RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

PERFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION.

1.

NAME OF THE

CANDIDATE& ADDRESS.MS. RINU ELSA EAPEN

NAVANEETHAM COLLEGE OF NURSING,

#132/1,HORAMAVU,BANASWADI

BANGALORE.

2. NAME OF THE

INSTITUTION.

NAVANEETHAM COLLEGE OF NURSING.

3.

COURSE OF STUDY &

SUBJECT.

M.Sc. (N) 1ST YEAR

PAEDIATRIC NURSING.

4.DATE OF ADMISSION.

17/06/2011

5. TITLE OF THE TOPIC.

“A STUDY TO ASSESS THE KNOWLEDGE AND

PRACTICE OF STAFF NURSES ON PREVENTION

OF NOSOCOMIAL INFECTION IN NEONATAL

INTENSIVE CARE UNIT AT SELECTED

HOSPITALS, BANGALORE WITH A VIEW TO

DEVELOPINFORMATION BOOKLET.”

1

BRIEF RESUME OF THE INTENDEDWORK.

6.1 INTRODUCTION.

“Whoever refuses to remember the inhumanity is prone to new risks of infection”

-Richard Von Weizeaecker.

Nosocomial infection is an infection acquired in hospital at least 72hours after admission. Also called

hospital acquired infection. All infection diagnosed 48 hours after admission till 72 hours after

discharge should be considered as nosocomial .All infections in new born delivered in the hospital

need to be considered “Acquired” except those caused by organisms reaching the body from the

mother or before the time of birth. This is true in early onset of systematic sepsis caused by Ecoli,

streptococci Group B. Listeria monocytogenes etc .Nosocomial infection accounts for half of all major

complications of hospitalization; the rest are medication errors, patient falls, and other non-infectious

events. In American hospitals, cross infection affects between 5-10% of patients at a cost in excess of

$4.5 billion. Further, with the advent of HMOs and incentives for out patient care, hospitals now have

a concentrated population of seriously ill patients, and an even greater risk of nosocomial

infection.Statistics show that about 35 million patients are admitted to 7,000 acute-care institutions in

the United States each year. This means that 1.75 million to 3.5 million patients are infected yearly in

the United States. If 10% of all nosocomial infections involve the bloodstream, then 175,000 to

350,000 patients acquire these life-threatening septicemic infections each year.1

The National Nosocomial Infection Surveillance System (NNIS) reports a rate of 14.1 nosocomial

infections per 1000 patient days.3 The risk of nosocomial infection in neonates is the direct

consequence of the severity of illness, prematurity, congenital defects, systemic diseases, level of

invasive monitoring, indiscriminate use of antibiotics, lapses in sterilization and disinfection

techniques and the nature of diagnostic procedures. Hospital-acquired infections are one of the leading

causes of preventable morbidity and mortality in neonatal intensive care units. Device-related

infections, such as catheter-associated blood stream infection (CASIs) and ventilator-associated

pneumonia (VAP), are the most common nosocomial infections. Respiratory syncytial viral (RSV)

2

Frequently causes nosocomial outbreaks in general paediatric wards and occasionally in neonatal

intensive care units. The primary blood stream infections are the commonest nosocomial infection (20-

30%) in Neonatal Intensive Care Units followed by the lower respiratory tract infections (20-25%)

staphylococcus, klebseilla, e-coli, pseudomonas aeurginosa, enterococci and Candida are the

commonly implicated pathogens. Measure employed to increase the survival rate in small babies have

added greatly to risks of nosocomial infections, example: IV drip, assisted respiration, Parental

Nutrition, Lavish use of broad spectrum antibiotics and extensive surgical manoeuvreson babies with

congenital malformations. Sepsis rate in neonatal intensive care unit (NICU) is among the highest

anywhere in the Hospital.2

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6.2 NEED FOR THE STUDY.

