广东省三级医院综合ICU现状和重症监护网的建设

目的 探讨广东省三级医院综合重症监护病房(ICU)建设现状,并为省卫生厅建立省重症监护网.方法 在危重病医学学术会议期间,采用问卷调查形式采集数据.结果 (1)ICU床位数为(13.30±7.39)张,医生人数、护士人数与床位数比分别是(0.67±0.27)和(1.90±0.50),封闭式、半封闭式和开放式管理模式分别占53.5%、41.9%和2.3%.(2)每床用房面积是(16.75±6.58)m2,感应式洗手盆数与床位数比为(0.50±0.28),正或负压病房、空气层流系统和营养准备室的配备率分别是44.2%、60.5%和51.2%.(3)人工气道建立与管理、机械通气技术、深静脉置管术、电复律与除颤术及肠外营养支持的开展率均达100%,独立完成气管插管和持续血液净化的开展率均达97.7%,74.4%的ICU开展血流动力学监测,95.3%的ICU开展镇静技术.(4)床旁多功能持续心电监护仪装备率是100%、其与床位数比为(0.96±0.15),复苏呼吸气囊或呼吸机与床位数之比分别是(0.80±0.38)和(0.83±0.31),便携式呼吸机装备率是61%,27.9%的ICU未开展无创机械通气,纤维支气管镜装备率为90.7%,95.3%的ICU能提供24 h血气分析.(5)所调查43家综合ICU分布于珠江三角洲地区,和粤东、粤北及粤两地区.结论 广东省三级医院综合ICU中大多数项目已达到或接近达到广东省重症监护病房建设指导意见和中国重症加强治疗病房建设与管理指南的要求.ICU平均水平已基本达到Ⅱ级,重症监护网能有效整合现有资源而提升本地区危重病救治水平.     

综合重症监护病房和重症监护网建设探讨

综合ICU床位数以6～12张病床为宜。医生人数与ICU床位数比例及护士人数与ICU床位数之比至少应该分别接近1:1和2．5:1。管理模式可选封闭式或半封闭式。至少应配备一间单间病房。床旁临时心脏起搏术、持续血液净化、肠外营养支持、疾病危重程度评分、镇静及其评分,所有ICU均应该开展。呼吸机,三级医院应每床1台,二级医院也应尽量接近此要求,且最好是具备呼吸功能监测的呼吸机,同时应配备一定数量的无创呼吸机和便携式呼吸机。纤维支气管镜至少配备1套。持续肾脏替代治疗仪应力求配置。滴注泵和微量注射泵应分别达到每床1台和2台,肠内营养注射泵最好能每床1台。重症监护网应具备有效的纵向与横向联系。     

广东省三级医院ICU现状调查

目的：分析广东省三级医院ICU现状,为提高广东省ICU总体水平提供依据。方法：采用表格问卷调查形式收集分析广东省47间三级医院ICU（院内最大或最主要的一个ICU）的资料。结果：①ICU规模及性质,ICU平均床位数为（15±8）张,ICU床位数占医院总床位数的2%;74%为综合ICU,26%为专科ICU;床位平均使用率为87%。②设备配置,床旁多功能持续心电监护仪平均数与ICU平均床位数比值为1.08∶1,呼吸机平均数与ICU平均床位数比值为0.83∶1,微量泵平均数与ICU平均床位数比值为1.98∶1,输液泵平均数与ICU平均床位数比值为1.01∶1。配备中央监护站、血液净化仪、纤维支气管镜、主动脉内球囊反搏仪、及床边X光机的比例分别为45/47、44/47、42/47、14/47、1/47。③人员配置,ICU医生平均人数与ICU床位数比值为0.85∶1;ICU护士平均人数与ICU床位数比值为2.8∶1。④技术开展情况,所有ICU均能独立开展机械通气技术和深静脉置管术;96%的ICU开展了纤维支气管镜检查,11%开展了持续血液净化,91%开展了有创血压监测,47%开展了漂浮导管技术。⑤实行急性生理学和慢性健康状况评分（APACHE）的ICU占9%（4/47）。结论：广东省ICU规模及性质、设备、人员配置和技术开展情况基本符合中国重症加强治疗病房建设与管理指南要求。但综合ICU比例有待进一步提高,床位数需进一步增加,ICU的一些重要技术尚有待普及,APACHE评分的应用有待推广。     

