降低加護病房中心靜脈導管相關血流感染率

1、降低加護病房中心靜脈導管相關血流感染率,急護組林富美、蘇芳玉黃錦鳳、徐玉玫、張青蕙、何雲(yún)仙,報告大綱,前言EBN問題與步驟文獻探討文獻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，外科加護病房27床主要收治手術後重癥病人及少數(shù)內(nèi)科病人，急診加護病房7床收治內(nèi)科為主外科為輔之重癥病人。,,加護病房病人嚴重病況危急，抵抗力差且侵入性醫(yī)療措施裝置多，如呼吸

2、治療管路、動靜脈導管、導尿管等等，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管。,,93年本院加護病房「中心靜脈導管使用率」平均為51.68 ﹪，比起臺灣醫(yī)療品質(zhì)指標計劃（THIS）醫(yī)學中心

3、數(shù)值相當（57.27 ﹪）但「中心靜脈導管相關血流感染率」本院指標平均8.470/00 較THIS醫(yī)學中心與區(qū)域醫(yī)院之平均數(shù)值4.020/00 高出許多。,喔? 「中心靜脈導管相關血流感染率」約為醫(yī)學中心與區(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！,STEP 1 Asking an answerable clinic

4、al question,Practice reflection Decision making,有什麼好問題,第一次共識問題 中心靜脈導管護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? --導管相關感染的因素很多 --很想與專案改善一魚兩吃呢！不如也先調(diào)查各家醫(yī)學中心現(xiàn)況,CDC在有關消毒劑使用之建議,Disinfect clean skin with appropriate an

5、tiseptic before insertion and at time of dressing change --2% chlorhexidine is preferred.Do not apply organic solvents (acetone or ether) to skin before the insertion and at dressing change.Clean injection ports with 7

6、0% Alcohol or Iodophor before accessing.Allow antiseptics to remain on insertion site and air dry- povidoneiodine should be allowed to air dry for 2 minutes or longer.,各醫(yī)院中心靜脈導管護理 使用之消毒劑,CDC強調(diào)的合適的消毒劑，有建議較為合適的-2%

7、 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。預防導管相關血流感染之防護，除了消毒劑外應有更多照護因子可介入。---主題可再想想---,此次EBN主要目的,利用EBN過程瞭解CDC預防血流導管相關感染防護措施的實證證據(jù)，是否能使中心靜脈導管相關血流感染率降低，以作為加護病房改善專案之參考。Decision making- 修訂留置中心靜脈導管病人照護標準規(guī)範,EBN 問題：

8、PICO,CDC預防導管相關血流感染防護介入是否較 現(xiàn)行一般照護能降低加護病房中心靜脈導管相關血流感染率,Intervention,,Problem or Patient,,Outcome,,,Comparison,,改善專案— 降低加護病房中心靜脈導管相關血流感染率,,Central venous catheter related BSI,防護感染主要原則CDC guideline,Educating &

9、training: insert & maintain catheters careUsing maximal sterile barrier precautionUsing chlorhexidine for skin antisepsisAvoiding routine replacement of CVC as a strategy to prevent infectionUsing antiseptic/a

10、ntibiotic impregnated short-term CVCMonitoring performance indicator,AJIC,Vol.30(8).December 2002.476-489,STEP 2 Search evidences,Search strategy關鍵字: Infection control;ICU; CDC Central venous catheters; blood s

11、tream infection;catheter-related bloodstream infection 血流感染率；中心靜脈導管,,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Nursing standard及研讀CDC Guideline摘要再分別往 hand hygiene ,antise

12、ptics, insertion,maintain care, education---等焦點搜尋,,STEP 3 Critical appraisal the evidences,名詞解釋,中心導管（Central line）：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堋?中心導管使用日數(shù)（Central line day）：在計算裝置使用日時，一個使用中心導管的加護病房病人算一個使用

13、日。 裝置相關的感染(Device-associated infection)：是指一位加護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加護病房時已存有或有潛伏感染。,中心導管相關之血流感染率,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準標準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。 標準2：發(fā)燒(>38℃)、發(fā)冷或低血壓 (hypotens

14、ion)等至少一項的臨床徵象標準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,Quality of Evidence,I a-Meta-analysis of Randomized controlled trialsI b-One randomized controlled trialII a-One well des

