp://www.sciencedirect.com/science?_ob=Article URL&_udi=B6WJ4-4M69P91-8 & _use. Accessed Nov 2, 2006.

18. Samuel J. B, James C, Jeannette P, Joseph C, Greenfield, Sousin L, Charles M,

et.al. The evaluation of a precordial ECG BELT: Technologist satisfaction and

accuracy of recording. Journal of Electrocardiology, 2001 April 34(2): P 155-9.

19. Elena B. S, Serge S B, Sergio L. P, Galen S. W, Olle P. Twelve-lead

electrocardiogram: The advantages of an orderly frontal lead display including

lead −aVR. Journal of Electrocardiology.2004. June 37(3): p141-7.

20. Robert H. B, Marc D. H, Fidela S. B,Howard S. Supine vs semirecumbent and

upright 12-lead electrocardiogram: does change in body position alter the

electrocardiographic interpretation for ischemia? The American Journal of

Emergency Medicine, 2007, 25(7): p 753-6.

21. Denis J, Juan S.,Katia S, Theodor L, Roman S. . Usefulness of Ambulatory 7-Day

20 ECG Monitoring for the Detection of Atrial Fibrillation and Flutter after Acute Stroke and Transient Ischemic Attack. Stroke. 2004; 35:1647.

22. Emmy H, Henk CP, Johannes B R, Rudolph W K, Patrick JE. Diagnostic yield of

patient-activated loop recorders for detecting heart rhythm abnormalities in

general practice: a randomized clinical trial. Family Practice 2005 22(5): p478-84

23. David A F, Richard H, Sue J, Jonathon M, Ellen T M, Roger H, Raftery J P et.al.

Screening versus routine practice in detection of atrial fibrillation in patients aged

65 or over: cluster randomized controlled trial. BMJ 2007; 35-8.

24. Jonathan M, David A F, Richard H, Sue J, Ellen T M, Roger H, Michael D et.al.

Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care

practitioners and interpretative diagnostic soft ware BMJ, 2007:p 121-4.

25. Melendez LJ,Jones D. T , Salcedo JR. Usefulness of three additional

electrocardiographic chest leads (V7, V8, and V9) in the diagnosis of acute

myocardial infarction.Canadian Medical Association Journal, 1998.119(7):p 745-8

26. Drighil A, Madias JE, Yazid A, et al. P-wave and QRS complex measurements in patients undergoing hemodialysis. Journal of electrocardiology 2005 Sept; 34(3): 350-2.

27. Atman P. S, Stanley A. R. Errors in the computerized electrocardiogram

interpretation of cardiac rhythm. Journal of Electrocardiology,2007 40(5)p385-90.

28 John P. B, Matthew P. B, Madeline A, William J. B. Impact of the 12-lead

21 electrocardiogram on ED evaluation and management. The American Journal of

Emergency Medicine2007 Mar 25(8): p 942-8.

29. Petrina M, Goodman SG, Eagle KA .The 12-lead electrocardiogram as a

predictive tool of mortality after acute myocardial infarction: current status in an

era of revascularization and reperfusion. Am Heart J 2006 Jul152(1):11-8

30. Murray D, Steven S. Dysrhythmia and electrocardiographic changes in diabetes

mellitus: pathophysiology and impact on the incidence of sudden cardiac death.

J Cardiovasc Med 2006 Aug 7(8):580-5.

31. Varma AV, Joseph J, Kumar MM. Indian Journal of Ophthalmology. 1999 31(3) p: 221-4

32. Singh RB, Sharma JP, Rastogi V, Raghuvanshi VS, Moshiri M, Verma SP, Janus

ED. Prevalence of coronary artery disease and coronary risk factors in rural and

urban populations of north India European Heart Journal 1997 18(11):1728-1735;

33. Rajesh B, Laddha P, Gehlot RS. Value of Troponin-T Test in the Diagnosis of

Acute Myocardial Infarction. JIACM 2002 3(1): 55-8

34.Rajan TR, Sharma M, Alpin M, Rex N (2003) Left septal fascicular block: myth or

reality? Indian Pacing and Electrophysiology Journal, 3 (3). p157-177.

35. Singh S. Effectiveness of structured teaching program on knowledge and practices

related to hand washing technique among food handlers. The Nursing journal of

India 2004; 10(5):105-6.