江苏省ICU现况调查分析

目的调查分析江苏省有关加强医疗病房(ICU)资源及学科建设问题,并提出建议。方法2005年3月至2005年9月,通过问卷方式调查江苏省二、三级医院ICU基本情况。结果61家医院共有各类ICU 180个,其中综合性ICU 56个,专科ICU 124个;专科ICU平均拥有数为三级医院(3．47±1．63)个,二级医院(0．65±0．80)个。采用封闭式管理模式的占60．66%。三级医院综合性ICU床位占医院总床位的1．15%±0．31%,二级医院为1．94%±0．76%。ICU医生数与床位之比三级医院为(0．74±0．28)：1;二级医院为(0．66±0．25)：1。护士数与床位数之比三级医院(1．65±0．56)：1;二级医院(1．56±0．50)：1。颅内压监测、脑电双频指数监测、主动脉球囊反搏开展率较低。面临的主要问题是工作压力大、待遇低、收治范围不明确、患者来源受限等。结论江苏省ICU发展迅速,已初具规模,但在技术项目上仍有较大发展空间。建议重视综合ICU建设,制定ICU建设管理规范及质控标准,加强人才培养,确定准入制度,进一步发挥ICU在危重病医学中的作用。     

山东省重症监护病房现状调查

目的 了解山东省重症监护病房(ICU)现状及存在的问题.方法 采用问卷调查方式,对全省二级以上医院ICU进行调查.结果 共调查了139家医院、196个ICU.①三级医院ICU中开放式管理占2.3%,半开放式管理占34.5%,封闭式管理占63.2%;二级医院ICU中开放式管理占13.7%,半开放式管理占41.3%,封闭式管理占45.0%.②床位使用率≥80%的ICU比例较高,约为49%～69%.③医师、护士与床位比例合理并达标的ICU仅占少部分,其中专职医师:床位≥1的约为13%～26%;护士:床位≥2.5的约为5%～20%.④二、三级医院的各个ICU均能良好开展基本生命支持技术,但具备调查表中16项技术的ICU则较少.结论 山东省ICU发展迅速,已初具规模,但仍有一定的欠缺,在技术项目上有较大发展空间,专业技术人员尚需进一步的规范化培训.建议重视重症医学科(综合ICU)建设,加强ICU建设管理规范及质量控制标准的落实,加强人才培养,确定准入制度,进一步发挥ICU在重症医学中的作用.     

全国30个省市三级医院重症监护病房医护人员呼吸治疗工作现状的问卷调查

目的 调查我国三级医院重症监护病房(ICU)呼吸治疗的仪器装备、工作内容和完成人等,为规范和发展呼吸治疗工作提供依据.方法 在2006年8月国内召开的三次大规模会议上发放问卷,调查30个省264家三级医院320个ICU的491名医护人员.结果 有创、无创呼吸机数与床位数之比分别为0.52: 1(2 189/4 185)和0.16:1(672/4 185).320个ICU中,超声、喷射式以及定量雾化吸入器的配用率分别为55.9%(179/320)、33.8%(108/320)和12.1%(39/320);机械通气中呼吸机设置、撤机、拔管主要由医师完成的ICU占92.1%、93.1%、83.5%,更换管路、吸痰、雾化、湿化主要由护士完成的ICU占83.7%、93.9%、91.6%、90.2%.491名回答者中撤机前行自主呼吸试验者占40.9%,不知道或从来不做者占26.2%;有创通气时未监测气道开口端温度者占27.1%;对撤机未拔管患者应用气管内持续滴入/泵入盐水湿化者占34.4%;55.6%的人员使用前检测呼吸机;管路更换频率依次为每周1次占48.1%,1～3 d和3～5 d更换1次者为25.0%、14.7%.结论 目前国内三级医院ICU的呼吸机数量较前已大幅增加,但对其他实用装置的应用尚不足;呼吸治疗工作主要由医生和护理人员共同承担,尚缺少专业的呼吸治疗师;机械通气、气道管理和呼吸机管理等呼吸治疗工作差异较大,缺乏统一的规范.     