“Prevention of infection is more cost effective than treating infection in neonates.”- BCHI&RC

Nosocomial infections are responsible for significant morbidity and late mortality among neonatal

Intensive Care unit patients. The number of neonatal patients at risk for acquiring nosocomial

Infections is increasing because of the improved survival of very low birth weight infants and their

need for invasive monitoring and supportive care. Effective strategies to prevent nosocomial infection

must include continuous monitoring and surveillance of infection rates and distribution of pathogen,

strategic nursery design and staffing, emphasis on hand washing compliance, minimizing central

venous catheter use and contamination, and prudent use of antimicrobial agents. Educational programs

and feedback to nursery personnel improve compliance with infection control programs. Nosocomial

infections are serious illnesses that can cause death in about 1% of all cases. Blood stream infections

in neonatal intensive care unit (NICU) patients have a mortality rate of almost 35%. Nosocomial

infections continue to be a problem in most healthcare centres throughout the world since; infection

control is misperceived and needs to be challenged, nurses need to be continually educated and made

aware of the reasons for instituting infection control practices for the safety of the patients as well as

for themselves. 3

In the hospital, neonatal mortality was reduced by 14% in the first year and by 21% in the second year

after SNCU became functional. Estimated neonatal deaths averted were 329, which would reduce

NMR of the district from 55 to 47 in 2 years.4

The cause of neonatal mortality is multifactor – low birth weight, birth asphyxia and atelectasis, birth

injuries, congenital malformation and infection during 2000-2003. The major causes of neonatal

mortality were preterm birth 28% and severe infection 26%. Each year, about 4 million new-born die

before they are 4 weeks old 98% of these deaths occur in developing countries. More than half of

infant mortality rates are highest in Sub-Saharan, Africa and Asia. Two thirds of new-born deaths

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occur in WHO region of Africa (28%) and South East Asia (36%). In India the SRS estimates for the

year 2003 is about 25 per 1000 live birth in early neonatal period (0-7 days), with about 28 for rural

areas and 12 for urban areas neonatal mortality rate for the whole country is about 37 per 1000 live

birth with approximately 41 for rural areas and 22 for urban areas.5

A quantitative study was carried out at Zambia regarding infection- prevention guidelines by health

care workers and convenient sampling method was used .Data was obtained using a self-administered

interview schedule and an observation checklist. A total of77health care workers who included

doctors, Registered Midwives and Nurses, Enrolled Midwives and Nurses, clinical Officers,

Laboratory Technicians and physiotherapists took part in the study. Additionally, 40 out of the 77

interviewed health workers were observed carrying out at least one procedure requiring compliance

with the Infection Prevention (IP) guidelines. This study revealed that, high compliance was associated

with inclusion of Guidelines in the Curricular, high knowledge of infection prevention/hospital

acquired infections, positive attitude towards infection prevention and availability of materials for

infection prevention. The study further revealed varied levels of compliance on different components

of infection prevention. The highest level of compliance (100%) was with single use of needles and

syringes while the lowest (35.1) was with decontamination of needles and syringes with 0.5% chlorine

solution prior to disposal. Compliance with hand hygiene was moderate (61%).The study findings

suggest a need for inclusion of Infection Prevention Guidelines in the health workers’ curricular,

provision of in-service training in infection prevention protocols and improvements in the supply of

materials for infection prevention. 6

A prospective study was performed in the NICU of Angers University Hospital during six month. And

it was conducted to evaluate the impact of information and prevention process specifically aimed at

neonatologists and nurses working in a neonatal intensive care unit at France (NICU) towards the

prophylaxis of nosocomial bloodstream infections. The objective was first to analyse nosocomial

infections within the unit, and secondly to evaluate the impact of a monthly report providing

information related to the number and characteristics of such infections. All cases of nosocomial

bloodstream infections and their characteristics were analysed. Then they published a nosocomial

infections report every month during the second period, in order to inform the medical staff and nurses

of the results. The impact of the information and prevention process was evaluated by comparing the

results between the2 periods, and also assessed the staff's interest by questionnaire. Two hundred and

fifty-four (first period) and 240 (second period) patients were included. A decrease in the specific

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incidence rate and density of catheter related bloodstream infections was observed between the 2

periods, especially for pre-terms with a birth weight< 1000g and gestational age<28 SA (P<0.01).

Coagulase negative Staphylococcus was identified in 82.3% and 62.5% of cases respectively. 54% of

the members of staff expressed their concerns related to the findings and were very interested to read

about the observations made during the study. 7

Hence the investigator felt that this study will help the staff nurses to enhance their knowledge and

practice regarding cross infection.

6

6.3 REVIEW OF LITERATURE.

Review of literature is key step in the research process. Literature review is essential to locate similar

of related studies that have already been completed which helped the investigator to develop deeper

insight in to the problem. Review of literature is a systematic identification, location, scrutiny and

summary of the written research.