15、igned controlled study without randomizationII b-One well designed quasi-experimental studyIII--Well designed non-experimental studies (comparative,correlation,other descriptive)IV- Expert committee

16、reports,export opinions,care study,文獻探討-Epidemiology,Primary bloodstream infections are a frequent cause of morbidity and mortality in intensive care units worldwide. （CDC,2003）NNIS （1997）reports CVC-BSI ra

17、te of 5.20/00 in American, ICU rates of CVC-associated BSI range 2.9 to 11.3,文獻探討-CRBSI造成的影響,CRBSI increases in ICU Length of stay, total hospital cost, ICU cost CRBSI increases risk of ICU mortalityOther predictors o

18、f ICU death were APACH III score（p<.001）, age（p=.04）, GI surgery （p=.003）, alcohol abuse （p=.04）（Dimick,2001）,Level I b,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?shù)臒o菌屏障穿刺技術不佳2002美國CDC的導管相關感染的預防規(guī)範,Skin antiseps

19、is,Title: Chlorhexidine Compared with Povidone-Iodine Solution for Vascular Catheter-Site Care – A meta-analysis Purpose: Evaluate the efficacy of skin disinfection with Chlor.Gluco. compared with P-I solution in prev

20、enting catheter-related BSI.Data sources: Multiple computerized database(1966-2001),reference lists of identified articles.Study selection: RCT compared ,catheter-site. : MEDLINE, CINAHL,EBMASE, Cochrane Library , I

21、nternational Pharmaceutical Abstracts---,Level I a,續(xù) 出處:Ann Intern Med,V.136(11),2002,Data Extraction: a standardized form , two reviewers abstracted data on study design , patient population, intervention, inciden

22、ce of CR-BSI from all included studies. Data Synthesis: 1.8 studies involving a total 4143 catheters met the criteria. 2.various catheter types were usedConclusion: Chlorhexidine gluconate reduced the risk

23、for CR-BSI by 49% (95%CI,0.28-0.88),Education (Lobo et al., 2005),Impact of an education program and policy changes on decreasing catheter-associated bloodstream infections in a MICU in Brazil Design: prospectively

24、 surveyed Intervention: highlight correct practices 1.CVC insertion, manipulation, and care/ monthly classes 2.Poster,discussion with staff,Level III,Education and training,Result:Primary bl

25、oodstream infections 20 0/00 (phase 1, pre-intervention),11 0/00 (phase 2, post-intervention ) 120/00 (phase 3,follow-year) The adhesion to the overall CVC care policy improved significantly (p<.01),Education

26、（Berenholtz, 2004）,Eliminating catheter-related bloodstream infections in the ICU（16 beds SICU）Design: a prospective cohort study with concurrent controlIntervention:a quality improvement team, （1）education （2）creati

27、ng a insertion cart（3）asking providers daily whether catheters could removed（4）a checklist to evidence-based guidelines for preventing CR-BSIs（5）empowering nurses to stop the catheter insertion

28、 procedure if a violation of the guidelines,Level II a,Education and training,Intervention: E: Surgical ICU（16床）, C: CVS ICU（15床）Results:（1）before, 62% followed infection control, after 100% （2）duri

29、ng, from 11.300/0 , first quarter 1998 to 0 00/0 , fourth quarter 2002; control ICU（15 beds CVS ICU）was from 5.7 to 1.6,Education (Rosenthal et al, 2003),Effect of an infection control program usi

30、ng education and performance feedback on rate of intravascular device-associated bloodstream infections in ICUs Argentina Design: To ascertain the effect of an infection control program using education and perfor

31、mance feedback on ICUIntervention: education and training for CDC and prevention,Level II b,Education and training,Results Phase I:baseline surveillance, 1219人數(shù) ; Phase II:education, 586人數(shù) Phase III: pe

32、rformance, 4140人數(shù)conclusion education and performance feedback result in a significant trend reduced of IVD-associated BSI,Hand hygiene（Aiello et al.,2001）,Assessment of tow hand hygiene regimens for int

33、ensive care unit personnelPurpose/Design: Prospective randomized clinical trial four consecutive weeksTo compare skin condition and skin microbiology among ICU personnel using one of two randomly assigned hand

34、hygiene regimens: a 2% chlorhexidine gluconate : 61% ethanol with emollients(ALC),Level I b,Hand hygiene,Result: 50 staff members (two ICU) 1.Participants in the ALC group had significant improvements in th

