【医学课件】 醫療照護相關泌尿道感染的預防與組合式照護

李聰明 醫師 馬偕感染科/感染管制中心主任醫師 臺灣感染管制學會理事長 醫療照護相關泌尿道感染的預防與組 合式照護 感染管制工作的重要性 “病人的安全是醫院的基石” Patient safety is the cornerstone of hospital “感染管制是病人安全的基石” Infection control is the cornerstone of patient safety - by Dr.李聰明 Dr. Chun-Ming Lee Estimated rates of HCAI worldwide At any time, hundreds of millions of people worldwide are suffering from infections acquired in health-care facilities In modern health-care facilities in the developed world: 510% of patients acquire one or more infections In developing countries the risk of HCAI is 220 times higher than in developed countries and the proportion of patients affected by HCAI can exceed 25% In intensive care units, HCAI affects about 30% of patients and the attributable mortality may reach 44% Background: Impact of CAUTI Most common type of healthcare-associated infection 30% of HAIs reported to NHSN Estimated 560,000 nosocomial UTIs annually Increased morbidity 7:1-6 Background: Pathogenesis of CAUTI Three sites of bacterial invasion. Along the walls of the catheter. Bacteria ascend up the external surface of catheter At the junction between the catheter and the drainage bag: Opening a closed drainage system lets the bugs in. At the drainage outlet. When emptying the foley bag, good technique must be observed. Risk of bacteriuria increases with days of catheterization 5% per day that catheter is in place Background: Pathogenesis of CAUTI Formation of biofilms by urinary pathogens common on the surfaces of catheters and collecting systems Bacteria within biofilms resistant to antimicrobials and host defenses Some novel strategies in CAUTI prevention have targeted biofilms Photograph from CDC Public Health Image Library: /phil/details.asp Scanning electron micrograph of S. aureus bacteria on the luminal surface of an indwelling catheter with interwoven complex matrix of extracellular polymeric substances known as a biofilm Pathogens causing nosocomial urinary tract infections 10 of Medical center/ Regional hospital/Both 4.5/3.6/4.14.0/3.0/3.53.9/2.6/3.24.0/2.4/3.23.7/2.7/3.23.7/2.8/3.23.6/2.5/3.03.3/2.2/2.7 r P value Medical center 0.882 0.0005 Regional hospital 0.788 0.0201 Total 0.888 0.0032 HAIs density in Hospitals, 2003-2010 (TNIS) HAI in H.: 4.46 in 2003 , 3.61 in 2010 11 of Medical center/ Regional hospital/Total 13.5/12.0/12. 8 12.5/11.0/11. 7 11.6/9.4/10. 4 12.7/8.6/10. 9 11.4/9.8/10. 7 12.0/9.3/10. 8 10.7/8.4/9.69.3/7.2/8.2 HAI in ICU: 13.45 in 2003 , 8.68 in 2010 HAIs density in ICUs, 2003-2010 (TNIS) 12 The proportions of site-specific HAIs in ICU of Medical Centers ,2003-2010 (TNIS) BSI:38%; UTI:37%; PNEU:12%; other : 8%; SSI: 5% in 2010 Taiwan CDC 13 The proportions of site-specific HAIs in ICU of Regional Hospitals,2003-2010 (TNIS) UTI:35%; BSI:29%; PNEU:23%; other :9%; SSI:3% in 2010 14 Type-specific Nosocomial Infections Density in ICUs of Hospitals, 2010 (TNIS) 3.5 2.5 15 Nosocomial Infection Density by ICU Types in Hospitals, 2010 (TNIS) 11.1 4.2 16 Relation between the utilization of invasive catheter and infection rate in ICUs , 2010 (TNIS) 86.6% 67.8%70.2% Copyright Prof Chris Griffith, UWIC 2007 How Many are Preventable ?How Many are Preventable ? “We have accepted infections as normal”“We have accepted infections as normal” B B DurdenDurden Prevention of HCAI Validated and standardized prevention strategies have been shown to reduce HCAI At least 50% of HCAI could be prevented Most solutions are simple and not resource- demanding and can be implemented in developed, as well as in transitional and developing countries SENIC study: Study on the Efficacy of Nosocomial Infection Control 30% of HCAI are preventable With infection control -31% -35%-35% -27% -32% Without infection control 14% 9% 19% 26% 18% LRTISSIUTIBSITotal Relative change in NI in a 5 year period (19701975) 0 10 20 30 -40 -30 -20 -10 % Haley RW et al. Am J Epidemiol 1985 Zero ToleranceZero Tolerance Pittsburgh Regional Health Initiative (40 hospitals) “All-out assault on central line associated bloodstream infections (CLABs) implementation of known methods” “Theoretical goal of zero” Overall 63% reduction in CLABs 1 hospital 90% (AGH) reduction in CLABs Copyright Prof Chris Griffith, UWIC 2007 What is a bundle? A bundle is a set of interventions (usually 3 to 5), when grouped and implemented together, promote best outcomes with a greater impact than if performed individually when planning bundle-based care, each aspect be well defined and based on evidence from at least 1 systematic review of multiple well-designed randomized controlled trials (RCT) or on data from at least 1 well-designed RCT What is a bundle? 