Infection is invasion and multiplication of micro organisms in body tissues, especially that causing

local cellular injury due to competitive metabolism, toxins, intracellular replication or antigen antibody

response. The term nosocomial infection or hospital-acquired infection is applied to any clinical

infection that was neither present nor was in its incubation period when the neonate entered the NICU.

Nosocomial infections may also make their appearance after discharge from the hospital, if the neonate

was in the incubation period at the time of discharge. There are three levels of neonatal care and an

isolation unit in an NICU. In level I care, over 80% of new born babies require minimal care which

can be provided by their mothers under the supervision of basic health care professionals. In level II

care infants weighing between 1200- 1800g or having gestational maturity of 30 to 34 weeks need

specialised neonatal care supervised by trained nurses and paediatricians. In level III care babies

weighing less than 122g or those born before 30 weeks of gestation is treated. 8

A study on effect of antiseptic hand washing v/s alcohol sanitizer on health care-associated infections

in neonatal intensive care units, compare that the effect of 2 hand hygiene regimens on infection rates

and skin condition and microbial counts of nurses' hands in neonatal intensive care units. Clinical trial

using across over design in 2 neonatal intensive care units in Manhattan, NY, from March 1,2001, to

January 31,2003, including 2932 neonatal hospital admissions (51 760 patient days) and 119 nurse

participants. Two hand hygiene products were tested: a traditional antiseptic hand wash and an alcohol

hand sanitizer. Each product was used for 11 consecutive months in each neonatal intensive care unit

in random. After adjusting for study site, birth weight, surgery, and follow-up time, there were no

significant differences in neonatal infections between the 2 products; odds ratios for alcohol compared

with hand washing were 0.98(95% confidence interval [CI], 0.77-1.25) for any infection, 0.99 (95%

CI, 0.77-1.33) for bloodstream infections, 1.61 (95% CI, 0.57-5.54) for pneumonia, 1.78 (95% CI,

0.94-3.37) for skin and soft tissue infections, and 1.26 (95% CI, 0.42-3.76) for central nervous system

infections. The skin condition of participating nurses was significantly improved during the alcohol

7

phase (P = .02 and P = .049 for observer and self-assessments, respectively), but there were no

significant differences in mean microbial counts on nurses' hands (3.21 and 3.11 log(10) colony-

forming units for hand washing and alcohol, respectively; P =.38) Infection rates and microbial counts

on nurses' hands were equivalent during hand washing and alcohol phases, and nurses' skin condition

was improved using alcohol. However, assessing the impact on infection rates of a single intervention

is challenging because of multiple contributory factors such as patient risk, unit design, and staff

behaviour.9

An intervention study with a 9-month follow-up among all of the health care workers at the neonatal

unit of the Children's Hospital, University of Geneva Hospitals, between March2001 and February

2004 .A multifaceted hand hygiene education program was introduced with compliance assessed

during successive observational surveys. Health care–associated infections were prospectively

monitored, and genotypic relatedness of bloodstream pathogens was assessed by pulsed-field gel

electrophoresis. A comparison of observed hand hygiene compliance and infection rates before,

during, and after the intervention was conducted. A total of 5325 opportunities for hand hygiene were

observed. Overall compliance improved gradually from 42% to 55% across study phases. This trend

remained significant after adjustment for possible confounders and paralleled the measured increase in

hand-rub consumption (from 66.6 to 89.2 L per 1000 patient-days). A 9-month follow-up survey

showed sustained improvement in compliance (54%), notably with direct patient contact(49% at

baseline vs. 64% at follow-up). Improved compliance was independently associated with infection risk

reduction among very low birth weight neonates. Bacteria caused by clonally related pathogens

markedly decreased after the intervention. 10

A study on nurses hand decontamination practice by Gould.D employed more rigorous criteria than

earlier research to judge the appropriateness and technique of nurses' hand contamination. During the 2

hours that they were observed nurses decontaminated hands after 28.7% patient contacts. The data

were then reanalysed so that only those activities likely to result in heavy contamination were

examined. This revealed that such 'essential' decontaminations were performed on 49.8%occasions.

