医学英国的感染预防专题.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,英国的感染预防,Rise of S.aureus bacteraemia,金黄色葡萄球菌血症病例的增加,England 1991-2003,英格兰,1991-2003,年,Slide adapted from Susan Hopkins,HPA/PHE,MRSA,MSSA,2,2000,2000,年,Media pressure forces formal mandatory surveillance for MRSA bacteraemia,来自媒体的压力使得,MRSA,菌血症的强制性监测得以正式实施,not unreasonable mortality is 30%,强制性监测不无道理,MRSA,血流感染死亡率为,30%,Assumptions,设定,Significant,Easy to detect,Preventable,这是具有重要意义，容易监测且可以预防的。,All cases reportable,regardless of provenance,无论病发地点在哪里，所有个案需要上报,Media frenzy,when numbers go up(and they did),当病死率上升时，媒体会发飙，而他们确实是这么做。,3,5,Quarterly MRSA Bacteraemia,England:2001-06,耐甲氧金黄色葡萄球菌血症病例的季度数据,英,格兰：,2001-2006,年,6,2004 Politicians Enough is enough!,2004,年,英国政客表示：“受够了！”,Health Minister sets ambitious target:50%reduction by 2008,英国卫生部长立下了远大的目标：到,2008,年感染率,降低,50%,。,Set from a baseline in 2003-4 that really meant that a reduction of 60%was required,这个目标是基于,2003-04,年的一个基,准数据，该数据意味着,60%,的感染率,降幅是势在必行了。,Many(myself included)thought this impossible,许多人认为这是无法实现的（包括我个人在内）,Lack of evidence,认为这缺乏证据支持,Widespread skepticism,广为流传的怀疑论,My hat tasted a lot nicer thanit looked,我的乌纱？,7,7,Actions,行动,Saving Lives bundles introduced,拯救生命,特别进行了解读,Government Improvement Team visits,拜访政府的“改进小组”,Who told organisations nothing that their own teams had not already been telling them,他们的改进小组并没有？,Other measures,其他方法,Financial penalties,罚款,Just to keep the Director of Finance committed,只需要让财务总监遵守执行,Regulation and inspection followed later,法规和审查会在后续发生,8,Quarterly MRSA Bacteraemia,England:2001-14,耐甲氧金黄色葡萄球菌血症病例的季度数据,英格兰：,2001-2014,年,Surveillance,9,ZERO MRSA organisations,没有一例,MRSA,感染的案例,12 months with no MRSA BSI,12,个月没有出现,MRSA,血流感染,10,What does this mean,这意味着什么？,England has gone from 434 HAI cases/month(Jan 2006)to 15 in November 2014;a 96.7%reduction,英格兰,2006,年一月份的院内感染数是,434,例，到,2014,年,11,月份仅发生了,15,例，降低了,96.7%,。,Annual totals still fall by 8.4%per month,一年下来感染率总共降低了每月,8.4%,Root cause analysis still demonstrates opportunities for improvement,根本原因分析出来仍然表示“还有降低感染率的机会”。,This was all about practice,这都是跟实践相关的,Doing the right thing,for every patient on every occasion,为每个病人在每个时候做正确的事,Zero tolerance,not to the infections,but to the bahaviors that increase risk,对增加感染风险的行为零容忍，而不是对感染本身,。,11,Annual C.difficile Notifications,艰难梭状芽孢杆菌感染的年度通数据报,England 2004-2007,英格兰,2004-2007,年,12,CDI,艰难梭状芽孢杆菌感染,Mandatory surveillance began in 2003,从,2003,年开始实施强制性监测,And went up for 3 years(surprise),感染率三年内出现了增加（这一点确实很意外）,Surveillance is information for ACTION,监测是行动部分的重要参考信息。,Target in 2007 and new guidance in 2008,2007,年定下的目标和,2008,年颁布的新政策指南,Stated that the increase was partly due to problems in awareness and implementation of the 1994 guidelines,在,1994,年的指南中阐述了感染率的增加其中一部分原因是“意识和执行的问题”,If we do not learn from our history we are condemned to repeat it,假如我们没有从历史中学习经验，我们很可能会重滔覆辙。,13,Actions,采取的措施,Central measures,中心方法,Target and financial penalties,制定目标及罚款规定,Department of Health Improvement Team visits,拜访卫生部“改进小组”,Root cause analysis,根本原因分析,With engagement from clinicians,与临床医生达成共识,Cleaning,清洁,High tech Hydrogen peroxide vapour(if time permits),高科技,使用过氧化氢蒸汽（如果时间允许的话）,High tech but more usable Sporicidal cleaning agent,高技术且更便于使用,杀芽孢消毒剂,Antimicrobial stewardship,抗菌药物管理,14,15,Quarterly,C.difficile,艰难梭状芽孢杆菌感染的季度数据,England 2y:2004-2014,英格兰：,2004-2014,年,Surveillance,16,Surveillance with no Target,没有目标的监测,WHAIP Report Jan 2010 WHAIP,于,2010,年的报告数据,17,Why the rise and fall?,数据上升和下降的原因是什么？