組合式感染控制措施（bundle intervention）降低呼吸器相關肺炎感染發生：某區域醫院內科加護病房推行經驗

Reducing Ventilator-associated Pneumonia in the Intensive Care Unit of a Community Hospital: Impact of Implementing VAP Bundle Care

許多重症病人需依賴呼吸器維生，但也衍生呼吸器相關肺炎（ventilator associated pneumonia, VAP）的醫療照護相關感染重要課題。在美國已有許多醫院推行組合式感染控制措施（infection control bundle）來降低醫療照護相關感染並獲得成功的例子。而組合式感染控制措施概念，最近也開始受到國內的注意，並列為醫院感染管制查核作業的重點項目之一。本院自2007年開始選定一個內科加護病房開始推行VAP bundle。推行內容有：1.每天提醒醫師評估病人是否可拔管，2.每天檢查氣管內囊壓力，3.使用鎮靜劑的病人需每天喚醒至少一次，4.接觸病人前後洗手，5.每8小時執行一次口腔護理，6.床頭抬高30度以上，7.病人翻身、翻動等處置先清除口中分泌物。以自行設計的茶鹼表加上內外稽核措施來推行。VAP bundle的遵從率由開始試行的16.7%進步到施行一年後的80.0%，比較推行VAP前後各三年之感染情形顯示，推行後：呼吸器使用比率減少10.3%；每個病人的平均加護病房住院天數減少1.96天。最重要的是VAP感染個案由推行前的每年平均8個案減少到推行後每年平均1.33個案（減少達83.3%），即推行VAP bundle的三年期間共減少20例VAP個案。且自2008年3月到2009年10月共有20個月期間達到零VAP感染個案的突破性紀錄。本院經驗顯示VAP bundle推行可有效減少呼吸器相關肺炎的發生。

Many critically ill patients rely on a ventilator for survival; however, ventilator-associated pneumonia (VAP) is a common and important nosocomial infection. Combined infection control measures (VAP bundle care) have been used to reduce infection rates in many hospitals in the United States successfully. The concept of bundle care has been an important issue for the Healthcare-Related Infection Control Audit in Taiwan over the last 2 years. VAP bundle care was implemented in the medical intensive care unit of our hospital in 2007. Our VAP bundle care includes the following measures: 1) daily readiness-to-wean assessments; 2) Daily checks of endotracheal cuff pressure; 3) daily “sedation vacations”; 4) hand hygiene; 5) oral care every 8 hours; 6) head-of-bed elevation above 30 degrees; and 7) suctioning of both the oropharynx and the endotracheal tube. The compliance rate for VAP bundle care was 16.7% in the trial period, and increased to 80.0% after the first year of implementation. The ventilator usage rate decreased by 10.3% after the implementation of VAP bundle care, and ICU stay decreased by a mean of 1.96 days/patient. The average number of VAP cases decreased from 8/year before VAP bundle care implementation to 1.33/year after implementation (a decrease of 83.3%). The implementation of VAP bundle care resulted in 20 fewer VAP cases over a 3-year period. Furthermore, a record 20-month period of zero VAP cases was achieved from March 2008 to October 2009. Our experience has shown that the implementation of VAP bundle care can be effective in reducing the incidence of VAP.