急護組 林富美、蘇芳玉 黃錦鳳、徐玉玫、張青蕙、何雲仙 降低加護病房中心靜脈導管相關血流感染率 急護組 林富美、蘇芳玉 黃錦鳳、徐玉玫、張青蕙、何雲仙

報告大綱 前言 EBN問題與步驟 文獻探討 文獻與本院情形之比較 討論 EBN過程評值 未來計劃方向

前言 本院內外科加護病房共46床，其中內科15床主要收治內科重症病人，外科加護病房27床主要收治手術後重症病人及少數內科病人，急診加護病房7床收治內科為主外科為輔之重症病人。

加護病房病人嚴重病況危急，抵抗力差且侵入性醫療措施裝置多，如呼吸治療管路、動靜脈導管、導尿管等等，這些裝置常是病源菌入侵人體的途徑。 九十三年血流感染在內外科加護病房一直輪流佔第一、二位。

九月份本院感染管制中心曾就加護病房做院內感染流行調查，經卡方檢定結果發現院內感染個案增加情形，並無統計學上意義 但結果發現血流感染人次之增加具統計上意義，而9位血流感染個案中，有8位有置入中心靜脈導管。

93年本院加護病房「中心靜脈導管使用率」平均為51.68 ﹪，比起台灣醫療品質指標計劃（THIS）醫學中心數值相當（57.27 ﹪）

喔? 「中心靜脈導管相關血流感染率」約為醫學中心與區域醫院的平均值的2倍 問題在那兒？ 我們能做些什麼來降低呢？ 這不是專案改善嗎？我們是要EBN呢！

STEP 1 Asking an answerable clinical question Practice reflection Decision making

有什麼好問題 第一次共識問題 中心靜脈導管護理使用甲消毒溶液會比 乙消毒溶液抗菌效果好嗎？ --查CDC的建議如何? 中心靜脈導管護理使用甲消毒溶液會比 乙消毒溶液抗菌效果好嗎？ --查CDC的建議如何? --導管相關感染的因素很多 --很想與專案改善一魚兩吃呢！ 不如也先調查各家醫學中心現況

CDC在有關消毒劑使用之建議 Disinfect clean skin with appropriate antiseptic before insertion and at time of dressing change --2% chlorhexidine is preferred. Do not apply organic solvents (acetone or ether) to skin before the insertion and at dressing change. Clean injection ports with 70% Alcohol or Iodophor before accessing. Allow antiseptics to remain on insertion site and air dry- povidoneiodine should be allowed to air dry for 2 minutes or longer.

各醫院中心靜脈導管護理 使用之消毒劑 忠孝 台大 國泰 馬偕 榮總 新光 長庚 三總 醫院名稱 置入時皮膚消毒溶液 中心靜脈導管 各醫院中心靜脈導管護理 使用之消毒劑 醫院名稱 置入時皮膚消毒溶液 中心靜脈導管 傷口護理溶液 忠孝 優碘酒精、75%酒精 75%酒精、優碘 台大 優碘酒精 、75%酒精 生理食鹽水、優碘 國泰 馬偕 優碘酒精、 75%酒精 榮總 75%酒精、優碘酒精 新光 長庚 三總 優碘

CDC強調的合適的消毒劑，有建議較為合適的-2% Chlorhexidine。但同時強調使用消毒劑的注意事項。 本院使用的消毒劑與大多數醫院雷同。 預防導管相關血流感染之防護，除了消毒劑外應有更多照護因子可介入。 ---主題可再想想---

此次EBN主要目的 利用EBN過程瞭解CDC預防血流導管相關感染防護措施的實證證據，是否能使中心靜脈導管相關血流感染率降低，以作為加護病房改善專案之參考。 Decision making- 修訂留置中心靜脈導管病人照護標準規範

EBN 問題： PICO CDC預防導管相關血流感染防護介入是否較 現行一般照護能降低加護病房中心靜脈導管相關血流感染率 改善專案— Intervention Outcome Problem or Patient Comparison 改善專案— 降低加護病房中心靜脈導管相關血流感染率 Central venous catheter related BSI

防護感染主要原則CDC guideline Educating & training: insert & maintain catheters care Using maximal sterile barrier precaution Using chlorhexidine for skin antisepsis Avoiding routine replacement of CVC as a strategy to prevent infection Using antiseptic/antibiotic impregnated short-term CVC Monitoring performance indicator AJIC,Vol.30(8).December 2002.476-489

STEP 2 Search evidences Search strategy 關鍵字: Infection control;ICU; CDC Central venous catheters; blood stream infection;catheter-related bloodstream infection 血流感染率；中心靜脈導管

