医院感染目标性监测译

1、Targeted Surveillance for Nosocomial InfectionsBarbara M. Soule, RN, MPA, CICChinese Society for Nosocomial InfectionsJuly 4-5, 2004 Suzhou, China1ICP 的工作内容IC Practitioner (ICP) Activities监测Surveillance项目管理ProgramManagement教育Education工作的多样性Miscellaneous暴发调查OutbreakInvestigation咨询Consultation2监测应具有流行

2、病学基础Surveillance has an Epidemiologic foundation为了计划和实施干预措施，研究处于某特定感染危险的人群（目标人群）中的问题和事件的分布Study the distribution of problems and events within a defined (targeted) population at risk for developing specific infections in order to plan & implement interventions.33种主要的监测方法3 Key Surveillance Methods 医院

3、范围的传统监测 Hospital-wide Traditional Surveillance所有的感染-全面-花费时间 All infections complete- time consuming有限的时间用于干预 Limits time for interventions定期监测 Periodic Surveillance对选择的感染或人群进行定期监测 Selected infections or populations periodically over time遗漏有些感染 Miss some infections 目标监测 Targeted Surveillance4名称Name优点

4、Advantages缺点Disadvantages目标性监测Targeted/ Focused Surveillance by Objective将有限的资源集中在高感染危险病区Concentrates limited resources to high risk areas; 重点放在有已知控制措施的感染上Focuses on HAI with known control measures; 能够确定确切的分母Can determine valid denominator; 灵活性，能够和其他控制策略结合起来Flexible, can be mixed with other strategi

5、es;增加监测的有效性Increases efficiency of surveillance; 使ICP能够开展其他工作Enables ICP to perform other activities仅能收集监测目标病人或危险的数据Collects data only for targeted patients or risks;漏掉未监测病区或病人的感染集聚或暴发May miss clusters or outbreaks in non-surveyed areas or groupsAdapted from Pottinger et al & Gaynes et al.优/缺点Advant

6、ages/Disadvantages5目标性监测Targeted Surveillance6美国CDC国家医院感染监测系统的目标性监测CDCs National Nosocomial Infections Surveillance (NNIS) System Targets:NNIS SystemAURICUHRNSurgicalPatientAntimicrobialUse and ResistanceIntensive CareUnit(Adult/Pediatric)High Risk Nursery (NICU)Risk adjustedSSIs byProcedures7你所在医院监

7、测系统的目标性监测 Your Hospital Surveillance System Targets:Your HospitalVAPICUBSISSIVentilator-Associated PneumoniaMedical /Surgical ICUsIntensive CareUnit(Pediatric)Primary BloodStream InfectionsPrimary OrthopedicNeurosurgical or CABGProcedures8哪些感染作为目标性监测Which infection to target?重点为具有高感染危险的病人Focus on pa

8、tients at high risk for HAI病人的护理病区Patient care areas重症监护病房ICUs, 心胸外科cardio-thoracic surgery, 癌症病房cancer ward特殊人群Specific populations新生儿neonates, 移植病人transplant patients, 血液透析病人hemodialysis pts操作/设备Procedures / DevicesCT 外科CT surgery, 中央静脉插管central vascular lines, 呼吸机ventilators具有流行病学意义的病原体Organisms

9、of epidemiologic importance MRSA, VRSA9针对后果的目标性监测Targeted Surveillance for Outcomes原发性血液系统感染 Primary Bloodstream infections呼吸机相关性肺炎 Ventilator-associated pneumonia手术部位感染 Surgical site infections MRSA, VRE infections血液透析病人经血管的感染 Vascular access infections in hemodialysis patients医疗机构中的锐器刺伤 Sharps inj

10、uries in healthcare providers10针对过程的目标性监测Targeted Surveillance for Processes医务人员的乙肝免疫率 Hepatitis B immunity rates in personnel医务人员对操作规则的依从性-隔离预防Personnel compliance with protocols - isolation precautions,灭菌质量监测 Sterilization quality assurance testing, 有效地环境清洁 Effective environmental cleaning抗微生物药物的使

11、用与管理 Antimicrobial prescribing and administration11怎样实施目标性监测How to implement targeted surveillance12第一步 Step One感染控制护士和医生每天查看微生物学报告 ICP and MD review Microbiology reports daily定期查阅过去的监测数据 Review past surveillance data periodically列出作为目标性监测的潜在感染或人群 Develop a list of the potential infections or popula

12、tions for targeted surveillance 13第二步 Step Two感染控制人员基于以下一个或多个标准选择目标性监测的医院感染 Infection control team selects nosocomial infections to target based on one or more of the following criteria:14选择过程或后果进行目标监测的的标准Criteria for Selecting Processes or Outcomes for Targeted Surveillance感染控制计划的目的 IC program obje

13、ctives感染并发症的危险频度或水平 Frequency or level of risk of infectious complications for 病区 area患者人群 patient population 操作 procedure 服务 service 发病率 Morbidity, 死亡率 Mortality, 费用 Cost预防的可能性 Possibility for prevention15第三步 Step Three ICP 应用一致的和认可的标准，对第二步决定的与感染有关的过程或结局进行数据收集ICP performs chart reviews on the infec

14、tion-related processes or outcomes identified in Step Two using standardized, consistent, approved definitions一定时期内持续认真的监测Consistent intensity and thoroughness of surveillance over time一定时期内同样的定义Same definitions over time16目标性监测：方法Targeted Surveillance: A Means to an End仅收集必要的数据Collect only necessar

