The Influence of Risk Factors on Nosocomial Pneumonia Events in
Hospital Al-Azis Intensive Care Unit Rantauprapat
Ibrahim Lubis
1
, Nurleli
2
, Jon Piter Sinaga
1
1
Public Health Faculty of DELI HUSADA Halth Institute, Deli Tua, Indonesia
2
Public HealthFaculty of STIKes Lhoksemawe, Aceh, Indonesia
Keywords: Nosocomial Pneumonia, Infection, Use of Antibiotics, ICU.
Abstract: Nosocomial pneumonia is a serious problem that can cause death directly or indirectly. The lightest thing
that can be felt with the occurrence of nosocomial pneumonia is the length of hospitalization, so the patient
have to pay great cost of care treatment. This study aims to determine the effect of risk factors on the
incidence of nosocomial pneumonia. The method of this study is analytic observational case control with a
retrospective approach. The analysis in this study was the analysis of multiple logistic regression at a real
level α = 0.05. The results showed that there was influence of age (p = 0.00; p <0.05), length of treatment (p
= 0.04; p <0.05), duration of mechanical ventilator use (p = 0.01; p < 0.05), antibiotic use (p = 0.00; p
<0.05) against nosocomial pneumonia. There was no sex effect on nosocomial pneumonia (p = 0.12; p>
0.05). From multivariate analysis showed that the most dominant factor influencing was age (p = 0.00).
Prevention of nosocomial pneumonia is suggested to be carried out by applying aseptic and antiseptic
principles during invasive procedures, implementing the patient safety principle, and using good personal
protective equipment.
1 INTRODUCTION
Infectious diseases are still the main cause of
high morbidity and mortality rates in the world. One
type of infection is a nosocomial infection.
Nosocomial infection is an infection that occurs in a
hospital or health care facility after being treated
2x24 hours. Before being treated the patient did not
have these symptoms and was not in the incubation
period Nosocomial infection is not a result of
previous illnesses. Hospital as a place of treatment is
also a health care facility that can be a source of
infection where sick people are treated. Nosocomial
infections can occur in patients, health workers and
also everyone who comes to the hospital. Infections
at this health center can be transmitted or obtained
through health workers, sick people, career visitors
or due to hospital conditions (Schwarzbold et al.,
2018)
The most common nosocomial infection is
nosocomial pneumonia after urinary tract infection,
which is as much as 13.18% or 5-10 episodes per
1000 hospitalizations. Nosocomial pneumonia
(Hospital-acquired pneumonia) is a pulmonary
infection that occurs more than 48 hours After being
treated in hospital and getting rid of all infections
that occur before entering the hospital and not in the
incubation period at hospital admission (Stenlund,
Sjödahl and Yngman-Uhlin, 2017)
The incidence of nosocomial pneumonia in the
ICU is more common than nosocomial pneumonia in
public areas, which is found in nearly 20% of all
infections in the ICU and 90% occur during
mechanical ventilation. Hospital-acquired
pneumonia is obtained in 9-27% of patients who are
intubated, the risk of hospital-acquired pneumonia is
highest at the time of initial admission to the ICU
(Frantzeskaki and Orfanos, 2018)
The mortality rate in nosocomial pneumonia is
20 - 50%, this rate increases in pneumonia caused by
P. aeroginosa or who has secondary bacteremia. The
mortality rate of patients in ICU patients has
increased 3-10 times compared to patients without
Pneumonia. Some studies say that the duration of
treatment increased 2-3 times compared to patients
without pneumonia. This certainly will increase the
cost of treatment in the hospital. In the United
States, it was reported that the length of treatment
increased by an average of 7 to 9 days (Xia, Gao and
Tang, 2016)
Several risk factors are suspected to trigger
nosocomial pneumonia including age over 60 years,
Lubis, I., Nurleli, . and Sinaga, J.
Influence of Risk Factors on Nosocomial Pneumonia Events in Hospital Al-Azis Intensive Care Unit Rantauprapat.
