集束照护策略对提高NICU医护人员手卫生依从性的作用

目的 探讨集束照护策略对提高新生儿重症监护病房(NICU)医护人员手卫生依从性的作用.方法 通过开展品质罔活动,实施医护人员手卫生的集束照护策略(care bundle),即:(1)加强培训和管理,增强手卫牛意识,强化手卫牛观念;(2)进行环境改造和流程再造,创建手卫生的氛围和方便的洗手设施;(3)加强监督,医护人员共同参与,保证洗手的正确性.对实施集束照护策略前后NICU医护人员入室及接触患儿前手卫生的落实情况进行比较分析. 结果NICU医护人员入室、接触患儿前手卫生实施率分别由集束照护策略实施前的32.1%、92.0%上升至实施后的97.4%、99.3%;新生儿院内感染的发生率由实施前的2.22%下降到实施后的1.38%.结论 集束照护策略能有效提高医护人员手卫生的依从性,预防医院内感染发生.     

Impact of an educational intervention on hand hygiene compliance and infection rate in a developing country neonatal intensive care unit

Nosocomial infections are a significant problem in neonatal intensive care units (NICUs) and hand hygiene (HH) has been stated as an effective mean to prevent spread of infections. The aim of study was to assess the baseline compliance HH practices and to evaluate the impact of hand washing educational programme on infection rate in a NICU. Continuous surveillance of nosocomial infections was done. A total of 15 797 and 12 929 opportunities for HH were observed in pre‐intervention and postintervention phases, respectively. Compliance of health‐care workers for all HH opportunities combined was 46% before intervention and improved significantly to 69% in postintervention (RR 1.49, CI 1.46–1.52, P < 0.0001). Compliance for nurses and doctors was similar. Nosocomial sepsis rate showed a significant decline from 96 per 1000 patient‐days in pre‐intervention to 47 per 1000 patient‐days in postintervention phase (RR 0.44, CI 0.33–0.58, P < 0.0001). We conclude that effective HH practices can serve as an economical and effective nosocomial infection control approach especially important in developing nations.     

Place des solutions hydro-alcooliques en réanimation

In intensive care unit, time related to hand washing is the most important reason associated with low compliance to hand hygiene. Alcohol-based-hand rubbing spares more time, has a better antimicrobial efficacy and exhibits better skin tolerance than hand washing. Nevertheless, alcohol-based-hand rubbing is not appropriate when hands are soiled. Alcohol-based-hand rubbing improves health care workers compliance to hand hygiene, but this effect has to be reinforced by a sustained hand hygiene promotion program. The effect of alcohol-based hand rubbing on nosocomial infections incidence has still to be demonstrated.     

我院危重病学科护理人员集束护理依从性的调查研究

目的了解危重病学科护理人员对呼吸机相关性肺炎集束化治疗的护理依从性,探讨其影响因素和改善措施。方法根据呼吸机相关性肺炎的主要临床预防措施自行设计调查表,对危重病学科的64名在职护理人员进行问卷调查。结果护理人员的集束护理平均依从性为80．85％,在7个护理项目中洗手的依从性最差为72．34％。护理人员自认为依从性低的因素主要是觉得重要但没有时间、觉得不重要、懒得做和疾病限制以及患者因素。结论应改善目前护理人员配置,加强集束护理相关教育培训,增强护理人员的主观护理意识和慎独精神,从而提高集束护理依从性。     

The role of health care workers in nosocomial infection transmission

The role of health care workers in nosocomial infection transmission has been documented and the importance of hand washing in preventing such transmission has been understood. There is a little evidence in the role of other method rather than hand washing in preventing nosocomial infection. It is quite important to keep high level of compliance of the hand washing in preventing nosocomial infection. We should challenge to keep it high with various methods or strategies.     

