The Ohio State University, 410 West 10th Ave, N-1150 Doan Hall Columbus, OH 43210, USA.
Crit Care. 2011;15(1):R38. doi: 10.1186/cc9988. Epub 2011 Jan 25.
In 2005 the American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) published guidelines for managing hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP). Although recommendations were evidence based, collective guidelines had not been validated in clinical practice and did not provide specific tools for local implementation. We initiated a performance improvement project designated Improving Medicine Through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) at four academic centers in the United States. Our objectives were to develop and implement the project, and to assess compliance with quality indicators in adults admitted to intensive care units (ICUs) with HAP, VAP, or HCAP.
The project was conducted in three phases over 18 consecutive months beginning 1 February 2006: 1) a three-month planning period for literature review to create the consensus pathway for managing nosocomial pneumonia in these ICUs, a data collection form, quality performance indicators, and internet-based repository; 2) a six-month implementation period for customizing ATS/IDSA guidelines into center-specific guidelines via educational forums; and 3) a nine-month post-implementation period for continuing education and data collection. Data from the first two phases were combined (pre-implementation period) and compared with data from the post-implementation period.
We developed a consensus pathway based on ATS/IDSA guidelines and customized it at the local level to accommodate formulary and microbiologic considerations. We implemented multimodal educational activities to teach ICU staff about the guidelines and continued education throughout post-implementation. We registered 432 patients (pre- vs post-implementation, 274 vs 158). Diagnostic criteria for nosocomial pneumonia were more likely to be met during post-implementation (247/257 (96.1%) vs 150/151 (99.3%); P = 0.06). Similarly, empiric antibiotics were more likely to be compliant with ATS/IDSA guidelines during post-implementation (79/257 (30.7%) vs 66/151 (43.7%); P = 0.01), an effect that was sustained over quarterly intervals (P = 0.0008). Between-period differences in compliance with obtaining cultures and use of de-escalation were not statistically significant.
Developing a multi-center performance improvement project to operationalize ATS/IDSA guidelines for HAP, VAP, and HCAP is feasible with local consensus pathway directives for implementation and with quality indicators for monitoring compliance with guidelines.
2005 年，美国胸科学会和传染病学会（ATS/IDSA）发布了医院获得性肺炎（HAP）、呼吸机相关性肺炎（VAP）和医疗保健相关性肺炎（HCAP）的管理指南。尽管这些建议是基于证据的，但集体指南尚未在临床实践中得到验证，也没有为当地实施提供具体工具。我们在美国的四个学术中心启动了一项名为通过医院获得性肺炎关键治疗途径评估改善医学（IMPACT-HAP）的绩效改进项目。我们的目标是制定和实施该项目，并评估在 ICU 中患有 HAP、VAP 或 HCAP 的成年人中符合质量指标的情况。
该项目在 2006 年 2 月 1 日开始的 18 个月内分三个阶段进行：1）为期三个月的规划期，用于审查文献以制定这些 ICU 中管理医院获得性肺炎的共识途径、数据收集表、质量绩效指标和基于互联网的存储库；2）为期六个月的实施期，通过教育论坛将 ATS/IDSA 指南定制为中心特定的指南；3）为期九个月的实施后继续教育和数据收集期。将前两个阶段的数据（实施前）与实施后的数据进行合并。
我们基于 ATS/IDSA 指南制定了一项共识途径，并在本地层面进行了定制，以适应配方和微生物学的考虑因素。我们实施了多种模式的教育活动，向 ICU 工作人员传授指南知识，并在实施后继续进行继续教育。我们登记了 432 名患者（实施前 vs 实施后，274 名 vs 158 名）。在实施后，更有可能满足医院获得性肺炎的诊断标准（247/257（96.1%） vs 150/151（99.3%）；P=0.06）。同样，经验性抗生素更有可能符合 ATS/IDSA 指南（257 名中的 79 名[30.7%] vs 151 名中的 66 名[43.7%]；P=0.01），这种效果在季度间隔内持续存在（P=0.0008）。获得培养物和使用降级之间的遵守情况在两个时期之间没有统计学上的显著差异。
制定一个多中心的绩效改进项目，以实现 ATS/IDSA 对 HAP、VAP 和 HCAP 的指南，通过实施本地共识途径指令和监测指南遵守情况的质量指标是可行的。
