多学科患者护理套餐在降低手术部位感染方面的有效性。
Effectiveness of a multidisciplinary patient care bundle for reducing surgical-site infections.
机构信息
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA.
Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA.
出版信息
Br J Surg. 2018 Nov;105(12):1680-1687. doi: 10.1002/bjs.10896. Epub 2018 Jul 4.
BACKGROUND
Surgical-site infection (SSI) is associated with significant healthcare costs. To reduce the high rate of SSI among patients undergoing colorectal surgery at a cancer centre, a comprehensive care bundle was implemented and its efficacy tested.
METHODS
A pragmatic study involving three phases (baseline, implementation and sustainability) was conducted on patients treated consecutively between 2013 and 2016. The intervention included 13 components related to: bowel preparation; oral and intravenous antibiotic selection and administration; skin preparation, disinfection and hygiene; maintenance of normothermia during surgery; and use of clean instruments for closure. SSI risk was evaluated by means of a preoperative calculator, and effectiveness was assessed using interrupted time-series regression.
RESULTS
In a population with a mean BMI of 30 kg/m , diabetes mellitus in 17·5 per cent, and smoking history in 49·3 per cent, SSI rates declined from 11·0 to 4·1 per cent following implementation of the intervention bundle (P = 0·001). The greatest reductions in SSI rates occurred in patients at intermediate or high risk of SSI: from 10·3 to 4·7 per cent (P = 0·006) and from 19 to 2 per cent (P < 0·001) respectively. Wound care modifications were very different in the implementation phase (43·2 versus 24·9 per cent baseline), including use of an overlying surface vacuum dressing (17·2 from 1·4 per cent baseline) or leaving wounds partially open (13·2 from 6·7 per cent baseline). As a result, the biggest difference was in wound-related rather than organ-space SSI. The median length of hospital stay decreased from 7 (i.q.r. 5-10) to 6 (5-9) days (P = 0·002). The greatest reduction in hospital stay was seen in patients at high risk of SSI: from 8 to 6 days (P < 0·001). SSI rates remained low (4·5 per cent) in the sustainability phase.
CONCLUSION
Meaningful reductions in SSI can be achieved by implementing a multidisciplinary care bundle at a hospital-wide level.
背景
手术部位感染（SSI）与大量医疗保健费用有关。为了降低癌症中心接受结直肠手术患者的高 SSI 率，实施了一项综合护理包，并对其疗效进行了测试。
方法
对 2013 年至 2016 年间连续治疗的患者进行了一项包括三个阶段（基线、实施和可持续性）的实用研究。干预措施包括与以下方面相关的 13 个组成部分：肠道准备；口服和静脉用抗生素的选择和管理；皮肤准备、消毒和卫生；手术期间保持正常体温；以及使用清洁器械进行闭合。通过术前计算器评估 SSI 风险，使用中断时间序列回归评估效果。
结果
在平均 BMI 为 30kg/m 的人群中，糖尿病发病率为 17.5%，吸烟史为 49.3%，在实施干预包后，SSI 率从 11.0%降至 4.1%（P=0.001）。SSI 率下降最大的是中高危 SSI 患者：从 10.3%降至 4.7%（P=0.006）和从 19%降至 2%（P<0.001）。实施阶段伤口护理方式有很大不同，包括使用覆盖表面真空敷料（从 1.4%基线上升至 17.2%）或让伤口部分敞开（从 6.7%基线上升至 13.2%）。因此，最大的差异在于伤口相关而不是器官间隙 SSI。住院时间中位数从 7（IQR 5-10）缩短至 6（5-9）天（P=0.002）。高危 SSI 患者的住院时间降幅最大：从 8 天降至 6 天（P<0.001）。在可持续性阶段，SSI 率保持在较低水平（4.5%）。
结论
通过在全院范围内实施多学科护理包，可以显著降低 SSI 率。
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