重癥監(jiān)護(hù)病房醫(yī)院感染的管理1

重癥監(jiān)護(hù)病房醫(yī)院感染的管理廣州醫(yī)學(xué)院第一附屬醫(yī)院護(hù)理部

劉桂卿醫(yī)院感染所致經(jīng)濟(jì)損失

（病例對(duì)照配對(duì)法）醫(yī)院研究每例增加每例增加時(shí)間費(fèi)用（元）住院天數(shù)*湘雅醫(yī)院90.4-91.33224.0018.1*福建省人93.1-122489.8915.68民醫(yī)院*中國(guó)醫(yī)大93.8-102413.9518.28附一院美國(guó)SENIC92年45.32億美元(全年)4主要內(nèi)容ICU醫(yī)院感染的流行病學(xué)ICU醫(yī)院感染的預(yù)防控制措施ICU醫(yī)院感染的監(jiān)測(cè)ICU侵入性診療相關(guān)感染的預(yù)防護(hù)理ICU醫(yī)院感染的流行病學(xué)ICU感染的發(fā)生具備三個(gè)環(huán)節(jié)：易感者感染源傳播途徑ICU病人的易感性病情危重，免疫功能下降侵入性診療技術(shù)的應(yīng)用接受免疫制劑治療長(zhǎng)期大量應(yīng)用抗生素饑餓、低蛋白飲食和靜脈高營(yíng)養(yǎng)感染源內(nèi)源性：微生物來(lái)自病人體內(nèi)或體表的正常菌群或條件致病菌，包括外來(lái)的定植菌外源性：病原微生物來(lái)自病人體外已感染的病人及帶菌者環(huán)境儲(chǔ)源：ICU的環(huán)境或液體可成為某些病原微生物存活并繁殖的場(chǎng)所傳播途徑空氣傳播接觸傳播血液/體液傳播染感院醫(yī)傳播途徑-空氣傳播定義：病原微生物經(jīng)由懸浮在空氣中的微粒--氣溶膠來(lái)傳播。飛沫型飛沫核型菌塵型醫(yī)源型傳播途徑-接觸傳播

直接接觸傳播：病人或醫(yī)務(wù)人員直接（不經(jīng)媒介）與感染源接觸而獲得感染。間接接觸傳播：病原體通過(guò)媒介物（如污染的手及器械等）傳給易感者。侵入性操作：是醫(yī)院中特有的傳播方式，較常見(jiàn)物品直接感染間接感染接觸感染+某醫(yī)院傳染科職工進(jìn)行不同工作后手指帶菌數(shù)工作類(lèi)型檢查次數(shù)總菌數(shù)(菌落數(shù))平均菌數(shù)(菌落數(shù))物理檢查4514290317.5護(hù)理治療5139741779.2接觸儀7接觸污衣3腸鏡檢查416040.0

1990年54家醫(yī)院侵入性

操作相關(guān)性現(xiàn)患率侵入性操作 觀察人數(shù) 感染人數(shù) 現(xiàn)患率%泌尿系插管 1610 202 12.55 人工呼吸機(jī) 527 95 18.03 透析療法 102 18 17.65 動(dòng)靜脈插管 366 24 6.56 引流 933 120 12.86 傳播途徑-血液/體液傳播血液、血液制品、輸液制品在采用、制作、包裝、運(yùn)輸、保存、輸注等操作過(guò)程中遭污染而造成感染。ICU醫(yī)院感染的預(yù)防控制措施消毒滅菌無(wú)菌技術(shù)隔離合理使用抗生素監(jiān)測(cè)評(píng)價(jià)建筑布局與設(shè)置合理

