重症监护病房中央导管相关血流感染的干预研究

目的探讨基于循证医学证据的集束化干预策略对重症监护病房(ICU)中央导管相关血流感染(CLABSI)发病率的影响。方法采用前瞻设计、多中心合作的方法,对全国41所医院54个ICU进行研究,2013年10月1日—2014年9月30日所有入住ICU并留置中央静脉导管(CVC)的患者作为监测对象。2013年10月—2014年3月收集基线资料作为干预前资料;2014年4—9月各参与医院进行干预措施的持续推广,此间收集的资料作为干预后资料,对干预前后资料进行比较。结果干预前后中央静脉导管使用率(44.18%VS44.63%)比较,差异有统计学意义(χ2=5.526,P=0.019)。干预前后CLABSI发病率比较,差异无统计学意义RR及95%CI为0.82(0.59-1.13),P=0.10]。干预前后置管部位构成比较,差异有统计学意义(χ2=76.264,P0.001),干预后股静脉置管(17.25%VS 13.72%)及两个及以上部位置管(2.27%VS 1.44%)的置管比例有所降低。干预后,手卫生的执行率和正确率分别为79.73%、91.47%,均高于干预前的76.14%、74.26%(均P0.001);干预前后皮肤消毒剂构成比较,差异有统计学意义(χ2=3.861,P0.001),其中氯己定乙醇所占比例升高(29.62%VS 50.56%)。除每日评估并记录外,其他防控措施的依从性干预前后比较,差异均有统计学意义(均P0.001);使用无菌大铺巾、置管者着装合格、端口消毒合格率均有不同程度提高。结论插管干预和维护干预两者结合的集束化干预策略得到有效落实,但其对CLABSI的干预效果有待更进一步研究。

Study on intervention in central line associated bloodstream infection in intensive care units

ObjectiveTo evaluate the effect of evidence based bundle intervention strategy on reducing the incidence of central line associated bloodstream infection (CLABSI).MethodsProspective and multicenter study was adopted, patients admitted to 54 intensive care units(ICUs) of 41 hospitals and with central venous catheters(CVCs) between October 1, 2013 and September 30,2014 were monitored . Baseline data between October 2013 and March 2014 were collected as pre intervention data; from April to September 2014, the participated hospitals performed intervention strategy, post intervention data were compared with pre intervention data.ResultsThe usage rate of CVCs before and after intervention was significantly different (44.18% vs 44.63%,χ2=5.526, P=0.019). Incidence of CLABSI before and after intervention was not significantly different(RR ，0.82［ 95%CI, 0.59-1.13］，P=0.10). Constituent ratio of catheter insertion sites between pre and post intervention was significantly different (χ2=76.264, P<0.001), femoral vein catheterization rate as well as proportion of two and above catheter insertion sites after intervention decreased（17.25% VS 13.72%; 2.27% VS 1.44%,respectively）; hand hygiene implementation rate and accuracy rate after intervention were both higher than before intervention (79.73% vs 76.14%, P<0.001; 91.47% vs 74.26%, P<0.001, respectively); constituent ratio of skin disinfectant application before and after intervention was significantly different(χ2=3.861, P<0.001), proportion of chlorhexidine ethanol increased (29.62% VS 50.56%); except daily assessment and record, compliance to other prevention and control measures before and after intervention were all significantly different(all P<0.001); utilization rate of maximal sterile barrier, qualified rate of dressing of operators,and port disinfection were all significantly enhanced.ConclusionBundle intervention in intubation and maintenance are implemented effectively, but intervention effect on CLABSI needs further study.