1 3 4 9 15 25 27 39 41 43 43 51 51 54 65 67 71 74 580
14 18 22 26 28 30 32 33 34 35 36 37 38 52 55 61 10 22 44 47
World Health Organization Clean Care is Safer CareSafe Surgery Saves Lives Antimicrobial resistance 50% care bundle 35 Keystone ICU project 10 2011-2012 bundle intervention2 I
1429 2013-2014 7CDCAHRQKeystone ICU project II
2009 2013 20099.882014 5.06 III
102-103 1 30:21 care bundle care bundle IV
V
2009-2011 2013-2014 18 2% Chlorhexidine Gluconate 32.0% 42.4% 1351 152,025 VI
201112179 VII
CLABSI VIII
IX
2013 X
1 15 80,000[1-3] 12%25% 3456 52023 [3,4] 1516 [5] [2-5] 50% Institute for Healthcare Improvement, IHI care bundle 20028.2 XI
20050 [6]Keystone ICU project 103ICUCLABSI[7] 20132014 CDCAHRQKeystone ICU project Central Line Insertion Bundle optimal catheter site selectionhand hygiene maximal sterile barrier precautions chlorhexidine skin antisepsis4 central line maintenance bundle daily review of line necessityhand hygiene dressing changescrub the hub replacement of administration sets5 20132014 XII
The Hippocratic Oath primum non nocere1999 Institute of MedicineIOM1To Err is Human: Building a Safer Health System1 2001 IOM Crossing the Quality Chasm: A New Health System for the 21st Century The Centers for Medicare & Medicaid Services, CMS200810National Quality Forum, NQF28never events vascular catheter-associated infection The Agency for Healthcare Research and Quality's, AHRQThe RAND Corporation The Johns Hopkins University The University of California, San Francisco, UCSF 1
Care Bundle for Prevention of CLABSI The Emergency Care Research Institute, ECRILeland Stanford Junior University WachterPronovostShekelle20133 10Patient Safety Strategies /Preoperative checklists and anesthesia checklists to prevent operative and postoperative events. Bundles that include checklists to prevent central line-associated bloodstream infections. Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols. Bundles that include headof-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia. Hand hygiene The do-not-use list for hazardous abbreviations. Multicomponent interventions to reduce pressure ulcers. Barrier precautions to prevent healthcareassociated infections. Use of real-time ultrasonography for central line placement. Interventions to improve prophylaxis for venous thromboembolisms. central venous catheter, CVC 2
care bundle John Hopkins UniversityDr. Peter Pronovost Michigan Health & Hospital Association, MHA Keystone ICU project103icu Centers for Disease Control and Prevention, CDC5 optimal catheter site selection hand hygienechlorhexidine skin antisepsismaximal sterile barrier precautions daily review of line necessity 3 CLABSI 10002.7CLABSI018 07.7/1000 181.4/1000 IHI 35 Keystone ICU project 3
Care Bundle for Prevention of CLABSI 1 Infusion 2 hemodynamiclumenedintravascular cathetergreat vessel 3 aortapulmonary artery superior vena cavainferior vena cava brachiocephalic veinsinternal jugular veins subclavian veinsexternal iliac veinscommon femoral veins/ Central Line Bundle CDC 1 Temporary Central LineNon-Tunneled Catheter Permanent Central LineTunneled Catheters Implanted CathetersPort-A 2Infusion Flush Ventilator- Associated Pneumonia Care Bundle Catheter-Associated Urinary Tract Infection Care Bundle Sepsis Management Care Bundle Sepsis Resuscitation Care Bundle 3CVCSwan- GanzDouble LumenTemporalDouble LumenPermanentPacemaker IABPNonlumened Port-AArterial Line 4
1 2 3 4 5 6 7 8 9 10 11 48 Hand Hygiene and Aseptic Technique 1 2 3 5
