呼吸器相關肺炎應用組合式照護的實證與臨床運用

Evidence and Clinical Application of Care Bundles for Ventilator- Associated Pneumonia

10.6530/YYN/2017.5.2

盧敏吉(Min-Chi Lu)；黃淑如(Shu-Ju Huang)；陳瀅淳(Ying-Chun Chen)；施智源(Zhi-Yuan Shi)；陳彥旭(Yen-Hsu Chen)；姜秀子(Chih-Chuan Kao)；薛博仁(Po-Ren Hsueh)；李聰明(Chun-Ming Lee)

呼吸器相關肺炎 ； 組合式照護 ； VAP bundle care ； Ventilator-associated pneumonia ； care bundles

源遠護理

11卷1期（2017 / 03 / 01）

12 - 17

繁體中文

呼吸器相關肺炎是醫學中心及區域醫院加護病房常見的醫療照護相關感染之一，僅次於泌尿道與血流感染；台灣感染管制學會之前於各醫院推行中心靜脈導管組合式照護，明顯的降低醫療照護相關血流感染；為了更進一步朝向零院內感染邁進，台灣感染管制學會承接疾病管制署計畫，自2013年開始展開呼吸器相關肺炎組合式照護的先驅計畫。參酌探討美國健康照護策進會（Institute for Healthcare Improvement, IHI）及相關的國外文獻，制定台灣本土呼吸器相關肺炎組合式照護措施，執行五個項目：(1)床頭抬高30-45度，(2)每日執行chlorhexidine口腔抗菌照護，(3)每日中止鎮靜劑，(4)排空呼吸器管路積水，與(5)每日拔管評估。這些整合性措施自2013年開始在參與先驅計畫的醫院施行，經歷教育訓練與臨床稽核的辛苦過程，初步獲致良好的成效，參與醫院加護病房的呼吸器相關肺炎於一年內降低了約20%。經由此先驅計畫在各層級醫院推行的經驗顯示，證實在台灣的醫療環境，能夠成功的執行呼吸器相關肺炎組合式照護，並且可以有效降低呼吸器相關肺炎的發生率，提高醫療照護品質。

Ventilator-associated pneumonia (VAP) is one of the major causes of healthcare-associated infections in the intensive care unit of medical centers and regional hospitals. Previously, the implementation of a central vascular catheter care bundles successfully reduced central line-associated bloodstream infections in a project led by the Infection Control Society of Taiwan (ICST). Therefore, in 2013, the ICST initiated a new project, supported by the Centers for Disease Control in Taiwan, to develop and promote the execution of a VAP care bundles in Taiwan. Taking into consideration the elements of VAP care bundles of the US Institute for Healthcare Improvement and evidence-based medicine in the literature, the ICST devised five elements for the VAP care bundle, including (1) maintaining head of bed at 30-45 degrees, (2) daily oral care using 0.12%-0.2% chlorhexidine, (3) daily interruption of sedatives, (4) draining of ventilator circuit, and (5) daily extubation assessment. Using this pioneer program from August 2013 to October 2014, the participating hospitals achieved an average reduction of 20% in VAP incidence. The experience of the VAP care bundle, both in Taiwan and in the literature, has shown its effectiveness in the reduction of VAP incidence, morbidity, and mortality, and has improved the quality of medical care.

1. Al-Tawfiq, J. A.,Abed, M. S.(2010).Decreasing ventilator associated pneumonia in adult inten sive care units using the Institute for Healthcare Improvement bundle.American Journal of Infection Control,38(7),552-556.
2. Bird, D.,Zambuto, A.,O’Donnell, C.,Silva, J.,Korn, C.,Burke, R.,Agarwal, S.(2010).Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unit.Archives of Surgery,145(5),465-470.
3. Bouadma, L.,Deslandes, E.,Lolom, I.,Le Corre, B.,Mourvillier, B.,Regnier, B.,Lucet, J. C.(2010).Long-term impact of a multifaceted prevention program on ventilator-associated pneumonia in a medical intensive care unit.Clinical Infectious Diseases,51(10),1115-1122.
4. Caserta, R. A.,Marra, A. R.,Durão, M. S.,Silva, C. V.,dos Santos, O. F. P.,Edmond, M. B.,Timenetsky, K. T.(2012).A program for sustained improvement inpreventing ventilator associated pneumonia in an intensive care setting.BMC Infectious Diseases,12(1),234.
5. Craven, D. E.,Goularte, T. A.,Make, B. J.(1984).Contaminated condensate in mechanical ventilator circuits. A risk factor for nosocomial pneumonia?.The American Review of Respiratory Disease,129(4),625-628.
6. Drakulovic, M. B.,Torres, A.,Bauer, T. T.,Nicolas, J. M.,Nogué, S.,Ferrer, M.(1999).Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: A randomised trial.Lancet,354(9193),1851-1858.
7. Dries, D. J.,McGonigal, M. D.,Malian, M. S.,Bor, B. J.,Sullivan, C.(2004).Protocol-driven ventilator weaning reduces use of mechanical ventilation, rate of early reintubation, and ventilator-associated pneumonia.The Journal of Trauma,56(5),943-952.
8. Girard, T. D.,Kress, J. P.,Fuchs, B. D.,Thomason, J. W.,Schweickert, W. D.,Pun, B. T.,Ely, E. W.(2008).Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): A randomised controlled trial.Lancet,371(9607),126-134.
9. Hillier, B.,Wilson, C.,Chamberlain, D.,King, L.(2013).Preventing ventilator-associated pneumonia through oral care, product selection, and application method: A literature review.AACN Advanced Critical Care,24(1),38-58.
10. Kollef, M. H. (2012). Clinical presentation and diagnosis of ventilator-associated pneumonia. Retrieved from http://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-ventilator-associated-pneumonia?view
11. Patel, S. B.,Kress, J. P.(2012).Sedation and analgesia in the mechanically ventilated patient.American Journal of Respiratory and Critical Care Medicine,185(5),486-497.
12. Speck, K.,Rawat, N.,Weiner, N. C.,Tujuba, H. G.,Farley, D.,Berenholtz, S.(2016).A systematic approach for developing a ventilator-associated pneumonia prevention bundle.American Journal of Infection Control,44(6),652-656.
13. Tablan, O. C.,Anderson, L. J.,Besser, R.,Bridges, C.,Hajjeh, R.(2004).Guidelines for Preventing Health-Care--Associated Pneumonia.MMWR,53
14. 衛生福利部疾病管制署（2015，12月3日）．100年院內感染監視年報．取自http://www.cdc.gov.tw/professional/info.aspx?treeid=BEAC9C103DF952C4&nowtreeid=ECDDD4FBA932D996&tid=3B45FA16D55AED82
15. 盧進德,石紫萍,丁良文(2012)。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。感染控制雜誌，22(6)，261-271。

1. 許雅雯(Ya-Wen Hsu);王淑娟(Shu-Chuan Wang);朱璧岑(Pi-Chen Chu)(2024)。運用ABCDEF組合式照護於呼吸衰竭個案之加護經驗。高雄護理雜誌。41(1)。86-97。