降低加護(hù)病房中心靜脈導(dǎo)管相關(guān)血流感染率

降低加護(hù)病房中心靜脈導(dǎo)管相關(guān)血流感染率

急護(hù)組林富美、蘇芳玉黃錦鳳、徐玉玫、張青蕙、何雲(yún)仙報告大綱前言EBN問題與步驟文獻(xiàn)探討文獻(xiàn)與本院情形之比較討論EBN過程評值未來計劃方向前言本院內(nèi)外科加護(hù)病房共46床，其中內(nèi)科15床主要收治內(nèi)科重癥病人，外科加護(hù)病房27床主要收治手術(shù)後重癥病人及少數(shù)內(nèi)科病人，急診加護(hù)病房7床收治內(nèi)科為主外科為輔之重癥病人。加護(hù)病房病人嚴(yán)重病況危急，抵抗力差且侵入性醫(yī)療措施裝置多，如呼吸治療管路、動靜脈導(dǎo)管、導(dǎo)尿管等等，這些裝置常是病源菌入侵人體的途徑。九十三年血流感染在內(nèi)外科加護(hù)病房一直輪流佔第一、二位。九月份本院感染管制中心曾就加護(hù)病房做院內(nèi)感染流行調(diào)查，經(jīng)卡方檢定結(jié)果發(fā)現(xiàn)院內(nèi)感染個案增加情形，並無統(tǒng)計學(xué)上意義但結(jié)果發(fā)現(xiàn)血流感染人次之增加具統(tǒng)計上意義，而9位血流感染個案中，有8位有置入中心靜脈導(dǎo)管。93年本院加護(hù)病房「中心靜脈導(dǎo)管使用率」平均為51.68﹪，比起臺灣醫(yī)療品質(zhì)指標(biāo)計劃（THIS）醫(yī)學(xué)中心數(shù)值相當(dāng)（57.27﹪）但「中心靜脈導(dǎo)管相關(guān)血流感染率」本院指標(biāo)平均8.470/00較THIS醫(yī)學(xué)中心與區(qū)域醫(yī)院之平均數(shù)值4.020/00高出許多。喔?「中心靜脈導(dǎo)管相關(guān)血流感染率」約為醫(yī)學(xué)中心與區(qū)域醫(yī)院的平均值的2倍問題在那兒？我們能做些什麼來降低呢？

這不是專案改善嗎？我們是要EBN呢！STEP1Askingananswerable

clinicalquestion

PracticereflectionDecisionmaking有什麼好問題第一次共識問題中心靜脈導(dǎo)管護(hù)理使用甲消毒溶液會比乙消毒溶液抗菌效果好嗎？

--查CDC的建議如何?

--導(dǎo)管相關(guān)感染的因素很多

--很想與專案改善一魚兩吃呢！不如也先調(diào)查各家醫(yī)學(xué)中心現(xiàn)況CDC在有關(guān)消毒劑使用之建議Disinfectcleanskinwithappropriateantisepticbeforeinsertionandattimeofdressingchange--2%chlorhexidineispreferred.Donotapplyorganicsolvents(acetoneorether)toskinbeforetheinsertionandatdressingchange.Cleaninjectionportswith70%AlcoholorIodophorbeforeaccessing.Allowantisepticstoremainoninsertionsiteandairdry-povidoneiodineshouldbeallowedtoairdryfor2minutesorlonger.各醫(yī)院中心靜脈導(dǎo)管護(hù)理

使用之消毒劑醫(yī)院名稱置入時皮膚消毒溶液

中心靜脈導(dǎo)管傷口護(hù)理溶液忠孝優(yōu)碘酒精、75%酒精75%酒精、優(yōu)碘臺大優(yōu)碘酒精、75%酒精生理食鹽水、優(yōu)碘國泰優(yōu)碘酒精、75%酒精生理食鹽水、優(yōu)碘馬偕優(yōu)碘酒精、75%酒精75%酒精、優(yōu)碘榮總優(yōu)碘酒精、75%酒精75%酒精、優(yōu)碘酒精新光優(yōu)碘酒精、75%酒精生理食鹽水、優(yōu)碘長庚優(yōu)碘酒精、75%酒精75%酒精、優(yōu)碘酒精三總優(yōu)碘酒精、75%酒精優(yōu)碘CDC強調(diào)的合適的消毒劑，有建議較為合適的-2%Chlorhexidine。但同時強調(diào)使用消毒劑的注意事項。本院使用的消毒劑與大多數(shù)醫(yī)院雷同。預(yù)防導(dǎo)管相關(guān)血流感染之防護(hù)，除了消毒劑外應(yīng)有更多照護(hù)因子可介入。---主題可再想想---此次EBN主要目的利用EBN過程瞭解CDC預(yù)防血流導(dǎo)管相關(guān)感染防護(hù)措施的實證證據(jù)，是否能使中心靜脈導(dǎo)管相關(guān)血流感染率降低，以作為加護(hù)病房改善專案之參考。Decisionmaking-

