醫(yī)院感染目標(biāo)性監(jiān)測譯

醫(yī)院感染的目標(biāo)性監(jiān)測

TargetedSurveillanceforNosocomialInfections

BarbaraM.Soule,RN,MPA,CICChineseSocietyforNosocomialInfectionsJuly4-5,2004Suzhou,China1ICP的工作內(nèi)容

IC

Practitioner(ICP)Activities

監(jiān)測Surveillance項(xiàng)目管理ProgramManagement教育Education工作的多樣性Miscellaneous暴發(fā)調(diào)查OutbreakInvestigation咨詢Consultation2

監(jiān)測應(yīng)具有流行病學(xué)基礎(chǔ)SurveillancehasanEpidemiologicfoundation為了計(jì)劃和實(shí)施干預(yù)措施，研究處于某特定感染危險的人群（目標(biāo)人群）中的問題和事件的分布Studythedistributionofproblemsandeventswithinadefined(targeted)populationatriskfordevelopingspecificinfectionsinorder

toplan&implementinterventions.33種主要的監(jiān)測方法3KeySurveillanceMethods

醫(yī)院范圍的傳統(tǒng)監(jiān)測

Hospital-wideTraditionalSurveillance

所有的感染-全面-花費(fèi)時間Allinfections–complete-timeconsuming

有限的時間用于干預(yù)Limitstimeforinterventions定期監(jiān)測PeriodicSurveillance

對選擇的感染或人群進(jìn)行定期監(jiān)測Selectedinfectionsorpopulationsperiodicallyovertime

遺漏有些感染Misssomeinfections

目標(biāo)監(jiān)測TargetedSurveillance4名稱Name優(yōu)點(diǎn)Advantages缺點(diǎn)Disadvantages目標(biāo)性監(jiān)測Targeted/FocusedSurveillancebyObjective將有限的資源集中在高感染危險病區(qū)Concentrateslimitedresourcestohighriskareas;

重點(diǎn)放在有已知控制措施的感染上FocusesonHAIwithknowncontrolmeasures;

能夠確定確切的分母Candeterminevaliddenominator;

靈活性，能夠和其他控制策略結(jié)合起來Flexible,canbemixedwithotherstrategies;

增加監(jiān)測的有效性Increasesefficiencyofsurveillance;

使ICP能夠開展其他工作EnablesICPtoperformotheractivities

僅能收集監(jiān)測目標(biāo)病人或危險的數(shù)據(jù)Collectsdataonlyfortargetedpatientsorrisks;

漏掉未監(jiān)測病區(qū)或病人的感染集聚或暴發(fā)Maymissclustersoroutbreaksinnon-surveyedareasorgroupsAdaptedfromPottingeretal&Gaynesetal.優(yōu)/缺點(diǎn)Advantages/Disadvantages5目標(biāo)性監(jiān)測

TargetedSurveillance6美國CDC國家醫(yī)院感染監(jiān)測系統(tǒng)的目標(biāo)性監(jiān)測

CDC’sNationalNosocomialInfectionsSurveillance(NNIS)SystemTargets:NNISSystemAURICUHRNSurgicalPatientAntimicrobialUseandResistanceIntensiveCareUnit(Adult/Pediatric)HighRiskNursery(NICU)RiskadjustedSSIsbyProcedures7你所在醫(yī)院監(jiān)測系統(tǒng)的目標(biāo)性監(jiān)測YourHospitalSurveillanceSystemTargets:YourHospitalVAPICUBSISSIVentilator-AssociatedPneumoniaMedical/SurgicalICUsIntensiveCareUnit(Pediatric)PrimaryBloodStreamInfectionsPrimaryOrthopedicNeurosurgicalorCABGProcedures8哪些感染作為目標(biāo)性監(jiān)測

Whichinfectiontotarget?

