降低加护病房中心静脉导管相关血流感染率

降低加護病房中心靜脈導管相關血流感染率

急護組林富美、蘇芳玉黃錦鳳、徐玉玫、張青蕙、何雲仙報告大綱前言EBN問題與步驟文獻探討文獻與本院情形之比較討論EBN過程評值未來計劃方向前言本院內外科加護病房共46床，其中內科15床主要收治內科重症病人，外科加護病房27床主要收治手術後重症病人及少數內科病人，急診加護病房7床收治內科為主外科為輔之重症病人。加護病房病人嚴重病況危急，抵抗力差且侵入性醫療措施裝置多，如呼吸治療管路、動靜脈導管、導尿管等等，這些裝置常是病源菌入侵人體的途徑。九十三年血流感染在內外科加護病房一直輪流佔第一、二位。九月份本院感染管制中心曾就加護病房做院內感染流行調查，經卡方檢定結果發現院內感染個案增加情形，並無統計學上意義但結果發現血流感染人次之增加具統計上意義，而9位血流感染個案中，有8位有置入中心靜脈導管。93年本院加護病房「中心靜脈導管使用率」平均為51.68﹪，比起台灣醫療品質指標計劃（THIS）醫學中心數值相當（57.27﹪）但「中心靜脈導管相關血流感染率」本院指標平均8.470/00較THIS醫學中心與區域醫院之平均數值4.020/00高出許多。喔?「中心靜脈導管相關血流感染率」約為醫學中心與區域醫院的平均值的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！STEP1Askingananswerable

clinicalquestion

PracticereflectionDecisionmaking有什麼好問題第一次共識問題中心靜脈導管護理使用甲消毒溶液會比乙消毒溶液抗菌效果好嗎？

--查CDC的建議如何?

--導管相關感染的因素很多

--很想與專案改善一魚兩吃呢！不如也先調查各家醫學中心現況CDC在有關消毒劑使用之建議Disinfectcleanskinwithappropriateantisepticbeforeinsertionandattimeofdressingchange--2%chlorhexidineispreferred.Donotapplyorganicsolvents(acetoneorether)toskinbeforetheinsertionandatdressingchange.Cleaninjectionportswith70%AlcoholorIodophorbeforeaccessing.Allowantisepticstoremainoninsertionsiteandairdry-povidoneiodineshouldbeallowedtoairdryfor2minutesorlonger.各醫院中心靜脈導管護理

使用之消毒劑醫院名稱置入時皮膚消毒溶液

中心靜脈導管傷口護理溶液忠孝優碘酒精、75%酒精75%酒精、優碘台大優碘酒精、75%酒精生理食鹽水、優碘國泰優碘酒精、75%酒精生理食鹽水、優碘馬偕優碘酒精、75%酒精75%酒精、優碘榮總優碘酒精、75%酒精75%酒精、優碘酒精新光優碘酒精、75%酒精生理食鹽水、優碘長庚優碘酒精、75%酒精75%酒精、優碘酒精三總優碘酒精、75%酒精優碘CDC強調的合適的消毒劑，有建議較為合適的-2%Chlorhexidine。但同時強調使用消毒劑的注意事項。本院使用的消毒劑與大多數醫院雷同。預防導管相關血流感染之防護，除了消毒劑外應有更多照護因子可介入。---主題可再想想---此次EBN主要目的利用EBN過程瞭解CDC預防血流導管相關感染防護措施的實證證據，是否能使中心靜脈導管相關血流感染率降低，以作為加護病房改善專案之參考。Decisionmaking-

修訂留置中心靜脈導管病人照護標準規範EBN問題：PICOCDC預防導管相關血流感染防護介入是否較現行一般照護能降低加護病房中心靜脈導管相關血流感染率Intervention

