加護病房內念珠菌菌血症之老年病人的流行病學、菌種分佈與預後因子－一個多中心研究

Epidemiology, species distribution, and prognostic factors of candidemia in elderly patients in intensive care units- a mul-ticenter study

背景：醫療不良事件(AMEs)的管理是促進病人安全的基石。根本原因分析(RCA)是探討重大病人安全不良事件問題，但是由於無法解釋更廣泛的因素而受到限制。本研究使用人為因素分類與分析工具(HFACS)回溯審視醫療不良事件，以了解影響醫療不良事件的人為因素及各層面中錯誤原因之分佈或系統性問題。方法：本研究回溯2012-2016年間有做過根本原因分析之醫療不良事件，以連續性取樣方式(continuous sampling)收集40例醫療不良事件，以人為因素分類與分析工具(HFACS)去系統性的挖掘每件案例發生錯誤之原因。結果：在行為層面中，分析結果主要為基礎技能錯誤(95%)、判斷和決策錯誤(87.5%)，其中在基礎技能錯誤當中以未依程序作業執行(81.6%)及未如預期設備操作(50%)佔多數；判斷和決策錯誤中以現場風險評估不確實(68.6%)及採取錯的步驟/行為(68.6%)佔多數。而在先決條件層面中，以團隊合作(27.5%)為主要因素包含溝通不良(81.8%)及重要訊息未以正確的方式即時傳達(72.7%)佔多數。在監督層面當中，以監督不周(92.9%)或監督不妥當(92.9%)為主要因素。在組織政策和流程方面(50%)，以組織系統的政策/風險未充分評估(35%)為主要因素。結論：本研究進一步了解醫療不良事件在過去使用根本原因分析未探討到的人為因素，反映出潛在的監督、組織行為或系統性的問題，促進病人安全預防錯誤再發生。

 

Background and purpose: Immunocompromised and elderly patients are at increasing risk of infection by Candida, a strain of fungus that can cause bloodstream infections in the critically ill. Methods: ICU patient data collected during 2009 to 2012 by four Southern Taiwanese hospitals was used to conduct a retrospective, multicenter study on candidemia patients older than 65 years of age. Results: Patient data for 198 patients was used for anal-ysis. The mean age of all patients was 77.9. Mean Charlson comorbidity index (CCI) and APACHE II scores were 10.2 (± 3.3) and 28.1 (± 7.9), respectively. We found significantly higher rates of C. albicans candidemia in young-old patients compared to old-old patients (71.8% vs. 53.1%, P=0.008). Overall ICU and in-hospital mortality was 40.9% and 64.6%, respectively. Multivariate analysis found ICU mortality of candidemia patients to be signif-icantly associated with prior exposure to broad spectrum antibiotics (P=0.039). Patients with high CCI scores and those who had recently undergone abdominal surgery were found to be less likely to contract non-albicans candidemia. Conclusion: We found significant differences between the clinical features and species distribution of candidemia in critically ill young-old and old-old patients. Prior exposure to broad spectrum antibiotics is a risk factor for candidemia, and also significantly impacts on mortality.