課前預(yù)習(xí)定義病人在醫(yī)療機(jī)構(gòu)因其他疾病接受治療的過程中所感染

Healthcare-associatedInfections醫(yī)療相Definition:Infectionsthatpatientsacquireduringthecourseofreceivingtreatmentforotherconditionswithinahealthcaresetting Settings:hospitals(IntensiveCareUnits,SpecialCareUnits,otherhospitalsettings),long-termcarefacilities(LTCFs),outpatientfacilitiessuchasambulatorysurgicalclinics,dialysiscenters機(jī)構(gòu)：醫(yī)院（重癥監(jiān)護(hù) ，特殊護(hù)理，其他）長期護(hù)理機(jī)構(gòu)，門診如門診手術(shù) ，透析Inhospitalsalone(annually)每年僅在醫(yī)1.7million1outof20patients(5%)acquirean99,000deathsassociatedwith$26-33billioninexcesshealthcare

170萬醫(yī)療相5%病例發(fā)生醫(yī)療相 死于醫(yī)療相260-330億額外醫(yī)療開EstimatesofHealthcare-associatedInfectionsinUSHospitalsAnnually每年在醫(yī)院中的醫(yī)數(shù)

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Procedure-relatedinfections操作相Surgicalsite 手術(shù)部 3- Healthcare-associatedInfectionsinNon-hospitalSettings非醫(yī)院內(nèi)的醫(yī)療相Long-termcare長期護(hù)1.7millionbedswith2.5millionresidents/yearnationally nsHealthcareSystem:133LTCFs,11,475退 醫(yī)療系統(tǒng)：133個(gè)長期護(hù)理機(jī)構(gòu)，11475名患√HAIprevalence:醫(yī)療相 患病率√Indwellingmedicaldevice:25%ofall內(nèi)置醫(yī)療器械：25%NCHS,Tsan,AJIC,Klevens,SeminDialysis,MMWRMay16,2008;Healthcare-associatedInfectionsinNon-hospitalSettings非醫(yī)院內(nèi)的醫(yī)療相Ambulatorysurgicalcenters:5,175門診手術(shù)中心：5175DataonHAIsfromoutbreaks;nonational爆發(fā)數(shù)據(jù)，無監(jiān)測Example:hepatitisCoutbreakassociatedwithsyringereuseresultedinlettersto>40,000endoscopycenter例如：重復(fù)使用針頭導(dǎo)致肝爆，手室因需要向萬出 件告知其 可能性NCHS,Tsan,AJIC,Klevens,SeminDialysis,MMWRMay16,2008;Healthcare-associatedInfectionsinNon-hospitalSettings非醫(yī)院內(nèi)的醫(yī)療相Dialysiscenters:4,950透析中心：4950家機(jī)Catheter-relatedbloodstreaminfections:4.2per100patientmonths導(dǎo)管相關(guān)血流 Incidenceofmethicillin-resistantStaphylococcusaureus(MRSA)bloodstreaminfection:100xgreaterthaninnondialysispopulation耐甲氧西林金黃色葡萄球菌 NCHS,Tsan,AJIC,Klevens,SeminDialysis,MMWRMay16,2008;MRSAInfectionsAreaPatientSafetyChallengeLimitedtoAcuteCareHospitalSetting ~ s“ial” 60%ntifiedbeforeonfirst2daysofhospitalizationbutwithcntactstohealtharesettings)60%的最初兩天發(fā)現(xiàn)（存在與醫(yī)療相關(guān)的接觸） 15%在醫(yī)院獲得，在社區(qū)發(fā)EmergingThreatsinHealthcareEstimateofClostridiumdifficileCases,bySetting醫(yī)療領(lǐng)域的 ：艱難梭Hospital-acquired,hospital-onset165,000,$1.3billioninexcesscosts,0

