南部某區域醫院加護病房加護病房中心導管血流感染率之時間序列分析及CVC Bundle介入成效之探討

目的: 中心導管相關血流感染是重要且致命的醫療照護相關感染，死亡率高，也造成高醫療成本。國內外已有多篇研究證實組合式照護措施，可有效降低醫療照護相關感染的發生。本院血流感染位居全院感染部位之冠，占54.6%，導管相關血流感染發生率約占71%，2013-2014年擬定「中心導管照護品質提升計畫」，期望藉由推廣中心導管組合式照護措施，以提升醫療照護人員對組合式照護措施認知與落實，以達有效降低中心導管相關血流感染發生情形。本研究將 1. 探討南部某區域醫院加護病房於2013年介入中心導管組合式照護措施後，導管相關血流感染率之時間趨勢變化。 2. 探討介入中心導管組合式照護措施後之相關指標、住院天數、中心導管使用率及加護病房粗死亡率等之執行成效。 3. 探討影響感染率相關趨勢變化之重要預測因子。方法: 本研究設計是採用準實驗的單一組介入時間數列設計。資料取自南部某區域醫院加護病房2012年~2015年所有使用中心導管個案，以時間數列分析ARIMA 模式進行預測介入後2013~2015年中心導管血流感染率之趨勢變化，以獨立樣本t檢定(t-test)，進行預測值與實測值的成效分析。結果: 自2012年1月起至2015年12月止，共計有1,954人使用中心靜脈導管，中心導管相關血流感染佔8.34%，以男性居多佔61.8%。於2013年4月介入CVC bundle後，中心導管血流感染率1.4‰(P= .039)，呼吸器相關肺炎感染率2.0‰ (P=.72)，導尿管相關泌尿道感染率2.35‰ (P=.78)，加護病房感染率5.10‰ (P=.025)。中心導管使用率58.88(P=.86);加護病房平均住院天數為15.72天，平均住院天數為43.57天。針對中心導管血流感染的影響因子共6項進行預測，經時間序列迴歸模型統計量分析Ljung-Box Q(18)P= .804，預測率為12.6%。此6項影響因子經時間序列迴歸分析TPN 使用P= .253、ICU住院>3週以上P= .852、3種以上導管使用率P= .934、DM比率P= .568、CA 比率P= .348，皆無顯著差異。結論與建議: 利用時間數列分析統計2013年介入後加護病房中心導管相關血流感染率之時間趨勢變化，呈現緩慢上升趨勢。同時期加護病房感染率及呼吸器相關肺炎等重要指標同步下降。以加護病房住院週數、使否有糖尿病或腫瘤病史、使用全靜脈營養注射及使用3種以上侵入性導管等要素當作預測因子進行檢定，皆無顯著差異。應再進一步分析感染個案感染原因及照護過程，找出本院有效預測因子，擬定有效的執行策略。持續維持中心導管組合式照護措施的推廣是重要的，提升遵從率，才能有效降低中心導管血流感染率的發生。

關鍵字

中心導管組合式照護措施；中心導管血流感染；時間序列分析；類實驗設計；介入分析

並列摘要

Purpose: Central vascular catheter-related bloodstream infections are hazardous and lethal, which cause high mortality rate and high medical treatment cost. There have been many studies confirm that the combination of care treatment reduce the possibility of infection effectively. The aim of study was to assess an interrupted time series study of catheter-related bloodstream infection (CRBSI) rate after the intervention of the central vascular catheter bundle care. Effectiveness of the central vascular catheter bundle care, and the risk factors of central vascular catheter-related bloodstream. Methods: The study design was a single group interrupted time series study. The CVC bundle was implemented on all patients admitted to the ICU starting Apirl 2013. Data of CRBSI rates from 2012 and 2015 were pooled to compare the differences between observed values and predicted values before and after the intervention . Results: CVC bundle care was implemented since April 2016. Our study showed that the central catheter bloodstream infection rate was 1.4 ‰ (P=.039), the ventilator-associated pneumonia (VAP) infection rate was 2.0 ‰ (P=.72), the catheter associated urinary tract (CA-UTI) infection rate was 2.35 ‰ (P=.78), and the ICU infection rate was 5.10 ‰ (P=.025). The overall central catheter utilization rate was 58.88% (P=.086); the mean length of ICU (intensive care unit) stay was 15.72 days, and the average length of a hospital stay was 43.57 days. This study was designed to adopt six risk factors to predict the infection rate related to the central catheter bloodstream infection. This study was based on Time Series Regression Model and verification value to Ljung-Box Q (18). The result showed that these six factors, CLABSI (P=.301), TPN usage (P=.253), ICU stay > 3 weeks (P=.852), above 3 catheter usage (P=.934), DM ratio (P=.568), and CA ratio (P=.348), have no significant differences. Conclusion and Suggestion: The time sequence analysis model was adopted to analyze the catheter-related bloodstream infection rate in 2013. Although it did not decrease, but only slowed down the trend of increase the CRBSI incidence. We found that the infection control of ICU and ventilator-associated pneumonia were improved. We conclude that promotion of CVC bundle care is an important event and effective intervention to control CRBSI. To effectively reduce the catheter-related bloodstream infection rate is to persistently support the combination of CVC bundle care and to enhance the compliance of the policy.