折筷子理論 折弓箭理論 What is a bundle? ICUs can create customized protocols to standardize the implementation of bundle care components. A primary benefit of bundle care is the structuring of care processes to promote consistency in the management of clinical conditions using evidence-based practices. Who can use the bundles? Anyone in any clinical setting with the agreement of the clinical team leaders can use the bundles. However , infection control teams will be able to offer support with regard to implementation and advice on data collection, analysis of data and feedback. All clinical staff know that these interventions are best practice but frequently their application in routine care is inconsistent A Care Bundle is a means to ensure that the application of all the interventions is consistent for all patients at all times thereby improving outcomes What are “Care Bundles”? Dr. Peter Pronovost is accredited with developing the 1st Care Bundle insertion and management of CVCs Intensivist in a hospital in Michigan Developed a checklist for insertion and management of CVCs to ensure that key interventions recommended by the CDC 2002 guidelines were implemented every time a CVC was inserted Background to Care Bundles 1.Hand decontamination pre insertion 2.Full sterile barrier precautions (operator 109:476-80 Implementation of a VAP Care Bundle in a regional ITU in Belfast Mach 2007 VAP rate 8.99 per 1000 ventilator days & the VAP care bundle compliance was 72% October 2008 VAP rate was 0 per 1000 ventilator days with VAP care bundle compliance was 95% Crookshanks H et al 2008 Implementation of CVC Care Bundle in a regional ITU in Belfast Mach 2007 CLABSI rate 10.75 per 1000 catheter days October 2008 CLABSI rate was 6.5 per 1000 catheters days with CVC care bundle compliance was 95% Crookshanks H et al 2008 Catheter associated Urinary Tract Infection Crookshanks Hetal 2008 Care bundle for CAUTI was not introduced. Urinary tract infections during the study period showed an slight increase The implementation of bundles to reduce hospital-acquired infection /pbsp/img_up/01318267061.pdf Mackay Memorial Hospital (MMH) Care Bundle in UTI MMH MMH At insertion-Checklist At insertion-Checklist For operative patients remove the catheter as soon as possible postoperatively, preferably within 24 hours. Category IB 導尿管留置應有的概念 Hand Hygiene immediately before and after insertion or any manipulation of the catheter device （導管裝置） or site（部位）. Category IB CDC：Guidelines for Prevention of Catheter-Associated Urinary Tract Infections , 2009 導管置入時必須使用aseptic technique（ 無菌技術） 及 sterile equipment （無 菌物品）. Category I B 無菌手套、布單、棉球及無菌的消毒溶液 for 尿道口消毒, 及 a single-use packet （單一包裝） of lubricant jelly for insertion. Category I B 導尿管留置應有的概念 CDC：Guidelines for Prevention of Catheter-Associated Urinary Tract Infections , 2009 務必維持一個無菌且持續性密閉系統Category IB 當 breaks in aseptic technique（破壞無菌系統 ）, disconnection（滑脫不連接）, or leakage（ 滲漏） occur, 集尿系統必須被更換. Category IB 除非阻塞（e.g.前列腺或膀胱手術後出血），不建 議執行bladder irrigation Category II 導尿管留置應有的概念 CDC：Guidelines for Prevention of Catheter-Associated Urinary Tract Infections , 2009 Post insertionMaintenance Bundle Post insertionMaintenance Bundle 維持導尿管及尿袋通暢，避免糾結kinking 集尿袋必須常規性排空（如 Q8h），每個病人應 分別使用不同的清潔的集尿桶 避免飛濺（splashing）及 the draining spigot （引流栓） and nonsterile collecting container（非無菌集尿桶） 接觸 尿袋必須維持在膀胱以下的位置，尿袋勿放在地 板上 Category IB導尿管留置應有的概念 CDC：Guidelines for Prevention of Catheter-Associated Urinary Tract Infections , 2009 Post insertionMaintenance Bundle 每日評估項目： 填寫方式：V 執行； 未執行； NA 未發生或不適用 每日醫師確認是否有留置導尿管的必要。 管路留置原因(可複選)：1.急性尿滯留或尿道阻塞或神經性 膀胱病人；2. 需要精確計算輸出量之病危病人；3.特定的手 術，如：泌尿系統或鄰近組織手術；4.預防髖部或會陰部傷口 染污；5. 改善臨終病人的生活品質；6.病人需長期固定不動 ，如胸腔或脊椎嚴重外傷或骨盆骨折病人；0.其他，請說明原 因。經醫師評估可拔除管路者，留置原因請填NA。 於執行所有導尿管照護前後確實執行洗手。