Reducing Ventilator Associated Pneumonia in the NICU through oral care education: A quality improvement project

BackgroundInadequate oral care in the Neonatal Intensive Care Unit (NICU) can lead to Ventilator Associated Pneumonia (VAP). VAP rate was reported at 2.52 per 1000 ventilator days for the 12 months prior to intervention. A root cause analysis of VAPs during this period revealed only 70% compliance with oral care. VAP contributes to higher costs for the hospital, patient pain and suffering, morbidity and mortality, length of time on mechanical ventilation and increased hospital length of stay. This Quality Project aims to reduce VAP in the NICU through multidisciplinary re-education on the importance of oral care, and fostering an interdisciplinary oral care team of Respiratory Therapists and Registered Nurses.MethodAn IRB approved interventional pre and post intervention review of VAP rate was conducted on intubated neonatal patients from June 1, 2015–May 31, 2017. Intervention consisted of education perform as an interdisciplinary oral care team. Education was coordinated between Respiratory (RT) and Nursing (RN) educators, Lactation, and unit leaders to ensure standardized education to all staff. An oral care poster was created and presented to both RT and NICU RN staff at department meetings. An oral care PowerPoint was created and sent to all NICU RN's and was required as annual mandatory education for all RT's. Encouragement was provided through random chart audits from June 2016–May 2017, praising staff that coordinated care, and reminding staff who did not through friendly face to face interaction and email of the importance of routine, coordinated oral care.ResultsNICU VAP rates dropped during June, and came back up in July 2016 and dropped again in March 2017. Chart review revealed insufficient oral care (72% and 78%) in the two days prior to VAP events. Oral Care poster and education were re-introduced in August 2016 and April 2017. NICU VAP rates post intervention, June 2016–May 2017, was reported as 0.78 per 1000 ventilator days.ConclusionsIdentifying the primary factor through VAP root cause analysis made us aware of a VAP bundle component that was not being routinely followed. Having identified oral care as a problem in our unit enabled us to form an educational intervention with a standardized oral care technique that was effective in increasing the frequency and efficacy of oral care. Utilizing a multidisciplinary team for oral care fosters a sense of importance and responsibility to the staff and improved collaboration in care.     

妊娠合并肺炎23例临床分析

目的:探讨妊娠合并肺炎的临床特征。方法:回顾性分析2005年1月1日—2013年12月30日我院收治的符合肺炎诊断标准,资料较完整的妊娠合并肺炎病例23例,按照孕周分为早期妊娠、中期妊娠、晚期妊娠3组,对各项临床特征进行统计学分析。结果:此期间妊娠合并呼吸系统疾病发生率3.652%(2 384/65 283),肺炎占妊娠合并呼吸系统疾病的0.965%(23/2 384),其中社区获得性肺炎占78.3%(18/23),医院获得性肺炎占21.7%(5/23)。23例患者中,早期妊娠合并肺炎2例(占8.7%),中期妊娠合并肺炎10例(占43.5%),晚期妊娠合并肺炎11例(47.8%),提示随着孕周的增加,罹患肺炎的人数增加。临床出现咳嗽82.6%(19/23),发热65.2%(15/23),呼吸急促60.9%(14/23),咳痰43.5%(10/23),气促在晚期妊娠合并肺炎患者中发生率较高,各组比较差异有统计学意义(P0.05);咳嗽、咳痰、畏寒、发热等症状在不同妊娠期发生率差异无统计学意义(均P0.05);不同孕周血常规、血生化指标差异无统计学意义(P0.05)。23例中合并贫血者占43.5%(10/23),说明贫血可能是孕妇罹患肺炎的高危因素之一。23例患者自然流产和早产的发生率均为8.7%(2/23),足月产82.6%(19/23),无新生儿死亡。结论:妊娠合并肺炎对母胎影响较大,伴发流产和早产发生率均较高。以社区获得性肺炎为主,妊娠晚期的肺炎病例数较妊娠早期、中期多,而临床表现与非妊娠妇女相似,但气促在妊娠晚期发生率较高。贫血是妊娠合并肺炎的高危因素之一。     