重點(diǎn)為具有高感染危險的病人FocusonpatientsathighriskforHAI病人的護(hù)理病區(qū)Patientcareareas重癥監(jiān)護(hù)病房ICU’s,心胸外科cardio-thoracicsurgery,

癌癥病房cancerward特殊人群Specificpopulations新生兒neonates,移植病人transplantpatients,血液透析病人hemodialysispts操作/設(shè)備Procedures/DevicesCT外科CT

surgery,中央靜脈插管centralvascularlines,呼吸機(jī)ventilators具有流行病學(xué)意義的病原體Organismsofepidemiologicimportance –MRSA,VRSA9針對后果的目標(biāo)性監(jiān)測

TargetedSurveillanceforOutcomes原發(fā)性血液系統(tǒng)感染PrimaryBloodstreaminfections呼吸機(jī)相關(guān)性肺炎Ventilator-associatedpneumonia手術(shù)部位感染Surgicalsiteinfections

MRSA,VREinfections血液透析病人經(jīng)血管的感染Vascularaccessinfectionsinhemodialysispatients醫(yī)療機(jī)構(gòu)中的銳器刺傷Sharpsinjuriesinhealthcareproviders10針對過程的目標(biāo)性監(jiān)監(jiān)測TargetedSurveillanceforProcesses醫(yī)務(wù)人員的的乙肝免疫疫率HepatitisBimmunityratesinpersonnel醫(yī)務(wù)人員對對操作規(guī)則則的依從性性-隔離預(yù)預(yù)防Personnelcompliancewithprotocols-isolationprecautions,滅菌質(zhì)量監(jiān)監(jiān)測Sterilizationqualityassurancetesting,有效地環(huán)境境清潔Effectiveenvironmentalcleaning抗微生物藥藥物的使用用與管理Antimicrobialprescribingandadministration11怎樣實(shí)施目目標(biāo)性監(jiān)測測Howtoimplementtargetedsurveillance12第一步StepOne感染控制護(hù)護(hù)士和醫(yī)生生每天查看看微生物學(xué)學(xué)報(bào)告ICPandMDreviewMicrobiologyreportsdaily定期查閱過過去的監(jiān)測測數(shù)據(jù)Reviewpastsurveillancedataperiodically列出作為目目標(biāo)性監(jiān)測測的潛在感感染或人群群Developalistofthepotentialinfectionsorpopulationsfortargetedsurveillance13第二步StepTwo感染控制人人員基于以以下一個或或多個標(biāo)準(zhǔn)準(zhǔn)選擇目標(biāo)標(biāo)性監(jiān)測的的醫(yī)院感染染Infectioncontrolteamselectsnosocomialinfectionstotargetbasedononeormoreofthefollowingcriteria:14選擇過程或或后果進(jìn)行行目標(biāo)監(jiān)測測的的標(biāo)準(zhǔn)準(zhǔn)CriteriaforSelectingProcessesorOutcomesforTargetedSurveillance感染控制計(jì)計(jì)劃的目的的ICprogramobjectives感染并發(fā)癥癥的危險頻頻度或水平平Frequencyorlevelofriskofinfectiouscomplicationsfor病區(qū)area患者人群patientpopulation操作procedure服務(wù)service發(fā)病率Morbidity,死亡率Mortality,費(fèi)用Cost預(yù)防的可能能性Possibilityforprevention15第三步StepThreeICP應(yīng)用一致的的和認(rèn)可的的標(biāo)準(zhǔn)，對對第二步?jīng)Q決定的與感感染有關(guān)的的過程或結(jié)結(jié)局進(jìn)行數(shù)數(shù)據(jù)收集ICPperformschartreviewsontheinfection-relatedprocessesoroutcomesidentifiedinStepTwousingstandardized,consistent,approveddefinitions一定時期內(nèi)內(nèi)持續(xù)認(rèn)真真的監(jiān)測Consistentintensityandthoroughnessofsurveillanceovertime一定時期內(nèi)內(nèi)同樣的定定義Samedefinitionsovertime16目標(biāo)性監(jiān)測測：方法TargetedSurveillance:AMeanstoanEnd僅收集必要要的數(shù)據(jù)Collectonlynecessarydata得到有意義義的信息Arriveatmeaningfulinformation17這樣您可以以做到SoYouCan:制定有意義義的干預(yù)措措施Developmeaningfulinterventions做減少感染染的工作DOsomethingtoreduceinfections改善患者的的醫(yī)療護(hù)理理Improvepatientcare!18目標(biāo)性監(jiān)測測的成功周周期TheCycleforSuccessThroughTargetedSurveillance是否有重要的問題Isthereanimportantproblem?

