英文版医院感染控制.pptx

Targeted Surveillance for Nosocomial InfectionsBarbara M.Soule,RN,MPA,CICChinese Society for Nosocomial InfectionsJuly 4-5,2004 Suzhou,China2IC Practitioner(ICP)ActivitiesSurveillanceProgramManagementEducationMiscellaneousOutbreakInvestigationConsultation3Surveillance has an Epidemiologic foundationStudy the distribution of problems and events within a defined (targeted)population at risk for developing specific infections in order to plan&implement interventions.43 Key Surveillance Methods Hospital-wide Traditional SurveillanceAll infections complete-time consumingLimits time for interventions Periodic SurveillanceSelected infections or populations periodically over timeMiss some infections Targeted Surveillance5Advantages/DisadvantagesAdapted from Pottinger et al&Gaynes et al.Targeted Surveillance7CDCs National Nosocomial Infections Surveillance(NNIS)System Targets:NNIS SystemAURICUHRNSurgicalPatientAntimicrobialUse and ResistanceIntensive CareUnit(Adult/Pediatric)High Risk Nursery(NICU)Risk adjustedSSIs byProcedures8Your Hospital Surveillance System Targets:Your HospitalVAPICUBSISSIVentilator-Associated PneumoniaMedical/Surgical ICUsIntensive CareUnit(Pediatric)Primary BloodStream InfectionsPrimary OrthopedicNeurosurgical or CABGProcedures9Which infection to target?Focus on patients at high risk for HAIPatient care areasICUs,cardio-thoracic surgery,cancer wardSpecific populationsneonates,transplant patients,hemodialysis ptsProcedures/DevicesCT surgery,central vascular lines,ventilatorsOrganisms of epidemiologic importance MRSA,VRSA10Targeted Surveillance forOutcomesPrimary Bloodstream infectionsVentilator-associated pneumonia,Surgical site infectionsMRSA,VRE infectionsVascular access infections in hemodialysis patientsSharps injuries in healthcare providers.11Targeted Surveillance for ProcessesHepatitis B immunity rates in personnelPersonnel compliance with protocols-isolation precautions,Sterilization quality assurance testing,Effective environmental cleaningAntimicrobial prescribing and administration12How to implement targeted surveillance13Step OneICP and MD review Microbiology reports dailyReview past surveillance data periodicallyDevelop a list of the potential infections or populations for targeted surveillance 14Step TwoInfection control team selects nosocomial infections to target based on one or more of the following criteria:15Criteria for Selecting Processes or Outcomes for Targeted SurveillanceIC program objectivesFrequency or level of risk of infectious complications for areapatient population procedure service Morbidity,Mortality,CostPossibility for prevention16Step ThreeICP performs chart reviews on the infection-related processes or outcomes identified in Step Two using standardized,consistent,approved definitions.Consistent intensity and thoroughness of surveillance over timeSame definitions over time 17Targeted Surveillance:A Means to an EndCollect only necessary data Arrive at meaningful information18So You Can:Develop meaningful interventionsDO something to reduce infectionsImprove patient care!19The Cycle for Success Through Targeted Surveillance1.Is there an important problem?What,why?Multidisciplinary Teams 2.Describe and understand the problem?Targeted Surveillance 3.How to affect change?Multidisciplinary TeamsEducationFeedbackNew protocolsNew products4.Do the changes work?Remeasure Adapted from:Richards C,et al.Emerg Infect Dis 200120NLMIgnaz Semmelweis Targeted Surveillance And InterventionFor Puerperal Sepsis21Targeted Surveillance for a ProcessTiming of Antibiotic Prophylaxis for Surgical Site InfectionNLM Archives221.Is There an Important Problem?Inappropriate surgical prophylaxis is a major infection risk exposes patient to unnecessary toxicityincreases antimicrobial resistanceexcess doses or inappropriate spectrum antibiotics do not reduce the incidence of surgical wound infection23“Ideal”ProphylaxisIdeal antibiotic for prophylaxisactive against pathogens most likely to contaminate woundadequate concentrations during potential contaminationadministered for a short time to reduce complications,resistance,and cost24Targeted 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 afterincisionAntibioticAdministered25Timing ofPerioperative Antimicrobial ProphylaxisClassen DC,et al.The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection.N Engl J Med 1992;326:281262.Perform Targeted Surveillance for This Problem1)Proportion of patients who receive prophylactic antibiotics within 1 hour before surgical incision#antibiotics 1 hour#surgeries with antibiotics27Perform Targeted Surveillance for This Problem2)Proportion of patients whose antibiotics were discontinued within 24 hours of the surgery end time#discontinue w/I 24 hours#surgeries receiving antibiotics28Possible Surgical Procedures to Determine Timing of Antibiotic ProphylaxisCABGColon surgeryHip and knee arthroplastyAbdominal and vaginal hysterectomyVascular surgery(e.g.,peripheral vascular surgery)293.To Affect ChangeMultidisciplinary Team to look at antibiotic delivery system:current and desiredRedesign system for timely AB deliveryMake antibiotic accessibleEducate nursing and operating room staff and anesthesiologists and surgeonsRecord time on patient chart304.Do the changes work?Re-measure 2 variables in 3 months after initiation of new improved procedureMeasure surgical site infection rates.31Targeted Surveillance for an InfectionOutcome32Targeted Surveillance for OutcomesNI Rate:VAPCR-BSIUTIFoley relatedNon-Foley related Drives Intervention For:Pneumonia preventionCR-BSI preventionFoley-care,d/c programPeri-care/hydration 331.Is There an Important Problem?Ventilator-associated pneumonia is a major infection risk for patientsincreased mortalityexcess length of stayexcess cost34Example:Challenge for Targeted SurveillanceReduce ventilator associated pneumonias(targeted adverse event)by 50%#VAP infections#1000 ventilator days35Reduction 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 cost effectivenessICHE 2003;24;11:859-63.36Reduction of VAP with Targeted Surveillance and InterventionsInverventions:Raise head of bedSterile water for tube feedingsIn-line suction catheters from 24-48-72-as neededCost savings$350,000 in one year.371.Is There an Important Problem?Catheter-related bloodstream infections are a serious infection riskdevice-relatedmorbidity and mortalityextra length of stayadditional medical costs380510152025JanAprilJulyOctJanAprilJulyOctJan989900SICU BSI Jan 98-MarchSICU BSI Jan 98-March 00Rate per 1,000 line daysRate per 1,000 line daysExample:Challenge for Targeted Surveillance392.Perform Targeted Surveillance for This Problem Monitor blood streaminfections in Surgical ICUpatients.403.Affect ChangeSuccessful interventions from targeted surveillance for BSI 1.Successful education program to reduce catheter associated blood stream infections2.Drapes and full PPE during insertion3.Monitoring and care for site 414.Do the changes work?Re-measure in 3 months after initiation of new improved procedureMeasure bloodstream infection rates.420510152025JanAprilJulyOctJanAprilJulyOctJan989900SICU BSI Jan 98-MarchSICU BSI Jan 98-March 00BSIBSIInterventionInterventionsRate per 1,000 line daysRate per 1,000 line daysExample:Challenge for Targeted Surveillance43With targeted surveillance