1、降低加護(hù)病房中心靜脈導(dǎo)管相關(guān)血流感染率急護(hù)組林富美、蘇芳玉黃錦鳳、徐玉玫、張青蕙、何雲(yún)仙報(bào)告大綱前言EBN問題與步驟文獻(xiàn)探討文獻(xiàn)與本院情形之比較討論EBN過程評(píng)值未來計(jì)劃方向前言本院內(nèi)外科加護(hù)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(hù)病房27床主要收治手術(shù)後重癥病人及少數(shù)內(nèi)科病人，急診加護(hù)病房7床收治內(nèi)科為主外科為輔之重癥病人。九月份本院感染管制中心曾就加護(hù)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(gè)案增加情形，並無統(tǒng)計(jì)學(xué)上意義但結(jié)果發(fā)現(xiàn)血流感染人次之增加具統(tǒng)計(jì)上意義，而9位血流感染個(gè)案中，有8位有置入中心靜脈導(dǎo)管。 93年本院加護(hù)病房中心靜脈導(dǎo)管使用率平均為51.68

2、 ，比起臺(tái)灣醫(yī)療品質(zhì)指標(biāo)計(jì)劃（THIS）醫(yī)學(xué)中心數(shù)值相當(dāng)（57.27 ）但中心靜脈導(dǎo)管相關(guān)血流感染率本院指標(biāo)平均8.470/00 較THIS醫(yī)學(xué)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(dǎo)管相關(guān)血流感染率約為醫(yī)學(xué)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 clinical question Practice reflection Decision makingCDC在有關(guān)消毒劑使用之建議Disinfect clean skin with appropriate

3、 antiseptic 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 70% Alcohol or Iodophor before accessing.Allow antiseptics to remain on insertion

4、 site and air dry- povidoneiodine should be allowed to air dry for 2 minutes or longer. CDC強(qiáng)調(diào)的合適的消毒劑，有建議較為合適的-2% Chlorhexidine。但同時(shí)強(qiáng)調(diào)使用消毒劑的注意事項(xiàng)。本院使用的消毒劑與大多數(shù)醫(yī)院雷同。預(yù)防導(dǎo)管相關(guān)血流感染之防護(hù)，除了消毒劑外應(yīng)有更多照護(hù)因子可介入。-主題可再想想-EBN 問題： PICOCDC預(yù)防導(dǎo)管相關(guān)血流感染防護(hù)介入是否較 現(xiàn)行一般照護(hù)能降低加護(hù)病房中心靜脈導(dǎo)管相關(guān)血流感染率Intervention Problem or PatientOutcomeCom

5、parison改善專案 降低加護(hù)病房中心靜脈導(dǎo)管相關(guān)血流感染率Central venous catheter related BSI防護(hù)感染主要原則CDC guidelineEducating & training: insert & maintain catheters careUsing maximal sterile barrier precautionUsing chlorhexidine for skin antisepsisAvoiding routine replacement of CVC as a strategy to prevent infectionUsing anti

6、septic/antibiotic impregnated short-term CVCMonitoring performance indicatorAJIC,Vol.30(8).December 2002.476-489STEP 2 Search evidencesSearch strategy關(guān)鍵字: Infection control;ICU; CDC Central venous catheters; blood stream infection;catheter-related bloodstream infection 血流感染率；中心靜脈導(dǎo)管中文：4 篇HINT(MEDLINE

7、)：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 ,antiseptics, insertion,maintain care, education-等焦點(diǎn)搜尋名詞解釋中心導(dǎo)管（Central line）：為短期輸液或監(jiān)測(cè)血液動(dòng)力狀況而插入中央循環(huán)系統(tǒng)的暫時(shí)性血管內(nèi)裝置或?qū)Ч堋?中心導(dǎo)管使用日數(shù)（Central line day）：在計(jì)算裝置使用日時(shí)，一個(gè)使用中心導(dǎo)管的加護(hù)病房病人算一個(gè)使用日。 裝置相關(guān)的感染(Device-as

8、sociated infection)：是指一位加護(hù)病房的病患在感染發(fā)生前的48 小時(shí)內(nèi)有使用一種醫(yī)療裝置。而此感染不是在病患住進(jìn)加護(hù)病房時(shí)已存有或有潛伏感染。中心導(dǎo)管相關(guān)之血流感染率必須符合全國(guó)院內(nèi)感染監(jiān)視手冊(cè)(NNIS)對(duì)實(shí)驗(yàn)室證實(shí)的血流感染之標(biāo)準(zhǔn)標(biāo)準(zhǔn)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(guān)。 標(biāo)準(zhǔn)2：發(fā)燒(38)、發(fā)冷或低血壓 (hypotension)等至少一項(xiàng)的臨床徵象標(biāo)準(zhǔn)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(xiàng)臨床徵象且臨床徵象或癥狀與陽性的實(shí)驗(yàn)結(jié)果與其他部位的感染無關(guān)文獻(xiàn)探討-EpidemiologyPrimary b

9、loodstream infections are a frequent cause of morbidity and mortality in intensive care units worldwide. （CDC,2003）NNIS （1997）reports CVC-BSI rate of 5.20/00 in American, ICU rates of CVC-associated BSI range 2.9 to 11.3文獻(xiàn)探討-CRBSI造成的影響CRBSI increases in ICU Length of stay, total hospital cost, ICU c

10、ost CRBSI increases risk of ICU mortalityOther predictors of ICU death were APACH III score（p.001）, age（p=.04）, GI surgery （p=.003）, alcohol abuse （p=.04）（Dimick,2001）Level I b Skin antisepsisTitle: Chlorhexidine Compared with Povidone-Iodine Solution for Vascular Catheter-Site Care A meta-analysis