PICU医务人员手消毒依从性情况调查及对策

[目的]调查儿科监护室医护人员对医院感染及手卫生的认知、洗手的依从性情况,分析影响手部卫生依从性的因素及手卫生和院内感染的关系。[方法]随机抽样调查儿科监护室的40名医护人员。[结果]大多数医护人员已经具备了医院感染的基本知识,在工作中积极进行预防和控制,一些医护人员对医院感染发生及控制工作有错误认识;个别医务人员对手卫生操作的依从率较低,影响手卫生低依从率的因素包括：手卫生设施不够便利、护理优先权（即对患儿的护理需要优先于手卫生）、缺少个人责任感等。[结论]儿科监护室医院感染疾病的发生与流行与儿科监护室医护人员的手部带茵状况密切相关,儿科监护室医护人员应重视手部卫生,提高洗手的依从性。     

The sedation practices of paediatric intensive care unit nurses and the influencing factors in China

Nurses play a key role in administering sedation to mechanically ventilated children, which impacts children's psychological, physiological and cognitive changes in the paediatric intensive care unit. This study aimed to survey the sedation practices of paediatric intensive care unit nurses on mechanically ventilated children in China and explored the influencing factors. A cross‐sectional survey was conducted based on electronic questionnaires comprised of the Nurse Sedation Practices Scale (Chinese version) in 14 different types of paediatric intensive care units of 11 academic hospitals in China from 15 February to 15 April 2017. A convenience sample of 495 nurses [73·4% response rate, (674)] completed the survey. Seven units applied Ramsay Sedation Scale as a sedative assessment tool. The majority of the nurses used observed behaviours and physiological changes of the ventilated children as indicators to assess the sedation level, and they had a positive attitude and intention, which may influence practice positively, whereas high clinical workload and the lack of communication between the nurses and families might hinder practice. The practice of sedation varied greatly in different regions, and the respondents of the northwest region scored lower. Paediatric nurses in China rarely used a validated paediatric instrument to assess sedation, and most nurses relied on physiological and behavioural cues. The quality of sedation training, nursing workload and regional economic disparity affected the sedation practice. The restricted visiting policy and lack of clearly defined nursing responsibilities around sedation may hinder effective sedation assessment and management. This study found that there was no paediatric‐validated tool popularized in paediatric intensive care units in China and explored influencing factors. We suggest that a validated tool, high‐quality training and hospital's policy, such as visiting regulation, should be promoted to improve the sedation practice.     

Reducing nosocomial infection in neonatal intensive care: An intervention study

Nosocomial infection is a common cause of morbidity and mortality for hospitalized neonates. This report describes measures taken to reduce the prevalence of nosocomial infection within a 34‐bed neonatal intensive care unit in Malaysia. Interventions included a one‐to‐one education programme for nursing staff (n = 30); the education of cleaners and health‐care assistants allocated to work in the unit; and the introduction of routine (weekly) screening procedure for all infants with feedback given to staff. The education programme for nurses focused on the application of standard precautions to three common clinical procedures: hand washing, tracheobronchial suctioning and nasogastric tube feeding. These were evaluated using competency checklists. The prevalence of nosocomial blood and respiratory tract infections declined over the 7‐month study period. This study highlights the importance of education in contributing to the control of nosocomial infection in the neonatal intensive care unit.     

The effectiveness of alcohol based hand rubs and compliance with hand hygiene

Pittet et al.'s (2000) study observed that an increase in compliance with hand hygiene, especially alcohol based hand rubs, was related to a decrease in the rate of nosocomial infections. The results of this study can be used in a group utilization project of providing information on efficacy and compliance issues related to hand hygiene. All HCWs, but most importantly nurses, can recommend hand hygiene programs on specific units to ensure client health and reduce unwanted health care cost. Feasibility issues would include teaching correct hand hygiene technique and compliance for new hospital employees and costs of educational materials. Considerations would be the length of program, location, and implementation strategies. Future research might focus on the use of a smaller sample size, where more control can be obtained, and the use of different hand hygiene techniques in the prevention of nosocomial infections.     

Ventilator-associated pneumonia in paediatric intensive care: a literature review