檢索結果 中文：4 篇 HINT(MEDLINE)：73 篇 ProQuest：13 篇 PubMed：24 篇 Cochrane：2 篇

資料太多怎麼篩選？ 先找Nursing standard及研讀CDC Guideline摘要 再分別往 hand hygiene ,antiseptics, insertion,maintain care, education---等焦點搜尋

STEP 3 Critical appraisal the evidences

名詞解釋 中心導管（Central line）：為短期輸液或監測血液動力狀況而插入中央循環系統的暫時性血管內裝置或導管。 中心導管使用日數（Central line day）：在計算裝置使用日時，一個使用中心導管的加護病房病人算一個使用日。 裝置相關的感染(Device-associated infection)：是指一位加護病房的病患在感染發生前的48 小時內有使用一種醫療裝置。而此感染不是在病患住進加護病房時已存有或有潛伏感染。

中心導管相關之血流感染率 必須符合全國院內感染監視手冊(NNIS)對 實驗室證實的血流感染之標準 標準1：一套或多套血液培養分離出致病菌且此致病菌與其它部位之感染無關。 標準2：發燒(>38℃)、發冷或低血壓 (hypotension)等至少一項的臨床徵象 標準3：一歲以下之嬰兒發燒(>38℃)、體溫過低(<37℃)、呼吸中止或心跳徐緩等至少一項臨床徵象且臨床徵象或症狀與陽性的實驗結果與其他部位的感染無關

Quality of Evidence I a-Meta-analysis of Randomized controlled trials I b-One randomized controlled trial II a-One well designed controlled study without randomization II b-One well designed quasi-experimental study III--Well designed non-experimental studies (comparative,correlation,other descriptive) IV- Expert committee reports,export opinions,care study

文獻探討-Epidemiology Primary bloodstream infections are a frequent cause of morbidity and mortality in intensive care units worldwide. （CDC,2003） NNIS （1997）reports CVC-BSI rate of 5.20/00 in American, ICU rates of CVC-associated BSI range 2.9 to 11.3

文獻探討-CRBSI造成的影響 CRBSI increases in ICU Length of stay, total hospital cost, ICU cost CRBSI increases risk of ICU mortality Other predictors of ICU death were APACH III score（p<.001）, age（p=.04）, GI surgery （p=.003）, alcohol abuse （p=.04）（Dimick,2001） Level I b

CVC 感染危險因素分析 輸液介面的污染 穿刺部位的選擇 頸內靜脈留置 不恰當的無菌屏障 穿刺技術不佳 2002美國CDC的導管相關感染的預防規範

Skin antisepsis Title: Chlorhexidine Compared with Povidone-Iodine Solution for Vascular Catheter-Site Care – A meta-analysis Purpose: Evaluate the efficacy of skin disinfection with Chlor.Gluco. compared with P-I solution in preventing catheter-related BSI. Data sources: Multiple computerized database (1966-2001),reference lists of identified articles. Study selection: RCT compared ,catheter-site. : MEDLINE, CINAHL,EBMASE, Cochrane Library , International Pharmaceutical Abstracts--- Level I a

續 出處:Ann Intern Med,V.136(11),2002 Data Extraction: a standardized form , two reviewers abstracted data on study design , patient population, intervention, incidence of CR-BSI from all included studies. Data Synthesis: 1.8 studies involving a total 4143 catheters met the criteria. 2.various catheter types were used Conclusion: Chlorhexidine gluconate reduced the risk for CR-BSI by 49% (95%CI,0.28-0.88)

Education (Lobo et al., 2005) Impact of an education program and policy changes on decreasing catheter-associated bloodstream infections in a MICU in Brazil Design: prospectively surveyed Intervention: highlight correct practices 1.CVC insertion, manipulation, and care/ monthly classes 2.Poster,discussion with staff Level III

Education and training Result: Primary bloodstream infections 20 0/00 (phase 1, pre-intervention),11 0/00 (phase 2, post-intervention ) 120/00 (phase 3,follow-year) The adhesion to the overall CVC care policy improved significantly (p<.01)

Education （Berenholtz, 2004） Eliminating catheter-related bloodstream infections in the ICU（16 beds SICU） Design: a prospective cohort study with concurrent control Intervention:a quality improvement team, （1）education （2）creating a insertion cart （3）asking providers daily whether catheters could removed（4）a checklist to evidence-based guidelines for preventing CR-BSIs （5）empowering nurses to stop the catheter insertion procedure if a violation of the guidelines Level II a

Education and training Intervention: E: Surgical ICU（16床）, C: CVS ICU（15床） Results: （1）before, 62% followed infection control, after 100% （2）during, from 11.300/0 , first quarter 1998 to 0 00/0 , fourth quarter 2002; control ICU（15 beds CVS ICU）was from 5.7 to 1.6

Education (Rosenthal et al, 2003) Effect of an infection control program using education and performance feedback on rate of intravascular device-associated bloodstream infections in ICUs Argentina Design: To ascertain the effect of an infection control program using education and performance feedback on ICU Intervention: education and training for CDC and prevention Level II b