重症监护室病人医院感染现状调查

目的了解重症监护室(ICU)医院感染现状,制定医院感染防控措施。方法采用目标性监测的方法,对某医院重症监护病房ICU患者医院感染情况进行调查。结果 2009年全年12个月内,该医院重症监护病房共入住患者867例,发生医院感染73例、158例次,感染发病率为8.42%,例次感染率为18.22%。平均病情严重程度ASIS评分为3.68分,调整病人日感染率为4.14‰,日医院例次感染率为8.94‰。在发生医院感染的病人中,呼吸机相关性肺炎占25.4‰,留置导尿管相关尿路感染占7.7‰,动静脉插管相关血流感染占7.4‰。结论重症监护病房病人医院感染发病率较高,感染部位以下呼吸道为主,应加强呼吸机相关肺炎的控制措施。     

上海市三级甲等医院重症监护室护士机械通气镇静知识的调查

[目的]了解上海市三级甲等综合性医院重症监护病房(ICU)护士对机械通气镇静知识掌握程度及其影响因素。[方法]按监护室工作年限进行分层抽样,在14所上海市三级甲等综合性医院中抽取ICU护士133名,采用ICU护士机械通气镇静知识掌握程度问卷进行调查。[结果]ICU护士机械通气镇静知识总分为10.74分±1.94分,镇静知识掌握程度与是否接受过镇静知识培训有关。[结论]护士对镇静知识掌握现状不容乐观,应对ICU护士开展机械通气相关知识培训并制定规范的操作流程及护理方案,以保证镇静治疗的良好疗效。     

呼吸内科重症监护病房机械通气患者医院感染的特点与管理

目的 了解呼吸重症监护病房机械通气患者医院感染的特点,探讨预防感染的措施.方法 采集呼吸重症监护病房57例发生医院感染患者的痰液标本进行细菌培养和药敏试验,分析并比较机械通气患者与同期非机械通气患者下呼吸道分泌物病原菌菌株的分布情况及两组患者常用抗生素对G-菌的耐药率.结果 呼吸重症监护病房57例医院感染患者中,24例机械通气患者感染G-菌株128株、G 菌株26株,33例非机械通气患者感染G-菌株35株、G 菌株16株;铜绿假单胞菌、鲍曼不动杆菌及金黄色葡萄球菌为感染的主要菌种;机械通气组常用抗生素物对G-菌耐药率均显著高于非机械通气组(P＜0.05).结论 呼吸重症监护病房中的机械通气患者易发生医院感染,且菌株的耐药率高;护理上应重视病房管理、医务人员管理和相应的消毒隔离措施,尤其加强对机械通气患者的护理,以降低医院感染的发生率.     

综合性重症监护病房医院感染目标性监测

目的了解综合性重症监护病房医院感染现状,分析感染特点,以便加强防控。方法通过目标性监测,对本医院综合重症监护病房住院患者医院感染状况进行了监测。结果本医院重症监护病房2009-2011年3年期间共入住患者1 796例,发生感染患者296例次,例次感染率为16.48%,日感染率9.53‰。在接受侵入性操作患者中,静脉插管相关性血流感染率5.34‰、呼吸机相关性肺部日感染率3.86‰、留置导尿管相关性泌尿道日感染率3.31‰。从感染病人标本中共检出397株病原菌,革兰阴性菌占52.4%。结论本医院综合重症监护病房医院感染发生率较高,主要危险因素为血管内插管、机械通气和泌尿道插管等侵入性操作,必须有针对性地制定有效干预措施。     

Clinical review: impact of emergency department care on intensive care unit costs

Critical care is both expensive and increasing. Emergency department (ED) management of critically ill patients before intensive care unit (ICU) admission is an under-explored area of potential cost saving in the ICU. Although limited, current data suggest that ED care has a significant impact on ICU costs both positive and negative. ICU practices can also affect the ED, with a lack of ICU beds being the primary reason for ED overcrowding and ambulance diversion in the USA. Earlier application in the ED of intensive therapies such as goal-directed therapy and noninvasive ventilation may reduce ICU costs by decreasing length of stay and need for admission. Future critical care policies and health services research should include both the ED and ICU in their analyses.     

Possibilities for cost containment in intensive care

An intensive care unit (ICU) is valuable but consumes a disproportionately high amount of health-care resources. Accordingly, cost containment has been deemed a mandatory task. A review of the literature from many countries was completed to determine the strategies for reducing the cost of care in the ICU. The results of this review show that cost reduction can be achieved by using a variety of the following strategies: (i) instituting a closed ICU, where all the patient care is directed by intensivists or full-time critical care trained physicians; (ii) the utilization of interdisciplinary approaches to the care of patients in the ICU; (iii) developing and implementing a program of television-guided remote intensivists; (iv) the use of an alerting and reminding system; and (v) increasing the number of intermediate care beds for patients who require only monitoring and intensive nursing. The conclusion reached is that many of these strategies provide evidence for hospital manager decisions regarding cost containment strategies for the delivery of health care in the ICU.     

