Pronovost Peter
Quality and Safety Research Group, Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.
Am J Infect Control. 2008 Dec;36(10):S171.e1-5. doi: 10.1016/j.ajic.2008.10.008.
A quality improvement initiative that included rigorous measurement, feasible interventions, and cultural change was shown to nearly eliminate catheter-related bloodstream infections (CR-BSIs) in patients in a surgical intensive care unit (ICU). To build on this research, a statewide collaborative cohort study was conducted using the same evidence-based interventions.
Interventions included handwashing, using full barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters. Both technical and adaptive (cultural) aspects of implementing the intervention were addressed through engagement, education, execution, and rigorous evaluation. A "team checkup tool" was developed to help senior leaders assess their role in ensuring compliance.
Of 108 ICUs in the study, 103 reported data. Analysis included data from 1981 ICU-months and 375,757 catheter-days. The regression model showed a significant decrease in CR-BSI rates from baseline, with incidence-rate ratios decreasing from 0.62 at zero to 3 months after implementing the intervention to 0.34 at 16 to 18 months. Preliminary analysis suggested CR-BSI rates were sustained 4 years after implementation of the intervention.
Results suggest that this program model can be generalized and be implemented on a large scale in the United States or the world to significantly reduce the rate of CR-BSIs and their associated morbidities, mortalities, and costs of care.
一项质量改进计划，包括严格的测量、可行的干预措施和文化变革，已证明几乎可以消除外科重症监护病房（ICU）患者的导管相关血流感染（CR-BSI）。为了在此研究基础上进一步开展工作，进行了一项全州范围的协作队列研究，采用相同的循证干预措施。
干预措施包括洗手、在插入中心静脉导管时采取全面屏障预防措施、用洗必泰清洁皮肤、尽可能避免使用股静脉部位以及拔除不必要的导管。通过参与、教育、执行和严格评估来解决实施干预措施的技术和适应性（文化）方面的问题。开发了一种“团队检查工具”，以帮助高层领导评估他们在确保合规方面的作用。
在该研究的108个ICU中，有103个报告了数据。分析包括来自1981个ICU月和375757个导管日的数据。回归模型显示，CR-BSI率从基线显著下降，实施干预措施后0至3个月的发病率比从0.62降至16至18个月时的0.34。初步分析表明，干预措施实施4年后CR-BSI率持续保持下降。
结果表明，该项目模式可以推广，并在美国或全球大规模实施，以显著降低CR-BSI率及其相关的发病率、死亡率和护理成本。