22 36. Saxena A. Cancer chemotherapy and its side effect management. The nursing

journal of India 2006 May ; 46(5): 109-110.

37. Erna JR. “Effectiveness of a need based planned teaching programme on care of

infants for mothers in selected areas of Udupi district” MAHE, Manipal.2004;

unpublished thesis

38. Kavitha K, “Effectiveness of planned health education on control and prevention

of diarrhoea among mothers having children below five years at selected rural

areas, Tirupathi, Andhrapradesh”. 2005; unpublished thesis

39. Krishna swami OR, Ranganatham M. Methodology of research in social sciences. New Delhi: Himalaya publishing house; 1998.p132-9. 40. Salerno SM, Alguire PC, Waxman HS. Competency in interpretation of 12-lead

electrocardiograms: a summary and appraisal of published evidence.Ann Intern

Med 2003 May 6; 138(9):751-60.

9.SIGNATURE OF THE CANDIDATE

10.REMARK OF THE GUIDE

23 Mrs.Ramai.p

11.NAME AND DESIGNATION OF Associate professor GUIDE Medical sugical nursing

12.SIGNATURE

13.CO GUIDE

14.SIGNATURE

15.HEAD OF THE DEPARTMENT

16.SIGNATURE

17.REMARKS OF PRINCIPAL

18.SIGNATURE

"A STUDY TO EVALUATE

THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAM ON KNOWLEDGE REGARDING PREVENTION OF NOSOCOMIAL INFECTION AMONG STAFF NURSES

WORKING AT SELECTED HOSPITALS, TUMKUR ”

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

SUBMITTED BY

Mr. VITHAL

FIRST YEAR M.Sc NURSING

MEDICAL SURGICAL NURSING

2012-2014

SRI SIDDHARTHA COLLEGE OF NURSING , AGALKOTE ,

25 B .H ROAD,TUMKUR

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

26 1 NAME OF THE CANDIDATE Mr. VITHAL SHANKAR & ADDRESS I YEAR M.Sc NURSING

SRI SIDDHARTHA COLLEGE

OF NURSING, AGALKOTE,

TUMKUR

2 NAME OF THE INSTITUTION SRI SIDDHARTHA COLLEGE OF NURSING,B.H ROAD,TUMKUR

3 COURSE OF THE STUDY & DEGREE OF MASTER OF NURSING SUBJECT MEDICAL SURGICAL NURSING

4 DATE OF ADMISSION 11-07-2012

5 TITLE OF THE TOPIC "A STUDY TO EVALUATE THE STRUCTYRED TEACHINGPROGRAM ON KNOWLEDGE REGARDING PREVENTION OF NOSOCOMIAL INFECTION AMONG STAFF NURSES WORKING AT SELECTED HOSPITALS,TUMKUR”

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION:-

27 Nosocomial infection is also called as 'Hospital

Acquired- Infection’, it is derived from the Greek word 'Nosocomeion' meaning hospital or hospitalization. It can be defined as an infection whose development is favoured by a hospital environment, such as one acquired by a patient during a hospital visit or one developing among hospital staff. Such infections include fungal ,viral and bacterial infections and are aggravated by the reduced resistance of individual patients .1

Two factors contribute to the occurrence of nosocomial infections. First, concentration of virulent forms of different organisms in the hospital and second is the presence of patients with anatomical and physiological defects.2

Nosocomial infections are important contributors for morbidity and mortality. They became more important public health problem with increasing economic and human impact because of increasing numbers and crowding of people, more frequent impaired immunity due to age, illness, treatments, new microorganisms, increasing bacterial resistance to antibiotics.3

28 Nosocomial infections occur worldwide and affect both developed and developing countries. Infections acquired in health care settings are a significant burden both for the patient and for public health. A prevalence survey conducted under the guidance of World Health Organisation in 55 hospitals of 14 countries representing 4 World Health

Organisation Regions Europe, Eastern Mediterranean, South-

East Asia and Western Pacific has showed an average of 8.7% of hospital patients had nosocomial infections. At any time, over 1.4 million people worldwide suffer from infectious complications acquired in hospital 4.

