感控操作方式的改变和相关规范的实施(英国)

1、Practice change and policy implementation. 感控操作方式的改变和相关规范的实施Yvonne Carter. 伊芳卡特Deputy Director, Infection Prevention and Control. The Royal Free London NHS Foundation Trust.英国国家医疗服务体系信托基金属下伦敦皇家自由医院感染预防及控制科主任Evidence based practice change. 基于证据的实操改变基于证据的实操改变In 2008, the Royal Free was the 6th worst h

2、ospital in England for hospital acquired infections. 在2008年，伦敦皇家自由医院是英国获得院内感染案例数量排名倒数第六的医院。Now the Royal Free is best performing in London acute hospitals. 目前，伦敦皇家自由医院是伦敦市表现最好的急性病医院。How? 是如何做到的呢？What were the evidence-based national strategies and guidance? Was the Royal Free compliant? 基于事实的国家政策和规范

3、是什么？伦敦皇家自由医院有曾经抱怨过吗？ National Strategies 国家政策国家政策Clostridium difficile How to deal with the problem. (DH and PHE 2008) 如何解决艰难梭状芽孢杆菌感染这个问题（英国卫生部和英格兰公共卫生局于2008年颁布） 1. Clinical definitions and laboratory diagnosis 临床和实验室的诊断定义临床和实验室的诊断定义testing available every day for Toxin A and B. 每天测试毒素A和毒素B 2. Surve

4、illance 监测手段监测手段mandatory national reporting scheme. 强制性的报告国家方案。investigation of all cases, including ribotype of samples. 调查所有病例，包括样本的核糖核酸型。 3. Management and treatment of CDI 艰难梭状芽孢杆菌感染的管理和治疗艰难梭状芽孢杆菌感染的管理和治疗antibiotic review. 抗生素检查Isolation and care. 隔离及护理clean with sporicidal product. 使用杀芽孢产品清洁。u

5、se Metronidazole or Vancomycin. 使用甲硝咪唑和万古霉素。 National Strategies 国家政策国家政策Clostridium difficile How to deal with the problem. (DH and PHE 2008) 如何解决艰难梭状芽孢杆菌感染这个难题（英国卫生部和英格兰公共卫生局与2008年颁布） 4. Prevention of CDI through antibiotic prescribing 通过使用抗生素处方预防艰难梭状芽孢杆菌感染通过使用抗生素处方预防艰难梭状芽孢杆菌感染 narrow spectrum. 窄谱

6、。 avoid: Clindamycin, Cephalosporins, Fluoroquinolones, Carbapenems and Aminopenicillins. 避免使用：克林霉素，头孢菌素，氟喹诺酮，碳青霉烯类和安基青霉素。 use Metronidazole or Vancomycin. 使用甲硝咪唑和万古霉素。National Strategies 国家政策国家政策5. Prevention through isolation 通过隔离进行预防通过隔离进行预防single room or cohort. 入住单人间或者所有获得感染的集体6. Prevention thr

7、ough environmental cleaning 通过环境清洁进行预防通过环境清洁进行预防Sporicidal agent / Chlorine 1,000 ppm 使用杀芽孢消毒产品或1000ppm含氯消毒剂7. Hand hygiene in the prevention of CDI 通过手卫生预防艰难梭状芽孢杆菌感染通过手卫生预防艰难梭状芽孢杆菌感染soap and water, not just gel. 使用肥皂和水，不仅仅是洗手啫喱。8. Coping with high prevalence 应对感染高发区应对感染高发区Increase IPC measures, inc

8、luding increase cleaning with sporicidal products. 增加感染预防及控制措施，包括增加使用杀芽孢产品进行清洁。9. CDI in the community 社区出现艰难梭状芽孢杆菌感染社区出现艰难梭状芽孢杆菌感染Central reporting. 集中上报。10. Death certification 死亡证明死亡证明Part of national comparative data. 国家比较数据的一部分。11. Governance, audit and performance indicators 管理，审查和绩效评定管理，审查和绩效

9、评定Comply with Health and Social Care Act (2008).遵守健康与社会保健法案（于2008年颁布）Clostridium difficile care plan 患艰难梭状芽孢杆菌感染的护理方案患艰难梭状芽孢杆菌感染的护理方案Care plan used across all hospital wards. 护理方案适用于医院的每个科室护理方案适用于医院的每个科室Enteric isolation. 肠隔离。Stool chart Bristol Stool Scale type. 布里斯托大便分类法。Use gloves and aprons. Mas

10、ks are not required. 需要佩戴手套和围裙，面罩则不需要。Disposable crockery and cutlery are not required if washed in dishwasher. 如果餐具可以用在洗碗机清洗则不需要一次性器皿和餐具。Bed linen does not need to be changed every day unless soiled. Treat as contaminated linen. 被单和枕套在没有脏污的情况下不需要每天更换。当作脏污的织物处理。Clinical waste bag. 医疗废物胶袋。Decontamina