Education and training Results Phase I:baseline surveillance, 1219人數 ; Phase II:education, 586人數 Phase III: performance, 4140人數 conclusion education and performance feedback result in a significant trend reduced of IVD-associated BSI

Hand hygiene（Aiello et al.,2001） Assessment of tow hand hygiene regimens for intensive care unit personnel Purpose/Design: Prospective randomized clinical trial four consecutive weeks To compare skin condition and skin microbiology among ICU personnel using one of two randomly assigned hand hygiene regimens: a 2% chlorhexidine gluconate : 61% ethanol with emollients(ALC) Level I b

Hand hygiene Result: 50 staff members (two ICU) 1.Participants in the ALC group had significant improvements in the Hand Skin Assessment scores at wk 4(p=0.04) and in Visual Skin Scaling scores  at wk 3 (p=0.01) and 4 (p=0.0005) 2. Then were no  significant differences in numbers of colony from units between participants in the CGH or ALC group at any time period.(193 hand cultures)

Maximal sterile barrier Title:Prevention of central venous catheter-related infections by using maximal sterile Barrier precautions during insertion. Objective:To investigated whether the use of maximal sterile barrier(mask,cap,sterile gloves,gown,and large drape) would lower the risk of acquiring catheter –related infections. Source:Infect Control Hosp Epidemiol (1996,Apr.15) Level I b

Maximal sterile barrier續 Design:RCT,Group I- nontunneled center catheter inserted under maximal sterile barrier . Gr.Ii—control precautions(sterile gloves & small drape) At catheter remove or postinsertion 3ms. were taken catheter culture & blood culture.

Maximal sterile barrier續 Result: 1. group1-176pts.; group II-167pts 2. group1- 4 catheter inf. ; group II-12 catheter inf.P=0.03,chi-square test 3.group II catheter-related septicemia rate was 6.3 times higher Group I (P=0.06,Fisher’s exact test) 4.67%of group II –catheter inf.- 2ms after insertion.25% of group I- catheter inf.- the same period. (p<0.01,Fisher’s exact test) Conclusion:Maximal sterile barrier reduce the risk of catheter infection & cost-effective.

Maximal sterile barrier 無菌屏障 穿刺地點 細菌定值 菌血症 手套 口罩 小鋪巾 手術室 23% 4% 大鋪巾 無菌手術衣 外科加護病房 11% 1% M.D Anderson Cancer Center, 1994 , USA

antiseptic catheter （Hanley et al., 2000） Evaluation of an antiseptic triple-lumen catheter in an ICU Design: retrospective review of surveillance records, primary bloodstream infection surveillance data, included risk factors, laboratory and microbiological data, insertion sites and dates Level III

antiseptic catheter 續 Outcome: CRBSIs rate Results: （1）5.400/0, in antiseptic, 11.3 in nonantiseptic triple-lumen catheter groups Conclusion: The use of antiseptic may reduce CRBSIs in ICU and maybe associated with a decrease in length of stay

antiseptic triple lumen catheter (盛等，1999) 抗感染安全尖端導管對降低細菌集落率及感染發生率之成效 方法 1.隨機取樣置入(Arrow，Pennsylvania)， N=20， 235條三腔導管(122條控制組，113條實驗組) 2.抗感染安全尖端導管溶入chlorhexidine & silver sulfadiazine的抗感染藥劑 結果 1.>15個單位的細菌集落(C,25條，E,9條) 2.細菌集落情形(C,20%條，E,8條) 3.血流感染(C,6位，E,3位) Level I b

antiseptic catheter 結果 4.局部發炎(C,4條，E,0條) 5.細菌集落情形(C,20%條，E,8條) 6.抗感染安全尖端導管比控制組減少5倍的 感染率(C,4.9%，E,0.9%)

Catheter-site care （Olivier, 1996） Prospective, randomized trial of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in ICU patients（SICU） Design: Prospective randomized clinical trial, E: 0.25% chlorthexidine gluconate, 0.25% benzalkonium chloride and 4% benzylalcohol; C:10% povidone iodine（betadine） Level I b

Catheter-site care Outcome: the rate of significant catheter colonization and catheter-related sepsis were significant lower in the E group; the rate of arterial catheter colonization was significant lower in the E group, the rate of arterial catheter-related sepsis was similar for two group Conclusion: The 0.25% chlorthexidine solution was superior to the 10% povidone solution in prevention catheter colonization and catheter-related sepsis due to Gram-postive bacteria

Surveillance for CRBSIs （Coopersmith, 2004） The impact of bedside behavior on catheter-related bacteremia in the ICU （SICU） Design: before and after education trial; audit result, a behavioral intervention was designed to improve compliance with evidence-based guidelines of CVC management Level I b