Mechanical ventilation of patients hospitalized in medical wards vs the intensive care unit--an observational, comparative study

BACKGROUND: In some hospitals, patients are mechanically ventilated on the wards in addition to the intensive care unit (ICU) because of the shortage of ICU beds. OBJECTIVE: The aim of the study was to compare the outcome and ventilatory management of medical patients mechanically ventilated on the medical wards and in the ICU. DESIGN: This was a prospective, observational, noninterventional study over a 6-month period. SETTING: The study was conducted in internal medicine wards and the ICU of a 500-bed community university-affiliated hospital. PATIENTS: Ninety-nine mechanically ventilated medical patients in the ICU or on the medical wards because of shortage of ICU beds were included in the study. RESULTS: Baseline characteristics of the patients ventilated in the ICU (group 1) and in the medical wards (group 2) were collected. Thirty-four patients were ventilated in the ICU and 65 in the wards during the study period. In-hospital survival rate in group 1 was 38% vs 20% in group 2 (P < .05). The Acute Physiologic and Chronic Health Evaluation (APACHE) II score in group 1 was 24 +/- 7 vs 27 +/- 7 in group 2 (P < .05). Other prognostic factors were similar. The age of the survivors in the 2 groups was similar: 57 +/- 25 years in group 1 vs 69 +/- 13 years in group 2 (P = NS). Mean number of ventilatory changes in group 1 was 7.5 +/- 1.4 per day per patient, whereas it was 1.3 +/- 1.0 in group 2 (P < .001). The number of arterial blood gas analyses in group 1 was 7.7 +/- 1.2 per day per patient compared with 2.3 +/- 1.3 in group 2 (P < .001). Twenty percent (20%) of the patients in group 1 had endotracheal tube-related inadvertent events compared with 62% of the patients in group 2 (P < .05). CONCLUSIONS: We conclude that in medical patients requiring mechanical ventilation, there is a higher in-hospital survival rate in ICU-ventilated patients as compared with ventilated patients managed on the medical wards. In addition, ICU provides a better monitoring associated with less endotracheal tube-related complications and more active ventilatory management.     

综合重症监护治疗病房患者发生腹泻的相关因素分析

目的 分析综合重症监护治疗病房(ICU)患者发生腹泻的相关因素,以指导临床制订最佳治疗方案。方法对2001年1月-2002年12月入住山东省聊城市人民医院综合ICU的危重患者共735例进行回顾性分析,结合文献,综合评价ICU内腹泻发生的原因。结果 735例中,入住ICU前无腹泻,入住24 h后发生腹泻者为86例,发生率为11.70％。引起腹泻的原因主要为:不适当肠内营养51例次(占59.30％),肠道感染18例次(占20.93％),滥用广谱抗生素15例次(占17.44％),大量使用胃肠动力药物11例次(占12.79％),与饥械通气有关者5例次(占5.81％)。而且综合ICU内发生腹泻患者的年龄[平均(57.71±13.40)岁]、急性生理学与慢性健康状况Ⅱ评分[平均(21.51±4.90)分]及住ICU时间[平均(8.0±1.2)d]均明显高于同期入住综合ICU未发生腹泻患者[分别为(51.20±11.31)岁,(12.01±1.20)分和(4.0±1.0)d,P均<0.05],并且发生腹泻的原因不同于普通病房患者引起腹泻的病因。结论 综合ICU患者发生腹泻有其特点和原因,应予以高度重视。     

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.     