ProblemorPatientOutcomeComparison改善專案—降低加護病房中心靜脈導管相關血流感染率CentralvenouscatheterrelatedBSI防護感染主要原則CDCguidelineEducating&training:insert&maintaincatheterscareUsingmaximalsterilebarrierprecautionUsingchlorhexidineforskinantisepsisAvoidingroutinereplacementofCVCasastrategytopreventinfectionUsingantiseptic/antibioticimpregnatedshort-termCVCMonitoringperformanceindicatorAJIC,Vol.30(8).December2002.476-489STEP2SearchevidencesSearchstrategy關鍵字:Infectioncontrol;ICU;CDCCentralvenouscatheters;bloodstreaminfection;catheter-relatedbloodstreaminfection血流感染率；中心靜脈導管中文：4篇HINT(MEDLINE)：73篇ProQuest：13篇PubMed：24篇Cochrane：2篇檢索結果資料太多怎麼篩選？先找Nursingstandard及研讀CDCGuideline摘要再分別往handhygiene,antiseptics,insertion,maintaincare,education---等焦點搜尋STEP3

Criticalappraisaltheevidences名詞解釋中心導管（Centralline）：為短期輸液或監測血液動力狀況而插入中央循環系統的暫時性血管內裝置或導管。中心導管使用日數（Centrallineday）：在計算裝置使用日時，一個使用中心導管的加護病房病人算一個使用日。裝置相關的感染(Device-associatedinfection)：是指一位加護病房的病患在感染發生前的48小時內有使用一種醫療裝置。而此感染不是在病患住進加護病房時已存有或有潛伏感染。中心導管相關之血流感染率必須符合全國院內感染監視手冊(NNIS)對實驗室證實的血流感染之標準標準1：一套或多套血液培養分離出致病菌且此致病菌與其它部位之感染無關。標準2：發燒(>38℃)、發冷或低血壓(hypotension)等至少一項的臨床徵象標準3：一歲以下之嬰兒發燒(>38℃)、體溫過低(<37℃)、呼吸中止或心跳徐緩等至少一項臨床徵象且臨床徵象或症狀與陽性的實驗結果與其他部位的感染無關QualityofEvidenceIa-Meta-analysisofRandomizedcontrolledtrialsIb-OnerandomizedcontrolledtrialIIa-OnewelldesignedcontrolledstudywithoutrandomizationIIb-Onewelldesignedquasi-experimentalstudyIII--Welldesignednon-experimentalstudies(comparative,correlation,otherdescriptive)IV-Expertcommitteereports,exportopinions,carestudy文獻探討-EpidemiologyPrimarybloodstreaminfectionsareafrequentcauseofmorbidityandmortalityinintensivecareunitsworldwide.（CDC,2003）NNIS（1997）reportsCVC-BSIrateof5.20/00inAmerican,ICUratesofCVC-associatedBSIrange2.9to11.3文獻探討-CRBSI造成的影響CRBSIincreasesinICULengthofstay,totalhospitalcost,ICUcostCRBSIincreasesriskofICUmortalityOtherpredictorsofICUdeathwereAPACHIIIscore（p<.001）,age（p=.04）,GIsurgery（p=.003）,alcoholabuse（p=.04）（Dimick,2001）LevelIb

CVC感染危險因素分析輸液介面的污染穿刺部位的選擇頸內靜脈留置不恰當的無菌屏障穿刺技術不佳2002美國CDC的導管相關感染的預防規範SkinantisepsisTitle:ChlorhexidineComparedwithPovidone-IodineSolutionforVascularCatheter-SiteCare–Ameta-analysisPurpose:EvaluatetheefficacyofskindisinfectionwithChlor.Gluco.comparedwithP-Isolutioninpreventingcatheter-relatedBSI.Datasources:Multiplecomputerizeddatabase(1966-2001),referencelistsofidentifiedarticles.Studyselection:RCTcompared,catheter-site.:MEDLINE,CINAHL,EBMASE,CochraneLibrary,InternationalPharmaceuticalAbstracts---LevelIa續出處:AnnInternMed,V.136(11),2002DataExtraction:astandardizedform,tworeviewersabstracteddataonstudydesign,patientpopulation,intervention,incidenceofCR-BSIfromallincludedstudies.DataSynthesis:1.8studiesinvolvingatotal4143cathetersmetthecriteria.2.variouscathetertypeswereusedConclusion:ChlorhexidinegluconatereducedtheriskforCR-BSIby49%(95%CI,0.28-0.88)Education(Loboetal.,2005)