35、e Hand Skin Assessment scores at wk 4(p=0.04) and in Visual Skin Scaling scores  at wk 3 (p=0.01) and 4 (p=0.0005) 2. Then were no  significant differences in numbers of colony from uni

36、ts between participants in the CGH or ALC group at any time period.(193 hand cultures),Maximal sterile barrier,Title:Prevention of central venous catheter-related infections by using maximal sterileBarrier p

37、recautions during insertion.Objective:To investigated whether the use of maximal sterile barrier(mask,cap,sterile gloves,gown,and large drape) would lower the risk of acquiring catheter –related infections. Source:Infe

38、ct Control Hosp Epidemiol (1996,Apr.15),Level I b,Maximal sterile barrier續(xù),Design:RCT,Group I- nontunneled center catheter inserted under maximal sterile barrier . Gr.Ii—control precautions(sterile gloves & smal

39、l drape) At catheter remove or postinsertion 3ms. were taken catheter culture & blood culture.,Maximal sterile barrier續(xù),Result: 1. group1-176pts.; group II-167pts 2. group1- 4 catheter inf. ; group II-12 cathet

40、er inf.P=0.03,chi-square test 3.group II catheter-related septicemia rate was 6.3 times higher Group I (P=0.06,Fisher’s exact test) 4.67%of group II –catheter inf.- 2ms after insertion.25% of group I- catheter in

41、f.- the same period. (p<0.01,Fisher’s exact test) Conclusion:Maximal sterile barrier reduce the risk of catheter infection & cost-effective.,Maximal sterile barrier,,M.D Anderson Cancer Center, 1994 , USA,ant

42、iseptic catheter （Hanley et al., 2000）,Evaluation of an antiseptic triple-lumen catheter in an ICU Design: retrospective review of surveillance records, primary bloodstream infection surveillance data, incl

43、uded risk factors, laboratory and microbiological data, insertion sites and dates,Level III,antiseptic catheter 續(xù),Outcome: CRBSIs rate Results:（1）5.400/0, in antiseptic, 11.3 in nonantiseptic triple-lumen cathete

44、r groupsConclusion: The use of antiseptic may reduce CRBSIs in ICU and maybe associated with a decrease in length of stay,antiseptic triple lumen catheter (盛等，1999),抗感染安全尖端導管對降低細菌集落率及感染發(fā)生率之成效方法 1.隨機取樣置入(Arrow，P

45、ennsylvania)， N=20， 235條三腔導管(122條控制組，113條實驗組) 2.抗感染安全尖端導管溶入chlorhexidine & silver sulfadiazine的抗感染藥劑結(jié)果 1.>15個單位的細菌集落(C,25條，E,9條) 2.細菌集落情形(C,20%條，E,8條) 3.血流感染(C,6位，E,3位),Level I b,antis

46、eptic catheter,結(jié)果 4.局部發(fā)炎(C,4條，E,0條) 5.細菌集落情形(C,20%條，E,8條) 6.抗感染安全尖端導管比控制組減少5倍的 感染率(C,4.9%，E,0.9%),Catheter-site care （Olivier, 1996）,Prospective, randomized trial of two antiseptic solutions for preventio

47、n of central venous or arterial catheter colonization and infection in ICU patients（SICU） Design: Prospective randomized clinical trial, E: 0.25% chlorthexidine gluconate, 0.25% benzalkonium chloride and 4% benzy

48、lalcohol; C:10% povidone iodine（betadine）,Level I b,Catheter-site care,Outcome: the rate of significant catheter colonization and catheter-related sepsis were significant lower in the E group; the rate of arterial cat

49、heter colonization was significant lower in the E group, the rate of arterial catheter-related sepsis was similar for two groupConclusion: The 0.25% chlorthexidine solution was superior to the 10% povidone solution i

50、n prevention catheter colonization and catheter-related sepsis due to Gram-postive bacteria,Surveillance for CRBSIs （Coopersmith, 2004）,The impact of bedside behavior on catheter-related bacteremia in the ICU（SICU）Des

51、ign: before and after education trial; audit result, a behavioral intervention was designed to improve compliance with evidence-based guidelines of CVC management,Level I b,Surveillance for CRBSIs,Results:audit 18 m（1）d