DOI: 10.5220/0009515903870394
In Proceedings of the International Conference on Health Informatics and Medical Application Technology (ICHIMAT 2019), pages 387-394
ISBN: 978-989-758-460-2
Copyright
c
 2020 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
387

male sex, length of ICU treatment, use of invasive
equipment> 48 hours (intubation, nasogastric tube,
mechanical ventilator), use of antibiotics (Xia, Gao
and Tang, 2016)
All studies on nosocomial pneumonia found that
most HAP subjects were male sex because this was
because male sex was more susceptible to
pneumonia. One of the causes of this vulnerability is
because men are more exposed to cigarette smoke
pollution which is a risk factor for pneumonia.
Halim research results (2014) in RSCM 204 patients
diagnosed with HAP, 109 people (53.4%) of whom
were men. In Thailand, Werarak (2010) also found
more male subjects affected by nosocomial
pneumonia were 102 out of 140 subjects (70%). In
North Sumatra, a study on the prevalence of
nosocomial pneumonia in the ICU in Haji Hospital
Medan by Ibrahim (2016) found the largest number
of nosocomial pneumonia events in the male gender
group of 20 people (86.95%).(Xiao et al., 2016)
Nosocomial pneumonia can have an impact on
increasing morbidity and mortality and increased the
length of stay. This needs serious attention from
hospital managers and medical personnel. Medical
staff in hospitals, especially in the ICU room need to
pay attention to any factors that cause nosocomial
pneumonia, so they can take appropriate action to
minimize or reduce the incidence of nosocomial
pneumonia in the ICU room. The importance of
doctors and nurses knowing what factors affect
nosocomial pneumonia in the ICU so that it can
minimize the impact caused by the background of
this research needs to be done.(Xiao et al., 2016)
2 RESEARCH METHOD
This type of research is an observational
case-control analytic study with a retrospective
approach, which is to see the effect of risk factors on
the incidence of nosocomial pneumonia. This
research was conducted on April 2019. The place of
this research was conducted at Elpi Al-
azisRantauprapat General Hospital. The population
in this study were all patients diagnosed with
nosocomial pneumonia based on CPIS scores in the
ICU room at Elpi Al-AzisRantauprapat General
Hospital. The sample in this study were 58 cases and
58 controls using the sample size determination in
health study software.
Bivariate analysis and multivariate analysis used
in this study are using chi-square and multiple
logistic regression.
3 RESULTS AND DISCUSSION
3.1 Univariate Analysis
Univariate analysis in this study focused on
variables of age, sex, duration of treatment, duration
of use of mechanical ventilators, use of antibiotics.
The description of univariate analysis in this study
can be seen as in the following table:
Table 1:Description of Univariate Variable Risk Factors
for Nosocomial Pneumonia in ICU Room of Elpi Al-Azis
Hospital Rantauprapat 2018
No Variabel
Pneumonia
(Case)
No
pneumonia
(Control)
Amount
N % N % %
1.
2.
Age
(Years)
>60 Years
<60 Years
39
19
75,0
29,7
13
45
25,0
75,3
52
64
100
100
1.
2.
Gender
Female
Male
17
41
39,5
56,2
26
32
60,5
43,8
43
73
100
100
1.
2.
Length of
treatment
There is
There is’t
38
20
64,4
35,5
21
37
35,6
64,9
59
57
100
100
Based on the table 1 it was found that patients
with age <60 years 64 people (55.2%) more than the
sample of patients with age> 60 years totaling 52
people (44.8%). And samples with male sex more
than women. The results obtained by the male type
73 people (62.9%), while the female gender 43
people (37.1%). Patients with> 5 days treatment 62
people (53.4%) more than <5 days treatment 54
(46.6%). Based on the table above, the results show
that the use of mechanical ventilators> 5 days is 60
people (51.7%), while the use of mechanical
ventilators <5 days is 56 people (48.3%). Based on
the table, the results showed that patients with prior
antibiotic use were 59 people (50.9%), while
patients with more than two or more antibiotic use
were 57 people (49.1%).