是什么，為什么？多專業(yè)的控制人員

What,why?

MultidisciplinaryTeams

2.描述并理解問題Describeandunderstandtheproblem?目標(biāo)性監(jiān)測TargetedSurveillance

3.怎樣去改進(jìn)Howtoaffectchange?

多專業(yè)的控制人員

MultidisciplinaryTeams

教育Education

反饋Feedback

新方案Newprotocols

新產(chǎn)品Newproducts4.改進(jìn)措施是否有效？Dothechangeswork?

再評價Remeasure

Adaptedfrom:RichardsC,etal.EmergInfectDis200119NLMIgnazSemmelweisTargetedSurveillanceAndInterventionForPuerperalSepsis20針對過程的目標(biāo)監(jiān)測測TargetedSurveillanceforaProcess抗生素預(yù)防防手術(shù)部位位感染的時時機(jī)選擇TimingofAntibioticProphylaxisforSurgicalSiteInfectionNLMArchives211.是重要問題題嗎？IsThereanImportantProblem?外科不合理理的預(yù)防使使用抗微生生物藥物是是一種主要要的感染危危險Inappropriatesurgicalprophylaxisisamajorinfectionrisk患者暴露于于不必要的的毒性exposespatienttounnecessarytoxicity增加耐藥性性increasesantimicrobialresistance過量或不適適當(dāng)?shù)目咕V使用并并不能降低低手術(shù)傷口口感染的發(fā)發(fā)生率excessdosesorinappropriatespectrumantibioticsdonotreducetheincidenceofsurgicalwoundinfection22理想的預(yù)防防使用方法法

