降低加护病房中心静脉导管相关血流感染率.ppt

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 本院內外科加護病房共46床 其中內科15床主要收治內科重症病人 外科加護病房27床主要收治手術後重症病人及少數內科病人 急診加護病房7床收治內科為主外科為輔之重症病人 加護病房病人嚴重病況危急 抵抗力差且侵入性醫療措施裝置多 如呼吸治療管路 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感染流行調查 經卡方檢定結果發現院內感染個案增加情形 並無統計學上意義但結果發現血流感染人次之增加具統計上意義 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 比起台灣醫療品質指標計劃 THIS 醫學中心數值相當 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醫學中心與區域醫院之平均數值4 020 00高出許多 喔 中心靜脈導管相關血流感染率 約為醫學中心與區域醫院的平均值的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 STEP1Askingananswerableclinicalquestion PracticereflectionDecisionmaking 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 不如也先調查各家醫學中心現況 CDC在有關消毒劑使用之建議 Disinfectcleanskinwithappropriateantisepticbeforeinsertionandattimeofdressingchange 2 chlorhexidineispreferred Donotapplyorganicsolvents acetoneorether toskinbeforetheinsertionandatdressingchange Cleaninjectionportswith70 AlcoholorIodophorbeforeaccessing Allowantisepticstoremainoninsertionsiteandairdry povidoneiodineshouldbeallowedtoairdryfor2minutesorlonger 各醫院中心靜脈導管護理使用之消毒劑 CDC強調的合適的消毒劑 有建議較為合適的 2 Chlorhexidine 但同時強調使用消毒劑的注意事項 本院使用的消毒劑與大多數醫院雷同 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 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 Decisionmaking 修訂留置中心靜脈導管病人照護標準規範 EBN問題 PICO CDC預防導管相關血流感染防護介入是否較現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 ProblemorPatient 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 CentralvenouscatheterrelatedBSI 防護感染主要原則CDCguideline Educating training insert maintaincatheterscareUsingmaximalsterilebarrierprecautionUsingchlorhexidineforskinantisepsisAvoidingroutinereplacementofCVCasastrategytopreventinfectionUsingantiseptic antibioticimpregnatedshort termCVCMonitoringperformanceindicator AJIC Vol 30 8 December2002 476 489 STEP2Searchevidences Searchstrategy關鍵字 Infectioncontrol ICU CDCCentralvenouscatheters bloodstreaminfection catheter relatedbloodstreaminfection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 STEP3Criticalappraisaltheevidences 名詞解釋 中心導管 Centralline 為短期輸液或監測血液動力狀況而插入中央循環系統的暫時性血管內裝置或導管 中心導管使用日數 Centrallineday 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日 裝置相關的感染 Device associatedinfection 是指一位加護病房的病患在感染發生前的48小時內有使用一種醫療裝置 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 必須符合全國院內感染監視手冊 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 發燒 38 發冷或低血壓 hypotension 等至少一項的臨床徵象標準3 一歲以下之嬰兒發燒 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症狀與陽性的實驗結果與其他部位的感染無關 QualityofEvidence Ia Meta analysisofRandomizedcontrolledtrialsIb OnerandomizedcontrolledtrialIIa OnewelldesignedcontrolledstudywithoutrandomizationIIb Onewelldesignedquasi experimentalstudyIII Welldesignednon experimentalstudies comparative correlation otherdescriptive IV Expertcommitteereports exportopinions carestudy 文獻探討 Epidemiology Primarybloodstreaminfectionsareafrequentcauseofmorbidityandmortalityinintensivecareunitsworldwide CDC 2003 NNIS 1997 reportsCVC BSIrateof5 20 00inAmerican ICUratesofCVC associatedBSIrange2 9to11 3 文獻探討 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靜脈留置不恰當的無菌屏障穿刺技術不佳2002美國CDC的導管相關感染的預防規範 Skinantisepsis Title ChlorhexidineComparedwithPovidone IodineSolutionforVascularCatheter SiteCare Ameta analysisPurpose EvaluatetheefficacyofskindisinfectionwithChlor GparedwithP Isolutioninpreventingcatheter relatedBSI Datasources Multiplecomputerizeddatabase 1966 2001 referencelistsofidentifiedarticles Studyselection RCTcompared catheter site MEDLINE CINAHL EBMASE CochraneLibrary InternationalPharmaceuticalAbstracts LevelIa 續出處 AnnInternMed V 136 11 2002 DataExtraction 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 discussionwithstaff LevelIII Educationandtraining 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 empoweringnursestostopthecatheterinsertionprocedureifaviolationoftheguidelines LevelIIa Educationandtraining Intervention E SurgicalICU 16床 C CVSICU 15床 Results 1 before 62 followedinfectioncontrol after100 2 during from11 300 0 firstquarter1998to000 0 fourthquarter2002 controlICU 15bedsCVSICU wasfrom5 7to1 6 Education Rosenthaletal 2003 Effectofaninfectioncontrolprogramusingeducationandperformancefeedbackonrateofintravasculardevice associatedbloodstreaminfectionsinICUsArgentinaDesign ToascertaintheeffectofaninfectioncontrolprogramusingeducationandperformancefeedbackonICUIntervention educationandtrainingforCDCandprevention LevelIIb Educationandtraining ResultsPhaseI baselinesurveillance 1219人數 PhaseII education 586人數PhaseIII performance 4140人數conclusioneducationandperformancefeedbackresultinasignificanttrendreducedofIVD associatedBSI Handhygiene Aielloetal 2001 