3.2 Bivariate Analysis
Bivariate analysis was used to determine the
effect between the independent variables and the
dependent variable using the Chi-Square test and the
result data obtained as follows:
ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology
388

3.2.1 Effect of Age on the Occurrence of
Nosocomial Pneumonia
Table 2: The Effect of Age on The Incidence of
Nosocomial Pneumonia in The ICU Room of Elpi Al-Azis
Hospital Rantauparapat in 2018
Incident of
Pnemonial
Patient Status
Amount
Pnemonia No Pnemonia
n % n % n %
>60 years
≤60 years
39
19
75,0
29,7
13
45
25,0
75,3
52
64
100
100

2
=21,7:p=
0,00(p.0,05)
OR=7,
10
95%CI(3,11-16,2
Based on the table 2 it can be seen that the
incidence of nosocomial pneumonia in the ICU is
highest at age> 60 years 39 patients out of 52 people
(75.0%) compared to those aged ≤ 60 years 19
patients out of 64 people (29.7%). Statistical
analysis showed that there was an influence of age
on the incidence of nosocomial pneumonia in the
ICU room at Elpi Al-Azis Hospital Rantauprapat (p
= 0.00; p <0.05). and odd ratio; 7.10 95% CI (3.11-
16.2). This means that the risk of pneumonia is 7.10
times greater for people aged> 60 years than for
those aged ≤ 60 years.
3.2.2 Effects of Gender on the Occurrence of
Nosocomial Pneumonia
Table 3: The Influence of Sex on the Occurrence of
Nosocomial Pneumonia in the ICU Room of Elpi Al-Azis
Hospital Rantauprapat in 2018
The
incidence of
pneumonia
Status Pasien
Amount
Pneumonia
No
Pneumonia
n % n % n %
>60 years
<60 years
17
41
39,5
56,2
26
32
60,5
43,8
43
73
100
100
X
2
=2,36;
p=0,12
(p>0,05)
OR=0,5
1
95%CI (0,23-
1,09)
Based on the table 3, it can be seen that the
incidence of nosocomial pneumonia in the ICU is
highest in male sex 41 out of 73 patients (56.2%).
compared with female sex 17 of 43 patients (39.5%)
The results of statistical analysis showed that there
was no gender-related to the incidence of
nosocomial pneumonia in the ICU room at Elpi Al-
Azis Hospital Rantauprapat (p = 0.12; p> 0.05 ).
3.2.3 Effect of Length of Treatment on the
Incidence of Nosocomial Pneumonia
Table 4:Effect of Duration of Care on the Occurrence of
Nosocomial Pneumonia in the ICU Room of Elpi Al-Azis
Hospital Rantauprapat in 2018
The
incidence
of
pneumonia
Status Pasien
Amount
Pneumoni
a
NonPne
umonia
n % n % n %
Length of
treatment
>5 days
<5 days
37
21
59,
7
38,
9
2
5
3
3
40,
3
61,
1
62
54
100
100
X
2
=4,19 ;
p=0,04
(p>0,05)
OR
=2,
32
95%CI(1,10-
4,90)
Based on the table 4, it can be seen that the
incidence of nosocomial pneumonia in the ICU is
highest in the duration of treatment> 5 days 37 of 62
patients (59.7%) compared to the duration of
treatment <5 days 21 of 54 patients (38.9%). The
results of the statistical analysis showed that there
was an effect of the length of treatment on the
incidence of nosocomial pneumonia in the ICU
room at Elpi Al-Azis Hospital Rantauprapat (p =
0.04; p <0.05). and odd ratio; 2.32 95% CI (1.10-
4.90). This means that the risk of pneumonia is 2.32
times greater for the duration of treatment than for
the duration of treatment<5 days.
3.2.4 The Effect of Long Use of Mechanical
Ventilators on the Occurrence of
Nosocomial Pneumonia
Table 5: The Effect of Antibiotic Use on The Incidence of
Nosocomial Pneumonia in The ICU Room of Elpi Al-Azis
Hospital Rantauparapat in 2018
Incident of
Pnemonial
Patient Status
Amount
Pnemonia
No
Pnemonia
n % N % n %
Use of
Antibiotics
There is
There isn’t
38
20
64,
4
35,
5
2
1
3
7
35,6
64,9
59
57
10
0
10
0

2
=8,83
;p=0,00(p.0,0
5)
OR
=3,
34
95%CI(1,56-
7,16)
Influence of Risk Factors on Nosocomial Pneumonia Events in Hospital Al-Azis Intensive Care Unit Rantauprapat
389

Based on the table 5 it can be seen that the
incidence of nosocomial pneumonia in the ICU
room was highest in the previous antibiotic use of 38
patients out of 59 people (64.4%) compared to
without the use of antibiotics before 21 patients out
of 57 people (35.6%). Statistical analysis showed
that there was an effect of antibiotic use on the
incidence of nosocomial pneumonia in the ICU
room at Elpi Al-Azis Hospital Rantauprapat (p =
0.00; p <0.05). and odd ratio; 3.34 95% CI (1.56 to
7.16). This means that the risk of pneumonia is 3.34
times greater for previous antibiotic use than for not
using previous antibiotics.
