英文医院感染控制

Targeted Surveillance for Nosocomial Infections,Barbara M. Soule, RN, MPA, CICChinese Society for Nosocomial InfectionsJuly 4-5, 2004 Suzhou, China,2,IC Practitioner (ICP) Activities,Surveillance,ProgramManagement,Education,Miscellaneous,OutbreakInvestigation,Consultation,3,Surveillance has an Epidemiologic foundation,Study the distribution of problems and events within a defined (targeted) population at risk for developing specific infections in order to plan & implement interventions.,4,3 Key Surveillance Methods,Hospital-wide Traditional SurveillanceAll infections complete- time consumingLimits time for interventions Periodic SurveillanceSelected infections or populations periodically over timeMiss some infections Targeted Surveillance,5,Advantages/Disadvantages,Adapted from Pottinger et al & Gaynes et al.,Targeted Surveillance,7,CDCs National Nosocomial Infections Surveillance (NNIS) System Targets:,NNIS System,AUR,ICU,HRN,SurgicalPatient,AntimicrobialUse and Resistance,Intensive CareUnit(Adult/Pediatric),High Risk Nursery (NICU),Risk adjustedSSIs byProcedures,8,Your Hospital Surveillance System Targets:,Your Hospital,VAP,ICU,BSI,SSI,Ventilator-Associated PneumoniaMedical /Surgical ICUs,Intensive CareUnit(Pediatric),Primary BloodStream Infections,Primary OrthopedicNeurosurgical or CABGProcedures,9,Which infection to target?,Focus on patients at high risk for HAIPatient care areasICUs, cardio-thoracic surgery, cancer wardSpecific populationsneonates, transplant patients, hemodialysis ptsProcedures / DevicesCT surgery, central vascular lines, ventilatorsOrganisms of epidemiologic importance MRSA, VRSA,10,Targeted Surveillance forOutcomes,Primary Bloodstream infectionsVentilator-associated pneumonia, Surgical site infectionsMRSA, VRE infectionsVascular access infections in hemodialysis patientsSharps injuries in healthcare providers.,11,Targeted Surveillance for Processes,Hepatitis B immunity rates in personnelPersonnel compliance with protocols - isolation precautions,Sterilization quality assurance testing, Effective environmental cleaningAntimicrobial prescribing and administration,12,How to implement targeted surveillance,13,Step One,ICP and MD review Microbiology reports dailyReview past surveillance data periodicallyDevelop a list of the potential infections or populations for targeted surveillance,14,Step Two,Infection control team selects nosocomial infections to target based on one or more of the following criteria:,15,Criteria for Selecting Processes or Outcomes for Targeted Surveillance,IC program objectivesFrequency or level of risk of infectious complications for areapatient population procedure service Morbidity, Mortality, CostPossibility for prevention,16,Step Three,ICP performs chart reviews on the infection-related processes or outcomes identified in Step Two using standardized, consistent, approved definitions. Consistent intensity and thoroughness of surveillance over timeSame definitions over time,17,Targeted Surveillance: A Means to an End,Collect only necessary data Arrive at meaningful information,18,So You Can:,Develop meaningful interventionsDO something to reduce infectionsImprove patient care!,19,The Cycle for Success Through Targeted Surveillance,Is there an important problem? What, why? Multidisciplinary Teams,2. Describe and understand the problem? Targeted Surveillance,3. How to affect change?Multidisciplinary TeamsEducationFeedbackNew protocolsNew products,4. Do the changes work? Remeasure,Adapted from: Richards C, et al. Emerg Infect Dis 2001,20,NLM,Ignaz Semmelweis Targeted Surveillance And InterventionFor Puerperal Sepsis,21,Targeted Surveillance for a Process,Timing of Antibiotic Prophylaxis for Surgical Site Infection,NLM Archives,22,1. Is There an Important Problem?,Inappropriate surgical prophylaxis is a major infection risk exposes patient to unnecessary toxicityincreases antimicrobial resistanceexcess doses or inappropriate spectrum antibiotics do not reduce the incidence of surgical wound infection,23,“Ideal” Prophylaxis,Ideal antibiotic for prophylaxisactive against pathogens most likely to contaminate woundadequate concentrations during potential contaminationadministered for a short time to reduce complications, resistance, and cost,24,Targeted Process SurveillanceTiming of Perioperative Antimicrobial Prophylaxis,Classen DC, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281,Incision,Hours beforeincision,Hours afterincision,AntibioticAdministered,25,Timing ofPerioperative Antimicrobial Prophylaxis,Classen DC, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281,26,2. Perform Targeted Surveillance for This Problem,1) Proportion of patients who receive prophylactic antibiotics within 1 hour before surgical incision # antibiotics 1 hour # surgeries with antibiotics,27,Perform Targeted Surveillance for This Problem,2) Proportion of patients whose antibiotics were discontinued within 24 hours of the surgery end time# discontinue w/I 24 hours # surgeries receiving antibiotics,28,Possible Surgical Procedures to Determine Timing of Antibiotic Prophylaxis,CABGColon surgeryHip and knee arthroplastyAbdominal and vaginal hysterectomyVascular surgery (e.g., peripheral vascular surgery),29,3. To Affect Change,Multidisciplinary Team to look at antibiotic delivery system: current and desiredRedesign system for timely AB deliveryMake antibiotic accessibleEducate nursing and operating room staff and anesthesiologists and surgeonsRecord time on patient chart,30,4. Do the changes work?,Re-measure 2 variables in 3 months after initiation of new improved procedureMeasure surgical site infection rates.,31,Targeted Surveillance for an InfectionOutcome,32,Targeted Surveillance for Outcomes,NI Rate:VAPCR-BSIUTIFoley relatedNon-Foley related,Drives Intervention For:Pneumonia preventionCR-BSI preventionFoley-care, d/c programPeri-care / hydration,33,1. Is There an Important Problem?,Ventilator - associated pneumonia is a major infection risk for patientsincreased mortalityexcess length of stayexcess cost,34,Example: Challenge for Targeted Surveillance,Reduce ventilator associated pneumonias (targeted adverse event) by 50% # VAP infections # 1000 ventilator days,35,Reduction of VAP with Targeted Surveillance and Interventions,Kwan KL, Baker SP, Fontecabio SA. Impact of a program ofintensive surveillance and interventions targeting ventilated patients in the reduction of ventilator-associated pneumonia, and its cost effectivenessICHE 2003;24;11:859-63.,36,Reduction of VAP with Targeted Surveillance and Interventions,Inverventions:Raise head of bedSterile water for tube feedingsIn-line suction catheters from 24 - 48 -72- as neededCost savings $350,000 in one year.,37,1. Is There an Important