Claridge Jeffrey A, Golob Joseph F, Fadlalla Adam M A, D'Amico Beth M, Peerless Joel R, Yowler Charles J, Malangoni Mark A
Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio 44109-1998, USA.
Surg Infect (Larchmt). 2009 Feb;10(1):59-64. doi: 10.1089/sur.2008.056.
In the era of pay for performance and outcome comparisons among institutions, it is imperative to have reliable and accurate surveillance methodology for monitoring infectious complications. The current monitoring standard often involves a combination of prospective and retrospective analysis by trained infection control (IC) teams. We have developed a medical informatics application, the Surgical Intensive Care-Infection Registry (SIC-IR), to assist with infection surveillance. The objectives of this study were to: (1) Evaluate for differences in data gathered between the current IC practices and SIC-IR; and (2) determine which method has the best sensitivity and specificity for identifying ventilator-associated pneumonia (VAP).
A prospective analysis was conducted in two surgical and trauma intensive care units (STICU) at a level I trauma center (Unit 1: 8 months, Unit 2: 4 months). Data were collected simultaneously by the SIC-IR system at the point of patient care and by IC utilizing multiple administrative and clinical modalities. Data collected by both systems included patient days, ventilator days, central line days, number of VAPs, and number of catheter-related blood steam infections (CR-BSIs). Both VAPs and CR-BSIs were classified using the definitions of the U.S. Centers for Disease Control and Prevention. The VAPs were analyzed individually, and true infections were defined by a physician panel blinded to methodology of surveillance. Using these true infections as a reference standard, sensitivity and specificity for both SIC-IR and IC were determined.
A total of 769 patients were evaluated by both surveillance systems. There were statistical differences between the median number of patient days/month and ventilator-days/month when IC was compared with SIC-IR. There was no difference in the rates of CR-BSI/1,000 central line days per month. However, VAP rates were significantly different for the two surveillance methodologies (SIC-IR: 14.8/1,000 ventilator days, IC: 8.4/1,000 ventilator days; p = 0.008). The physician panel identified 40 patients (5%) who had 43 VAPs. The SIC-IR identified 39 and IC documented 22 of the 40 patients with VAP. The SIC-IR had a sensitivity and specificity of 97% and 100%, respectively, for identifying VAP and for IC, a sensitivity of 56% and a specificity of 99%.
Utilizing SIC-IR at the point of patient care by a multidisciplinary STICU team offers more accurate infection surveillance with high sensitivity and specificity. This monitoring can be accomplished without additional resources and engages the physicians treating the patient.
在绩效付费以及机构间结果比较的时代，拥有可靠且准确的监测方法以监控感染并发症至关重要。当前的监测标准通常涉及由训练有素的感染控制（IC）团队进行前瞻性和回顾性分析相结合的方法。我们开发了一个医学信息学应用程序，即外科重症监护感染登记系统（SIC - IR），以协助进行感染监测。本研究的目的是：（1）评估当前IC实践与SIC - IR收集的数据之间的差异；（2）确定哪种方法在识别呼吸机相关性肺炎（VAP）方面具有最佳的敏感性和特异性。
在一家一级创伤中心的两个外科和创伤重症监护病房（STICU）（1号病房：8个月，2号病房：4个月）进行前瞻性分析。SIC - IR系统在患者护理点同时收集数据，IC则利用多种管理和临床方式收集数据。两个系统收集的数据包括患者住院天数、呼吸机使用天数、中心静脉导管使用天数、VAP病例数以及导管相关血流感染（CR - BSI）病例数。VAP和CR - BSI均按照美国疾病控制与预防中心的定义进行分类。对VAP病例进行单独分析，真正的感染由对监测方法不知情的医生小组确定。以这些真正的感染作为参考标准，确定SIC - IR和IC的敏感性和特异性。
两个监测系统共评估了769例患者。将IC与SIC - IR进行比较时，每月患者住院天数中位数和呼吸机使用天数中位数存在统计学差异。每月每1000个中心静脉导管使用日的CR - BSI发生率没有差异。然而，两种监测方法的VAP发生率存在显著差异（SIC - IR：每1000个呼吸机使用日14.8例，IC：每1000个呼吸机使用日8.4例；p = 0.008）。医生小组确定了40例（5%）发生43例VAP的患者。在这40例VAP患者中，SIC - IR识别出39例，IC记录了22例。SIC - IR识别VAP的敏感性和特异性分别为97%和100%，IC的敏感性为56%，特异性为99%。
多学科STICU团队在患者护理点使用SIC - IR可提供更准确的感染监测，具有高敏感性和特异性。这种监测无需额外资源即可完成，并且让治疗患者的医生参与其中。
