醫(yī)院感染目標(biāo)性監(jiān)測譯

1、Targeted Surveillance for Nosocomial InfectionsBarbara M. Soule, RN, MPA, CICChinese Society for Nosocomial InfectionsJuly 4-5, 2004 Suzhou, China1ICP 的工作內(nèi)容IC Practitioner (ICP) Activities監(jiān)測Surveillance項(xiàng)目管理ProgramManagement教育Education工作的多樣性Miscellaneous暴發(fā)調(diào)查OutbreakInvestigation咨詢Consultation2監(jiān)測應(yīng)具有流行

2、病學(xué)基礎(chǔ)Surveillance has an Epidemiologic foundation為了計(jì)劃和實(shí)施干預(yù)措施，研究處于某特定感染危險(xiǎn)的人群（目標(biāo)人群）中的問題和事件的分布Study the distribution of problems and events within a defined (targeted) population at risk for developing specific infections in order to plan & implement interventions.33種主要的監(jiān)測方法3 Key Surveillance Methods 醫(yī)院

3、范圍的傳統(tǒng)監(jiān)測 Hospital-wide Traditional Surveillance所有的感染-全面-花費(fèi)時(shí)間 All infections complete- time consuming有限的時(shí)間用于干預(yù) Limits time for interventions定期監(jiān)測 Periodic Surveillance對選擇的感染或人群進(jìn)行定期監(jiān)測 Selected infections or populations periodically over time遺漏有些感染 Miss some infections 目標(biāo)監(jiān)測 Targeted Surveillance4名稱Name優(yōu)點(diǎn)

4、Advantages缺點(diǎn)Disadvantages目標(biāo)性監(jiān)測Targeted/ Focused Surveillance by Objective將有限的資源集中在高感染危險(xiǎn)病區(qū)Concentrates limited resources to high risk areas; 重點(diǎn)放在有已知控制措施的感染上Focuses on HAI with known control measures; 能夠確定確切的分母Can determine valid denominator; 靈活性，能夠和其他控制策略結(jié)合起來Flexible, can be mixed with other strategi

5、es;增加監(jiān)測的有效性Increases efficiency of surveillance; 使ICP能夠開展其他工作Enables ICP to perform other activities僅能收集監(jiān)測目標(biāo)病人或危險(xiǎn)的數(shù)據(jù)Collects data only for targeted patients or risks;漏掉未監(jiān)測病區(qū)或病人的感染集聚或暴發(fā)May miss clusters or outbreaks in non-surveyed areas or groupsAdapted from Pottinger et al & Gaynes et al.優(yōu)/缺點(diǎn)Advant

6、ages/Disadvantages5目標(biāo)性監(jiān)測Targeted Surveillance6美國CDC國家醫(yī)院感染監(jiān)測系統(tǒng)的目標(biāo)性監(jiān)測CDCs National Nosocomial Infections Surveillance (NNIS) System Targets:NNIS SystemAURICUHRNSurgicalPatientAntimicrobialUse and ResistanceIntensive CareUnit(Adult/Pediatric)High Risk Nursery (NICU)Risk adjustedSSIs byProcedures7你所在醫(yī)院監(jiān)

7、測系統(tǒng)的目標(biāo)性監(jiān)測 Your Hospital Surveillance System Targets:Your HospitalVAPICUBSISSIVentilator-Associated PneumoniaMedical /Surgical ICUsIntensive CareUnit(Pediatric)Primary BloodStream InfectionsPrimary OrthopedicNeurosurgical or CABGProcedures8哪些感染作為目標(biāo)性監(jiān)測Which infection to target?重點(diǎn)為具有高感染危險(xiǎn)的病人Focus on pa

8、tients at high risk for HAI病人的護(hù)理病區(qū)Patient care areas重癥監(jiān)護(hù)病房ICUs, 心胸外科cardio-thoracic surgery, 癌癥病房cancer ward特殊人群Specific populations新生兒neonates, 移植病人transplant patients, 血液透析病人hemodialysis pts操作/設(shè)備Procedures / DevicesCT 外科CT surgery, 中央靜脈插管central vascular lines, 呼吸機(jī)ventilators具有流行病學(xué)意義的病原體Organisms

9、of epidemiologic importance MRSA, VRSA9針對后果的目標(biāo)性監(jiān)測Targeted Surveillance for Outcomes原發(fā)性血液系統(tǒng)感染 Primary Bloodstream infections呼吸機(jī)相關(guān)性肺炎 Ventilator-associated pneumonia手術(shù)部位感染 Surgical site infections MRSA, VRE infections血液透析病人經(jīng)血管的感染 Vascular access infections in hemodialysis patients醫(yī)療機(jī)構(gòu)中的銳器刺傷 Sharps inj