The most frequent nosocomial infections are infections are surgical wound, urinary tract infections and lower respiratory tract infections. Surgical site infections are the third most common nosocomial infections in surgical patients- accounting for about 24% of the total number of nosocomial infections .It’s rate has varied from a low of 2.5% to high of

41.9%.5

29 The effectiveness of infection control practices depends on nurse’s consciousness and consistency by using effective aseptic technique. It is human nature to forget key procedural steps, or when hurried, to take short cuts that break aseptic procedures. However, failure to comply with basic procedures places the client at risk for an infection that can seriously impair recovery or lead to death.6

The nurse follows certain principles and practices including standard precautions to prevent and control of infection and it spread. During daily routine care the nurse basic medical aseptic techniques to break the infection chain for example, use gloves and a mask during dressing to break the entry of pathogens. The term standard precaution applies to blood and body fluids, non-intact skin, mucous membranes from all clients. The precautions will protect the client and provide protection of healthcare staff as directed by the occupational safety and health administration.7

For Infection control, nurse is responsible for the surveillance and analysis for hospital acquired infection;

30 educating employees about infection control and ensuring the implementation of various infection control polices in the hospital. Assessing environmental control through surveillance monitoring. Conduct environmental rounds in all inpatient and outpatient care areas. Collect data on the incidence of selected device use in identified intensive care units. Participating in quality/performance improvement activities by assessing, monitoring, and measuring hospital acquired infections and evaluation outcomes on a continuous basis.8

Nurses play a pivotal role in preventing hospital-acquired infections (HAI), not only by ensuring that all aspects of their nursing practice is evidence based, but also through nursing research and patient education. They instruct other nurses and health care staff on proper sanitation procedures.Nurses in all roles and settings can demonstrate leadership in infection prevention and control by using their knowledge, skill and judgment to initiate appropriate and immediate infection control procedure.9

6.2 NEED FOR THE STUDY :-

Hospital-acquired infections add to functional disability and emotional stress of the patient and may, in some cases, lead to disabling conditions that reduce the quality of life. Nosocomial infections are also one of the leading causes of death5. The Centres for Disease Control

And Prevention has estimated roughly 1.7 million hospital-associated infections, from all types of bacteria cause or contribute to 99,000 deaths each year.10

Nosocomial infections occur in about 5-10 percent of hospital admissions, worldwide. In India, the nosocomial infection rate is alarming and is estimated at about 30-35 percent of all hospital

32 admissions. Nosocomial infections typically affect immunocompromised patients due to factors like age, underlying diseases, medical or surgical treatments. Aging of the population and increasingly aggressive medical and therapeutic interventions, including implanted foreign bodies, organ transplantations, and xenotransplantation, have created a plethora of vulnerable individuals. Another important factor is the poor state of government hospitals in India. The highest infection rates are in intensive care unit (ICU) patients. Nosocomial infection rates in adult and pediatric ICUs are approximately three times higher than other hospital wards. In these areas, patients with invasive vascular catheters and monitoring devices have more bloodstream infections due to coagulase-negative staphylococci. 11

A quasi experimental study conducted to evaluate the effect of an educational training programme for 100 randomly selected hospital nurses on universal precautions in Chang Hospital in China.

Questionnaire were administered to the 100 nurses prior to and four months after the training. The result showed that educational training significantly improved Chinese nurses knowledge, practice and behaviors related to universal precautions. There was remain room for improvement in glove use and needle stick injury reporting. 12

Nosocomial infections are commonly transmitted when hospital officials become complacent and personnel do not practice

33 correct hygiene regularly. Also, increased use of outpatient treatment in recent decades means that a greater percentage of people who are hospitalized today are likely to be seriously ill with more weakened immune systems than in the past. Moreover, some medical procedures bypass the body's natural protective barriers. Since medical staff move from patient to patient, the staff themselves serve as a means for spreading pathogens essentially, the staff act as vectors.

Ayyat AA ,et al (2000 ) conducted a study in Egypt to assess the knowledge, attitude and practice of staff and student nurses .

A questionnaire is designed and distributed to all student nurses in the school and to all staff nurses working in the hospital . They used

Scoring system for data analysis. Result showed the overall scoring of

Knowledge Attitude and Practice for the three items studied are below

80%, which means that they really need health education about these items ..13

Prevention is better than cure .Nurses are working 24 hours in hospital with the patients .They are the caretakers of the patient.

During clinical posting investigator has personally witnessed various patients who has acquired nosocomial infections and associated complications.so as a future nurse the investigator has felt there is need to educate staff nurses about nosocomial infection and preventive measures . This study would serve as a baseline guide for further development and growth of nursing care and enhance the preventive

34 strategies used to minimize nosocomial infection for the patient or client, hospital setting, and care giver itself.