11、te all re-usable equipment with Sporicidal wipes before leaving the room. 离开病房前用杀芽孢干巾杀芽孢干巾清洁所有可重复使用的设备 Discard all single use/disposable equipment/dressings. 丢弃所有一次性设备或衣物。Terminal clean, then steam clean, on transfer/discharge. Use Sporicidal wipes. 终末消毒，然后熏蒸消毒，用于转移或出院病人。使用杀芽孢干巾使用杀芽孢干巾。Wash hands be

12、fore visiting patients and when leaving the room. Alcohol gel alone is not sufficient. 探访病人前和离开病房后要洗手。仅仅是酒精啫喱是不足够的。Clostridium difficile ward rounds 对感染艰难梭状芽孢杆菌的病人查房对感染艰难梭状芽孢杆菌的病人查房Information available for staff and patients. 共享信息给护理人员及病人。Correct isolation measures in place. 在合适的地点进行恰当的隔离方式。Care pl

13、an made individual. 定制个人护理方案。Appropriate antibiotic prescribing. 酌合理使用抗生素。Stool chart in use. 使用大便分类法。Sporicidal wipes in use. 使用杀芽孢干巾。Nurses and cleaners know how to use them. 护士及清洁人员需要知道怎么使用以上的方法。Feedback to clinical staff. 反馈信息给临床科室 人员。Strategies to reduce Clostridium difficile降低艰难梭状芽孢杆菌感染的策略降低艰难

14、梭状芽孢杆菌感染的策略Individual patient packs: 病人个人套装：病人个人套装：Patient information leaflet. 病人资料彩页。Patient care plan. 病人护理方案。Patient pathway. 病人治疗线路图。Two packs of sporicidal wipes. 两包杀芽孢干巾。Instructions on a poster for display. 杀芽孢干巾的使用说明海报Changing to Peracetic acid releasing Sporicidal wipes. 转变到释放过氧乙酸的清洁方式转变到释

15、放过氧乙酸的清洁方式 - 杀芽孢干巾杀芽孢干巾CDI rates not improving. 艰难梭状芽孢杆菌感染率没有再上升Policies and practices recently reviewed. 评估最近的政策和实操Focus on environmental hygiene. 关注环境卫生。关注环境卫生。Traditional chlorine agents- not user-friendly. 传统含氯消毒剂 不利于使用者。Alternative effective product - Clinell Sporicidal wipes 可供选择的有效产品 Clinell伽

16、玛杀芽孢干巾After one year - infections 72% lower. 使用杀芽孢干巾一年以后 感染率降低了72%Cost per infection about 4,000, representing saving of 660.000. 每例感染需要花费4千英镑治疗费，一年下来节省了66万英镑（660万人民币） Using the sporicidal wipes. 使用杀芽孢干巾使用杀芽孢干巾Activate wipes with water. 使用自来用水激活干巾。Wipes are used for all cleaning for patients with C.

17、difficile. 干巾是用于清洁患艰难梭状芽孢杆菌感染的病人区域。This includes the room, the bed-side equipment and medical equipment, toilet/commode areas and furniture. 清洁的区域包括病房，床边设备和医疗设备，卫生间/坐便椅和家具。Some hospitals use the wipes for cleaning all commodes between any patient use and for cleaning dirty utility room every day. 一些

18、医院使用杀芽孢干巾每天清洁所有的不同病人之间使用过的坐便椅和清洁脏污的杂物间。Evidence based practice change.基于证据的实操改变基于证据的实操改变Employ the same policy and practices across all wards 对所有科室采用相同的政策和实操方式对所有科室采用相同的政策和实操方式How can you measure improvement if everyone is doing something different? 当每个人做的事情都不尽相同的时候你该如何衡量提升？Patients have confidence

19、if they know what to expect because every area does the same thing. 假如病人知道他们期望的是什么，那他们会对医院有信心，因为每个区域都做同样的事。Staff know what policy and practice is wherever they work avoid confusion 无论在哪里，护理人员都要清楚知道政策和实操方式 避免产生困惑。Base policies and practices on good evidence do the right thing all the time. 基于政策和实操方式

20、总是做正确的事情。Employ the same policy and practices across all wards 对所有科室采用相同的政策和实操方式对所有科室采用相同的政策和实操方式what about hospital reputation? 医院的声誉会怎么样？what about surveillance schemes what happens when infection data becomes nationally known? 监测方案是什么 当感染数据上报全国的时候会发生什么？being at the bottom is humiliating and feels

21、 professionally bad. 在感染率名列最高的时候感觉非常丢脸并且毫无专业性可言。how would it feel if that was your mother who got an infection? 假如是你的母亲发生了感染你会有什么感受？For the future - think about the wider community 关于将来的计划关于将来的计划 设想更广泛的设想更广泛的社区保健社区保健Share ward and hospital policies and practices 分享科室和医院的政策和实际操作方法Region/ area meeting

22、s to share ideas and knowledge 召开区域/地区会议分享想法和知识Think of wider groups share policies 考虑更广泛的团体 分享政策。National policies (Health and Social Care Act 2008) 国家政策（健康与社会保健法案于2008年颁布）Change thinking 改变观念改变观念Find out about beliefs and how staff think 弄清楚他们的想法及信念 - Ive always done things my way 我总是按照自己的方式来做事Im

