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医院感染的目标性监测TargetedSurveillanceforNosocomialInfectionsBarbaraM.Soule,RN,MPA,CICChineseSocietyforNosocomialInfectionsJuly4-5,2004Suzhou,China2ICP的工作内容ICPractitioner(ICP)Activities监测Surveillance项目管理ProgramManagement教育Education工作的多样性Miscellaneous暴发调查OutbreakInvestigation咨询Consultation3监测应具有流行病学基础SurveillancehasanEpidemiologicfoundation为了计划和实施干预措施，研究处于某特定感染危险的人群（目标人群）中的问题和事件的分布Studythedistributionofproblemsandeventswithinadefined(targeted)populationatriskfordevelopingspecificinfectionsinordertoplan&implementinterventions.43种主要的监测方法3KeySurveillanceMethods医院范围的传统监测Hospital-wideTraditionalSurveillance所有的感染-全面-花费时间Allinfections–complete-timeconsuming有限的时间用于干预Limitstimeforinterventions定期监测PeriodicSurveillance对选择的感染或人群进行定期监测Selectedinfectionsorpopulationsperiodicallyovertime遗漏有些感染Misssomeinfections目标监测TargetedSurveillance5名称Name优点Advantages缺点Disadvantages目标性监测Targeted/FocusedSurveillancebyObjective将有限的资源集中在高感染危险病区Concentrateslimitedresourcestohighriskareas;重点放在有已知控制措施的感染上FocusesonHAIwithknowncontrolmeasures;能够确定确切的分母Candeterminevaliddenominator;灵活性，能够和其他控制策略结合起来Flexible,canbemixedwithotherstrategies;增加监测的有效性Increasesefficiencyofsurveillance;使ICP能够开展其他工作EnablesICPtoperformotheractivities仅能收集监测目标病人或危险的数据Collectsdataonlyfortargetedpatientsorrisks;漏掉未监测病区或病人的感染集聚或暴发Maymissclustersoroutbreaksinnon-surveyedareasorgroupsAdaptedfromPottingeretal&Gaynesetal.优/缺点Advantages/Disadvantages目标性监测TargetedSurveillance7美国CDC国家医院感染监测系统的目标性监测CDC’sNationalNosocomialInfectionsSurveillance(NNIS)SystemTargets:NNISSystemAURICUHRNSurgicalPatientAntimicrobialUseandResistanceIntensiveCareUnit(Adult/Pediatric)HighRiskNursery(NICU)RiskadjustedSSIsbyProcedures8你所在医院监测系统的目标性监测YourHospitalSurveillanceSystemTargets:YourHospitalVAPICUBSISSIVentilator-AssociatedPneumoniaMedical/SurgicalICUsIntensiveCareUnit(Pediatric)PrimaryBloodStreamInfectionsPrimaryOrthopedicNeurosurgicalorCABGProcedures9哪些感染作为目标性监测Whichinfectiontotarget?•重点为具有高感染危险的病人FocusonpatientsathighriskforHAI•病人的护理病区Patientcareareas–重症监护病房ICU’s,心胸外科cardio-thoracicsurgery,癌症病房cancerward•特殊人群Specificpopulations–新生儿neonates,移植病人transplantpatients,血液透析病人hemodialysispts•操作/设备Procedures/Devices–CT外科CTsurgery,中央静脉插管centralvascularlines,呼吸机ventilators•具有流行病学意义的病原体Organismsofepidemiologicimportance–MRSA,VRSA10针对后果的目标性监测TargetedSurveillanceforOutcomes•原发性血液系统感染PrimaryBloodstreaminfections•呼吸机相关性肺炎Ventilator-associatedpneumonia•手术部位感染Surgicalsiteinfections•MRSA,VREinfections•血液透析病人经血管的感染Vascularaccessinfectionsinhemodialysispatients•医疗机构中的锐器刺伤Sharpsinjuriesinhealthcareproviders11针对过程的目标性监测TargetedSurveillanceforProcesses•医务人员的乙肝免疫率HepatitisBimmunityratesinpersonnel•医务人员对操作规则的依从性-隔离预防Personnelcompliancewithprotocols-isolationprecautions,•灭菌质量监测Sterilizationqualityassurancetesting,•有效地环境清洁Effectiveenvironmentalcleaning•抗微生物药物的使用与管理Antimicrobialprescribingandadministration12怎样实施目标性监测Howtoimplementtargetedsurveillance13第一步StepOne•感染控制护士和医生每天查看微生物学报告ICPandMDreviewMicrobiologyreportsdaily•定期查阅过去的监测数据Reviewpastsurveillancedataperiodically•列出作为目标性监测的潜在感染或人群Developalistofthepotentialinfectionsorpopulationsfortargetedsurveillance14第二步StepTwo感染控制人员基于以下一个或多个标准选择目标性监测的医院感染Infectioncontrolteamselectsnosocomialinfectionstotargetbasedononeormoreofthefollowingcriteria:15选择过程或后果进行目标监测的的标准CriteriaforSelectingProcessesorOutcomesforTargetedSurveillance•感染控制计划的目的ICprogramobjectives•感染并发症的危险频度或水平Frequencyorlevelofriskofinfectiouscomplicationsfor病区area患者人群patientpopulation操作procedure服务service•发病率Morbidity,死亡率Mortality,费用Cost•预防的可能性Possibilityforprevention16第三步StepThreeICP应用一致的和认可的标准，对第二步决定的与感染有关的过程或结局进行数据收集ICPperformschartreviewsontheinfection-relatedprocessesoroutcomesidentifiedinStepTwousingstandardized,consistent,approveddefinitions–一定时期内持续认真的监测Consistentintensityandthoroughnessofsurveillanceovertime–一定时期内同样的定义Samedefinitionsovertime17目标性监测：方法TargetedSurveillance:AMeanstoanEnd•仅收集必要的数据Collectonlynecessarydata•得到有意义的信息Arriveatmeaningfulinformation18这样您可以做到SoYouCan:•制定有意义的干预措施Developmeaningfulinterventions•做减少感染的工作DOsomethingtoreduceinfections•改善患者的医疗护理Improvepatientcare!19目标性监测的成功周期TheCycleforSuccessThroughTargetedSurveillance1.是否有重要的问题Isthereanimportantproblem?是什么，为什么？多专业的控制人员What,why?MultidisciplinaryTeams2.描述并理解问题Describeandunderstandtheproblem?目标性监测TargetedSurveillance3.怎样去改进Howtoaffectchange?多专业的控制人员MultidisciplinaryTeams教育Education反馈Feedback新方案Newprotocols新产品Newproducts4.改进措施是否有效？Dothechangeswork?再评价RemeasureAdaptedfrom:RichardsC,etal.EmergInfectDis200120NLMIgnazSemmelweisTargetedSurveillanceAndInterventionForPuerperalSepsis21针对过程的目标监测TargetedSurveillanceforaProcess抗生素预防手术部位感染的时机选择TimingofAntibioticProphylaxisforSurgicalSiteInfectionNLMArchives221.是重要问题吗？IsThereanImportantProblem?•外科不合理的预防使用抗微生物药物是一种主要的感染危险Inappropriatesurgicalprophylaxisisamajorinfectionrisk–患者暴露于不必要的毒性exposespatienttounnecessarytoxicity–增加耐药性increasesantimicrobialresistance–过量或不适当的抗菌谱使用并不能降低手术伤口感染的发生率excessdosesorinappropriatespectrumantibioticsdonotreducetheincidenceofsurgicalwoundinfection23理想的预防使用方法“Ideal”Prophylaxis•理想的预防性应用Idealantibioticforpr