Division of Internal Medicine-Infectious Diseases, University of Texas Southwestern, Dallas.
Department of Epidemiology, University of Texas Health Science Center School of Public Health, Dallas Campus.
Am J Med. 2016 Feb;129(2):195-203. doi: 10.1016/j.amjmed.2015.09.016. Epub 2015 Oct 28.
The purpose of this study is to improve the quality of care and patient outcomes for Staphylococcus aureus bacteremia.
A quasi-experimental pre- and postintervention study design was used to compare process and clinical endpoints before and after a quality-improvement initiative. All inpatients >18 years of age with a positive blood culture for S. aureus during the specified pre- and postintervention period with clinical information available in the electronic medical record were included. An institutional protocol for the care of patients with S. aureus bacteremia was developed, formalized, and distributed to providers using a pocket card, an electronic order set, and targeted lectures over a 9-month period.
There were 167 episodes of S. aureus bacteremia (160 patients) identified in the preintervention period, and 127 episodes (123 patients) in the postintervention period. Guideline adherence improved in the postintervention period for usage of transesophageal echocardiogram (43.9% vs 20.2%, P <.01) and adequate duration of intravenous therapy (71% vs 60%, P = .05). In a multivariate Cox proportional hazard model, the variables associated with increased relapse-free survival were postintervention period (hazard ratio [HR] 0.48; confidence interval [CI], 0.24-0.95; P .035) and appropriate source control (HR 0.53; CI, 0.24-0.92; P .027). Regardless of intervention, presence of cancer was associated with an increased risk of relapse or mortality at 90 days (HR 2.88; P <.0001; CI, 1.35-5.01).
A bundled educational intervention to promote adherence to published guidelines for the treatment of S. aureus bacteremia resulted in a significant improvement in provider adherence to guidelines as well as increased 90-day relapse-free survival.
本研究旨在提高金黄色葡萄球菌菌血症患者的护理质量和临床结局。
采用准实验前后对照设计，比较质量改进措施实施前后的过程和临床结局。纳入标准为在指定的干预前后期间，年龄＞18 岁且血培养阳性的金黄色葡萄球菌住院患者，且电子病历中可获取临床信息。制定了金黄色葡萄球菌菌血症患者护理的机构方案，使用袖珍卡、电子医嘱集和有针对性的讲座，历时 9 个月，将方案正式化并分发给医务人员。
在干预前期间共发现 167 例金黄色葡萄球菌菌血症（160 例患者），在干预后期间共发现 127 例金黄色葡萄球菌菌血症（123 例患者）。在干预后期间，指南的遵循情况有所改善，包括经食管超声心动图的使用（43.9% vs 20.2%，P <.01）和静脉治疗的持续时间（71% vs 60%，P =.05）。在多变量 Cox 比例风险模型中，与无复发生存率增加相关的变量为干预后期间（风险比 [HR] 0.48；95%置信区间 [CI]，0.24-0.95；P =.035）和适当的源头控制（HR 0.53；95%CI，0.24-0.92；P =.027）。无论干预措施如何，癌症的存在与 90 天内的复发或死亡率增加相关（HR 2.88；P <.0001；95%CI，1.35-5.01）。
针对金黄色葡萄球菌菌血症治疗指南的实施捆绑式教育干预措施，可显著提高医务人员对指南的遵循度，并增加 90 天无复发生存率。