Background: Ventilator‐associated pneumonia (VAP) has been identified as the most common nosocomial infection in intensive care units (ICUs) with associated health and financial costs. To date, more research has been carried out in adult ICUs than in paediatric units, thus prompting a review and investigation of the implications for paediatric practice. Aims: To identify relevant paediatric literature surrounding VAP and use this in association with research carried out in the adult environment to establish the implications of VAP and possible management strategies. Search strategies: A literature search was undertaken using databases within DialogDatastar to identify the extent to which VAP has been researched in both paediatric and adult centres. This information was used to try and gain a clearer concept of the impact and management of VAP in the paediatric setting. Key words and combinations included VAP, intensive care, paediatric, antibiotics, positioning, suction, economics, management, nosocomial and morbidity and mortality. Results of analysis: Despite the documented significance of VAP in terms of its financial and health implications, discrepancies and inconsistencies exist surrounding the identification and treatment of VAP. This is reflected in paediatric centres by a dearth of literature on the subject and the lack of a national standard as to the management and prevention of VAP. Inappropriate management of VAP plays an important role in the development and spread of multiresistant bacteria within hospitals. Conclusions: While inadequate paediatric research exists, extrapolating from adult research suggests that the financial and health costs of VAP are substantial and can be reduced by introducing simple low‐cost measures. Such measures include improving education surrounding VAP and its implications and making small changes in practice to improve and maintain oral hygiene standards. Implications: With a growing cohort of paediatric patients requiring short‐ and long‐term ventilation, progress must be made in identifying the extent and impact of VAP in paediatric ICUs and among the community ventilated patients. This will require changes in practice and attitudes towards VAP for which an appropriate knowledge base would need to be established using audit and research. These issues are particularly relevant in the current environment given the links with multiresistant strains of bacteria within hospitals and the community.     

The effect of single-dose and continuous skeletal muscle paralysis on respiratory system compliance in paediatric intensive care patients

Objective To investigate the effect of single dose and continuous skeletal muscle paralysis on respiratory system compliance in 53 paediatric intensive care patients.Design Prospective clinical study.Setting Multidisciplinary paediatric intensive care unit.Patients Twenty-three children ventilated for acute pulmonary pathology, and 30 ventilated for isolated intracranial pathology, who initially had normal lungs.Interventions The 23 patients with acute pulmonary pathology received a single dose of muscle relaxant to facilitate diagnostic procedures. Fifteen patients with isolated intracranial pathology received continuous skeletal muscle paralysis for longer than 24 h, and the other 15 received no paralysis.Measurements and results Respiratory system complicance deteriorated by 14% from 0.519±0.2 to 0.445±0.18 ml cmH₂O^–1 kg^–1 (p<0.001) following a single dose of muscle relaxant in the 23 patients with acute pulmonary pathology. In the 15 with isolated intracranial pathology who received continuous skeletal muscle paralysis there was a progressive deterioration in compliance, which reached 50% of the initial compliance by day 4 of paralysis (p<0.001) and improved back to normal following discontinuation of paralysis. There were no changes in compliance in the 15 patients with isolated intracranial pathology who were ventilated but not paralysed. The paralysed patients required mechanical ventilation longer than the non-paralysed patients (p<0.001), and 265 of these patients developed nosocomial pneumonia (p=0.03), a complication that was not seen in the non-paralysed patients.Conclusions Skeletal muscle paralysis results in immediate and progressive deterioration of respiratory system compliance and increased incidence of nosocomial pneumonia. The benefits of paralysis should be balanced against the risks of deteriorating pulmonary function.     

The clinical nurse specialists' use of collaborative governance to improve compliance with hand hygiene practices in the medical intensive care unit (MICU)

Despite many efforts on the local and national levels to improve compliance with hand hygiene practices such as hand washing, compliance among healthcare workers remains low. This article will discuss the clinical nurse specialists' use of a collaborative governance structure to provide peer-to-peer education and accountability for hand hygiene compliance in the medical intensive care unit.     

Hydration and Nosocomial Pneumonia: Killing Two Birds with One Stone (a Toothbrush)

Clear and compelling evidence exists in the literature to suggest that nosocomial pneumonia is linked to poor oral care. In nursing homes and intensive care units, practicing good oral care has been demonstrated to reduce the risk of aspiration pneumonia ( Furr, Binkley, McCurren, & Carrico, 2004 ). In an oral care program implemented in a 29‐bed rehabilitation unit, lung status was improved in 77% of patients who were admitted with aspiration pneumonia. Key components of the forces of magnetism (American Nurses Credentialing Center, n.d.) were used to implement the program, including autonomy and interdisciplinary relationships. The rehabilitation unit also applied the theory proposed by Higgins and Howell, which promotes using champions to make important process changes (1990). This article reviews the steps one rehabilitation unit took to implement an oral care plan.     