10、uries in healthcare providers10針對過程的目標(biāo)性監(jiān)測Targeted Surveillance for Processes醫(yī)務(wù)人員的乙肝免疫率 Hepatitis B immunity rates in personnel醫(yī)務(wù)人員對操作規(guī)則的依從性-隔離預(yù)防Personnel compliance with protocols - isolation precautions,滅菌質(zhì)量監(jiān)測 Sterilization quality assurance testing, 有效地環(huán)境清潔 Effective environmental cleaning抗微生物藥物的使

11、用與管理 Antimicrobial prescribing and administration11怎樣實(shí)施目標(biāo)性監(jiān)測How to implement targeted surveillance12第一步 Step One感染控制護(hù)士和醫(yī)生每天查看微生物學(xué)報(bào)告 ICP and MD review Microbiology reports daily定期查閱過去的監(jiān)測數(shù)據(jù) Review past surveillance data periodically列出作為目標(biāo)性監(jiān)測的潛在感染或人群 Develop a list of the potential infections or popula

12、tions for targeted surveillance 13第二步 Step Two感染控制人員基于以下一個(gè)或多個(gè)標(biāo)準(zhǔn)選擇目標(biāo)性監(jiān)測的醫(yī)院感染 Infection control team selects nosocomial infections to target based on one or more of the following criteria:14選擇過程或后果進(jìn)行目標(biāo)監(jiān)測的的標(biāo)準(zhǔn)Criteria for Selecting Processes or Outcomes for Targeted Surveillance感染控制計(jì)劃的目的 IC program obje

13、ctives感染并發(fā)癥的危險(xiǎn)頻度或水平 Frequency or level of risk of infectious complications for 病區(qū) area患者人群 patient population 操作 procedure 服務(wù) service 發(fā)病率 Morbidity, 死亡率 Mortality, 費(fèi)用 Cost預(yù)防的可能性 Possibility for prevention15第三步 Step Three ICP 應(yīng)用一致的和認(rèn)可的標(biāo)準(zhǔn)，對第二步?jīng)Q定的與感染有關(guān)的過程或結(jié)局進(jìn)行數(shù)據(jù)收集ICP performs chart reviews on the infec

14、tion-related processes or outcomes identified in Step Two using standardized, consistent, approved definitions一定時(shí)期內(nèi)持續(xù)認(rèn)真的監(jiān)測Consistent intensity and thoroughness of surveillance over time一定時(shí)期內(nèi)同樣的定義Same definitions over time16目標(biāo)性監(jiān)測：方法Targeted Surveillance: A Means to an End僅收集必要的數(shù)據(jù)Collect only necessar

15、y data 得到有意義的信息Arrive at meaningful information17這樣您可以做到 So You Can:制定有意義的干預(yù)措施Develop meaningful interventions做減少感染的工作 DO something to reduce infections改善患者的醫(yī)療護(hù)理 Improve patient care!18目標(biāo)性監(jiān)測的成功周期The Cycle for Success Through Targeted Surveillance是否有重要的問題 Is there an important problem? 是什么，為什么？多專業(yè)的控制

16、人員 What, why? Multidisciplinary Teams 2.描述并理解問題 Describe and understand the problem? 目標(biāo)性監(jiān)測Targeted Surveillance 3. 怎樣去改進(jìn) How to affect change?多專業(yè)的控制人員 Multidisciplinary Teams教育Education反饋Feedback新方案New protocols新產(chǎn)品New products4. 改進(jìn)措施是否有效？ Do the changes work? 再評價(jià)Remeasure Adapted from: Richards C, e

17、t al. Emerg Infect Dis 200119NLMIgnaz Semmelweis Targeted Surveillance And InterventionFor Puerperal Sepsis20針對過程的目標(biāo)監(jiān)測Targeted Surveillance for a Process抗生素預(yù)防手術(shù)部位感染的時(shí)機(jī)選擇Timing of Antibiotic Prophylaxis for Surgical Site InfectionNLM Archives211.是重要問題嗎？Is There an Important Problem?外科不合理的預(yù)防使用抗微生物藥物是一

18、種主要的感染危險(xiǎn) Inappropriate surgical prophylaxis is a major infection risk 患者暴露于不必要的毒性 exposes patient to unnecessary toxicity增加耐藥性 increases antimicrobial resistance過量或不適當(dāng)?shù)目咕V使用并不能降低手術(shù)傷口感染的發(fā)生率excess doses or inappropriate spectrum antibiotics do not reduce the incidence of surgical wound infection22理想的預(yù)

19、防使用方法“Ideal” Prophylaxis理想的預(yù)防性應(yīng)用Ideal antibiotic for prophylaxis有效地殺滅可能污染傷口的病原菌 active against pathogens most likely to contaminate wound在潛在的污染期間保持足夠的濃度 adequate concentrations during potential contamination短期應(yīng)用以減少并發(fā)癥，耐藥及費(fèi)用 administered for a short time to reduce complications, resistance, and cost2