红细胞分布宽度对老年社区获得性肺炎危险分层及预后的评估价值

目的 探讨红细胞分布宽度（RDW）对老年社区获得性肺炎（CAP）病情危重程度的关系及对预后的评估价值。方法 采用回顾性研究的方法.选取2014年1月至2015年5月，上海市浦东新区周浦医院ICU收治的符合社区获得性肺炎（CAP）诊断的老年患者88例，收集患者一般资料，检测血降钙素原（PCT）、C反应蛋白（CRP）、血常规、N氨基末端脑钠肽（NT-proBNP）、D-二聚体检查，行急性生理学与慢性健康状况评分系统Ⅱ（APACHE II）及肺炎严重度评分(PSI)。根据28天预后分为存活组(52例)与死亡组（36例）。分析RDW与PSI评分的关系。采用Logistic回归分析确定老年CAP预后的独立危象因素。绘制受试者工作（ROC）曲线评估RDW与生物标志物组合对老年CAP的预后的预测价值。结果 1.死亡组的RDW、D-二聚体、APACHE II评分及PSI评分明显高于存活组（P＜0.01或P＜0.05）；2.RDW随着PSI评分升高而升高，两者呈正相关关系（r=0.49 P＜0.01）；3..RDW、D-二聚体、APACHE II评分及PSI评分均是老年CAP患者28天死亡的独立预测因素；4. RDW、D-二聚体的曲线下面积（AUC）分别为0.81、0.76，截断值分别为12.98%，0.43mg/L。RDW联合D-二聚体的AUC为0.86。结论 RDW对老年CAP患者有一定的危险分层级预后评估价值。联合检测RDW及D-二聚体能提高老年CAP预后的评估价值。     

The presence of pneumococcal bacteremia does not influence clinical outcomes in patients with community-acquired pneumonia: results from the Community-Acquired Pneumonia Organization (CAPO) International Cohort study

BACKGROUND: It remains unknown whether pneumococcal bacteremia increases the risk of poor outcomes in hospitalized patients with community-acquired pneumonia (CAP). The objective of this study was to investigate whether the presence of pneumococcal bacteremia influences the clinical outcomes of hospitalized patients with CAP. METHODS: We performed secondary analyses of the Community-Acquired Pneumonia Organization database of hospitalized patients with CAP and pneumococcal bacteremia, and patients with CAP and negative blood culture findings. To identify the effect of pneumococcal bacteremia on patient outcomes, we modeled all-cause mortality and CAP-related mortality using logistic regression analysis, and time to clinical stability and length of hospital stay using Cox proportional hazards models. RESULTS: We studied 125 subjects with pneumococcal bacteremic CAP and 1,847 subjects with nonbacteremic CAP. The multivariable regression analysis revealed a lack of association of pneumococcal bacteremic CAP and time to clinical stability (hazard ratio, 0.87; 95% confidence interval [CI], 0.7 to 1.1; p = 0.25), length of hospital stay (hazard ratio, 1.14; 95% CI, 0.91 to 1.43; p = 0.25), all-cause mortality (odds ratio [OR], 0.68; 95% CI, 0.36 to 1.3; p = 0.25), and CAP-related mortality (OR, 0.86; 95% CI, 0.35 to 2.06; p = 0.73). CONCLUSIONS: Pneumococcal bacteremia does not increase the risk of poor outcomes in patients with CAP. Factors related to severity of disease are confounders of the association between pneumococcal bacteremia and poor outcomes. This study indicates that the presence of pneumococcal bacteremia by itself should not be a contraindication for deescalation of therapy in clinically stable hospitalized patients with CAP.     