AssessmentoftowhandhygieneregimensforintensivecareunitpersonnelPurpose Design ProspectiverandomizedclinicaltrialfourconsecutiveweeksTocompareskinconditionandskinmicrobiologyamongICUpersonnelusingoneoftworandomlyassignedhandhygieneregimens a2 chlorhexidinegluconate 61 ethanolwithemollients ALC LevelIb Handhygiene Result 50staffmembers twoICU 1 ParticipantsintheALCgrouphadsignificantimprovementsintheHandSkinAssessmentscoresatwk4 p 0 04 andinVisualSkinScalingscoresatwk3 p 0 01 and4 p 0 0005 2 ThenwerenosignificantdifferencesinnumbersofcolonyfromunitsbetweenparticipantsintheCGHorALCgroupatanytimeperiod 193handcultures Maximalsterilebarrier Title Preventionofcentralvenouscatheter relatedinfectionsbyusingmaximalsterileBarrierprecautionsduringinsertion Objective Toinvestigatedwhethertheuseofmaximalsterilebarrier mask cap sterilegloves gown andlargedrape wouldlowertheriskofacquiringcatheter relatedinfections Source InfectControlHospEpidemiol 1996 Apr 15 LevelIb Maximalsterilebarrier續 Design RCT GroupI nontunneledcentercatheterinsertedundermaximalsterilebarrier Gr Ii controlprecautions sterilegloves smalldrape Atcatheterremoveorpostinsertion3ms weretakencatheterculture bloodculture Maximalsterilebarrier續 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 M DAndersonCancerCenter 1994 USA antisepticcatheter Hanleyetal 2000 Evaluationofanantiseptictriple lumencatheterinanICUDesign retrospectivereviewofsurveillancerecords primarybloodstreaminfectionsurveillancedata includedriskfactors laboratoryandmicrobiologicaldata insertionsitesanddates LevelIII antisepticcatheter續 Outcome CRBSIsrateResults 1 5 400 0 inantiseptic 11 3innonantiseptictriple lumencathetergroupsConclusion TheuseofantisepticmayreduceCRBSIsinICUandmaybeassociatedwithadecreaseinlengthofstay antiseptictriplelumencatheter 盛等 1999 抗感染安全尖端導管對降低細菌集落率及感染發生率之成效方法1 隨機取樣置入 Arrow Pennsylvania 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 silversulfadiazine的抗感染藥劑結果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 LevelIb antisepticcatheter 結果4 局部發炎 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 sitecare Olivier 1996 Prospective randomizedtrialoftwoantisepticsolutionsforpreventionofcentralvenousorarterialcathetercolonizationandinfectioninICUpatients SICU Design Prospectiverandomizedclinicaltrial E 0 25 chlorthexidinegluconate 0 25 benzalkoniumchlorideand4 benzylalcohol C 10 povidoneiodine betadine LevelIb Catheter sitecare Outcome therateofsignificantcathetercolonizationandcatheter relatedsepsisweresignificantlowerintheEgroup therateofarterialcathetercolonizationwassignificantlowerintheEgroup therateofarterialcatheter relatedsepsiswassimilarfortwogroupConclusion The0 25 chlorthexidinesolutionwassuperiortothe10 povidonesolutioninpreventioncathetercolonizationandcatheter relatedsepsisduetoGram postivebacteria SurveillanceforCRBSIs Coopersmith 2004 Theimpactofbedsidebehavioroncatheter relatedbacteremiaintheICU SICU Design beforeandaftereducationtrial auditresult abehavioralinterventionwasdesignedtoimprovecompliancewithevidence basedguidelinesofCVCmanagement LevelIb SurveillanceforCRBSIs Results audit18m 1 documentingthedressingdate 11 to21 p 99 maximalsterilebarrierprecautions 50 to80 p 29 2 CRBSIsrate3 4to2 800 0 during15mafterintervention 穿刺部位選擇 Deshpandeetal 2005 Theincidenceofinfectiouscomplicationsofcentralvenouscathetersatthesubclavian internaljugular andfemoralsitesinanintensivecareunitpopulation PurposeTheobjectivewastoassesstheriskofcentralvenouscathetersinfectionwithrespecttothesiteofinsertioninanintensivecareunitpopulation Thesubclavian internaljugular andfemoralsiteswerestudied Design Prospective observationalstudy LevelIII 穿刺部位選擇 SubjectsAllpatientsweretriagedintotheICUbyon sitecriticalcaremedicinefellows Group1waspatientswithonecatheteratonesite Group2waspatientswithcathetersatmultiplesites Atotalof831centralvenouscathetersand4735catheterdaysin657patientswerestudied 穿刺部位選擇 ResultsIngroup1 1 theincidenceofinfectionwassubclavian 0 881infections 1000catheterdays internaljugular 0 1000 andfemoral 298 1000 p 0 2635 2 Theincidenceofcolonizationwassubclavian 0 881colonization 1000catheterdays internaljugular 2 00 1000 andfemoral 5 96 1000 p 0 1338 穿刺部位選擇 Results 2Ingroup2 therewasalsonostatisticallysignificantdifferenceintheincidenceofinfectionandcolonizationamongthethreeinsertionsites InsertionsiteSelection Jacques 2001 Complicationsoffemoralandsubclavianvenouscatheterizationincriticalillpatients arandomizedcontrolledtrialIntervention randomizedcontrolledtrialassignedtofemoralsite n 145 orsubclaviansite n 144 LevelIb InsertionsiteSelection Results 1 Femoralcatheterizationwasassoc