“Ideal”Prophylaxis理想的預(yù)防防性應(yīng)用Idealantibioticforprophylaxis有效地殺滅滅可能污染染傷口的病病原菌activeagainstpathogensmostlikelytocontaminatewound在潛在的污污染期間保保持足夠的的濃度adequateconcentrationsduringpotentialcontamination短期應(yīng)用以以減少并發(fā)發(fā)癥，耐藥藥及費(fèi)用administeredforashorttimetoreducecomplications,resistance,andcost23TargetedProcessSurveillanceTimingofPerioperativeAntimicrobialProphylaxisClassenDC,etal.Thetimingofprophylacticadministrationofantibioticsandtheriskofsurgical-woundinfection.NEnglJMed1992;326:281IncisionHoursbeforeincisionHoursafterincisionAntibioticAdministered24圍手術(shù)期抗抗微生物藥藥物預(yù)防應(yīng)應(yīng)用的時機(jī)機(jī)TimingofPerioperativeAntimicrobialProphylaxisClassenDC,etal.Thetimingofprophylacticadministrationofantibioticsandtheriskofsurgical-woundinfection.NEnglJMed1992;326:281252.針對該該問題題進(jìn)行行目標(biāo)標(biāo)性監(jiān)監(jiān)測PerformTargetedSurveillanceforThisProblem1)手術(shù)切切口前前一小小時接受預(yù)預(yù)防性性抗生生素的的患者者比例例Proportionofpatientswhoreceiveprophylacticantibioticswithin1hourbeforesurgicalincision術(shù)前1小時時使用用抗生生素的的人數(shù)數(shù)，#antibiotics1hour使用抗抗生素素的所所有病病人數(shù)數(shù)，#surgerieswithantibiotics26針對問問題進(jìn)進(jìn)行目目標(biāo)監(jiān)監(jiān)測PerformTargetedSurveillanceforThisProblem2)手術(shù)術(shù)結(jié)結(jié)束束后后24小小時時內(nèi)內(nèi)停停用用抗抗生生素素的的患患者者比比例例Proportionofpatientswhoseantibioticswerediscontinuedwithin24hoursofthesurgeryendtime#discontinuew/I24hours#surgeriesreceivingantibiotics27手術(shù)術(shù)操操作作決決定定預(yù)預(yù)防防性性的的抗抗生生素素給給藥藥時時間間選選擇擇PossibleSurgicalProcedurestoDetermineTimingofAntibioticProphylaxis冠脈脈搭搭橋橋手手術(shù)術(shù)CABG結(jié)腸腸手手術(shù)術(shù)Colonsurgery髖和和膝膝關(guān)關(guān)節(jié)節(jié)形形成成術(shù)術(shù)Hipandkneearthroplasty經(jīng)腹腹或或陰陰道道子子宮宮切切除除術(shù)術(shù)Abdominalandvaginalhysterectomy血管管手手術(shù)術(shù)Vascularsurgery(e.g.,peripheralvascularsurgery)283.改進(jìn)進(jìn)ToAffectChange多學(xué)學(xué)科科小小組組檢檢查查抗抗生生素素給給藥藥制制度度：：現(xiàn)現(xiàn)狀狀和和期期望望的的制制度度MultidisciplinaryTeamtolookatantibioticdeliverysystem:currentanddesired重新新設(shè)設(shè)計(jì)計(jì)抗抗生生素素的的及及時時應(yīng)應(yīng)用用制制度度RedesignsystemfortimelyABdelivery抗生生素素的的可可得得性性，，Makeantibioticaccessible培訓(xùn)訓(xùn)護(hù)護(hù)理理和和手手術(shù)術(shù)室室人人員員以以及及麻麻醉醉師師和和外外科科大大夫夫Educatenursingandoperatingroomstaffandanesthesiologistsandsurgeons在病歷上上記錄給給藥時間間，Recordtimeonpatientchart294.改進(jìn)工作作有效嗎嗎？Dothechangeswork?在新的改改良操作作開始后后的3個個月內(nèi)重重新檢查查2個變變量Re-measure2variablesin3monthsafterinitiationofnewimprovedprocedure監(jiān)測手術(shù)術(shù)部位感感染率Measuresurgicalsiteinfectionrates.30針對感染染結(jié)果的目標(biāo)性性監(jiān)測TargetedSurveillanceforanInfectionOutcome31TargetedSurveillanceforOutcomes醫(yī)院感染染率NIRate:VAPCR-BSIUTIFoleyrelatedNon-Foleyrelated采取干預(yù)預(yù)措施的的目的DrivesInterventionFor:PneumoniapreventionCR-BSIpreventionFoley-care,d/cprogramPeri-care/hydration321.是重要問問題嗎？？IsThereanImportantProblem?呼吸機(jī)相相關(guān)性肺肺炎對患患者是一一個主要要感染危危險Ventilator-associatedpneumoniaisamajorinfectionriskforpatients增加病死死率increasedmortality延長住院院時間excesslengthofstay增加醫(yī)療療費(fèi)用excesscost33Example:ChallengeforTargetedSurveillance將呼吸機(jī)機(jī)相關(guān)性性肺炎降降低50％Reduceventilatorassociatedpneumonias(targetedadverseevent)by50%#VAPinfections#1000ventilatordays34通過目標(biāo)標(biāo)監(jiān)測和和干預(yù)減減少呼吸吸機(jī)相關(guān)關(guān)性肺炎炎ReductionofVAPwithTargetedSurveillanceandInterventionsKwanKL,BakerSP,FontecabioSA.Impactofaprogramofintensivesurveillanceandinterventionstargetingventilatedpatientsinthereductionofventilator-associatedpneumonia,anditscosteffectivenessICHE2003;24;11:859-63.35ReductionofVAPwithTargetedSurveillanceandInterventions干預(yù)措施施Interventions:抬高床頭頭Raiseheadofbed管道給予予滅菌水水Sterilewaterfortubefeedings24-48-72-根據(jù)需要要應(yīng)用氣氣管導(dǎo)管管In-linesuctioncathetersfrom24-48-72-asneeded每年節(jié)約約花費(fèi)$350，，000Costsavings$350,000inoneyear.361.IsThereanImportantProblem?導(dǎo)管相關(guān)關(guān)血流感感染是一一種嚴(yán)重重的感染染危險因因素Catheter-relatedbloodstreaminfectionsareaseriousinfectionrisk導(dǎo)管相關(guān)關(guān)的device-related發(fā)病率和和病死率率morbidityandmortality延長住院院時間extralengthofstay額外醫(yī)藥藥花費(fèi)additionalmedicalcosts370510152025JanAprilJulyOctJanAprilJulyOctJan'98'99