23、senior I know what Im doing 我职位高 我很清楚自己在做什么Dont confront 不要进行比较provide evidence 提供证据suggest trial 建议试用encourage colleagues to review your change 鼓励同事回顾你的转变find out what is stopping progress and focus on changing small things first develop a culture that isnt scared of change. 找出什么原因阻止了进程，先关注小的改变 培养成

24、习惯便不会让你害怕改变。Change thinking 改变观念改变观念Dont talk act. 少说话，多做事。The best way to persuade people is by example. 说服别人最好的方法是通过实例Dont expect people to do what you say get busy and work with them. 不要指望你说什么别人就会做什么 跟他们一起工作并且忙碌起来吧。IPC practice-educator role. 感控的实操 扮演教育者的角色Cost savings 节省治疗费用节省治疗费用Reduction in C.

25、difficile saved 660,000 (based on 4,000 per case) 艰难梭状芽孢杆菌感染的降低能节省66万英镑的治疗费用。（基于4000英镑每个病例）Infection leads to an average extra 11 days in hospital 病人发生了感染导致不得不额外住院治疗平均达11天。If patients do not get infections, the bed can be available for other patients and procedures that will generate better income.

26、假如病人没有发生感染，那么提高床位周转率，让给其他新来病人并给医院可以带来更高的收入。Centralised policies make cost savings purchasing cleaning products, equipment and other items across all hospital sites is less expensive. 集中采购的政策节省了治疗费用 集中购买清洁消毒产品。仪器设备和其他物品通过医院购买会价格便宜。It is good to have budget responsibility with each clinical area, but

27、go with the evidence.每个临床科室承担预算控制义务是好的政策，但需要提交相关证据。MRSA bacteraemias and other MDR organisms 耐甲氧西林金黄色葡萄球菌血症和其他多重耐药菌耐甲氧西林金黄色葡萄球菌血症和其他多重耐药菌Using the same process introducing Disinfection wipes produced reduction in MRSA and other pathogenic organisms. 使用相同的程序 推荐能减少耐甲氧西林金黄色葡萄球菌和其他致病菌的清洁消毒湿巾Toolkit for

28、the early detection, management and control of carbapenemase -producing Enterobacteriaceae Department of Health England. 早期感染检测工具包，产碳青霉烯酶肠杆菌的管理及控制早期感染检测工具包，产碳青霉烯酶肠杆菌的管理及控制 英国卫生局。英国卫生局。KEY MESSAGE: No increased frequency of cleaning is required but scrupulous routine cleaning is required 关键信息： 不需要增加清

29、洁的频次 但是需要仔细认真的进行每一次清洁THIS INCLUDES THE FOLLOWING: 包含以下内容： adherence to high standards of cleaning should be promoted and audited 需要促进和审查是否遵守高标准的清洁方式 Toolkit for the early detection, management and control of carbapenemase -producing Enterobacteriaceae Department of Health England. 早期感染检测工具包，早期感染检测工具

30、包，产碳青霉烯酶肠杆菌的管理及控制产碳青霉烯酶肠杆菌的管理及控制 英国卫生局。英国卫生局。 routine but stringent decontamination of equipment is required after use with an affected patient, especially when the equipment may be shared with other patients. 被感染病患者使用的仪器设备使用后需要进行常规 且严格的去污程序，特别是当仪器设备可能需要与其 他病人共用的时候。 there are no extra decontaminatio

31、n requirements for endoscopes above the normal organisational procedures. 在常规的组织程序下，对内窥镜没有额外的去污要求。Clinical Leads IPC group 临床带领感控团队临床带领感控团队Driving force behind infection prevention and control 来自感控团队的推动力Board to Ward 医院管理层到科室的推动Fortnightly, chaired by Medical Director 每两周一次，由医疗主任主持Includes Lead Cons

32、ultant, Nurse and Operational Manager from each clinical service. 包括来自各个临床科室的首席顾问，护士和运营经理。Includes Directors of Nursing (DIPC), Facilities, Estates, Pharmacy, Governance/risk, Bed/site manager, therapists. 包括护理主任（感控主任），设备科负责人，资产管理科负责人，药剂科负责人，行政/风险管理科负责人，床/地点负责人，治疗师。Standing agenda items infection ra

33、tes/data, Infection investigations and decontamination 常务议程项目 感染率、数据，感染病例调查和清洁。Seasonal pressures monitored here before creation of dedicated pressure/outbreak group if necessary. 成立专门的团队专注因季节变化导致的病毒感染 或感染暴发Get the right people 培养正确的人员培养正确的人员train IPC Champions 培训感控团队的冠军clinical skill competence assessments 临床操作技能评估targeted education and role modelling working at the bed-side, all staff groups. 有针对性的教育及角色示范 所有护理人员围成一组，在床边进行演示。staff development and re-skilling 护理人员的发展