3.2.5 The Effect of Antibiotic Use on the
Occurrence of Nosocomial Pneumonia
Table 6:The Effect of Antibiotic Use on the Occurrence of
Nosocomial Pneumonia in the ICU Room of Elpi Al-Azis
Hospital Rantauprapat in 2018
The
incidence
of
pneumonia
Status Pasien
Amount
Pneumonia
No
Pneumonia
n % n % n %
Use of
Antibiotics
There is
There is’t
38
20
64,4
35,5
21
37
35,6
64,9
59
97
100
100
X
2
=8,83 ;
p=0,00
(p>0,05)
OR
=3,
34
95%CI (1,56-
7,16)
Based on the table 6 it can be seen that the
incidence of nosocomial pneumonia in the ICU
room was highest in the previous antibiotic use of 38
patients out of 59 people (64.4%) compared to
without the use of antibiotics before 21 patients out
of 57 people (35.6%). Statistical analysis showed
that there was an effect of antibiotic use on the
incidence of nosocomial pneumonia in the ICU
room at Elpi Al-Azis Hospital Rantauprapat (p =
0.00; p <0.05). and odd ratio; 3.34 95% CI (1.56 to
7.16). This means that the risk of pneumonia is 3.34
times greater for previous antibiotic use than for not
using previous antibiotics.
3.3 Multivariate Analysis
Multivariate analysis in this study is intended to look
at the effect of independent variables on the
dependent variable together for the sake of estimation.
Based on the results of the bivariate analysis,
candidate variables included in the logistic regression
analysis can be seen as in the following table.
Table 7: The final table of regression test results
Variabel p Odds
95% CI
Lower Upper
Age 0,00 8,29 3,24 21,1
Prolonged Use
of Mechanical
Ventilators
0,00 3,55 1,39 9,07
Use of
Antibiotics
0,01 3,01 1,22 7,41
Konstanta 0,00
Based on the table 7 it can be seen that
together the regression model is feasible to be used
to determine the effect of risk factors on the
incidence of nosocomial pneumonia (p <0.00).
Individually, the results of the analysis found that
there was an influence of age on the incidence of
nosocomial pneumonia (p <0.00) with an odds ratio
(OR) of 8.29; 95% CI (3.24-21.1). This means that
the incidence of nosocomial pneumonia in the ICU
room is 8.29 times greater in patients aged> 60 years
compared to patients aged <60 years. The analysis
also found the effect of the duration of mechanical
ventilator use on the incidence of nosocomial
pneumonia in the ICU room at Elpi Al-Azis Hospital
Rantauprapat (p <0.00) with an odds ratio (OR) of
3.55; 95% CI (1.39-9.07). This means that the risk of
pneumonia incidence is 3.55 times greater for use of
mechanical ventilators> 5 days than with the use of
mechanical ventilators <5 days. Statistical analysis
showed that there was an effect of antibiotic use on
the incidence of nosocomial pneumonia in the ICU
room at Elpi Al-Azis Hospital Rantauprapat (p
<0.01). and odd ratio; 3.01 95% CI (1.22-7.41). This
means that the risk of pneumonia is 3.01 times
greater for previous antibiotic use than for not using
previous antibiotics. From the results of this study, it
was also found that the sex and duration of treatment
variables did not affect the incidence of nosocomial
pneumonia in the ICU (p> 0.05). From the results of
this study, it was also found that the age variable
was the most dominant variable affecting the
incidence of nosocomial pneumonia in the ICU
Room of Elpi Al-Azis Hospital Rantauprapat.
