後SARS疫情強化感染管制措施改善加護病房醫療照護相關感染之成效

Multidisciplinary Teamwork Helps Reduce the Risk of Acquiring Healthcare-Associated Infections in Intensive Care Units

為降低加護病房住院病人醫療照護相關感染密度，本院自2004年起，推動包括感染管制醫師、感染管制師、加護病房主任、護理長、行政主管等跨科部團隊合作模式，共同檢討及改善醫療照護相關感染案件。感染管制醫師負責全院抗生素處方合理性之審查，針對臨床醫師開立之抗生素處方，線上逐筆審核藥物之合理性，經審核不同意使用者，開立之處方將於48小時後不再發藥，需依照建議更改藥物或改為臨床照會再評估。跨科別團隊成員參考專業醫學會公布的指引，訂定中心靜脈導管、留置導尿管、呼吸器使用適應症及感染管制措施、檢核表等，並每日評估放置導管之適應症，以儘早拔除導管。行政主管積極介入共同探討醫療照護相關異常及群聚感染案件，以確認誇科部團隊於降低加護病房病人感染之成效。以2004年為介入實施點，比較前三年資料（2003年發生嚴重急性呼吸道症候群（severe acute respiratory syndrome, SARS）院內群聚感染，該區間資料予以剔除），2000至2002及2004至2006年全院加護病房平均感染密度分別為16.3‰（3,079／188,785人日）及11.8‰（2,181／184,933人日），以卡方檢定，P＜0.001，呈顯著下降。2000至2009年感染趨勢以卡方檢定，P＜0.001，也呈顯著下降。推動跨科部團隊合作模式，於降低醫學中心加護病房病人醫療照護相關感染具有其成效。

Healthcare-associated infections (HAIs) in intensive care unit (ICU) are of increasing concern. In order to reduce rates of HAI in ICUs, teamwork was initiated in 2004 by a multidisciplinary critical-care task force, including infectious disease (ID) physicians, infection control practitioners (ICP), ICU critical-care physicians, ICU head nurses, and administration directors, at CGMHKS, a 2500-bed (including 206-beds in ICU) facility serving as a primary care and tertiary referral centre in southern Taiwan. Specifically, ID physicians were responsible for hospital-wide antimicrobial stewardship by reviewing all prescribed antimicrobials online and making comments on them that included approval of prescription and suggestion for changing prescription in case of disapproval; ICU intensivists were responsible for putting forward indications for urinary and central venous catheter placement, infection control measures, and timing for removal of these devices. All proposals made by the ICU intensivists were reviewed by ICPs and ID physicians to ensure that the proposals were consistent with the evidence-based medicine and/or in accordance with guidelines put forward by professional societies. Accordingly, ICPs and ID physicians worked together to established checklists for helping ICU staff to adhere to urinary catheter, central venous catheter, and ventilator care bundles. The administration director provided administration and technical support, evaluated the evolutionary HAIs rates, and ensured that the multidisciplinary critical-care task force held meetings periodically for implementation of infection control. Excluding the HAIs in 2003, when a SARS nosocomial outbreak occurred, we found overall HAI rates of 11.8‰(2,181/184,933 [2004-2006]) vs. 16.3‰ (3,079/188,785 [2000-2002]) (P < 0.001); the HAI rate showed a significant decline between 2000 and 2009 (Chi-square test for trend; P < 0.001). Our data indicated that teamwork by a multidisciplinary critical-care task force is important and effective in reducing HAIs in ICUs in large medical centers.