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Hidronetal.ICHEStateofPreventionHICPAC/CDCEvidence-basedPreventionGuidelinesaredevelopedforeachtypeofinfectionandbasedonsystematicreviewsofthemedicalli ture在系統(tǒng)綜述醫(yī)學(xué)文 Categoriesof 類Category1A1AStrongmendation/strongormoderatequalityof強(qiáng)烈建議/高質(zhì)量或中等質(zhì)量的文Category1B1BStrongmendation/weakqualityofevidenceor強(qiáng)烈建議/稍弱 或已被接受的操StateofPreventionHICPAC/CDCEvidence-basedPreventionCategory1C1CStrongmendationrequiredbystateorfederal國家 要求的，強(qiáng)烈建Category22Weakmendationsupportedbylimited非強(qiáng)烈建議 有Nomendation/unresolved無建議/未解決的問Insufficientevidencetosupporta不足，無法支持建StateofPreventionSuboptimalAdherencetoHICPAC/CDC對HICPAC/CDC的建議執(zhí)行差強(qiáng)Handhygieneadherence手衛(wèi)生規(guī)范執(zhí)5%81overallaverage405-81%按照標(biāo)準(zhǔn)（總體平均Surgicalantimicrobialprophylaxis手術(shù)抗生素預(yù)<50%adherencetomendations執(zhí)行小于FullcompliancewithmajorHAIguidelines全面執(zhí)行HAI指南Among1,256UShospitals—30.7%to在1256家醫(yī)院中-30.7%到Central-linebloodstreaminfectionsprevention—中心靜脈血 預(yù)防-ArchSurg StateofPreventionSuccessfulPreventionofBloodstreamInfectionsMichigan&Pennsylvania密西根州和賓夕法尼亞州成功預(yù)防中心靜脈血ImplementationofCDC/HICPACInfectionPreventionGuideline執(zhí)行CDC/HICPAC中心靜脈 Forinsertionandremovalofintravascularcatheters介入和移除血液導(dǎo)Intensivecareunits重癥監(jiān)SWPennsylvania(66),Michigan(103)Interventionstoincreasedadherencetomendationsweresimilar Educationofstaff人員教育Creationofacentral-linecart中心靜脈介入操作車Data/feedbackonadherencetopracticesand數(shù)據(jù)反MutoetalMMWROt45rttJl6ryrounds每日多部門巡Strategiestoimprovesafetyculture營造安全醫(yī)的人文環(huán)StateofpreventionPreventsBloodstreamInfections Pennsylvania賓 Michigan密西根108103ICUsat67 hospitals,1820 18

PronovostP.NewEnglJMed2006;355:2725-TrendsinMRSABloodstreamInfectionsbyICUNationalHealthcareSafetyNetworkHospitals,1997-根據(jù)不同ICU類別對MRSA血 趨勢的分析，國 網(wǎng)，1997-Estimated據(jù)估計(jì)PooledMeanAnnualCLABSIRatePooledMeanAnnualCLABSIRateper1,000CentralLine 防止7000例血 的發(fā) 1,800lives 挽救了1800患者的生 $50-180Minaverted43避免了0.5-1.8 的經(jīng)3損21 PreliminaryEstimatesofPreventableInfections,Deaths&BasedonPublished 可防止 和經(jīng)濟(jì)損失，基 文獻(xiàn)的初步估Typeof