6.3 REVIEW OF LITERATURE:-

Review of literature is a key step of research process. A thorough literature review on prior research provides a foundation on which to base knowledge. The review of literature is defined as a broad, comprehensive in depth, systematic and critical

35 review of scholarly publications, unpublished scholarly print materials, audio-visual materials and personal communications.

Review of literature can be studied in following three headings :

1. Studies related to incidence and prevalence of Nosocomial

Infection.

2. Studies related to prevention of Nosocomial Infection.

3. Studies related to Structured Teaching on prevention of Nosocomial

Infections.

1.. Studies related to incidence and prevalence of

Nosocomial Infection. :-

Ambanna Gowda (2010) conducted a– Prospective study To study the prevalence of nosocomial infections in the ICU. He selected total of 50 cases developing infection after 48 hours after admission into intensive care unit and with detailed History, physical examination and required lab investigations. Results will be analyzed statistically among 50 patients who had nosocomial infections in the

ICU, (14)28% had UTI, (11) 22% LRTI, (10)20% CRBSI, (8)16% Soft tissue infections & (7) 14% had Pneumonias. Among 7 cases of Pneumonias 5 were associated with VAP. He concluded that: NIs is seen worldwide but is less studied and are given less emphasis in developing countries 14.

36 Jan Muhammad Shaik ,Et al(2008) conducted an observational study at Tertiary Care Hospital , Pakistan, on risk of acquiring infection in Intensive CareUnit. They included 333 samples of above 16 years of age admitted in ICU more than 48 hours and observed .result showed that out of 333 patients 97 patients had acquired nosocomial infection .the frequency of nosocomial infection was 29.12 %.hence they concluded that patients admitted in ICU are more risk for acquiring nosocomial infection than others. 15

Meena Agarwal ,Et al (2003) ,conducted a study Prospective study to determine the incidence of post operative nosocomial infection among neurological patients in post operative period at AIIMS.They included 2441 neurosurgical post operative patients and excluded patients of pre operative infections , then analysed for one year .After study result showed 7.3% of patients have got post operative nosocomial infection.16

2. Studies related to prevention of Nosocomial

Infection:-

SureshChandra Yadav et al(2012) conducted a comparative

study is to identify the need for using prophylactic antibiotic in clean and clean-contaminated surgeries, to identify the prevalence of organisms in patients who are not given prophylactic antibiotics and to study whether presence of risk factors increase the incidence of surgical site infection . he collected 100 cases admitted under two groups of 50

37 each: group A were given prophylactic antibiotic and group B were not given any such antibiotic and All surgeries other than clean and clean- contaminated surgical cases where excluded from the study. They got

Results Out of 50 patients in group B who were not given prophylactic antibiotic, 6 patients had more than one risk factor for development of

SSI and both of them developed SSI. Group A had 35 clean surgical cases and 15 clean contaminated cases, out of which none of them were infected .17

Kibret M et al (2010) conducted, a cross-sectional study on

Antibiogram of nosocomial urinary tract infection at Ethiopia. They selected 1254 patients for a year. Their Antimicrobial susceptibility tests were done using disc diffusion technique as per the standard of Kirby-

Bauer method and got result. as Of the 1 254 patients, 118 (9.4%) developed nosocomial UTIs. Thus , they have concluded that catheterisation and preoperative antibiotic prophylaxis were found to be risk factor for nosocomial infection.18

William & Water man (2001) conducted a study on effective hand washing with lotion or soap to remove nosocomial bacteria pathogenesis persisting on fingertip it is called intra hospital spread. 30 seconds hand wash with a nonseptic lotion a study in liver pool to examine the nurses' practice when performing aseptic technique. The data was collected through observations and formal interview from 21 trained nurses selected conveniently. The result showed reduced

38 frequency of hand washing, the transfer technique and maintaining the principles of the glove technique required for procedures .19

