麻省总医院ICU细菌感染控制措施英文课件.ppt

1 InfectionControlMeasuresintheICU AdayinthelifeofabacteriumintheICU B TaylorThompson MDDirector MICUMassachusettsGeneralHospitalAssociateProfessorofMedicineHarvardMedicalSchooltthompson1 partners org 2 PresentationOutline NosocomialtransmissionWherebacterialiveandhowtheygetaroundInfectionControlintheICU CentralroleforandhygieneReviewtheMGHexperience 3 WHOGlobalSafetyChallenge FirstTarget 2005 2006 HealthCareAssociatedInfectionsHandHygieneascornerstone 4 5EssentialStepsforCrossTransmission PittetetalLancetInfectDis2006 5 ICUpatientsarerapidlycolonizedwithpathogenicbacteria SkincolonizedinhourstodaysStaph aureus Proteusmirabilis Klebsiellaspp present 100 106CFU cm2skinPerineal inguinal axilla trunk upperextremitiesandhandsDialysis CRF diabetes dermatitis broadspectrumAbxincreaseriskPatientsshed106squames day widespreadcontaminationoftheroom ReviewedinPittetetalLancetInfectDis2006 6 5EssentialStepsforCrossTransmission PittetetalLancetInfectDis2006 7 TransmissiontoHandsfromSkinandEnvironment PittetetalLancetInfectDis2006 8 Transfertothehandsofhealthcareworkers HCWs hands I CleanActivities lifting takingradialarterypulse measuringbloodpressure Upto100 1000cfufromHCWshandsHCWsinterceptedbeforehandwashinMRSAcolonizedpatient17 ofworker sglovespositive Phillips BMJ1977 McBride JHospInf2004 9 Transfertothehandsofhealthcareworkers HCWs hands II SurveillanceculturesofHCWshandsinICU21 ofMDs 5 ofnursespositive n 328 SerialCulturesofNSICUHCWshands100 positiveforGNRand64 positiveforstaphaureusatleastonceRings artificialorlongnails dermatitisincreasefrequencyofhandcontaminationofHCWs Daschner JHospInf1988 Maki AnnIntMed1978 Trick ClinInfDis2003 10 Morecontaminationwithmorecare Pittet ArchIntMed1999 11 ContaminationofHealthcareWorkerswithVREduringRoutinePatientExaminations Atleastonesite33 49 67 Gloves Hands 31 49 63 Gowns18 49 37 Stethoscopes15 49 31 Allthreesites12 49 24 Stethoscopeafterwipe1 49 2 Zachary InfectControlHospEpidemiol 2001 12 5EssentialStepsforCrossTransmission PittetetalLancetInfectDis2006 13 BacterialSurvivaltimesonhands Acinetobacterspp60minE coli6min mean Klebsiellaspp2min mean VRE60minPseudomonassp30min 180insputumRotavirus16 survive20min 2 survive60min 14 15 ContaminationofICUPatientCharts Sterileswabofoutsideofbinders chartskeptoutsidetheICUroom PanhotraAmJInfectControl2005 PercentofICUchartsculturepositivebyorganism 16 5EssentialStepsforCrossTransmission PittetetalLancetInfectDis2006 17 Handwashingcomplianceratesbyoccupation PittetDetal AnnInternMed1999 130 126 18 5EssentialStepsforCrossTransmission PittetetalLancetInfectDis2006 19 MGHNosocomialMRSA1995 1999 20 Strategiestodecreasetransmission ProvenorProposedStrategiesAntibioticstewardshipProperhandhygieneCohortingpatientsReducingLOSGownsandglovesIsolationofpatientsAppropriatestaffingratiosAntibioticcroprotationSurveillanceculturesDecolonizationofpatients chlorhexidinebodywashes muciprocin DecolonizationofhealthcareworkercarriersPaucityofRCTsonefficacyofindividualapproachesEfficacyofanindividualapproachmayvarybypathogenNeareradicationofapathogenfromahospital oracountry requiresabundleofapproaches eg SearchandDestroy intheNetherlands 21 CompulsiveAntibioticPrescribing CAP CAPisawidespreadandseriousafflictionFirstyearmedicalstudentsarefreeofthediseaseInternsandfirstyearresidentsareseverelyafflicted life longhabitdifficulttobreakCAPissupportedbyawellorganizedgroupofantibioticpushersAntibioticsAnonymousSelfhelpgroup available24hours willtalkyouthroughtheurgetoprescribemorethantwoantibiotics otherabuses Lockwoodetal NEJMp465 466 1974 22 Isisolationsafeforthepatient Cases ConsecutivepatientsadmittedandisolatedforMRSAControls PatientsinthesameroomimmediatelybeforeandafteracaseSimilarbaselinecharacteristicsCasesMorelikelytohaveunrecordedvitalsigns absentMDprogressnotes andtocomplainabouttheircareTwicetherateofpreventableadverseeventsSimilarmortality 17 casesvs10 controls p 0 16 Stelfox JAMA2003 23 CommunicationCampaign 24 MGHHandHygiene HH Campaign 2000HHTaskForce D HooperandP Wright Calstatdispensershospitalwide2002Poster EducationalCampaign20048 washbeforecontact 48 aftercontactHHChampionsoneachfloor PizzaNewPosterCampaignMonitoringandfeedbackofHHratesbyunit floor RN MD 25 MGHHandHygieneCampaign 2005 2006Benchmarkagainstpeers morepeerpressure Onthespot CoffeeCentralcouponsPatientsasadvocates patientlearningcenter2007HHQualityincentiveprogram ifratesofHHbeforeandafterpatientcontact 90 onagivenfloor ICU monetarybonuspaidatyearsendtoRNs MDs Rates reminderssenttounitsmonthly 26 MGHQuarterlyHandHygienerates 2004 07 Aftercontact Beforecontact withthepatientorpatient senvironment 8 High 90 High 93 JCAHOexpectation 90 Targetfor2007 90 MGHgoal 100 47 27 28 Conclus