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避免的經(jīng)濟(jì)損失（十億美金PUrinarytractSurgicalsiteUmschied,C.UniversityofPennsylvania.PresentationatHICPAC,MarchKeysfortheEliminationofHealthcare-associatedInfections Datafor行動(dòng)Improvedimplementationofexistingbest強(qiáng)化對現(xiàn)有措施的Recognizeexcellencein認(rèn)可和Addressgapsin填補(bǔ)Identifyandrespondtoemerging發(fā)現(xiàn)并應(yīng)對新DataforAction行動(dòng)StateInitiatives:PublicReportingofHAIs,全美倡議：醫(yī)療相 的公開報(bào)告DisclosuresofratesHHS nforHAINational5Year健康與公眾服務(wù)部的醫(yī)療相 指來National5-Year協(xié)作Bloodstreaminfections50%依從靜脈導(dǎo)管的操100%Clostridiumdifficile(hospitalizations)艱難梭菌（住院30%Clostridiumdifficileinfections艱難梭30%Urinarytractinfections25%MRSAinvasiveinfectionsMRSA侵入（人群50%MRSAbacteremia(hospital)MRSA菌血癥（醫(yī)院25%25%SurgicalCareImprovementProject手術(shù)護(hù)理改善項(xiàng)目95%NHSN=NationalHealthcareSafetyNetwork NHDS=NationalHospitalDischargeSurveyHCUP=HealthcareCostandUtilizationProject EIPs=EmergingInfectionsProgramSCIP=SurgicalCareImprovementProjectRecognizeExcellencein認(rèn)可和激 國會(huì)：醫(yī)Healthreformbillsproposemandatorynationalpublic醫(yī) 法案要求公開報(bào)告醫(yī)療相 數(shù)HAIpreventionwouldbetiedtoMedicare/Medicaid醫(yī)療相 與醫(yī) 關(guān)CentersforMedicareandMedicaidServices 醫(yī)Reducedpaymentforhospital-acquiredconditions(HACs)healthcare-associated 降低對醫(yī)療相 的費(fèi)用支EffectiveOctober 2008年生Includeshospital-associatedbloodstreaminfections,urinaryinfections,andselectedsurgicalsite 包括血 ，部份手術(shù)切Payforreporting/performance對報(bào)告和良好表現(xiàn)進(jìn)TopCDCmendationstopreventhealthcareassociatedinfections StateofPreventionHICPAC/CDCEvidence-basedPreventionGuidelinesaredevelopedforeachtypeofinfectionandbasedonsystematicreviewsofthemedicalli ture在系統(tǒng)綜述醫(yī)學(xué)文 Categoriesof 類Category1A1AStrongmendation/strongormoderatequalityof強(qiáng)烈建議/高質(zhì)量或中等質(zhì)量的文Category1B1BStrongmendation/weakqualityofevidenceor強(qiáng)烈建議/稍弱 或已被接受的操Topreventcatheterassociatedurinarytract預(yù)防 插管相Insertcathetersonlyforappropriate 必要時(shí)再進(jìn)行Leavecatheters ceonlyaslongas 置管時(shí)間要合Ensurethatonlyproperly sinsertand 僅接受過專業(yè)培訓(xùn)的人員才能進(jìn)行插管Insertcathetersusingaseptictechniqueandsterileequipmentcare 進(jìn)行必要的清Followasepticinsertion,maintainacloseddrainagesystem Maintainunobstructedurine 保持ComplywithCDChandhygienemendationsandStandard Topreventsurgicalsite預(yù)防手Before 手術(shù)Administerantimicrobialprophylaxisinaccordancewithbasedstandardsand生

根據(jù)相關(guān)標(biāo)準(zhǔn)和指南Treatremoteinfections-wheneverpossiblebefore 在擇期手術(shù)前對其 進(jìn)行治Avoidhairremovalattheoperativesiteunlessitwillinterferetheoperation;donotuse進(jìn)行備皮；避免使用剃

如果對手術(shù)無干擾，不采用剃毛Useappropriateantisepticagentandtechniqueforskin Topreventsurgicalsite預(yù)防手During KeepORdoorsclosedduringsurgeryexceptasneededpassageof nel,andthe閉，除非必要的設(shè)AfterSurgery手術(shù)Maintainimmediatepostoperative正

保持手術(shù)室保持患者術(shù)后Protectprimaryclosureincisionswithsteriledressing保持傷口清Controlbloodglucoselevelduringtheimmediatepost-operativeperiod(cardiac)保持血糖正常水平Discontinueantibioticsaccordingtoevidence-basedand 根據(jù)基于循證醫(yī)學(xué)制Topreventcentrallineassociatedbloodstream預(yù)防中心靜脈插管相關(guān)血RemoveunnecessarycentrallinesFollowproperinsertionpracticesFacilitateproperinsertionpracticesComplywithCDChandhygienemendationsUseappropriateagentforskinantisepsis采用合理的皮膚 ChoosepropercentrallineinsertionsitesPerformadequatehub/accessportdisinfection對插管部件進(jìn)行消ProvidestaffeducationoncentrallinemaintenanceandTopreventClostridiumdifficileinfections預(yù)防艱ContactPrecautionsfordurationof ComplywithCDChandhygieneAdequatecleaninganddisinfectionofequipmentandLaboratory-basedalertsystemforimmediatenot