修訂留置中心靜脈導(dǎo)管病人照護(hù)標(biāo)準(zhǔn)規(guī)範(fàn)EBN問題：PICOCDC預(yù)防導(dǎo)管相關(guān)血流感染防護(hù)介入是否較現(xiàn)行一般照護(hù)能降低加護(hù)病房中心靜脈導(dǎo)管相關(guān)血流感染率Intervention

ProblemorPatientOutcomeComparison改善專案—降低加護(hù)病房中心靜脈導(dǎo)管相關(guān)血流感染率CentralvenouscatheterrelatedBSI防護(hù)感染主要原則CDCguidelineEducating&training:insert&maintaincatheterscareUsingmaximalsterilebarrierprecautionUsingchlorhexidineforskinantisepsisAvoidingroutinereplacementofCVCasastrategytopreventinfectionUsingantiseptic/antibioticimpregnatedshort-termCVCMonitoringperformanceindicatorAJIC,Vol.30(8).December2002.476-489STEP2SearchevidencesSearchstrategy關(guān)鍵字:Infectioncontrol;ICU;CDCCentralvenouscatheters;bloodstreaminfection;catheter-relatedbloodstreaminfection血流感染率；中心靜脈導(dǎo)管中文：4篇HINT(MEDLINE)：73篇ProQuest：13篇PubMed：24篇Cochrane：2篇檢索結(jié)果資料太多怎麼篩選？先找Nursingstandard及研讀CDCGuideline摘要再分別往handhygiene,antiseptics,insertion,maintaincare,education---等焦點搜尋STEP3

Criticalappraisaltheevidences名詞解釋中心導(dǎo)管（Centralline）：為短期輸液或監(jiān)測血液動力狀況而插入中央循環(huán)系統(tǒng)的暫時性血管內(nèi)裝置或?qū)Ч?。中心?dǎo)管使用日數(shù)（Centrallineday）：在計算裝置使用日時，一個使用中心導(dǎo)管的加護(hù)病房病人算一個使用日。裝置相關(guān)的感染(Device-associatedinfection)：是指一位加護(hù)病房的病患在感染發(fā)生前的48小時內(nèi)有使用一種醫(yī)療裝置。而此感染不是在病患住進(jìn)加護(hù)病房時已存有或有潛伏感染。中心導(dǎo)管相關(guān)之血流感染率必須符合全國院內(nèi)感染監(jiān)視手冊(NNIS)對實驗室證實的血流感染之標(biāo)準(zhǔn)標(biāo)準(zhǔn)1：一套或多套血液培養(yǎng)分離出致病菌且此致病菌與其它部位之感染無關(guān)。標(biāo)準(zhǔn)2：發(fā)燒(>38℃)、發(fā)冷或低血壓(hypotension)等至少一項的臨床徵象標(biāo)準(zhǔn)3：一歲以下之嬰兒發(fā)燒(>38℃)、體溫過低(<37℃)、呼吸中止或心跳徐緩等至少一項臨床徵象且臨床徵象或癥狀與陽性的實驗結(jié)果與其他部位的感染無關(guān)QualityofEvidenceIa-Meta-analysisofRandomizedcontrolledtrialsIb-OnerandomizedcontrolledtrialIIa-OnewelldesignedcontrolledstudywithoutrandomizationIIb-Onewelldesignedquasi-experimentalstudyIII--Welldesignednon-experimentalstudies(comparative,correlation,otherdescriptive)IV-Expertcommitteereports,exportopinions,carestudy文獻(xiàn)探討-EpidemiologyPrimarybloodstreaminfectionsareafrequentcauseofmorbidityandmortalityinintensivecareunitsworldwide.（CDC,2003）NNIS（1997）reportsCVC-BSIrateof5.20/00inAmerican,ICUratesofCVC-associatedBSIrange2.9to11.3文獻(xiàn)探討-CRBSI造成的影響CRBSIincreasesinICULengthofstay,totalhospitalcost,ICUcostCRBSIincreasesriskofICUmortalityOtherpredictorsofICUdeathwereAPACHIIIscore（p<.001）,age（p=.04）,GIsurgery（p=.003）,alcoholabuse（p=.04）（Dimick,2001）LevelIb