20、3Targeted Process SurveillanceTiming of Perioperative Antimicrobial ProphylaxisClassen DC, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281IncisionHours beforeincisionHours afterincisionAntibioticAdministered24圍手術(shù)期抗微生

21、物藥物預(yù)防應(yīng)用的時(shí)機(jī)Timing of Perioperative Antimicrobial ProphylaxisClassen DC, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281252. 針對該問題進(jìn)行目標(biāo)性監(jiān)測Perform Targeted Surveillance for This Problem1) 手術(shù)切口前一小時(shí)接受預(yù)防性抗生素的患者比例Proportion

22、of patients who receive prophylactic antibiotics within 1 hour before surgical incision術(shù)前1小時(shí)使用抗生素的人數(shù)，# antibiotics 1 hour 使用抗生素的所有病人數(shù)，# surgeries with antibiotics26針對問題進(jìn)行目標(biāo)監(jiān)測Perform Targeted Surveillance for This Problem2) 手術(shù)結(jié)束后24小時(shí)內(nèi)停用抗生素的患者比例 Proportion of patients whose antibiotics were discontinu

23、ed within 24 hours of the surgery end time# discontinue w/I 24 hours # surgeries receiving antibiotics27手術(shù)操作決定預(yù)防性的抗生素給藥時(shí)間選擇Possible Surgical Procedures to Determine Timing of Antibiotic Prophylaxis冠脈搭橋手術(shù)CABG結(jié)腸手術(shù)Colon surgery髖和膝關(guān)節(jié)形成術(shù)Hip and knee arthroplasty經(jīng)腹或陰道子宮切除術(shù)Abdominal and vaginal hysterectom

24、y血管手術(shù)Vascular surgery (e.g., peripheral vascular surgery)283. 改進(jìn)To Affect Change多學(xué)科小組檢查抗生素給藥制度：現(xiàn)狀和期望的制度 Multidisciplinary Team to look at antibiotic delivery system: current and desired重新設(shè)計(jì)抗生素的及時(shí)應(yīng)用制度Redesign system for timely AB delivery抗生素的可得性，Make antibiotic accessible培訓(xùn)護(hù)理和手術(shù)室人員以及麻醉師和外科大夫Educate n

25、ursing and operating room staff and anesthesiologists and surgeons在病歷上記錄給藥時(shí)間，Record time on patient chart294.改進(jìn)工作有效嗎？ Do the changes work?在新的改良操作開始后的3個(gè)月內(nèi)重新檢查2個(gè)變量 Re-measure 2 variables in 3 months after initiation of new improved procedure監(jiān)測手術(shù)部位感染率Measure surgical site infection rates.30針對感染結(jié)果的目標(biāo)性監(jiān)測

26、Targeted Surveillance for an Infection Outcome31Targeted Surveillance for Outcomes醫(yī)院感染率NI Rate:VAPCR-BSIUTIFoley relatedNon-Foley related采取干預(yù)措施的目的Drives Intervention For:Pneumonia preventionCR-BSI preventionFoley-care, d/c programPeri-care / hydration 321.是重要問題嗎？Is There an Important Problem?呼吸機(jī)相關(guān)性肺

27、炎對患者是一個(gè)主要感染危險(xiǎn)Ventilator - associated pneumonia is a major infection risk for patients增加病死率 increased mortality延長住院時(shí)間 excess length of stay增加醫(yī)療費(fèi)用 excess cost33Example: Challenge for Targeted Surveillance將呼吸機(jī)相關(guān)性肺炎降低50 Reduce ventilator associated pneumonias (targeted adverse event) by 50% # VAP infect

28、ions # 1000 ventilator days34通過目標(biāo)監(jiān)測和干預(yù)減少呼吸機(jī)相關(guān)性肺炎Reduction of VAP with Targeted Surveillance and InterventionsKwan KL, Baker SP, Fontecabio SA. Impact of a program ofintensive surveillance and interventions targeting ventilated patients in the reduction of ventilator-associated pneumonia, and its cos

29、t effectivenessICHE 2003;24;11:859-63.35Reduction of VAP with Targeted Surveillance and Interventions干預(yù)措施Interventions:抬高床頭Raise head of bed管道給予滅菌水Sterile water for tube feedings24 - 48 -72- 根據(jù)需要應(yīng)用氣管導(dǎo)管In-line suction catheters from 24 - 48 -72- as needed每年節(jié)約花費(fèi)$350，000 Cost savings $350,000 in one year.361. Is There an Important Problem?導(dǎo)管相關(guān)血流感染是一種嚴(yán)重的感染危險(xiǎn)因素Catheter-related bloodstream infections are a serious infection risk導(dǎo)管相關(guān)的device-related發(fā)病率和病死率morbidity and mortality延長住院時(shí)間extra length of stay額外醫(yī)藥花費(fèi)additional medical costs370510152025JanAprilJulyOctJanAprilJulyOctJan989