Reducing ventilator-associated pneumonia in intensive care: Impact of implementing a care bundle
Reducing ventilator-associated pneumonia in intensive care: Impact of implementing a care bundle
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DOI：
10.1097/ccm.0b013e3182227d52
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发表时间：
2011-10-01
影响因子：
8.8
通讯作者：
Walsh, Timothy S.
中科院分区：
文献类型：
--
作者：
Morris, Andrew Conway;Hay, Alasdair W.;Walsh, Timothy S.
目的：呼吸机相关性肺炎是最常见的重症监护病房获得性感染。尽管人们普遍认为循证干预措施可以降低呼吸机相关性肺炎的风险，但围绕将其作为“一揽子”护理实施的重要性仍存在争议。本研究的目的是确定实施这种捆绑的效果，同时控制类似研究中出现的潜在混杂变量。设计：在现有的独立感染监测项目的背景下进行的前后研究。设置：一个18张床位的混合内外科教学医院重症监护室。患者：所有患者在干预前后接受重症监护48小时或更长时间。一个四要素的呼吸机相关性肺炎预防包，包括床头抬高，口服氯己定凝胶，镇静保持，和断奶协议实施的一部分，苏格兰患者安全计划使用研究所的卫生保健改善methods.Measurements和主要结果：遵守床头抬高和洗必泰凝胶为95%-100%，记录遵守“唤醒和断奶”元素为70%，使整体捆绑的依从率为70%。与干预前相比，干预后呼吸机相关肺炎显着减少（每1，000个呼吸机日32例降至每1，000个呼吸机日12例; p < .001）。统计过程控制图显示，在捆绑实施后，减少最为明显。住院时间>= 6天和>= 14天的患者队列在呼吸机相关性肺炎获得方面有更大的减少，并且抗生素使用也减少了（分别减少了1天和3天; p = 0.008/0.007）。耐甲氧西林金黄色葡萄球菌的感染率也降低了（10%至3.6%; p <0.001）。结论：实施呼吸机相关性肺炎预防捆绑包与呼吸机相关性肺炎的统计学显著减少相关，这在我们单位早期的特设呼吸机相关性肺炎预防指南中没有实现。尽管无法满足所有元素95%的捆绑合规目标，但仍出现了这种情况。我们的数据支持系统性方法，以实现高比率的过程中遵守，并建议系统引入可以降低感染的发生率和抗生素的使用，特别是对于需要较长时间的通气的患者。(Crit Care Med 2011; 39：2218-2224）
Objectives: Ventilator-associated pneumonia is the most common intensive care unit-acquired infection. Although there is widespread consensus that evidenced-based interventions reduce the risk of ventilator-associated pneumonia, controversy has surrounded the importance of implementing them as a "bundle" of care. This study aimed to determine the effects of implementing such a bundle while controlling for potential confounding variables seen in similar studies.Design: A before-and-after study conducted within the context of an existing, independent, infection surveillance program.Setting: An 18-bed, mixed medical-surgical teaching hospital intensive care unit.Patients: All patients admitted to intensive care for 48 hrs or more during the periods before and after intervention.Interventions: A four-element ventilator-associated pneumonia prevention bundle, consisting of head-of-bed elevation, oral chlorhexidine gel, sedation holds, and a weaning protocol implemented as part of the Scottish Patient Safety Program using Institute of Health Care Improvement methods.Measurements and Main Results: Compliance with head-of-bed elevation and chlorhexidine gel were 95%-100%; documented compliance with "wake and wean" elements was 70%, giving overall bundle compliance rates of 70%. Compared to the preintervention period, there was a significant reduction in ventilator-associated pneumonia in the postintervention period (32 cases per 1,000 ventilator days to 12 cases per 1,000 ventilator days; p < .001). Statistical process control charts showed the decrease was most marked after bundle implementation. Patient cohorts staying >= 6 and >= 14 days had greater reduction in ventilator-associated pneumonia acquisition and also had reduced antibiotic use (reduced by 1 and 3 days; p = .008/.007, respectively). Rates of methicillin-resistant Staphylococcus aureus acquisition also decreased (10% to 3.6%; p < .001).Conclusions: Implementation of a ventilator-associated pneumonia prevention bundle was associated with a statistically significant reduction in ventilator-associated pneumonia, which had not been achieved with earlier ad hoc ventilator-associated pneumonia prevention guidelines in our unit. This occurred despite an inability to meet bundle compliance targets of 95% for all elements. Our data support the systematic approach to achieving high rates of process compliance and suggest systematic introduction can decrease both infection incidence and antibiotic use, especially for patients requiring longer duration of ventilation. (Crit Care Med 2011; 39:2218-2224)