CVC感染危險因素分析輸液介面的污染穿刺部位的選擇頸內(nèi)靜脈留置不恰當(dāng)?shù)臒o菌屏障穿刺技術(shù)不佳2002美國CDC的導(dǎo)管相關(guān)感染的預(yù)防規(guī)範(fàn)SkinantisepsisTitle:ChlorhexidineComparedwithPovidone-IodineSolutionforVascularCatheter-SiteCare–Ameta-analysisPurpose:EvaluatetheefficacyofskindisinfectionwithChlor.Gluco.comparedwithP-Isolutioninpreventingcatheter-relatedBSI.Datasources:Multiplecomputerizeddatabase(1966-2001),referencelistsofidentifiedarticles.Studyselection:RCTcompared,catheter-site.:MEDLINE,CINAHL,EBMASE,CochraneLibrary,InternationalPharmaceuticalAbstracts---LevelIa續(xù)出處:AnnInternMed,V.136(11),2002DataExtraction:astandardizedform,tworeviewersabstracteddataonstudydesign,patientpopulation,intervention,incidenceofCR-BSIfromallincludedstudies.DataSynthesis:1.8studiesinvolvingatotal4143cathetersmetthecriteria.2.variouscathetertypeswereusedConclusion:ChlorhexidinegluconatereducedtheriskforCR-BSIby49%(95%CI,0.28-0.88)Education(Loboetal.,2005)

Impactofaneducationprogramandpolicychangesondecreasingcatheter-associatedbloodstreaminfectionsinaMICUinBrazilDesign:prospectivelysurveyedIntervention:highlightcorrectpractices1.CVCinsertion,manipulation,andcare/monthlyclasses2.Poster,discussionwithstaffLevelIIIEducationandtraining

Result:Primarybloodstreaminfections200/00(phase1,pre-intervention),110/00(phase2,post-intervention)120/00(phase3,follow-year)TheadhesiontotheoverallCVCcarepolicyimprovedsignificantly(p<.01)Education（Berenholtz,2004）Eliminatingcatheter-relatedbloodstreaminfectionsintheICU（16bedsSICU）Design:aprospectivecohortstudywithconcurrentcontrolIntervention:aqualityimprovementteam,（1）education（2）creatingainsertioncart（3）askingprovidersdailywhethercatheterscouldremoved（4）achecklisttoevidence-basedguidelinesforpreventingCR-BSIs（5）empoweringnursestostopthecatheterinsertionprocedureifaviolationoftheguidelinesLevelIIaEducationandtrainingIntervention:E:SurgicalICU（16床）,C:CVSICU（15床）Results:（1）before,62%followedinfectioncontrol,after100%（2）during,from11.300/0,firstquarter

1998to000/0,fourthquarter

2002;controlICU（15bedsCVSICU）wasfrom5.7to1.6Education(Rosenthaletal,2003)Effectofaninfectioncontrolprogramusingeducationandperformancefeedbackonrateofintravasculardevice-associatedbloodstreaminfectionsinICUsArgentinaDesign:ToascertaintheeffectofaninfectioncontrolprogramusingeducationandperformancefeedbackonICUIntervention:educationandtrainingforCDCandpreventionLevelIIbEducationandtrainingResultsPhaseI:baselinesurveillance,1219人數(shù);

PhaseII:education,586人數(shù)PhaseIII:performance,4140人數(shù)conclusioneducationandperformancefeedbackresultinasignificanttrendreducedofIVD-associatedBSIHandhygiene（Aielloetal.,2001）AssessmentoftowhandhygieneregimensforintensivecareunitpersonnelPurpose/Design:ProspectiverandomizedclinicaltrialfourconsecutiveweeksTocompareskinconditionandskinmicrobiologyamongICUpersonnelusingoneoftworandomlyassignedhandhygieneregimens:a2%chlorhexidinegluconate:61%ethanolwithemollients(ALC)LevelIb

Handhygiene

Result:50staffmembers(twoICU)1.ParticipantsintheALCgrouphadsignificantimprovementsintheHandSkinAssessmentscoresatwk4(p=0.04)andinVisual

SkinScalingscores

atwk3(p=0.01)and4(p=0.0005)

2.Thenwereno

significantdifferencesinnumbersofcolonyfromunitsbetweenparticipantsintheCGHorALCgroupatanytimeperiod.(193handcultures)MaximalsterilebarrierTitle:Preventionofcentralvenouscatheter-relatedinfectionsbyusingmaximalsterileBarrierprecautionsduringinsertion.Objective:Toinvestigatedwhethertheuseofmaximalsterilebarrier(mask,cap,sterilegloves,gown,andlargedrape)wouldlowertheriskofacquiringcatheter–relatedinfections.Source:InfectControlHospEpidemiol(1996,Apr.15)Level