Surveillance for CRBSIs Results:audit 18 m （1）documenting the dressing date（11% to 21%; p<.001）, stopcock use （70% to 24% ;p<.001）, hand hygience（17% to 30% ;p>.99）maximal sterile barrier precautions（50% to 80% ;p=.29） （2）CRBSIs rate 3.4 to 2.8 00/0（during 15 m after intervention）

穿刺部位選擇（Deshpande et al., 2005） The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population. Purpose The objective was to assess the risk of central venous catheters infection with respect to the site of insertion in an intensive care unit population. The subclavian, internal jugular, and femoral sites were studied. Design: Prospective, observational study Level III

穿刺部位選擇 Subjects All patients were triaged into the ICU by on-site critical care medicine fellows. Group 1 was patients with one catheter at one site. Group 2 was patients with catheters at multiple sites. A total of 831 central venous catheters and 4735 catheter days in 657 patients were studied.

穿刺部位選擇 ResultsIn group 1, （1）the incidence of infection was subclavian: 0.881 infections /1000 catheter days , internal jugular: 0/1000, and femoral:298/1000(p=0.2635) （2）The incidence of colonization was subclavian:0.881 colonization/1000 catheter days, internal jugular: 2.00/1000, and femoral:5.96/1000 (p=0.1338)

穿刺部位選擇 Results-2 In group 2, there was also no statistically significant difference in the incidence of infection and colonization among the three insertion sites. .

Insertion site Selection （Jacques, 2001） Complications of femoral and subclavian venous catheterization in critical ill patients: a randomized controlled trial Intervention: randomized controlled trial assigned to femoral site（n=145）or subclavian site （ n=144 ） Level I b

Insertion site Selection Results: 1.Femoral catheterization was associated with a higher incidence rate of overall infectious complications （19.8 vs 4.5%; p<.001; incidence density of 20 vs 3.7 00/0） 2.bloodstream infection 4.4 vs 1.5%; p=.07; incidence density of 4.5 vs 1.2 00/0） 3.thrombotic complication （21.5 vs 1.9%; p<.001; complete thrombosis （6 vs 0%; p=.01）

Insertion site Selection Results: 4.catheter-related mechanical were similar Conclusion: Femoral venous catheterization is associated with a greater risk of infectious and thrombotic complications than subclavian catheterization in ICU patients.

STEP 4 Applying Evidence to Patients 文獻分析 本院現況 Maximal sterile barrier 洞巾60*60公分 Disinfectant 消毒範圍約10*10公分 消毒劑 Antiseptic catheter 7~14天（>14天） Maintain care 72小時

討論 最大無菌屏障是否還有需要加強的地方? 是否要更改消毒劑？ 裝備穿戴:帽子 口罩 手套 無菌衣 洞巾 消毒範圍 從三個成人加護病房開始宣導與執行 評估執行成效後修訂規範再水平展開至全院

討論 教育推行 執行面的監測與分析 結果面 醫師：透過科務會議說明宣導 並藉由臨床技能中心加強技術訓練 護士：透過晨會及病房會議宣導,擬定教育時間與課程 執行面的監測與分析 技術操作過程的正確性 結果面 感染率的改善

STEP 5 Evaluation 問題的適切性？！ 文獻搜尋 符合臨床實用性 符合PICO的結構 急需要加以映證問題 以BSI 及ICU為關鍵字 搜尋範圍太廣泛 無法鎖定問題點 以CDC Guideline 為搜尋主軸 隨即增加文獻完整性及焦點 符合搜尋資料庫的廣度性

STEP 5 Evaluation 文獻評讀 臨床應用性 文獻評選多屬Level 1 & 2 可信度高 可供標準規範修訂之參考 但無法馬上立竿見影 需要持續推行與監控

Risk factor of CRBSI 宿主因素、住院天數、注射部位、皮膚準備、導管插入者經驗、導管材質、放置部位和留置時間、導管照護、使用輸液管路之數目、輸液成分、敷料更換頻率及其他部位感染等 導管發現相關而未拔除導管者將有20%再發生菌血症，但拔除導管者僅有3%再感染（郭, 2002） 宿主因素，高齡、接受手術、疾病嚴重度高、WBC減少、接受類固醇或免疫抑制治療、心血管移植或缺損、嚴重營養不良等潛在性疾病

未來計劃方向 經本次EBN過程中學習到更多研究方法與設計，計劃未來可進一步做為本院 「中心靜脈導管相關血流感染因素分析」之探討

~Process recording~ 成員調動攪亂了一江秋水 線上作業當然優先囉！ ~~~~「停」了~~~~ 忙- 忙- 忙 猛然抬頭已接近報告時 啊 ！強棒出擊得分囉！ ~~~如期與大家分享~~~

謝謝聆聽 敬請指教 !