Differences were found between hospitals related to the availability of hand decontaminating agents,

particularly when nursing workload became high. A scoring system to assess technique was developed

for the study. Mean score was 8.6 out of 12. Technique was superior for nurses employed in intensive

care units regardless of the hospital in which data were collected (P < 0.0001). Nurses' knowledge of

infection control was poor, but those with more knowledge decontaminated hands more appropriately

(P < 0.004), although they did not have abetter technique. It is recommended that future research move

8

beyond mere description, with its inevitable conclusion that clinical staff should improve performance,

turning toward the identification of local barriers to effective practice. This could be followed by

improvement in resources and educational intervention should these emerge as problematic.11

A study on factors associated with hand hygiene practices in two neonatal intensive care units by

Cohen B, Saiman C, Cimiotti J, Larson E to determine whether hand hygiene practices differ between

levels of contact with neonates; to characterize the hand hygiene practices of different types of

personnel; and to compare hand hygiene practices in neonatal intensive care units (NICU) using

different products. Research assistants observed staff hand hygiene practices during 38 sessions in two

NICUs. Patient touches were categorized as touching within the neonates' environment but only

outside the Isolate (Level 1), touching within the Isolate but not the neonate directly (Level 2) or

directly touching the neonate (Level 3). Hand hygiene practices for each touch were categorized into

five groups: cleaned hands and new gloves, unclean hands and new gloves; used gloves; clean hands

and no gloves, unclean hands and no gloves. Research assistants observed 1472 touches. On average

each neonate or his or her immediate environment was touched 78 times per shift. Nurses (P = 0.001),

attending physicians (P = 0.02) and physicians-in-training (P = 0.03)were more likely to use

appropriate practices during Level 3 touches, but only 22.8% of all touches were with cleaned and/or

newly gloved hands. The mean number of direct touches by staff members with cleaned hands was

greater in the NICU using an alcohol-based hand rub than in the NICU using antimicrobial soap (P <

0.01).12

A study on hand hygiene practices in a neonatal care unit, conducted by Asare A, Enweronu-Laryea

CC, Newman MJ showed that Compliance with hand hygiene recommendations is the most important

measure in preventing health care-associate disinfections. The objective of this study was to assess the

nature of patient contact and the hand hygiene practices of nurses and physicians in the neonatal

intensive care unit in a tertiary hospital in Ghana. Unobtrusive observation of patient contact, hand

hygiene practices, and hand washing technique among nurses and physicians attending randomly

selected new born for five hours daily for two weeks. Patient contact categorized as low-risk or high-

risk. Hand hygiene practice before and after patient contact categorized as clean uncontaminated,

cleaner-contaminated, new gloves, unchanged gloves. Compliance to alcohol rub use assessed. The

patient to nurse/physician ratio varied from 9:1 to 12:1. There were 97 patient contacts of which 49

were high-risk and48 low-risk. Most (73%) patient contacts were from nurses. Compliance to hand

hygiene recommendations before versus after patient contact was 15.4%versus 38.5% for physicians 9

and 14.1% versus 9.9% for nurses. Gloves were used for 60.8%patient contacts (85.7% high-risk,

35.4% low-risk); however, compliance to recommended procedure occurred in only 12.2% of high-

risk contacts and none of the low-risk contacts. Gloves were not changed between patients in 43.7% of

high-risk contacts and 88.2% of low-risk contacts. Hand washing protocol was generally followed.

Alcohol hand rub was always available but was not used for hand hygiene.13

An interview study was conducted among 173 nurses in two hospitals to explore their views

concerning infection risks to themselves and patients and to identify any problems they perceived in

safely performing infection control precautions during routine activities. Subjects were interested in

the topic of infection control and keen to perform optimally, but perceived difficulties related to lack

of expert guidance whether or not they had access to an infection control nurse. In one hospital

subjects identified shortages of vital equipment (gloves, appropriate hand washing agents), and this

was corroborated on a checklist used independently to document the availability of resources. When

the opinions of nurses working in intensive care, surgical and medical units were compared, few

differences emerged other than those explained by variation in supplies of equipment, except that

intensive care unit nurses were more likely to rate their patients and themselves as particularly at risk

of infection, Nurses who had been qualified longer, with more than 3 year experience in their

specialty, were more conscious of infection risks. 14

A study was conducted to evaluate the effects of a hand hygiene program on compliance with hand

hygiene and the rate of nosocomial infections in a neonatal intensive care unit(NICU). And the setting

was level-III NICU in a teaching hospital and the participants was nurses, physicians and other

healthcare workers in the NICU. A multimodal campaign for hand hygiene promotion was conducted

beginning in September 1998. This program consisted of formal lectures, written instructions and

posted reminders regarding hand hygiene and proper hand washing techniques, covert observation,

financial incentives, and regular group feedback on compliance. Surveillance of hand washing

compliance and nosocomial infections before and during the program was analysed. Overall

compliance with hand hygiene improved from 43% at baseline to 80% during the promotion program.