3. Studies related to Structured Teaching on prevention of Nosocomial Infections:-

Labeau SO et al(2010) . conducted a survey study to assess the Nurses' knowledge of evidence-based guidelines for the prevention of surgical site infection at Belgium(2009)by development of an evaluation tool .They developed a multiple-choice knowledge test concerning evidence-based Surgical Site Infection prevention .sample was 809 ICU nurses . Demographics included were gender, ICU experience, number of ICU beds, and whether respondents had obtained a specialized ICU qualification. Based on the test results, an item analysis was performed. They got result: as nurses' mean score on the knowledge test was 29%. Males were shown to have better scores .they concluded that Opportunities exist to improve ICU nurses' knowledge about Surgical Site Infection prevention recommendations. Current guidelines should support their ongoing training and education. 20

Zoabi,Titler .(2011) conducted a study on Compliance of hospital staff with guidelines for the active surveillance of methicillin- resistant Staphylococcus aureus (MRSA) and its impact on rates of

39 nosocomial MRSA bacteraemia at Nazareth, Israel , they assessed compliance with MRSA surveillance guidelines by assessing adherence to the screening protocol and reviewing medical and nursing charts of patients colonized with MRSA, and observed hand hygiene opportunities among health care workers and colonized patients. Rates of nosocomial

MRSA bacteraemia and of adherence with hand hygiene among overall hospital staff were obtained from archived data for the period 2001-

2010 they .got result as Only 32.4% of eligible patients were screened for MRSA carriage on admission, and 69.9% of MRSA carriers did not receive any eradication treatment. The mean rate of adherence to glove use among nurses and doctors was 69% and 31% respectively (P<0.01) and to hand hygiene 59% and 41% respectively (P<0.01). The hospital overall rate of adherence to hand hygiene increased from 42.3% in 2005 to 68.1% in 2010..21

Yinnon AM, et al(2011) conducted a study to Improving implementation of infection control guidelines to reduce nosocomial infection rates by using checklists three hospitals over the course of one year. at-, Jerusalem, Israel. They used tools as checklists ,it included 20 subheadings (± 150 items). Project nurses conducted rounds in the study

(but not control) departments; during each round ,the nurses selected

15-20 items for observation, marked the checklists according to appropriateness of observed behaviour and provided on-the-spot corrective education. Rates of adherence to the checklist, antibiotic use, number of obtained and positive cultures, and positive staff hand and

40 patient environment cultures were reported monthly as a report card to relevant personnel and administrators. The rate of nosocomial infections was determined in the first and last months .proved that the use of checklists during the conduct of infection control rounds, combined with monthly reports, was associated with a significant decrease in nosocomial infections in study departments .22

6.4 STATEMENT OF PROBLEM :-

“A study to evaluate the effectiveness of structured teaching programme on knowledge regarding prevention of nosocomial infection among staff nurses working at Selected hospitals, Tumkur”

6.5 OBJECTIVES OF THE STUDY:

1) To assess the knowledge of staff nurses regarding prevention of nosocomial Infection.

2) To develop and conduct structured teaching programme for staff nurses on prevention of nosocomial infection.

3) To evaluate the effectiveness of structured teaching programme by comparing pre-test and post-test knowledge scores.

41 4) To find the association between pre-test knowledge scores with selected demographic variables.

6.6 OPERATIONAL DEFINITIONS:

1. Structured teaching program: Refers to the systematically developed institutional method and teaching aids for staff nurse.

2. Effectiveness: It refers to a measure of match between stated goals and their achievement.

3. Knowledge: It refers to the correct response of nurses to items on preventive aspects of nosocomial infection .

4. Staff Nurse: It refers to the one who is registered nurses with a B.Sc Nursing or GNM qualification, 6.7 ASSUMPTIONS :-

These are the statement taken for granted or considered true, even though they have not been scientifically tested.

1) Nurse may have some knowledge regarding prevention of

Nosocomial infection.

2) Structural teaching programme will improve the knowledge of student nurses regarding prevention of Nosocomial Infection.

3) Nurses may have interest to gain knowledge regarding prevention of Nosocomial Infection.

6.8 HYPOTHESIS OF THE STUDY:

42 H1 :- There will be significant difference between mean pre and post test knowledge scores of staff nurses regarding prevention of nosocomial Infection.

H2 :- There will be significant association between pretest knowledge scores of staff nurses with selected demographic variables.

6.9 MATERIAL AND METHOD :-

7. 0 Source of Data :-

The data will be collected from staff nurses of selected

hospitals at Tumkur.

7.1 Methods of Data collection:

Structured questionnaire will be prepared

1.Research Design :-

Quasi experimental one group pre-test post-test research design .