11、Purpose: Evaluate the efficacy of skin disinfection with Chlor.Gluco. compared with P-I solution in preventing catheter-related BSI.Data sources: Multiple computerized database(1966-2001),reference lists of identified articles.Study selection: RCT compared ,catheter-site. : MEDLINE, CINAHL,EBMASE, C

12、ochrane Library , International Pharmaceutical Abstracts- Level I a續(xù) 出處:Ann Intern Med,V.136(11),2002Data Extraction: a standardized form , two reviewers abstracted data on study design , patient population, intervention, incidence of CR-BSI from all included studies. Data Synthesis: 1.8 studies inv

13、olving a total 4143 catheters met the criteria. 2.various catheter types were usedConclusion: Chlorhexidine gluconate reduced the risk 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 infe

14、ctions in a MICU in Brazil Design: prospectively surveyed Intervention: highlight correct practices 1.CVC insertion, manipulation, and care/ monthly classes 2.Poster,discussion with staffLevel IIIEducation （Berenholtz, 2004）Eliminating catheter-related bloodstream infections in the ICU（16 beds SICU）

15、Design: a prospective cohort study with concurrent controlIntervention:a quality improvement team, （1）education （2）creating 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 cath

16、eter insertion procedure if a violation of the guidelinesLevel II aEducation and trainingIntervention: E: Surgical ICU（16床）, C: CVS ICU（15床）Results:（1）before, 62% followed infection control, after 100% （2）during, from 11.300/0 , first quarter 1998 to 0 00/0 , fourth quarter 2002; control ICU（15 beds

17、 CVS ICU）was from 5.7 to 1.6Education (Rosenthal et al, 2003)Effect of an infection control program using 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 educa

18、tion and performance feedback on ICUIntervention: education and training for CDC and preventionLevel II bEducation and trainingResults Phase I:baseline surveillance, 1219人數(shù) ; Phase II:education, 586人數(shù) Phase III: performance, 4140人數(shù)conclusion education and performance feedback result in a significant

19、 trend reduced of IVD-associated BSIHand hygiene（Aiello et al.,2001）Assessment of tow hand hygiene regimens for intensive care unit personnelPurpose/Design: Prospective randomized clinical trial four consecutive weeksTo compare skin condition and skin microbiology among ICU personnel using one of tw

20、o randomly assigned hand 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 the Hand Skin Assessment scores at wk 4(p=0.04) and in VisualSkin Scalin

21、g scores at wk 3 (p=0.01) and 4 (p=0.0005) 2. Then were no significant differences in numbers of colony from units between participants in the CGH or ALC group at any time period.(193 hand cultures)Maximal sterile barrierTitle:Prevention of central venous catheter-related infections by using maximal

22、 sterileBarrier precautions 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:Infect Control Hosp Epidemiol (1996,Apr.15)Level I bMaximal sterile ba

23、rrier續(xù) Design:RCT,Group I- nontunneled center catheter inserted under maximal sterile barrier . Gr.Iicontrol precautions(sterile gloves & small drape) At catheter remove or postinsertion 3ms. were taken catheter culture & blood culture.Maximal sterile barrier續(xù)Result: 1. group1-176pts.; group II-167p

24、ts 2. group1- 4 catheter inf. ; group II-12 catheter inf.P=0.03,chi-square test 3.group II catheter-related septicemia rate was 6.3 times higher Group I (P=0.06,Fishers exact test) 4.67%of group II catheter inf.- 2ms after insertion.25% of group I- catheter inf.- the same period. (p15個(gè)單位的細(xì)菌集落(C,25條，

25、E,9條) 2.細(xì)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 antiseptic catheter結(jié)果 4.局部發(fā)炎(C,4條，E,0條) 5.細(xì)菌集落情形(C,20%條，E,8條) 6.抗感染安全尖端導(dǎo)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 prevention of central venous or arterial cathete

26、r colonization and infection in ICU patients（SICU） Design: Prospective randomized clinical trial, E: 0.25% chlorthexidine gluconate, 0.25% benzalkonium chloride and 4% benzylalcohol; C:10% povidone iodine（betadine） Level I bCatheter-site care Outcome: the rate of significant catheter colonization an

27、d catheter-related sepsis were significant lower in the E group; the rate of arterial catheter 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 solut

28、ion in prevention catheter colonization and catheter-related sepsis due to Gram-postive bacteriaSurveillance for CRBSIs （Coopersmith, 2004）The impact of bedside behavior on catheter-related bacteremia in the ICU（SICU）Design: before and after education trial; audit result, a behavioral intervention w

29、as designed to improve compliance with evidence-based guidelines of CVC management Level I bSurveillance for CRBSIsResults:audit 18 m（1）documenting the dressing date（11% to 21%; p.001）, stopcock use （70% to 24% ;p.99）maximal sterile barrier precautions（50% to 80% ;p=.29）（2）CRBSIs rate 3.4 to 2.8 00/

30、0（during 15 m after intervention）穿刺部位選擇（Deshpande et al., 2005）The incidence of infectious 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 in

31、fection 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 studyLevel III穿刺部位選擇SubjectsAll patients were triaged into the ICU by on-site critical care medicine fellows.Group 1

32、 was patients with one catheter at one site. Group 2 was patients with catheters at multiple sites.A total of 831 central venous 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

33、, internal jugular: 0/1000, and femoral:298/1000(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 statistically 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 critical ill patients: a randomized controlled trialIntervention: randomized controlled trial assigned to