Service de Réanimation Médicale et des Maladies Infectieuses, Hôpital Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris, Université Paris 7-Denis Diderot, Paris, France.
Crit Care Med. 2010 Mar;38(3):789-96. doi: 10.1097/CCM.0b013e3181ce21af.
To determine the effect of a 2-yr multifaceted program aimed at preventing ventilator-acquired pneumonia on compliance with eight targeted preventive measures.
Pre- and postintervention observational study.
A 20-bed medical intensive care unit in a teaching hospital.
A total of 1649 ventilator-days were observed.
The program involved all healthcare workers and included a multidisciplinary task force, an educational session, direct observations with performance feedback, technical improvements, and reminders. It focused on eight targeted measures based on well-recognized published guidelines, easily and precisely defined acts, and directly concerned healthcare workers' bedside behavior. Compliance assessment consisted of five 4-wk periods (before the intervention and 1 month, 6 months, 12 months, and 24 months thereafter).
Hand-hygiene and glove-and-gown use compliances were initially high (68% and 80%) and remained stable over time. Compliance with all other preventive measures was initially low and increased steadily over time (before 2-yr level, p < .0001): backrest elevation (5% to 58%) and tracheal cuff pressure maintenance (40% to 89%), which improved after simple technical equipment implementation; orogastric tube use (52% to 96%); gastric overdistension avoidance (20% to 68%); good oral hygiene (47% to 90%); and nonessential tracheal suction elimination (41% to 92%). To assess overall performance of the last six preventive measures, using ventilator-days as the unit of analysis, a composite score for preventive measures applied (range, 0-6) was developed. The median (interquartile range) composite scores for the five successive assessments were 2 (1-3), 4 (3-5), 4 (4-5), 5 (4-6), and 5 (4-6) points; they increased significantly over time (p < .0001). Ventilator-acquired pneumonia prevalence rate decreased by 51% after intervention (p < .0001).
Our active, long-lasting program for preventing ventilator-acquired pneumonia successfully increased compliance with preventive measures directly dependent on healthcare workers' bedside performance. The multidimensional framework was critical for this marked, progressive, and sustained change.
确定一项为期 2 年的多方面计划对预防呼吸机相关性肺炎的效果，该计划旨在预防 8 项针对性预防措施。
干预前后的观察性研究。
一家教学医院的 20 张病床的重症监护病房。
共观察 1649 个呼吸机日。
该计划涉及所有医护人员，包括一个多学科工作组、一个教育课程、带绩效反馈的直接观察、技术改进和提醒。它以基于公认的已发表指南、易于准确界定的行为以及直接涉及医护人员床边行为的 8 项针对性措施为重点。依从性评估包括 5 个为期 4 周的时期（干预前和干预后 1 个月、6 个月、12 个月和 24 个月）。
手卫生和手套-手术服的使用依从性最初很高（分别为 68%和 80%），且随时间保持稳定。所有其他预防措施的依从性最初较低，但随时间稳步增加（在 2 年水平之前，p <.0001）：床头抬高（5%至 58%）和气管套囊压力维持（40%至 89%），在简单的技术设备实施后有所改善；口胃管使用（52%至 96%）；避免胃过度膨胀（20%至 68%）；良好的口腔卫生（47%至 90%）；非必要的气管抽吸消除（41%至 92%）。为了评估最后六项预防措施的整体表现，使用呼吸机日作为分析单位，开发了一个用于预防措施应用的综合评分（范围 0-6）。五次连续评估的中位数（四分位间距）综合评分分别为 2（1-3）、4（3-5）、4（4-5）、5（4-6）和 5（4-6）分；随时间显著增加（p <.0001）。干预后呼吸机相关性肺炎的患病率下降了 51%（p <.0001）。
我们积极、持久的预防呼吸机相关性肺炎计划成功提高了与医护人员床边表现直接相关的预防措施的依从性。多维框架对于这种显著、渐进和持续的变化至关重要。
