1、医院感染的目标性监测 Targeted Surveillance for Nosocomial Infections,Barbara M. Soule, RN, MPA, CIC Chinese Society for Nosocomial Infections July 4-5, 2004 Suzhou, China,2,ICP 的工作内容 IC Practitioner (ICP) Activities,监测Surveillance,项目管理Program Management,教育Education,工作的多样性Miscellaneous,暴发调查Outbreak Investigati
2、on,咨询Consultation,3,监测应具有流行病学基础 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.,4,3种主要的监
3、测方法 3 Key Surveillance Methods,医院范围的传统监测 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 populationsperiodically over time遗漏有些感染 Miss some infections目标监
4、测 Targeted Surveillance,5,Adapted from Pottinger et al & Gaynes et al.,优/缺点Advantages/Disadvantages,目标性监测 Targeted Surveillance,7,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 System,AUR,ICU,HRN,Surgical Patient,Antimicrobial Use and Resistance,In
5、tensive Care Unit (Adult/Pediatric),High Risk Nursery (NICU),Risk adjusted SSIs by Procedures,8,你所在医院监测系统的目标性监测 Your Hospital Surveillance System Targets:,Your Hospital,VAP,ICU,BSI,SSI,Ventilator- Associated Pneumonia Medical /SurgicalICUs,Intensive Care Unit (Pediatric),Primary Blood Stream Infecti
6、ons,Primary Orthopedic Neurosurgical or CABG Procedures,9,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 patients 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
7、hemodialysis pts 操作/设备Procedures / Devices CT 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 of epidemiologic importance MRSA, VRSA,10,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
8、位感染 Surgical site infectionsMRSA, 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 injuries in healthcare providers,11,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 complian
9、ce with protocols - isolation precautions, 灭菌质量监测 Sterilization quality assurance testing, 有效地环境清洁 Effective environmental cleaning 抗微生物药物的使用与管理 Antimicrobial prescribing and administration,12,怎样实施目标性监测 How to implement targeted surveillance,13,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 Micr
10、obiology 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 populations for targeted surveillance,14,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 on
11、e or more of the following criteria:,15,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 objectives 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 Morbidit
12、y, 死亡率 Mortality, 费用 Cost 预防的可能性 Possibility for prevention,16,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 infection-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
13、 and thoroughness of surveillance over time 一定时期内同样的定义Same definitions over time,17,目标性监测：方法 Targeted Surveillance: A Means to an End,仅收集必要的数据Collect only necessary data 得到有意义的信息Arrive at meaningful information,18,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
14、 reduce infections 改善患者的医疗护理Improve patient care!,19,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
15、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 products,4. 改进措施是否有效？Do the changes work?再评价 Remeasure,Adapted from: Richards C, et al. Emerg Infect Dis 2001,20,NLM,Ignaz SemmelweisTargeted Surveillance And Intervention For Puerperal Sepsis,21,针对过程的目标监测 Targeted Su
16、rveillance 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 Infection,NLM Archives,22,1.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
17、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 infection,23,理想的预防使用方法 “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 t
18、o 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 cost,24,Targeted Process Surveillance Timing of Perioperative Antimicrobial Prophylaxis,Classen DC, et al. The timing of
19、prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281,Incision,Hours before incision,Hours after incision,Antibiotic Administered,25,围手术期抗微生物药物预防应用的时机 Timing of Perioperative Antimicrobial Prophylaxis,Classen DC, et al. The timing of prophylac
20、tic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281,26,2. 针对该问题进行目标性监测 Perform Targeted Surveillance for This Problem,1) 手术切口前一小时 接受预防性抗生素的患者比例 Proportion of patients who receive prophylactic antibioticswithin 1 hour before surgical incision术前1小时使用抗生
21、素的人数，# antibiotics 1 hour使用抗生素的所有病人数，# surgeries with antibiotics,27,针对问题进行目标监测 Perform Targeted Surveillance for This Problem,2) 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 discontinued within 24 hours of the surgery end time# discontinue w/I 24 hours# surgeries receiving anti
22、biotics,28,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 hysterectomy 血管手术Vascular surgery (e.g., peripheral vascular surgery),29,3. 改进 To Affect Change,多学科小
23、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 nursing and operating room staff and anesthesiologists and surgeons 在病历上记录给药时间，Reco
24、rd time on patient chart,30,4.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.,31,针对感染结果的目标性监测 Targeted Surveillance for an Infection Outcome,32,Targeted Surveillance for
25、 Outcomes,医院感染率NI Rate:VAP CR-BSIUTIFoley relatedNon-Foley related,采取干预措施的目的Drives Intervention For:Pneumonia prevention CR-BSI preventionFoley-care, d/c program Peri-care / hydration,33,1.是重要问题吗？ Is There an Important Problem?,呼吸机相关性肺炎对患者是一个主要感染危险Ventilator - associated pneumonia is a major infecti
26、on 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 cost,34,Example: 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 infections# 1000 ventilator days,35,通过目标监测和干预减少呼吸机相关性肺炎Reduction of
27、 VAP with Targeted Surveillance and Interventions,Kwan KL, Baker SP, Fontecabio SA. Impact of a program of intensive surveillance and interventions targeting ventilated patientsin the reduction of ventilator-associated pneumonia, and its cost effectiveness ICHE 2003;24;11:859-63.,36,Reduction of VAP
28、 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 feedings 24 - 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.,37,1. Is There an Important Problem?,导管相关血流感染是一
29、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 costs,38,Example: Challenge for Targeted Surveillance,39,2.针对问题进行目标监测 Perform Targeted Surveillance for This Problem,对外
30、科ICU患者进行血液感染的监测 Monitor blood stream infections in Surgical ICU patients.,40,3. 改进Affect Change 血液系统感染目标性监测的成功干预措施 Successful interventions from targeted surveillance for BSI,成功的教育计划以减少导管相关血液系统感染 Successful education program to reduce catheter associated blood stream infections置管时应用无菌手术巾和全套个人防护设备Dra
31、pes and full PPE during insertion对插管部位进行监测和护理Monitoring and care for site,41,4. 改进是否有效 Do the changes work?,新的改良操作实施后3个月内再检查 Re-measure in 3 months after initiation of new improved procedure 监测血流感染率 Measure bloodstream infection rates.,42,Example: Challenge for Targeted Surveillance,43,Improve Outcomes!,With targeted surveillance,目标性监测改善结局,