The rate of nosocomial infections decreased from 15.13 to 10.69 per 1,000 patient-days (P = .003) with

improved hand washing compliance. In particular, respiratory tract infections decreased from 3.35 to

1.06 per 1,000 patient-days during the hand washing campaign (P = .002).Furthermore, the correlation

between nosocomial infection of the respiratory tract and Hand washing compliance also reached

statistical significance (r = -0.385; P = .014).15

10

The observational study on hand hygiene practice in a NICU shows that hand hygiene has been

singled out as the most important measure in preventing hospital-acquired infection. However, hand

hygiene compliance among health care workers (HCWs) remains low. The objective of this study was

to assess the frequency and nature of patient contacts in neonatal intensive care units and observe the

compliance and technique of hand hygiene among HCWs before and after the implementation of a

multimodal intervention program. The nature and frequency of patient contacts, the hand hygiene

compliance, and hand-washing techniques of HCWs were observed unobtrusively to reflect the

baseline compliance and to investigate factors for non-compliance. The intervention consisted of

problem-based and task-orientated hand hygiene education, enhancement of minimal handling

protocol and clustering of nursing care, liberal provision of alcohol-based hand antiseptic,

improvement in hand hygiene facilities, on-going regular hand hygiene audit, and implementation of

health care-associated infection surveillance. The observational study was repeated 6 months after the

completion of the intervention program, which extended over 1-year period. Overall hand hygiene

compliance increased from 40% to 53% before patient contact and 39% to 59% after patient contact.

More marked improvement was observed for high-risk procedures (35%-60%). The average number of

patient contacts also decreased from 2.8 to 1.8 per patient per hour. There was improvement in most

aspects of hand-washing technique in the post intervention stage. The health care-associated infection

rate decreased from 11.3 to 6.2 per 1000 patient-day.16

6.4 STATEMENT OF THE PROBLEM.

11

A study to assess the knowledge and practice of staff nurses on prevention of nosocomial infection in

neonatal intensive care unit, at selected hospitals, Bangalore with a view to develop information

booklet.

6.5 OBJECTIVESOF THE STUDY.

1. To assess the knowledge of nurses regarding nosocomial infection.

2. To assess the practice of staff nurses regarding nosocomial infection.

3. To find the correlation between the knowledge and practice of nurses about nosocomial

infection.

4. To develop an information booklet regarding nosocomial infection.

6.6 RESEARCH HYPOTHESIS.

H1: There will be significant association between the knowledge and practice among staff nurses

regarding nosocomial infection.

H2: There will be significant association between the knowledge and practice regarding nosocomial

infection with their demographic variables.

6.7 RESEARCH VARIABLES.

Independent variables: Information Booklet.

Dependent variables: Knowledge and practice of staff nurses.

6.8 OPERATIONAL DEFINITIONS.

12

1. Assess: It refers to determine the value of knowledge and practice regarding nosocomial

infection.

2. Knowledge: It is gaining information regarding nosocomial infection.

3. Practice: It refers to the condition of being skilled through repeated exercise related to

nosocomial infection.

4. Staff Nurse: The Nurses who are working in Neonatal Intensive Care Units (NICU).

5. Prevention: Stay away from nosocomial infection.

6. NICU (Neonatal Intensive Care Unit): It is emergency unit for neonates, who are in distress

and who needs intensive care.

7. Nosocomial infection: An infection that is acquired at a hospital or other healthcare facility.

6.9 ASSUMPTIONS.

1. Staff nurses will be having some knowledge regarding cross infection.

2. Staff nurses knowledge influences the prevention of cross infection.

3. Information booklet may influence their knowledge and practice regarding cross infection.

6.10 DELIMITATIONS.

1. This study is limited to a selected hospital, NICU in Bangalore.

2. This study is limited to 30 staff nurses.

7. MATERIALS AND METHODS.

7.1 SOURCES OF DATA.

Data will be collected from the staff nurses in selected Neonatal Intensive Care Units (NICU) at

selected hospital, Bangalore.