新生儿监护室患儿家属的压力源干预研究

目的 通过对新生儿监护室患儿家属的压力源进行的分析,给予实施干预。方法 选择2013年6月~2014年6月我科住院的患儿家属300名为研究对象。心理因素用焦虑自评量表（SAS）和抑郁自评量表（SDS）进行分析。针对压力源实施干预,干预前为对照组,干预后为实验组。干预后300例家属再进行前后的心理因素对比。结果通过对患儿家属进行心理压力干预,增加患儿家属对疾病知识的认识,对新生儿监护病房环境和对我们医务人员工作的了解。使抑郁、焦虑等负性情绪均低于干预前,比较差异有统计学意义（P<0.05）。结论了解和识别家属的压力源,减少其压力应激,实施护理干预及情感支持有利于满足家属需求,优化服务,减少医患纠纷,和谐医患关系,提高了患儿家属的满意度。      

手卫生培训对社区医护人员手部带菌含量的效果研究

目的:探讨手卫生培训对减少社区医护人员手部带菌含量的效果.方法:选择沙园社区卫生服务中心作为手卫生培训干预组,昌岗社区卫生服务中心作为对照组,每中心随机抽选医护人员各60名,对干预组的医护人员进行手卫生强化培训,培训前对两组医护人员在接触病人或操作后进行手微生物采样.在培训后分别对对照组和干预组进行手微生物采样进行追踪,比较分析、并提出对策,检查干预组成员手卫生的依从性及效果.结果:经过强化培训后,干预组与对照组相比,每平方厘米手部所含细菌菌落明显减少,医护人员洗手依从性增加,P＜0.05,差异有统计学意义.结论:手卫生培训能使社区医护人员掌握正确手卫生的方法,提高手卫生的依从性,有效降低社区医护人员手部细菌的含量,降低社区医院感染的发生率.     

Study of paediatric intensive care units in Spain

Objective: To describe the organisation of paediatric intensive care units in Spain and the medical assistance provided during 1996.¶Methods: A written questionnaire was sent to all the paediatric ICUs linked to or within the Spanish public health system.¶Results: Thirty-one of the 34 paediatric ICUs replied. All are medico-surgical units. Eighteen treat only paediatric patients, 12 paediatric and neonatal patients, and one paediatric and adult patients. Fifteen units have fewer than seven beds, eight have between 7 and 12 beds, and eight between 13 and 18 beds. Of the paediatric ICUs, 83.8 % are staffed by paediatricians specialised in paediatric intensive care. The mean number of on-call on site periods of duty for each member of the medical staff was 5.1 ± 1.7 per month. Thirty of the 31 units undertake paediatric resident training, 13 train residents specialising in paediatric intensive care and 12 participate in medical student training.¶In 1996 there were 9,585 admissions (309 ± 182 patients per ICU) signifying 35.3 ± 14 patients/bed. Of the patients, 65.9 % were medical and 34.1 % surgical. The mean duration of stay was 5.6 ± 2.1 days. The mortality rate was 5.4 ± 3.2 %. The main causes of death were multiple organ failure and brain death.¶Conclusions: In Spain, paediatric intensive care is principally performed by specialised paediatricians. Although the general results for 1996 are similar to those of other European countries, efficiency studies are necessary to plan and re-organise the paediatric intensive care units in Spain.     

Effects of a Relationship-Enhancing Program of Care on Outcomes

Purpose: To examine the effects of a relationship-enhancing program of care (REPC) on resident and care provider outcomes.
Design and Methods: A quasi-experimental, repeated measures design, with intervention and comparison groups. Questionnaires were distributed to 50 residents, and observations were conducted of 40 residents and 34 nursing staff at baseline and 3 months after the intervention, on two Canadian nursing home units. An investigator-designed educational program based on Winnicott's theory of relationships and the empirical literature, was provided to care providers and their supervisors on the intervention unit. Repeated measures analysis of variance (RM-ANOVA) was used to compare the intervention and comparison groups in regard to changes in the outcomes over time.
Findings: The REPC had statistically significant effects on (a) residents' perceptions of care providers' relational care, (b) care providers' relational behaviors, and (c) continuity of care.
Conclusions: Evidence showed that these care providers were taught how to enhance their relational skills with residents living in long-term care facilities without added staff. Recommendations for practice and research are discussed.     