IbMaximalsterilebarrier續(xù)Design:RCT,GroupI-nontunneledcentercatheterinsertedundermaximalsterilebarrier.Gr.Ii—controlprecautions(sterilegloves&smalldrape)Atcatheterremoveorpostinsertion3ms.weretakencatheterculture&bloodculture.Maximalsterilebarrier續(xù)Result:1.group1-176pts.;groupII-167pts2.group1-4catheterinf.;groupII-12catheterinf.P=0.03,chi-squaretest3.groupIIcatheter-relatedsepticemiaratewas6.3timeshigherGroupI(P=0.06,Fisher’sexacttest)4.67%ofgroupII–catheterinf.-2msafterinsertion.25%ofgroupI-catheterinf.-thesameperiod.(p<0.01,Fisher’sexacttest)Conclusion:Maximalsterilebarrierreducetheriskofcatheterinfection&cost-effective.Maximalsterilebarrier無菌屏障穿刺地點細(xì)菌定值菌血癥手套口罩小鋪巾手術(shù)室23%4%手套口罩大鋪巾無菌手術(shù)衣外科加護(hù)病房11%1%M.DAndersonCancerCenter,1994,USA

antisepticcatheter

（Hanleyetal.,2000）Evaluationofanantiseptictriple-lumencatheterinanICUDesign:retrospectivereviewofsurveillancerecords,primarybloodstreaminfectionsurveillancedata,includedriskfactors,laboratoryandmicrobiologicaldata,insertionsitesanddatesLevelIIIantisepticcatheter

續(xù)Outcome:CRBSIsrateResults:（1）5.400/0,inantiseptic,11.3innonantiseptictriple-lumencathetergroupsConclusion:TheuseofantisepticmayreduceCRBSIsinICUandmaybeassociatedwithadecreaseinlengthofstayantiseptictriplelumencatheter

(盛等，1999)抗感染安全尖端導(dǎo)管對降低細(xì)菌集落率及感染發(fā)生率之成效方法1.隨機取樣置入(Arrow，Pennsylvania)，N=20，235條三腔導(dǎo)管(122條控制組，113條實驗組)2.抗感染安全尖端導(dǎo)管溶入chlorhexidine&silversulfadiazine的抗感染藥劑結(jié)果1.>15個單位的細(xì)菌集落(C,25條，E,9條)2.細(xì)菌集落情形(C,20%條，E,8條)3.血流感染(C,6位，E,3位)LevelIb

antisepticcatheter

結(jié)果4.局部發(fā)炎(C,4條，E,0條)5.細(xì)菌集落情形(C,20%條，E,8條)6.抗感染安全尖端導(dǎo)管比控制組減少5倍的感染率(C,4.9%，E,0.9%)Catheter-sitecare（Olivier,1996）Prospective,randomizedtrialoftwoantisepticsolutionsforpreventionofcentralvenousorarterialcathetercolonizationandinfectioninICUpatients（SICU）Design:Prospectiverandomizedclinicaltrial,E:0.25%chlorthexidinegluconate,0.25%benzalkoniumchlorideand4%benzylalcohol;C:10%povidoneiodine（betadine）LevelIbCatheter-sitecare

Outcome:therateofsignificantcathetercolonizationandcatheter-relatedsepsisweresignificantlowerintheEgroup;therateofarterialcathetercolonizationwassignificantlowerintheEgroup,therateofarterialcatheter-relatedsepsiswassimilarfortwogroupConclusion:The0.25%chlorthexidinesolutionwassuperiortothe10%povidonesolutioninpreventioncathetercolonizationandcatheter-relatedsepsisduetoGram-postivebacteriaSurveillanceforCRBSIs（Coopersmith,2004）Theimpactofbedsidebehavioroncatheter-relatedbacteremiaintheICU（SICU）Design:beforeandaftereducationtrial;auditresult,abehavioralinterventionwasdesignedtoimprovecompliancewithevidence-basedguidelinesofCVCmanagementLevelIbSurveillanceforCRBSIsResults:audit18m（1）documentingthedressingdate（11%to21%;p<.001）,stopcockuse（70%to24%;p<.001）,handhygience（17%to30%;p>.99）maximalsterilebarrierprecautions（50%to80%;p=.29）（2）CRBSIsrate3.4to