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7.2 METHODOLOGY.

Research approach: on experimental.

Research design: Descriptive design.

Research setting: The study will be conducted in selected Neonatal Intensive Care Units Bangalore.

Population: Staff nurses those who are working in selected Neonatal Intensive Care Units in

Bangalore.

Sample size: Sample comprises to 30 staff nurses.

Sampling technique: The simple random sampling technique will be used for the selection of

sample.

7.2. 11 SAMPLINGCRITERIA.

INCLUSION CRITERIA:

1. Staff nurses those who are working in NICU.

2. Staff nurses those who are willing to participate in this study.

3. This study will include staff nurses who are available during the time of study.

EXCLUSION CRITERIA:

1. Other than Nurses who are in Neonatal Intensive Care Unit (NICU).

2. Those who are giving critical care to the patients.

3. Those who are not willing to participate.

14

7.2 12 TOOLS FOR DATA COLLECTION.

Data collection is planned through the structure questionnaire on prevention of cross infection. The

questionnaire will consist three parts they are:

Part A – Demographic variables of staff nurses like age, experience, education.

Part B – Structured questionnaire on knowledge of staff nurses on prevention of nosocomial infection.

Part C – Checklist on practice of prevention of nosocomial infection.

7.3.13 DATA ANALYSIS METHOD.

Data analysis will be done through descriptive and inferential statistics.

1. Frequency and Percentage distribution of demographic variables of staff nurses.

2. Frequency and Percentage Distribution of knowledge of staff nurses on prevention of

nosocomial infection.

3. Frequency and Percentage Distribution of practice of staff nurses on prevention of nosocomial

infection.

4. Spearman’s rank correlation coefficient is used to find the correlation between knowledge and

practice regarding nosocomial infection.

5. The chi squared(X2) test will be used to find out the association between the demographic

variables with knowledge and practice score

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION?

No, the researcher is assessing the level of knowledge and practice regarding nosocomial infection.

7.4 HAS ETHICAL CLEARENCE BEEN OBTAINED?

15

Permission will be obtained from the institutional ethical research committee of Navaneetham College

of Nursing, Bangalore.

Permission will be obtained from authorities of a selected hospital, Bangalore.

Informed consent will be obtained from staff nurses, who are willing to participate in the study.

8. LIST OF REFERENCES .

16

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intensive care Units. January2010 ;( 77): Pp 15-26.

2. Indian journal of paediatrics. Volume 77, January2010; Pp: 37-39.

3. Adams chapman,Ira MD, Stoll, Barbara J.MD. Prevention of nosocomial infection in the

neonatal intensive care unit. April 2002; 2(14): Pp 157-64.

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new-born care unit on neonatal mortality rate. 2009; 29(2):Pp 150-155.

5. K Park. Preventive and social medicine.2007 ;( 19):Pp450-452.

6. Katowa p mukwato, C.M Ngoma, M. Maimbolwa.compliance with infection prevention

guidelines by health care workers. November 2007 ;( 35): Pp 110-16.

7. Leboucher B, Leblanc M, Berlie I, Savagner C, Lemarie C, Le Bouedec S. Effectiveness of an

informative report of nosocomial bloodstream infections in a neonatal intensive care unit. May

2006; 13 (5): Pp 436-41.

8. Meharban Singh. care of the newborn.2010 ;( 7): Pp 4-5.

9. Larson EL, Cimotti J, Haas J, Parides M, Della-Latta P, Saiman L. Effect of antiseptic hand

washing v/s alcohol sanitizer on health care associated infections in nurses in NICU. April

2005; 159 (4):Pp377-83.

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of Health Care associated Infection Risk in Neonates by Successful Hand Hygiene Promotion.

July 2007; Pp 382-90.

11. Gould D. Nurses hand decontamination practice. September 1994; 28 (1):Pp15-30.

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13. Asare A, Enweronu- Larvea CC, Newman MJ. Hand hygiene practices in a neonatal intensive

care unit in Ghana. june2009; (5): Pp 325-36.

14. Ream E, Gould D. Nurses Views of infection control. June 1994; 19(6):Pp1121 – 31.

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15. Won SP, Chou HC, Hsieh WS, Chen CY, Huang SM, et. Hand washing program for the

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