Impactofaneducationprogramandpolicychangesondecreasingcatheter-associatedbloodstreaminfectionsinaMICUinBrazilDesign:prospectivelysurveyedIntervention:highlightcorrectpractices1.CVCinsertion,manipulation,andcare/monthlyclasses2.Poster,discussionwithstaffLevelIIIEducationandtraining

Result:Primarybloodstreaminfections200/00(phase1,pre-intervention),110/00(phase2,post-intervention)120/00(phase3,follow-year)TheadhesiontotheoverallCVCcarepolicyimprovedsignificantly(p<.01)Education（Berenholtz,2004）Eliminatingcatheter-relatedbloodstreaminfectionsintheICU（16bedsSICU）Design:aprospectivecohortstudywithconcurrentcontrolIntervention:aqualityimprovementteam,（1）education（2）creatingainsertioncart（3）askingprovidersdailywhethercatheterscouldremoved（4）achecklisttoevidence-basedguidelinesforpreventingCR-BSIs（5）empoweringnursestostopthecatheterinsertionprocedureifaviolationoftheguidelinesLevelIIaEducationandtrainingIntervention:E:SurgicalICU（16床）,C:CVSICU（15床）Results:（1）before,62%followedinfectioncontrol,after100%（2）during,from11.300/0,firstquarter

1998to000/0,fourthquarter

2002;controlICU（15bedsCVSICU）wasfrom5.7to1.6Education(Rosenthaletal,2003)Effectofaninfectioncontrolprogramusingeducationandperformancefeedbackonrateofintravasculardevice-associatedbloodstreaminfectionsinICUsArgentinaDesign:ToascertaintheeffectofaninfectioncontrolprogramusingeducationandperformancefeedbackonICUIntervention:educationandtrainingforCDCandpreventionLevelIIbEducationandtrainingResultsPhaseI:baselinesurveillance,1219人數;

PhaseII:education,586人數PhaseIII:performance,4140人數conclusioneducationandperformancefeedbackresultinasignificanttrendreducedofIVD-associatedBSIHandhygiene（Aielloetal.,2001）AssessmentoftowhandhygieneregimensforintensivecareunitpersonnelPurpose/Design:ProspectiverandomizedclinicaltrialfourconsecutiveweeksTocompareskinconditionandskinmicrobiologyamongICUpersonnelusingoneoftworandomlyassignedhandhygieneregimens:a2%chlorhexidinegluconate:61%ethanolwithemollients(ALC)LevelIb

Handhygiene

Result:50staffmembers(twoICU)1.ParticipantsintheALCgrouphadsignificantimprovementsintheHandSkinAssessmentscoresatwk4(p=0.04)andinVisual

SkinScalingscores

atwk3(p=0.01)and4(p=0.0005)

2.Thenwereno

significantdifferencesinnumbersofcolonyfromunitsbetweenparticipantsintheCGHorALCgroupatanytimeperiod.(193handcultures)MaximalsterilebarrierTitle:Preventionofcentralvenouscatheter-relatedinfectionsbyusingmaximalsterileBarrierprecautionsduringinsertion.Objective:Toinvestigatedwhethertheuseofmaximalsterilebarrier(mask,cap,sterilegloves,gown,andlargedrape)wouldlowertheriskofacquiringcatheter–relatedinfections.Source:InfectControlHospEpidemiol(1996,Apr.15)Level