The impact of an education program on hand hygiene compliance and nosocomial infection incidence in an urban Neonatal Intensive Care Unit: An intervention study with before and after comparison

Background

Nosocomial bloodstream infections are a major cause of morbidity and mortality in neonatal intensive care units. Appropriate hand hygiene is singled out as the most important measure in preventing these infections. However, hand hygiene compliance among healthcare professionals remains low despite the well-known effect on infection reduction.

Objectives

We studied the effectiveness of a hand hygiene education program on the incidence of nosocomial bloodstream infections.

Design

Observational study with two pretests and two posttest measurements and interrupted time series analysis.

Setting

A 27 bed level IIID neonatal intensive care unit in a teaching hospital in the Netherlands.

Participants

Healthcare professionals who had physical contact with very low birth weight (VLBW) infants.

Methods

The study was conducted during a period of 4 years. Medical and nursing staff followed a problem-based education program on hand hygiene. Hand hygiene practices before and after the education program were compared by guided observations. The incidence of nosocomial infections in VLBW infants was compared. In addition, numbers of nosocomial bloodstream infections per day-at-risk in very low birth weight infants were analyzed by a segmented loglinear regression analysis.

Results

During 1201 observations hand hygiene compliance before patient contact increased from 65% to 88% (p < 0.001). Median (interquartile range) drying time increased from 4 s (4-10) to 10 s (7-14) (p < 0.001).The proportion of very low birth weight infants with one or more bloodstream infections and the infection rate per 1000 patient days (relative risk reduction) before and after the education program on hand hygiene intervention decreased from 44.5% to 36.1% (18.9%, p = 0.03) and from 17.3% to 13.5% (22.0%, p = 0.03), respectively.At the baseline the nosocomial bloodstream infections per day-at-risk decreased by +0.07% (95% CI −1.41 to +1.60) per month and decreased with −1.25% (95% CI −4.67 to +2.44) after the intervention (p = 0.51). The level of instant change was −14.8% (p = 0.48).

Conclusions

The results are consistent with relevant improvement of hand hygiene practices among healthcare professionals due to an education program. Improved hand hygiene resulted in a reduction in nosocomial bloodstream infections.     

手卫生干预措施提高新生儿重症监护室手消毒依从性的观察与效果

目的研究提高新生儿重症监护室的手消毒依从性。方法建立手卫生干预措施,并用视频监测手段观察干预前后共13个月的各类接触。结果实施手卫生干预措施后手消毒依从性从25．15％上升为88．20％;培训后护理员的手消毒依从性较医生和护士低,夜间护士和护理员的手消毒依从性低于白班（P〈0．01）。结论手卫生干预措施能有效提高手消毒的依从性。     

Nurses' implementation of guidelines for ventilator-associated pneumonia from the Centers for Disease Control and Prevention.

BACKGROUND: Ventilator-associated pneumonia accounts for 47% of infections in patients in intensive care units. Adherence to the best nursing practices recommended in the 2003 guidelines for the prevention of ventilator-associated pneumonia from the Centers for Disease Control and Prevention should reduce the risk of ventilator-associated pneumonia. OBJECTIVE: To evaluate the extent to which nurses working in intensive care units implement best practices when managing adult patients receiving mechanical ventilation. METHODS: Nurses attending education seminars in the United States completed a 29-item questionnaire about the type and frequency of care provided. RESULTS: Twelve hundred nurses completed the questionnaire. Most (82%) reported compliance with hand-washing guidelines, 75% reported wearing gloves, half reported elevating the head of the bed, a third reported performing subglottic suctioning, and half reported having an oral care protocol in their hospital. Nurses in hospitals with an oral care protocol reported better compliance with hand washing and maintaining head-of-bed elevation, were more likely to regularly provide oral care, and were more familiar with rates of ventilator-associated pneumonia and the organisms involved than were nurses working in hospitals without such protocols. CONCLUSIONS: The guidelines for the prevention of ventilator-associated pneumonia from the Centers for Disease Control and Prevention are not consistently or uniformly implemented. Practices of nurses employed in hospitals with oral care protocols are more often congruent with the guidelines than are practices of nurses employed in hospitals without such protocols. Significant reductions in rates of ventilator-associated pneumonia may be achieved by broader implementation of oral care protocols.