15、y data 得到有意义的信息Arrive at meaningful information17这样您可以做到 So You Can:制定有意义的干预措施Develop meaningful interventions做减少感染的工作 DO something to reduce infections改善患者的医疗护理 Improve patient care!18目标性监测的成功周期The Cycle for Success Through Targeted Surveillance是否有重要的问题 Is there an important problem? 是什么，为什么？多专业的控制

16、人员 What, why? Multidisciplinary Teams 2.描述并理解问题 Describe and understand the problem? 目标性监测Targeted Surveillance 3. 怎样去改进 How to affect change?多专业的控制人员 Multidisciplinary Teams教育Education反馈Feedback新方案New protocols新产品New products4. 改进措施是否有效？ Do the changes work? 再评价Remeasure Adapted from: Richards C, e

17、t al. Emerg Infect Dis 200119NLMIgnaz Semmelweis Targeted Surveillance And InterventionFor Puerperal Sepsis20针对过程的目标监测Targeted Surveillance for a Process抗生素预防手术部位感染的时机选择Timing of Antibiotic Prophylaxis for Surgical Site InfectionNLM Archives211.是重要问题吗？Is There an Important Problem?外科不合理的预防使用抗微生物药物是一

18、种主要的感染危险 Inappropriate surgical prophylaxis is a major infection risk 患者暴露于不必要的毒性 exposes patient to unnecessary toxicity增加耐药性 increases antimicrobial resistance过量或不适当的抗菌谱使用并不能降低手术伤口感染的发生率excess doses or inappropriate spectrum antibiotics do not reduce the incidence of surgical wound infection22理想的预

19、防使用方法“Ideal” Prophylaxis理想的预防性应用Ideal antibiotic for prophylaxis有效地杀灭可能污染伤口的病原菌 active against pathogens most likely to contaminate wound在潜在的污染期间保持足够的浓度 adequate concentrations during potential contamination短期应用以减少并发症，耐药及费用 administered for a short time to reduce complications, resistance, and cost2

20、3Targeted Process SurveillanceTiming of Perioperative Antimicrobial ProphylaxisClassen DC, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281IncisionHours beforeincisionHours afterincisionAntibioticAdministered24围手术期抗微生

21、物药物预防应用的时机Timing of Perioperative Antimicrobial ProphylaxisClassen DC, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281252. 针对该问题进行目标性监测Perform Targeted Surveillance for This Problem1) 手术切口前一小时接受预防性抗生素的患者比例Proportion

22、of patients who receive prophylactic antibiotics within 1 hour before surgical incision术前1小时使用抗生素的人数，# antibiotics 1 hour 使用抗生素的所有病人数，# surgeries with antibiotics26针对问题进行目标监测Perform Targeted Surveillance for This Problem2) 手术结束后24小时内停用抗生素的患者比例 Proportion of patients whose antibiotics were discontinu

23、ed within 24 hours of the surgery end time# discontinue w/I 24 hours # surgeries receiving antibiotics27手术操作决定预防性的抗生素给药时间选择Possible Surgical Procedures to Determine Timing of Antibiotic Prophylaxis冠脉搭桥手术CABG结肠手术Colon surgery髋和膝关节形成术Hip and knee arthroplasty经腹或阴道子宫切除术Abdominal and vaginal hysterectom

24、y血管手术Vascular surgery (e.g., peripheral vascular surgery)283. 改进To Affect Change多学科小组检查抗生素给药制度：现状和期望的制度 Multidisciplinary Team to look at antibiotic delivery system: current and desired重新设计抗生素的及时应用制度Redesign system for timely AB delivery抗生素的可得性，Make antibiotic accessible培训护理和手术室人员以及麻醉师和外科大夫Educate n

25、ursing and operating room staff and anesthesiologists and surgeons在病历上记录给药时间，Record time on patient chart294.改进工作有效吗？ Do the changes work?在新的改良操作开始后的3个月内重新检查2个变量 Re-measure 2 variables in 3 months after initiation of new improved procedure监测手术部位感染率Measure surgical site infection rates.30针对感染结果的目标性监测

26、Targeted Surveillance for an Infection Outcome31Targeted Surveillance for Outcomes医院感染率NI Rate:VAPCR-BSIUTIFoley relatedNon-Foley related采取干预措施的目的Drives Intervention For:Pneumonia preventionCR-BSI preventionFoley-care, d/c programPeri-care / hydration 321.是重要问题吗？Is There an Important Problem?呼吸机相关性肺

27、炎对患者是一个主要感染危险Ventilator - associated pneumonia is a major infection risk for patients增加病死率 increased mortality延长住院时间 excess length of stay增加医疗费用 excess cost33Example: Challenge for Targeted Surveillance将呼吸机相关性肺炎降低50 Reduce ventilator associated pneumonias (targeted adverse event) by 50% # VAP infect

28、ions # 1000 ventilator days34通过目标监测和干预减少呼吸机相关性肺炎Reduction of VAP with Targeted Surveillance and InterventionsKwan 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 cos

29、t effectivenessICHE 2003;24;11:859-63.35Reduction of VAP with Targeted Surveillance and Interventions干预措施Interventions:抬高床头Raise head of bed管道给予灭菌水Sterile water for tube feedings24 - 48 -72- 根据需要应用气管导管In-line suction catheters from 24 - 48 -72- as needed每年节约花费$350，000 Cost savings $350,000 in one year.361. Is There an Important Problem?导管相关血流感染是一种严重的感染危险因素Catheter-related bloodstream infections are a serious infection risk导管相关的device-related发病率和病死率morbidity and mortality延长住院时间extra length of stay额外医药花费additional medical costs370510152025JanAprilJulyOctJanAprilJulyOctJan989