1998-2003年北京地区重症加强治疗病房急性呼吸窘迫综合征的临床流行病学调查

目的调查北京地区重症加强治疗病房(ICU)中急性呼吸窘迫综合征(ARDS)的发病情况、原发病、病死率及其影响因素。方法根据1994年欧美ARDS联席会议提出的ARDS诊断标准,回顾性调查1998年5月—2003年4月北京地区8家三级综合医院ICU中ARDS患者的病因、病死率及影响因素。结果383例ARDS患者占同期ICU收治危重患者的4．5%;脓毒症(21．7%)、肺炎(16．2%)、大手术(13．1%)、重症胰腺炎(12．8%)及多发性创伤(10．7%)是最常见的原发病;ARDS起病距原发病时间为(61．8±43．7)h。ARDS总病死率为52．0%,对病死率分别以年龄(≤39、40～64、≥65岁)、性别(男)进行调整,调整前后的病死率差异均有显著性(P均＜0．05),对急性生理学与慢性健康状况评分系统Ⅱ评分(APACHEⅡ,≤12、13～19、≥20分)进行调整后的病死率5年间差异均无显著性。脓毒性休克(36．2%)与心功能衰竭(20．6%)是主要死亡原因,仅14．6%患者死于呼吸衰竭。结论ARDS是北京地区ICU中常见危重症,死亡率仍较高,且近年来并未下降。     

A data base system for pediatric intensive care

Summary A data base system has been designed at the pediatric intensive care unit of St. Görans Hospital in Stockholm. Information on all cases treated during 1982 was retrieved, including information from another file containing data on inpatient stays in the county of Stockholm. Thus an automatic follow-up study was made and the results of intensive care were expressed as mortality occurring at the intensive care unit (ICU), mortality up to 180 days after discharge, average length of stay in the ICU and average number of bed days as inpatients from discharge from the ICU up to 180 days later. Altogether, 705 ICU days of 626 patients were retrieved. Mortality in the ICU was 8.6% and increased to 12.5% 180 days after discharge from the ICU. The average period of hospitalization after discharge from the ICU was 19 days.Cases diagnosed as IRDS were studied specifically and the mortality was 53% in cases with birth weights less than 1500 g and 13% in cases with birth weights of 1500 g or more. High mortality and long hospitalization after discharge from the ICU was seen in cases with neurological complications. All information was retrieved interactively from a display terminal at the department. This could be done at any hour of the day.     

A profile of European intensive care unit physiotherapists

Objective: To determine the profile and role of the physiotherapist in European intensive care units (ICUs). Design: Postal questionnaire. Setting: 460 ICUs in 17 western European countries.¶Participants: Heads of intensive care physiotherapy. Results: One hundred and two completed questionnaires were analyzed, representing 22 % of the questionnaires sent: 48 % were from university hospitals, 45 % of the hospitals had more than 700 beds, and 50 % had more than 24 ICU beds. 38 % of the hospitals had more than 30 physiotherapists working in the hospital, but 25 % had no exclusive ICU physiotherapist. 34 % had a physiotherapist available during the night, and 85 % during the weekend. In almost 100 % of ICUs the physiotherapist performed respiratory therapy, mobilization, and positioning. The physiotherapist played an active role in the adjustment of mechanical ventilation in 12 % of the respondent's units, in weaning from mechanical ventilation in 22 % of units, in extubation in 25 %, and in the implementation of non-invasive mechanical ventilation (NIV) in 46 %. Among the physiotherapists, there were equivalent numbers of university and non-university graduates. Differences in the role of the physiotherapist were apparent between countries. For example, 80 % of respondents from the United Kingdom stated that physiotherapists were available during the night, while in Germany and Sweden physiotherapists were available at night in none of the respondent's units. Conclusions: Even though the response rate was limited, variations in the role and profile of the ICU physiotherapist are apparent across Europe. The involvement of physiotherapists in more specialized techniques is also a function of the number of physiotherapists working exclusively in an ICU.     

Oral care practices of intensive care nurses: A descriptive study

The aim of this study was to investigate intensive care unit (ICU) nurses’ views and practices on oral care and to define the factors related to oral care measures. A study was carried out in eight ICUs of a teaching hospital in 2008. One hundred one nurses constituted the study sample. The data were collected using ‘Oral Care Practices Survey’ which included demographic characteristics (5 items) and current oral care practices (13 items). Oral care was given the highest priority by nearly 60% of the nurses. The most commonly used solution was sodium bicarbonate (79.2%), and the most frequently used equipment was foam swab (82.2%). Oral care was carried out less than every 4 h per day by 44.5% of the nurses. The oral care products and solutions were reported to be different in almost every unit. The relationship between the use of toothpaste and the place of employment was statistically significant (x² = 24.566, d.f. = 6, P = 0.000). There was a statistical significance between the clinics and frequency of oral care (x² = 81.486, d.f. = 42, P = 0.000). This study suggests that there is a wide variety of type and frequency of oral care measures among ICU nurses. Optimal oral care supported by evidence is an effective prevention method for eliminating oral complications.