ICU應(yīng)設(shè)在相對(duì)獨(dú)立的區(qū)域，內(nèi)部分三個(gè)區(qū)ICU的床位設(shè)置三個(gè)區(qū)域應(yīng)設(shè)洗手設(shè)備和物品室內(nèi)有良好通風(fēng)設(shè)備，有條件安裝層流空氣凈化裝置。配置靜脈高營(yíng)養(yǎng)配制室、消毒室及隔離室ICU工作人員的要求接受醫(yī)院感染知識(shí)培訓(xùn)，定期體檢，增強(qiáng)預(yù)防醫(yī)院感染的意識(shí)。遵守ICU的管理要求，認(rèn)真洗手。嚴(yán)格執(zhí)行無(wú)菌技術(shù)、消毒隔離、疫情報(bào)告等制度。正確使用化學(xué)消毒劑。盡量減少人員流動(dòng)，嚴(yán)格控制入室人員。環(huán)境和物品消毒管理按II類(lèi)環(huán)境要求進(jìn)行消毒管理保持室內(nèi)環(huán)境清潔和空氣凈化ICU的用品固定專(zhuān)用，用后處理呼吸治療儀器設(shè)備的消毒ICU污物的消毒處理保持室內(nèi)環(huán)境清潔和空氣凈化ICU的空氣消毒法循環(huán)風(fēng)紫外線空氣消毒器的應(yīng)用靜電吸附式空氣消毒器的應(yīng)用ICU各類(lèi)物體表面的消毒ICU內(nèi)禁止養(yǎng)花加強(qiáng)ICU及床單位的終末消毒ICU物品管理、用后處理ICU的一切物品，包括儀器、治療、護(hù)理用具和痰杯等必須固定專(zhuān)用。應(yīng)用一次性醫(yī)療用品，用后進(jìn)行消毒毀形無(wú)害化處理。呼吸治療儀器設(shè)備的消毒人工呼吸機(jī)管道及濕化器的消毒簡(jiǎn)易人工呼吸氣囊、霧化吸入器的消毒喉鏡、氣管鏡、支氣管鏡等纖維內(nèi)窺鏡的消毒呼吸機(jī)管道清洗消毒ICU污物的消毒處理生活垃圾的處理醫(yī)用垃圾的處理放射垃圾的處理可燃性與非燃性污物的處理傳染病人污物的處理。合理使用抗生素醫(yī)生應(yīng)掌握正確使用抗生素的各種知識(shí)，根據(jù)藥物的適應(yīng)癥，藥敏試驗(yàn)等合理選用。護(hù)士應(yīng)了解抗生素的藥理作用和配制要求，準(zhǔn)確掌握給藥劑量、時(shí)間和方法，并觀察用藥后的反應(yīng)。有感染流行或暴發(fā)流行時(shí)，對(duì)ICU病人、接觸者和環(huán)境進(jìn)行流行病學(xué)調(diào)查定期進(jìn)行細(xì)菌學(xué)監(jiān)測(cè)發(fā)現(xiàn)或疑有感染時(shí)，及時(shí)上報(bào)ICU醫(yī)院感染的監(jiān)測(cè)醫(yī)院感染監(jiān)測(cè)的定義

醫(yī)院感染監(jiān)測(cè)是指系統(tǒng)地觀察一定人群中的醫(yī)院感染發(fā)生和分布以及影響感染的各種因素，對(duì)監(jiān)測(cè)資料進(jìn)行定期整理分析，并向有關(guān)人員和單位發(fā)送，以便采取控制行動(dòng)。醫(yī)院感染監(jiān)測(cè)的類(lèi)型全面綜合性監(jiān)測(cè)：醫(yī)院感染發(fā)病率、現(xiàn)患率、罹患率等調(diào)查目標(biāo)性監(jiān)測(cè)：部門(mén)監(jiān)測(cè)、輪轉(zhuǎn)式監(jiān)測(cè)，從優(yōu)監(jiān)測(cè)。ICU醫(yī)院感染的常用監(jiān)測(cè)對(duì)ICU病人感染的監(jiān)測(cè)監(jiān)測(cè)對(duì)象監(jiān)測(cè)項(xiàng)目酌情檢測(cè)標(biāo)本氣管內(nèi)吸出的痰培養(yǎng)呼吸機(jī)管道或濕化瓶液體培養(yǎng)動(dòng)靜脈插管拔管后管內(nèi)液體或頭端培養(yǎng)各種引流物培養(yǎng)血、尿液培養(yǎng)對(duì)ICU環(huán)境的監(jiān)測(cè)呼吸機(jī)管道培養(yǎng)濕化液培養(yǎng)導(dǎo)管頭端培養(yǎng)ICU監(jiān)測(cè)細(xì)菌菌落數(shù)衛(wèi)生學(xué)標(biāo)準(zhǔn)環(huán)境類(lèi)別（II類(lèi)）