IbMaximalsterilebarrier續Design:RCT,GroupI-nontunneledcentercatheterinsertedundermaximalsterilebarrier.Gr.Ii—controlprecautions(sterilegloves&smalldrape)Atcatheterremoveorpostinsertion3ms.weretakencatheterculture&bloodculture.Maximalsterilebarrier續Result:1.group1-176pts.;groupII-167pts2.group1-4catheterinf.;groupII-12catheterinf.P=0.03,chi-squaretest3.groupIIcatheter-relatedsepticemiaratewas6.3timeshigherGroupI(P=0.06,Fisher’sexacttest)4.67%ofgroupII–catheterinf.-2msafterinsertion.25%ofgroupI-catheterinf.-thesameperiod.(p<0.01,Fisher’sexacttest)Conclusion:Maximalsterilebarrierreducetheriskofcatheterinfection&cost-effective.Maximalsterilebarrier無菌屏障穿刺地點細菌定值菌血症手套口罩小鋪巾手術室23%4%手套口罩大鋪巾無菌手術衣外科加護病房11%1%M.DAndersonCancerCenter,1994,USA

antisepticcatheter

（Hanleyetal.,2000）Evaluationofanantiseptictriple-lumencatheterinanICUDesign:retrospectivereviewofsurveillancerecords,primarybloodstreaminfectionsurveillancedata,includedriskfactors,laboratoryandmicrobiologicaldata,insertionsitesanddatesLevelIIIantisepticcatheter

續Outcome:CRBSIsrateResults:（1）5.400/0,inantiseptic,11.3innonantiseptictriple-lumencathetergroupsConclusion:TheuseofantisepticmayreduceCRBSIsinICUandmaybeassociatedwithadecreaseinlengthofstayantiseptictriplelumencatheter

(盛等，1999)抗感染安全尖端導管對降低細菌集落率及感染發生率之成效方法1.隨機取樣置入(Arrow，Pennsylvania)，N=20，235條三腔導管(122條控制組，113條實驗組)2.抗感染安全尖端導管溶入chlorhexidine&silversulfadiazine的抗感染藥劑結果1.>15個單位的細菌集落(C,25條，E,9條)2.細菌集落情形(C,20%條，E,8條)3.血流感染(C,6位，E,3位)LevelIb

antisepticcatheter

結果4.局部發炎(C,4條，E,0條)5.細菌集落情形(C,20%條，E,8條)6.抗感染安全尖端導管比控制組減少5倍的感染率(C,4.9%，E,0.9%)Catheter-sitecare（Olivier,1996）Prospective,randomizedtrialoftwoantisepticsolutionsforpreventionofcentralvenousorarterialcathetercolonizationandinfectioninICUpatients（SICU）Design:Prospectiverandomizedclinicaltrial,E:0.25%chlorthexidinegluconate,0.25%benzalkoniumchlorideand4%benzylalcohol;C:10%povidoneiodine（betadine）LevelIbCatheter-sitecare

Outcome:therateofsignificantcathetercolonizationandcatheter-relatedsepsisweresignificantlowerintheEgroup;therateofarterialcathetercolonizationwassignificantlowerintheEgroup,therateofarterialcatheter-relatedsepsiswassimilarfortwogroupConclusion:The0.25%chlorthexidinesolutionwassuperiortothe10%povidonesolutioninpreventioncathetercolonizationandcatheter-relatedsepsisduetoGram-postivebacteriaSurveillanceforCRBSIs（Coopersmith,2004）Theimpactofbedsidebehavioroncatheter-relatedbacteremiaintheICU（SICU）Design:beforeandaftereducationtrial;auditresult,abehavioralinterventionwasdesignedtoimprovecompliancewithevidence-basedguidelinesofCVCmanagementLevelIbSurveillanceforCRBSIsResults:audit18m（1）documentingthedressingdate（11%to21%;p<.001）,stopcockuse（70%to24%;p<.001）,handhygience（17%to30%;p>.99）maximalsterilebarrierprecautions（50%to80%;p=.29）（2）CRBSIsrate3.4to