52、ocumenting the dressing date（11% to 21%; p.99）maximal sterile barrier precautions（50% to 80% ;p=.29）（2）CRBSIs rate 3.4 to 2.8 00/0（during 15 m after intervention）,穿刺部位選擇（Deshpande et al., 2005）,The incidence of infectio

53、us complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population. PurposeThe objective was to assess the risk of central venous catheters inf

54、ection with respect to the site of insertion in an intensive care unit population. The subclavian, internal jugular, and femoral sites were studied.Design: Prospective, observational study,Level III,穿刺部位選擇,Subjects

55、All patients were triaged into the ICU by on-site critical care medicine fellows.Group 1 was patients with one catheter at one site. Group 2 was patients with catheters at multiple sites.A total of 831 central venou

56、s catheters and 4735 catheter days in 657 patients were studied.,穿刺部位選擇,ResultsIn group 1, （1）the incidence of infection was subclavian: 0.881 infections /1000 catheter days , internal jugular: 0/1000, and femoral:298/

57、1000(p=0.2635)（2）The incidence of colonization was subclavian:0.881 colonization/1000 catheter days, internal jugular: 2.00/1000, and femoral:5.96/1000 (p=0.1338),穿刺部位選擇,Results-2In group 2, there was also no statisti

58、cally significant difference in the incidence of infection and colonization among the three insertion sites..,Insertion site Selection （Jacques, 2001）,Complications of femoral and subclavian venous catheterization in c

59、ritical ill patients: a randomized controlled trialIntervention: randomized controlled trial assigned to femoral site（n=145）or subclavian site （ n=144 ）,Level I b,Insertion site Selection,Results:1.Femoral cathe

60、terization was associated with a higher incidence rate of overall infectious complications （19.8 vs 4.5%; p<.001; incidence density of 20 vs 3.7 00/0）2.bloodstream infection 4.4 vs 1.5%; p=.07; incid

61、ence density of 4.5 vs 1.2 00/0）3.thrombotic complication （21.5 vs 1.9%; p<.001; complete thrombosis （6 vs 0%; p=.01）,Insertion site Selection,Results: 4.catheter-related mechanical were similarConclusion: Fem

62、oral venous catheterization is associated with a greater risk of infectious and thrombotic complications than subclavian catheterization in ICU patients.,STEP 4 Applying Evidence to Patients,討論,最大無菌屏障是否還有需要加強的地方?裝備穿戴:

63、帽子 口罩 手套 無菌衣 洞巾消毒範圍是否要更改消毒劑？從三個成人加護病房開始宣導與執(zhí)行評估執(zhí)行成效後修訂規(guī)範再水平展開至全院,討論,教育推行醫(yī)師：透過科務會議說明宣導 並藉由臨床技能中心加強技術訓練護士：透過晨會及病房會議宣導,擬定教育時間與課程執(zhí)行面的監(jiān)測與分析技術操作過程的正確性結(jié)果面感染率的改善,STEP 5 Evaluation,問題的適切性？！符合臨床實用性符合PICO的結(jié)構急需要加以映證問題文

64、獻搜尋以BSI 及ICU為關鍵字 搜尋範圍太廣泛 無法鎖定問題點以CDC Guideline 為搜尋主軸 隨即增加文獻完整性及焦點符合搜尋資料庫的廣度性,STEP 5 Evaluation,文獻評讀文獻評選多屬Level 1 & 2 可信度高臨床應用性可供標準規(guī)範修訂之參考 但無法馬上立竿見影 需要持續(xù)推行與監(jiān)控,Risk factor of CRBSI,宿主因素、住院天數(shù)、注射部位、皮膚準備、導管插入者經(jīng)驗、導

65、管材質(zhì)、放置部位和留置時間、導管照護、使用輸液管路之數(shù)目、輸液成分、敷料更換頻率及其他部位感染等導管發(fā)現(xiàn)相關而未拔除導管者將有20%再發(fā)生菌血癥，但拔除導管者僅有3%再感染（郭, 2002）宿主因素，高齡、接受手術、疾病嚴重度高、WBC減少、接受類固醇或免疫抑制治療、心血管移植或缺損、嚴重營養(yǎng)不良等潛在性疾病,未來計劃方向,經(jīng)本次EBN過程中學習到更多研究方法與設計，計劃未來可進一步做為本院 「中心靜脈導管相關血流感染因素分析」