評(píng)價(jià)標(biāo)準(zhǔn) 空氣（cfu/cm3）≤200未檢出致病菌 物體表面（cfu/cm2）≤5未檢出致病菌，新生兒監(jiān)護(hù)室不得檢出沙門(mén)氏菌醫(yī)務(wù)人員手（cfu/cm2）≤5未檢出致病菌，新生兒監(jiān)護(hù)室不得檢出沙門(mén)氏菌皮膚粘膜（cfu/cm2）≤5未檢出致病菌 使用中（cfu/ml）≤100未檢出致病菌消毒液監(jiān)測(cè)方法簡(jiǎn)介采樣時(shí)間、采樣方法、檢測(cè)方法及注意事項(xiàng)按衛(wèi)生部“消毒技術(shù)規(guī)范”空氣監(jiān)測(cè)：治療室、營(yíng)養(yǎng)配制室、病房物品和環(huán)境表面監(jiān)測(cè)：治療臺(tái)、治療車(chē)、潔凈工作臺(tái)、水龍頭、門(mén)把手……。手和皮膚粘膜監(jiān)測(cè)消毒液的監(jiān)測(cè)醫(yī)院人員的監(jiān)測(cè)空氣培養(yǎng)潔凈臺(tái)培養(yǎng)門(mén)把手細(xì)菌培養(yǎng)手的細(xì)菌培養(yǎng)消毒液濃度測(cè)試咽部細(xì)菌培養(yǎng)ICU侵入性診療相關(guān)感染的預(yù)防護(hù)理氣管切開(kāi)及機(jī)械通氣相關(guān)

感染和防護(hù)相關(guān)感染：氣管切開(kāi)創(chuàng)口感染，下呼吸道感染。感染因素傳染源傳播途徑易感因素發(fā)病機(jī)理氣管切開(kāi)和留置導(dǎo)管，使第一道防線的鼻道和口咽失去調(diào)溫、濕化、過(guò)濾的作用；管道的刺激和壓迫影響了咳嗽反射和氣管纖毛運(yùn)動(dòng)；氣管套囊對(duì)氣管壁的壓迫使氣管粘膜層血流量發(fā)生改變。氣管切開(kāi)后不同時(shí)期氣管粘膜變化觀察時(shí)觀察正常炎癥反炎性反應(yīng)間(天)例數(shù)例數(shù)應(yīng)例數(shù)率(%)2-74218348110-28238156530-4810377060-703213390-180541203年11004年2200預(yù)防護(hù)理嚴(yán)格無(wú)菌技術(shù)操作減少氣管粘膜的損傷正確掌握吸痰技術(shù)濕化氣道減少口腔細(xì)菌的定植靜脈導(dǎo)管感染和防護(hù)相關(guān)感染：導(dǎo)管局部感染、全身性感染即導(dǎo)管敗血癥。感染因素導(dǎo)管-皮膚戳口接頭污染血源感染輸液污染發(fā)病機(jī)理靜脈炎及血栓形成導(dǎo)管材料不佳的直接刺激全身抵抗力下降預(yù)防護(hù)理嚴(yán)格無(wú)菌技術(shù)操作正確選擇導(dǎo)管選擇合適置管位置預(yù)防液體的污染觀察局部情況謝謝！謝謝！I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlUiTiQfNbK8H5D2A-x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPePeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUjRfOcK9H6H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t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