老年人社区获得性肺炎临床分析

社区获得性肺炎(community-acquired pneumonia,CAP)是威胁人类生命健康的主要疾病之一[1]。有报道显示其发病率为0.2%~1.2%[2],特别是老年人发病率更高。本文回顾2004年1月至2005年11月因CAP住院的患者临床资料,分析老年人CAP的基础疾病、临床特点、病原菌分布情况。1资料和方     

Resolution of symptoms in patients with community-acquired pneumonia treated on an ambulatory basis

OBJECTIVE: To describe the resolution of five symptoms commonly associated with community-acquired pneumonia (CAP). METHODS: Three hundred and ninety-nine patients with CAP (Fine Classes I to III) recorded the severity (from 0 to 5) of fatigue, cough, dyspnoea, sputum, and pleuritic chest pain daily from enrollment to day 14 and also on days 30 and 42. A total symptom score was obtained by multiplying an individual score by four and summing the score of the five symptom (transformed score). A total symptom score of 20 on day 14, the patients with a score > 20 (n = 122; 33%) had higher symptom scores at all time points out to 42 days. The median time to return to work was 6 days. CONCLUSION: The pneumonia symptom severity score is a useful tool for advising patients regarding the time to symptomatic resolution of pneumonia.     

呼吸机相关性肺炎临床资料和危险因素的回顾分析

目的 通过回顾性分析呼吸机相关性肺炎（VAP）患者的临床资料和危险因素,提高对VAP的认识。方法 收集1996年1月－1999年10月入住我院呼吸重症监护室行机械通气患者的临床资料,按诊断标准分发生VAP组和未发生VAP组,对两组患者的临床特点、相关危险因素、病原菌分布和预后等进行比较分析。结果 共收集病例58例次,发生VAP组28例次（28／58,48.3%),未发生VAP组30例次。发生VAP组机械通气时间明显长于未发生VAP组（机械通气≥20d者,发生VAP组占32.1%,未发生VAP组占6.7%）,深静脉穿刺留置导管的比例也高于未发生VAP组。发生VAP组中有25例次病原菌培养阳性,主要致病菌为不动杆菌属、真菌和铜绿假单胞菌。发生VAP组死亡9例,未发生VAP组死亡2例（P＜0.05)。结论 VAP的发生可以显著提高病死率,应予重视。     

重症肺炎并发横纹肌溶解症与急性肾衰竭的诊断治疗并文献复习

目的探讨肺炎并发横纹肌溶解症、急性肾衰竭的诊断和治疗,改善患者预后。方法分析两例重症肺炎患者的临床表现和诊治过程,并检索2004-2013年共10年的文献进行复习。结果两例重症肺炎患者均为男性,分别为40、62岁,血清肌酸激酶(CK)升高分别达10 109、8 406U/L,伴肌红蛋白尿、血肌酐升高分别达242、721μmol/L;病例1因严重低氧血症给予机械通气治疗,病例2因严重肾衰竭接受血液透析,治疗后二者呼吸和肾功能均完全恢复;文献检索到肺炎并发横纹肌溶解症、急性肾衰竭病例20例,年龄24~85岁,男性16例占80.0%;病原体主要为军团菌7株、甲型流感病毒5株和葡萄球菌属5株(耐甲氧西林菌株4株);8例接受机械通气治疗,11例接受血液净化治疗,6例患者同时接受机械通气和血液净化治疗,其中死亡3例、存活17例,其中16例肾功能完全恢复。结论肺炎并发横纹肌溶解症、急性肾衰竭临床少见,病情严重需同时接受机械通气和血液净化治疗者死亡风险高,而存活患者的肾功能几乎均能恢复正常。     

阿奇霉素与清开灵序贯疗法治疗小儿肺炎对比研究

目的：对比阿奇霉素与清开灵序贯疗法治疗小儿肺炎的临床效果。方法将98例肺炎患儿按照治疗方法不同分为两组,各49例。对照组给予清开灵序贯疗法治疗,观察组给予阿奇霉素序贯疗法治疗,比较两组临床效果及不良反应情况。结果观察组患儿退热时间、咳嗽消退时间、肺部啰音消退时间、气促消退时间及住院时间均短于对照组（ P ＜0．01）;观察组总有效率高于对照组（ P ＜0．05）;两组患儿不良反应发生率比较,差异无统计学意义（ P ＞0．05）。结论阿奇霉素序贯疗法能有效治疗小儿肺炎,缓解和消除患儿临床症状,缩短住院时间,不良反应发生率低,值得在临床推广应用。