2. Variables:-

Dependent variables - performance in pre test and post test.

Independent variables - Structured teaching program.

43 3 Setting of the study :-

The study will be conducted in selected hospital at Tumkur.

4.Population :-

The population for the study is staff nurses working in Selected

hospital,Tumkur.

5. Data Collection Instrument :-

Structural knowledge questionnaire will be used for data collection.

6 .Sampling Techniques :-

In this study Non Probability purposive sampling technique

is used for the study.

7. Sample Size :

Sample consist of 50 staff nurses.

8. Criteria for sample collection :-

INCLUSIVE CRITERIA: - Study includes the staff nurses who are

 willing to participate in the study.

 Present during the period of data collection.

EXCLUSIVE CRITERIA: Study includes the student nurses who are

44  Not willing to participate in the study.

 Not present during the period of data collection.

9. Plan for data analysis:-

The data analysis shall be done through descriptive and inferential statistics like frequency, mean, mean percentage, paired”t”test and“chi-square“test.

7.2 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR

INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR BRIEFLY? OTHER

HUMAN OR ANIMALS? IF SO, PLEASE DESCRIBE.

“ No”

7.3 ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION ?

Yes,informed consent has been obtained from the the concerned authorities and subjects. Privacy, confidentiality and anonymity will be guarded. Scientific objectivity of the study will be maintained with honesty and impartially.

7.4 LIST OF REFRENCE:

1.http://www.wikipedia.org.

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203:532.

4.Tikhomirov E. WHO Programme for the Control of Hospital

Infections. chemiotherapia;1987. 3:148–151.

5 Ponce-de-Leon S. The needs of developing countries and the resources required. J Hosp Infect; 1991,18 (Supplement):376–381.

6 Dider. Hand hygiene and aseptic in the emergency department.American journal of infection control; vol-104; 2009. page-

170 to174.

7..Mangram, Alicia, et.al, The center for disease control and prevention. Journal of infection control; 2007. page-110.

8. Jacqueline M.Smith . A journal of Infection Control Nurse; Nov3.;

Calgary;2004.

9. Mukerjee AK. Hospital Acquired Infection Guidelines for

Control. Government of India; New Delhi; 1992.

46 10.Klevens,R Monlna et al.Estimating health care associated infections and deaths in US hospitals. Public health reports;

122.2(2007); 160-166

11 Vasudha Mukherjee .Nosocomial Infections in India:

Assuming Dangerous Proportions.India ; . 20 Jul 2001

12. Hung Jang, Wang, Lin, Ferrie Burgers. A survey to determine knowledge of nurses in a clinical setting about universal precautions.China; 2002.

13. Ayyat AA ,et al. A kap study among staff and student nurses about infection control ,J.Egypt soc parasitol ;2000; 30(2).511-

14.Ambanna Gowda.A study on prevalence of nosocomialinfections in ICU. abstract Rguhs.Bangalore.2010.

15.Jan Muhammad Shaik,Et al. Frequency, pattern and etiology of nosocomial infection in intensive care unit an experience at a tertiary care hospital. J Ayub Med Coll Abbottabad Pakistan. 2008 ;Oct-

Dec;20(4):37-40.

16 Meena Agarwal ,Et al. The nursing journal of India, volume

LXXXXIV,no.19.sept. India 2003.

17 Sureshchandra Yadav et al. A comparative study of risk factors and role of preoperative antibiotic prophylaxis in prevention of surgical site infection .Bangalore RGUHS .2012.

47 18. Kibret M,Abera B. Antimicrobial susceptibility patterns of

E.coli from clinical sources. African health science;2011.

19.Williams and Watermen. A study on aseptic technique at

Liverpool. American journal of infection control. August , 2001.1-7.

20.Labeau SO et al . study to assess the Nurses' knowledge of evidence-based guidelines for the prevention of surgical site infection .

Belgium. Worldviews Evidence Based Nursing. 2010 Mar;7(1):16-24.

21.Zoabi et al,a study on Compliance of hospital staff with guidelines for the active surveillance of methicillin-resistant

Staphylococcus aureus (MRSA) .Israil. Medical

Association.2011;13(12).740-44

22. Yinnon AM . improving implementation of infection control guidelines

to reduce nosocomial infection rates . J Host infection.2012 ;81(3) 169-76.