4 DISCUSSION
4.1 Univariate Analysis
Based on the table above it was found that patients
with age <60 years 64 people (55.2%) more than the
sample of patients with age> 60 years totaling 52
people (44.8%). And samples with male sex more
ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology
390

than women. The results obtained by the male type
73 people (62.9%), while the female gender 43
people (37.1%). Patients with> 5 days treatment 62
people (53.4%) more than <5 days treatment 54
(46.6%). Based on the table above, the results show
that the use of mechanical ventilators> 5 days is 60
people (51.7%), while the use of mechanical
ventilators <5 days is 56 people (48.3%). Based on
the table, the results showed that patients with prior
antibiotic use were 59 people (50.9%), while
patients with more than two or more antibiotic use
were 57 people (49.1%).
4.2 Bivariate Analysis
4.2.1 Effect of Age on the Occurrence of
Nosocomial Pneumonia
Age variable is the most dominant factor in this
study, this is because according to the observations
of researchers in the field that in the ICU room of
Elpi Al-Azis Hospital Rantauprapat the average
patient using a mechanical ventilator is a patient
aged> 60 years. In addition, patients aged> 60 years
are patients who have an average length of stay> 5
days which is another risk factor that influences the
prevalence of nosocomial pneumonia.
4.2.2 Effects of Gender on the Occurrence of
Nosocomial Pneumonia
The gender variable is not meaningfully caused by
the following things. in healthy conditions and
young age, there are differences in endurance
between men and women where female endurance is
better than men. The hormone estrogen in women
can activate nitric oxide synthase (N0S3) which can
increase phagocytosis so that it can fight
microorganisms well. In general, men are often
exposed to nosocomial pneumonia because it is
thought to be influenced by sex-specific hormones
such as steroid hormones, such as androgens,
estrogens, and progesterone as a modifying factor in
the immune response and can inhibit the
inflammatory process. Then the male gender is more
susceptible to certain diseases including HAP
(Sweeney and Khatri, 2016)
4.2.3 Effect of Length of Treatment on the
Incidence of Nosocomial Pneumonia
Length of stay can be caused by the patient's medical
condition or the presence of nosocomial infection
that extends the length of the stay can reach 5-20
days (MOH, 2005). Richard Johnson and Jennifer
Simpson (2009) stated that the length of stay could
increase due to nosocomial infection to 13.3 days, 2
times longer than normal. Apart from medical
conditions, length of stay can also be caused by non-
medical conditions, such as administrative delays in
hospitals, lack of planning in providing services to
patients (patient scheduling) or policies in the
medical field. (I Wayan Journalist, 2012).
4.2.4 The Effect of Long Use of Mechanical
Ventilators on the Occurrence of
Nosocomial Pneumonia
The use of mechanical ventilators increases the risk
of nosocomial pneumonia by transferring
oropharyngeal microorganisms to the trachea
through the endotracheal tube during intubation and
decreased endurance of the patient due to severe
underlying disease. Tracheal colonization is the
presence of microorganisms from cultures obtained
from tracheal samples that initially had no signs of
the process of airway infection. In Elpi Al-Azis
General Hospital, Rantauprapat, according to the
researchers' observations, most patients who use
mechanical ventilators are> 60 years old and with a
duration of> 5 days. Another thing that researchers
found was the procedure of installing a mechanical
ventilator in patients who were under-attention
because the anesthesiologist had more than one
place of duty.
4.2.5 The Effect of Antibiotic Use on the
Occurrence of Nosocomial Pneumonia
Irrational use of antibiotics can cause resistance to the
patient's body which allows the patient's immune
system to become weak which is susceptible to
microorganisms that cause HAP. The choice of
empirical antibiotics for critical patients in the ICU
requires several considerations, including the specific
pattern of germs in the ICU, and the possibility of
infecting germs that have become resistant to empiric
antibiotics given previously. Because of the critical
condition of the patient, the bactericidal effect of
antibiotics becomes less efficient and has the potential
to cause germ resistance.
4.3 Multivariate Analysis
To determine the effect of risk factors on the
incidence of nosocomial pneumonia (p <0.00).
