1. INTRODUCTION

Nurses are expected to do more with less, are expected to work long hours, and are expected to deliver a high standard of care. Government regulations, state laws and the threat of litigation lingering require that nurses remain knowledgeable of the latest and most current information that affects their clinical practice and be aware of the legal implication of documentation in the medical record regardless whether it is an electronic format or handwritten.

Understanding the legal implications of health care is frequently stated: It’s not if you get sued but when you get sued. There has been an increase in the number of malpractice cases in part, due to an increased awareness of patients’ and consumers’ rights.

Nurses have to bear heavy responsibilities. Failure to fulfil these responsibilities may result in allegations of negligence that can lead to malpractice lawsuits. Allegations of negligence can arise against a nurse from almost any action or failure to act that result in patient injury. Learn about related laws and regulations, malpractice, and ways of preventing malpractice allegations by defining the relevant issues nurses are facing in health care on a daily basis. (http://www.lorman.com/training/nursing/legal-issues-facing-healthcare-workers-on-a-daily-basis).

In view of the above, this article is intended to remind all nurse practitioners that the most fundamental function of any nurse is to ensure safety for her / his patients. Omitting basic actions such as washing her or his hands regularly and as indicated in any health facility’s protocol on infections control can cause contamination and spreading infection from one patient to another. It is imperative to wash hands after working with one patient before tending to another one.

One of the most common threats to hospitalised patients is a nosocomial infection. Nosocomial: Originating or taking place in a hospital, acquired in a hospital, especially in reference to an infection. The term “nosocomial” comes from two Greek words: “nosus” meaning “disease” + “komeion” meaning “to take care of.”

Hence, “nosocomial” should apply to any disease contracted by a patient while under medical care. However, common usage of the term “nosocomial” is now synonymous with hospital-acquired. Nosocomial infections are infections that have been caught in a hospital and are potentially caused by organisms that are resistant to antibiotics. A nosocomial infection is specifically one that was not present or incubating prior to the patient’s being admitted to the hospital, but occurring within 72 hours after admittance to the hospital.

A bacterium named Clostridium difficile is now recognised as the chief cause of nosocomial diarrhoea in the US and Europe. Methicillin-resistant  (MRSA) is a type of staph bacteria that is resistant to certain antibiotics and may be acquired during hospitalisation. Candida colonisation and Candida infection often occurs in critically ill patients admitted to intensive care units (ICU

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2. WHAT ARE HOSPITAL-ACQUIRED INFECTIONS?

An infection that is diagnosed even after a patient has been discharged can be considered ‘hospital-acquired’ if it can be traced back to the hospital stay. For example, a wound infection that only develops after discharge from hospital would still be regarded as a nosocomial infection.
Hospital Acquired Infections (HAIs) greatly increase patient fatality rates, the risk of patients acquiring other infections, and length of stay in the hospital, therefore also increasing health care costs

3. HOW COMMON ARE HAIS?

In developed countries, about 5 to 10% of patients admitted to acute care hospitals acquire an infection which was not present or incubating on admission. The rate for developing countries can exceed 25%. The statistics for South Africa probably fall somewhere in between these numbers. Unfortunately, there are no good, large-scale surveys of nosocomial infection rates in South Africa. (Whitelaw in Health24: 2000 – 2018)

4. TYPES OF HOSPITAL-ACQUIRED INFECTIONS

HAIs may be caused by viruses, bacteria or fungi. They can affect different parts of the body, most commonly the urinary tract, the respiratory tract, wounds and the blood. Bloodstream infections can be caused by a wide variety of organisms, including yeasts (e.g. Candida albicans). The most common organisms causing bloodstream infection vary from hospital to hospital, but include E. coli, S. aureus, and Klebsiella, Enterobacter and Candida albicans

5. RISK FACTORS FOR HOSPITAL-ACQUIRED INFECTIONS

The following factors increase the risk for HAIs:

• Increased resistance to antibiotics
•  Antibiotics (antibacterial) are a powerful tool for fighting bacterial infection.
• However, a feature of HAIs is that the organisms causing HAI are often resistant to numerous antibiotics.
• Organisms in the hospital environment are exposed to many different antibiotics, and multi-drug resistant bacteria are now common in many hospitals.
• In some instances, the organisms causing HAIs are resistant to all available antibiotics. This is fortunately still rare, but is a cause for great concern.

Certain invasive medical procedures:

• Procedures such as intubation, urinary catheters and intravenous lines (drips) increase the risk of hospital-acquired pneumonia, urinary tract infection and bloodstream infection, respectively.
• Patients who have had surgical procedures are obviously at risk of wound sepsis.
• The nature and extent of the surgery can affect the risk of developing wound sepsis – surgery that involves cutting through an infected area would be at higher risk of post-operative wound infection.
• Patients with burns are also at risk of infection of the burn wound, and great care is taken to keep the wounds as clean as possible while they heal.

Poor hospital organisation

Factors which may include contaminated water and air conditioning systems, staff shortages, poor hospital layout e.g. beds too close to each other, and staff failing to follow hygiene and safety precautions such as hand-washing and adequate sterilisation of equipment.

The severity of the patient’s illness, state of the immune system, and length of stay in the hospital.

The elderly and children are also generally more vulnerable to HAIs.