,Rise,上升,No focus(MRSA the main agenda),没有针对性（,MRSA,是主要议程）,Virulent,highly transmissible strains,高致病性的有毒菌株,Lack of recognition of the role of the environment,对环境的影响因素缺乏认知,Failure to isolate,隔离失败,Failure to follow guidelines from 1994!,没有遵循,1994,年颁布的政策指南。,Fall,下降,Targets,目标,New focus,新的焦点,Antibiotic stewardship(including Specialist Pharmacists),抗菌药物管理（包括药剂师专家）,Environmental control,环境控制,18,So.Its all much better,那么,现在都变得好多了,MRSA,Clostridium difficile down,MRSA,C,.diff,感染率下降,Death rates fell at 30%each year for the past three years,过去三年内的死亡率每年降低到,30%,Not reported in the media anymore,媒体没有再报道相关的新闻,So what next?,那么下一步该做什么呢,?,These of course are not the only infections!,这些当然不是唯一的感染！,19,IPC Programme,感染预防控制的管理流程,We need to find a way of better ways of engaging with those who will deliver the programme,I had the worst job title in the world;I controlled nothing,我有着全世界最差的职位；我什么都不能控制,What motivates people?,有什么激励的方法,?,What are their desires.or fears.,他们的追求或恐惧是什么,?,20,Motivators,激励方法,Towards,Away from,Antibiotic prescribing,抗生素处方,ARHAI(Government Advisory Committee)Start Smart and Focus programme(2011),耐药性及院内感染（政府咨询委员会颁布）“,Start Smart and Focus,”管理流程颁布于,2011,年,Importance of good standards of prescribing and review of treatment,制定一个合适的标准和对治疗进行回顾的重要性,22,Antibiotic prescribing,抗生素处方,Hospital standard for stop/review dates and indications was 80%,医院在过去对抗生物素处方停用或继续使用的,审查范围标准是,80%,。,Wards were audited,科室需要接受审查,Multiple clinical teams per ward with outlying patients,每个科室有许多临床小组和其他科室的病人,No ownership from clinicians,临床医生没有抗生素处方的所有权,Ward Managers felt the pressure,科室主任感受到压力,We never achieved this standard,我们从来没有达到过这个标准,23,Audit of prescribing,审查的规定,Stop/review dates by hospital ward,由科室确定评审的结束或复审日期,Target 80%,Actual 77%,24,Antibiotic prescribing,审查的规定,We did two things,我们会做两件事,We increased the standard from 80%to 90%,标准从,80%,提高到,90%,Possibly a lower standard did not demonstrate a true desire for high quality prescribing,较低的标准很可能没有展现出一个高质量审查的真,实需求,We changed method to audit by clinician teams not wards,我们改变了审查方式，由临床医生审查而不是科室。,25,Antibiotic Prescribing,审查的规定,Getting Personal-Stop/Review Dates 2012-14,26,27,Samuel Butler(1612-80),He that complies against his will is of his own opinion still,28,Southport ITU,绍斯波特医院重症治疗室,2009-IC Team feel that Central Catheter-related Bloodstream Infections are too high,2009,年,感控小组发现中心静脉导管相关性血流,感染率太高了,Clinicians do not,临床医生不会,But have no idea what their rate is,但是他们不知道感染率是多少,Data collected,收集数据,Rate of infection 10.97/1000 device days,每,1000,个仪器设备使用日的感染率为,10.97,State of Michigan was 1.4,而在美国密歇根州仅为,1.4,Ah.I asked them to write why this was down on a post-it note,然而,我有让他们在便利贴写上为什么感染率这么低,29,Receiving Bad News:Five stages of griefKbler-Ross,接收到坏消息,:,悲痛五部曲,Bundle Approach,31,1,2,3,4,5,Total,Step 1,X,X,60%,Step 2,100%,Step 3,X,80%,Step 4,X,80%,Step 5,100%,Step 6,X,80%,Overall,80%,60%,80%,100%,80%,31,Only one in five had optimal care,CR and CA-BSI in ITU 2009-14,2009-2014,年导管有关血流感染和导管相关性血流感染在重症治疗室的数据,Rate/1000 device days,1000,个仪器设备使用日的数据,How can we make progress?,我们如何能够再往前一步？,We have to convince our clinical colleagues that infections can be prevented,我们需要让临床科室的同事明白感染是可以预防的,I was called an Infection Control Specialist but I controlled nothing,我过去被称为感控领域 的专家，但并未能控制什么,Providing high quality data helps clinicians review the effectiveness of their work,提供有力的数据帮临床医生回顾他们工作的有效性。,Then we can advise our colleagues of the best evidence and help them change practice,然后我们可以把最好的研究证据给临床医生作参考，然后帮助他们改变实际操作习惯。,Behaviour change is our biggest challenge,改变习惯是我们最大的挑战,33,33,