Individually, the results of the analysis found that
there was an influence of age on the incidence of
nosocomial pneumonia (p <0.00) with an odds ratio
(OR) of 8.29; 95% CI (3.24-21.1). This means that
Influence of Risk Factors on Nosocomial Pneumonia Events in Hospital Al-Azis Intensive Care Unit Rantauprapat
391

the incidence of nosocomial pneumonia in the ICU
room is 8.29 times greater in patients aged>60 years
compared to patients aged <60 years. The analysis
also found the effect of the duration of mechanical
ventilator use on the incidence of nosocomial
pneumonia in the ICU room at Elpi Al-Azis Hospital
Rantauprapat (p <0.00) with an odds ratio (OR) of
3.55; 95% CI (1.39-9.07). This means that the risk of
pneumonia incidence is 3.55 times greater for use of
mechanical ventilators>5 days than with the use of
mechanical ventilators <5 days. Statistical analysis
showed that there was an effect of antibiotic use on
the incidence of nosocomial pneumonia in the ICU
room at Elpi Al-Azis Hospital Rantauprapat (p
<0.01). and odd ratio; 3.01 95% CI (1.22-7.41). This
means that the risk of pneumonia is 3.01 times
greater for previous antibiotic use than for not using
previous antibiotics. From the results of this study, it
was also found that the sex and duration of treatment
variables did not affect the incidence of nosocomial
pneumonia in the ICU (p> 0.05). From the results of
this study, it was also found that the age variable
was the most dominant variable affecting the
incidence of nosocomial pneumonia in the ICU
Room of Elpi Al-Azis Hospital Rantauprapat.
5 CONCLUTION
There was an influence of age on the incidence of
nosocomial pneumonia (p <0.00) with an odds ratio
(OR) of 8.29; 95% CI (3.24-21.1). This means that
the incidence of nosocomial pneumonia in the ICU
room is 8.29 times greater in patients aged> 60 years
compared to patients aged <60 years. There was a
long-term effect of the use of mechanical ventilators
on the incidence of nosocomial pneumonia in the
ICU room of Elpi Al-Azis Hospital Rantauprapat (p
<0.00) with an odds ratio (OR) of 3.55; 95% CI
(1.39-9.07). This means that the risk of pneumonia
incidence is 3.55 times greater in the use of old
mechanical ventilators compared with the use of
short mechanical ventilators. There is an influence
of the use of antibiotics on the incidence of
nosocomial pneumonia in the ICU room of Elpi Al-
Azis Hospital Rantauprapat (p <0.01). and odd ratio;
3.01 95% CI (1.22-7.41). This means that the risk of
pneumonia is 3.01 times greater for the use of
antibiotics ≥ 2 types of antibiotics compared to 1
type of antibiotics. Sex and duration of treatment
had no effect on the incidence of nosocomial
pneumonia in the ICU (p> 0.05). From the results of
this study, it was also found that the most dominant
age variable influenced the incidence of Nosocomial
Pneumonia in the ICU of Elpi Al-Azis Hospital
Rantauprapat in 2018.
6 SUGGESTION
For doctors and medical staff especially those who
served in the ICU room at Elpi Al-AzisRatauprapat
Hospital to provide higher service and attention to
patients aged>60 years, especially regarding hygiene
in efforts to prevent early nosocomial infections,
apply aseptic and antiseptic principles during the
procedure invasive, the implementation of the
principle of patient safety, and the use of good
personal protective equipment. Remind doctors to
use antibiotics if more than one week needs to be
evaluated whether they need to be continued,
stopped or replaced according to culture results. In
the treatment of patients need to be guided by
clinical pathway diagnosis of the disease so that
patients are not too long in the hospital and not too
long the patient uses a mechanical ventilator. For
doctors and other medical personnel so that the
results of this study can be used as epidemiological
data for Elpi Al-Azis General Hospital
Rantauprapat, specifically the ICU section, to take
steps to prevent and reduce the incidence of
nosocomial pneumonia such as education, early
detection or providing adequate management. To the
Elpi Al-Azis General Hospital Rantauprapat
especially those responsible for completing medical
record data, such as doctors and paramedics to
complete medical record data and write neatly and
clearly so that readers can understand correctly and
correctly. Further research needs to be done with
more samples and a longer period. If possible can
use a prospective research design by taking into
account various limitations in this study. Research
into other factors that have to do with the risk of
nosocomial pneumonia is needed.
ACKNOWLEDGEMENTS
My deep thanks to DELI HUSADA Deli Tua Health
Institute for providing the opportunity for all
lecturers on this beloved campus to gain Knowledge
in Writing the Scientific Journal and provide new
Experiences in holding the International
Conferences. Hopefully with the implementation of
this activity in the future I can contribute to the
progress of DELI HUSADA Deli Tua Health
Institute.
ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology
392

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