6. CAN HOSPITAL-ACQUIRED INFECTIONS BE PREVENTED?

There is no way to eliminate the risk of hospital-acquired infections completely.

However, the following measures by hospital staff and patients themselves can help to reduce the incidence of HAIs:

• Following correct hygiene procedures e.g. correct hand washing and use of alcohol hand-rubs, proper disposal of body fluids, and providing a clean health-care environment and sterile medical equipment.
• Hospital visitors should respect any restrictions e.g. on numbers of visitors, not sitting on patient’s beds etc. Visitors should also follow basic hygiene precautions such as hand-washing before and after visiting and should stay at home if they themselves have an infection.
• As the risk of acquiring an infection increases the longer a patient stays in hospital, patients should be encouraged to get up, have any intravenous lines and urinary catheters removed and go home as soon as it is medically advisable.

To help prevent the proliferation of antibiotic-resistant bacteria, doctors should be cautious about over-prescription. The full course of medication prescribed must be completed. If a patient does not complete the course of antibiotics the condition may re-occur.

It is imperative that every health practitioner know that infection control in the workplace aims to prevent pathogens being passed from one person to another and to assume that everyone is potentially infectious. Last, but perhaps the most important is regular washing and keeping the workplace clean.

Almost two decades ago in 1999, the Institute of Medicine (IOM) described the nation’s health care system as fractured, prone to errors, and detrimental to safe patient care.

It defined patient safety as freedom from accidental injury and further stated that ensuring patient safety involves the establishment of operational systems and processes that minimise the likelihood of errors and maximise the likelihood of intercepting them when they occur (IOM, 2000).

Although significant progress has been made in preventing some infection types, there is much more work to be done. On any given day, about one in 25 hospital patients has at least one healthcare-associated infection.

CDC publishes yearly reports to help each state better understand their progress and target areas that need assistance. The data used in these come from two complementary HAI surveillance systems, the National Healthcare Safety Network (NHSN) and the Emerging Infections Program Healthcare-Associated Infections Community-Interface (EIP HAIC).

In 2014, results of a project known as the HAI Prevalence Survey were published. The Survey described the burden of HAIs in U.S. hospitals and reported that, in 2011, there were an estimated 722,000 HAIs in U.S. acute care hospitals. Additionally, about 75,000 patients with HAIs died during their hospitalisations. More than half of all HAIs occurred outside of the intensive care unit (Centre for Disease Control and Prevention: 2018).

World Health Organisation Department of Communicable Disease, Surveillance and Response: Prevention of hospital-acquired infections A practical guide 2nd edition (WHO/CDS/CSR/EPH/2002.12)

The Role of the nursing staff regarding the prevention of hospital-acquired infections as described in the above document is as follows:

Implementation of patient care practices for infection control. Nurses should be familiar with practices to prevent the occurrence and spread of infection, and maintain appropriate practices for all patients throughout the duration of their hospital stay. The senior nursing administrator is responsible for:

participating in the Infection Control Committee

promoting the development and improvement of nursing techniques, and ongoing review of aseptic nursing policies, with approval by the Infection Control Committee

developing training programs for members of the nursing staff

supervising the implementation of techniques for the prevention of infections in specialised areas such as the operating suite, the intensive care unit, the maternity unit and newborns

Monitoring of nursing adherence to policies. The nurse in charge of a ward is responsible for:

• maintaining hygiene, consistent with hospital policies and good nursing practice on the ward
• monitoring aseptic techniques, including handwashing and use of isolation
• reporting promptly to the attending physician any evidence of infection in patients under the nurse’s care
• initiating patient isolation and ordering culture specimens from any patient showing signs of a communicable disease, when the physician is not immediately available
• limiting patient exposure to infections from visitors, hospital staff, other patients, or equipment used for diagnosis or treatment
• maintaining a safe and adequate supply of ward equipment, drugs and patient care supplies. The nurse in charge of infection control is a member of the infection control team and responsible for
• identifying nosocomial infections
• investigation of the type of infection and infecting organism
• participating in training of personnel
• surveillance of hospital infections
• participating in outbreak investigation
• development of infection control policy and review and approval of patient care policies relevant to infection control
• ensuring compliance with local and national regulations
• liaison with public health and with other facilities where appropriate
• Providing expert consultative advice to staff health and other appropriate hospital programs in matters relating to the transmission of infections.

7. CONCLUSION

In conclusion, attention is given to the definition of a medic-legal hazard and how easy it can be to cause one e.g. by not washing your hands after tending to another patient after you have been to the toilet; meaning hands have to be washed at all times before tending to a patient.

A medico-legal risk or hazard is brought about through incorrect conduct towards, or neglect of a patient and the patient can lodge a legal complaint against the nursing practitioner or the institution that employs the nurse practitioner (Booysen; Erasmus & van Zyl, 2009:19).

Each year, almost 300,000 people die as a result of preventable medical errors. Infections, wounds, and injuries acquired by hospital patients can cause serious illness and suffering and, in many cases, even death. However, with a little preparation, families of hospital patients can take steps to assure that their loved ones get the proper care and treatment that they need to stay safe and get better
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Because the practices of medicine and nursing are so intimately concerned with people’s bodies, personal vulnerabilities and wellbeing, it is subject to legal and ethical restrictions, all of which have evolved or been designed to protect patients’ interests. They constrain healthcare practitioners to behave competently and ethically and to conduct themselves with probity.