Care Bundle for Prevention of CLABSI 4 Chlorhexidine Skin Antisepsis 10.5% chlorhexidine chlorhexidine iodophor70%70% alcohol tincture of iodine 2chlorhexidine preparations with alcoholprovidone-iodine in alcohol 3 4chlorhexidine 2 unresolved issue Maximal Sterile Barrier Precautions 1 2sterile sleeve Daily Review of Line Necessity 1 2 3 4guidewire 5guidewire 6
6 Hand Hygiene 1 2 Dressing Change 10.5% chlorhexidine chlorhexidineiodophor tincture of iodine 2 3 4 52 67 7 8 9 10streile sleeve 11 7
Care Bundle for Prevention of CLABSI Replacement of Administration Sets 1 96 7 2 24 3 propofol 6 12 Scrub the Hub 75% 5 15 8
1 9
Care Bundle for Prevention of CLABSI 2 10
2011CDC time out 11
Care Bundle for Prevention of CLABSI 1 2 3 2%chlorhexidine 12
1 2 13
Care Bundle for Prevention of CLABSI 1 2 3 4 5 6 7 8 9 10 11 12 14
1 2 3 4 5 6 7 8 9 10 11 12 CVC bundle 1~2 15
Care Bundle for Prevention of CLABSI 20~30% 1~2 1 Leadership 2 (1) 1 (2) 16
3 (1) (2) 1 (1) 17
Care Bundle for Prevention of CLABSI (2) 2E-learning 1 2 2011 3 4 ICU 5 5 6 7 8 9 10 11 12 13 PDCA 14 15 TRM 16 Clean Care is Safer Care: from local research to global spread 17 & Global aspects of infection control 18 Implementing Care Bundles Preventing vascular catheter-associated infection: the next 19 steps 18
3 (1) 4 (2) 5 4 (1) 19
Care Bundle for Prevention of CLABSI (2) (3) 20 (4) 5 20
2% chlorhexidine 1 21
Care Bundle for Prevention of CLABSI 1 CVC 1 2 1-2 3 1 4 1 5 1 6 1 7 1 8 2 9 CVC 1 10 1 11 SIZE 12 SIZE 22
13 6 1 14 3 34 4 1-2 15 3.54.5 1 16 1 17 2% CHG 1 18 75% 1 19 1 20 10cc 5cc3cc 1 21 250cc 1 22 1 23 1 24 1 25 1 2 3 300152-180 10010-12 3 2% chlorhexidine 4 23
Care Bundle for Prevention of CLABSI time out 55 24
indicatormeasurement 3 25
Care Bundle for Prevention of CLABSI 1. opportunities performed actions 2.indication / opportunities () 1. 2. 1. 2. 48 3. 26
1. 2. 3. 4. 2011-2012 2014418 6~ 27
Care Bundle for Prevention of CLABSI ICURCC 1030418 1. CVC(other than dialysis) 2. Dialysis CVC 3. Swan-Ganz 4. PICC(peripherally inserted central catheter) 5. Port-A 6. 1. Femora femoral 2. Jugular 3. Lower extremity 4. Subclavian 5. Upper extremity 1. 2. 3. 4. 5. 1.2.3. 4.5. 2%chlorhexidine PPEPPE 28
1.CVCPICC 2 2. 3. 4. 5. 6.femoral 4 7. 8. (1) (2) 2-1~2-22-1~2-21 2-12% chlorhexidine2% chlorhexidine 2% chlorhexidine chlorhexidine 2% chlorhexidine 2-2 (3) 3-1~3-33-1~3-31 3-1~3-3 3-1PPE 3-2PPE 3-3 (4) 4-1 (5) (6) 29
Care Bundle for Prevention of CLABSI ICURCC 1030418 CVC(other than dialysis) Dialysis CVCSwan-Ganz PICC(peripherally inserted central catheter) Port-A FemoralJugular Lower extremitysubclavian Upper extremity 1.2% chlorhexidine 2.2% chlorhexidine 70%-75% 3. 30
1.CVCSwan-GanzPICCPort-A 2.CVCPICC 2 3. 4. (1) (2) (3) (4) (5) (6) a. b. c. d. e. 2% chlorhexidine 2% chlorhexidine2% chlorhexidine chlorhexidine 2% chlorhexidine f. 2% chlorhexidine 70%-75% 2%chlorhexidine2% chlorhexidine g. h. i. (7) (8) 31
Care Bundle for Prevention of CLABSI 32
(2014/mm/dd) 2014 5 ICURCC 1 2 3 4 5 1 2 3Femoralfemoral 422-12-2 2-1 533-13-2 3-3 33-13-23-3 3-33-3 64-14-1 7 33
Care Bundle for Prevention of CLABSI (2014/mm/dd) 2014 5 ICURCC 1 2 3 4 5 1 2 3 4 5 5 3 6 34
35 (2014/mm/dd) 2014 ICURCC ICURCC ICURCC ICURCC 1 2 3 4 1 2 3 4. X X X X 1 2 3 4 5
Care Bundle for Prevention of CLABSI (2014/mm/dd) 2014 ICURCC CVCother than dialysisdialysis CVCSwan-Ganz PICC Port-A Femoral JugularLower extremity(picc) SubclavianUpper extremitypicc 1. 2. 2-12%chlorhexidine 2-2 3. 3-1PPE 3-2PPE 3-3 4. 4-1 chlorhexidine ICURCC CVCother than dialysisdialysis CVCSwan-Ganz PICC Port-A Femoral JugularLower extremitypicc SubclavianUpper extremitypicc 1. 2. 2-12%chlorhexidine 2-2 3. 3-1PPE 3-2PPE 3-3 4. 4-1 chlorhexidine 1 36
37 (2014/mm/dd) 2014 1 2 3 4 1 1 1 1 1,2 3 1 22%chlorhexidine 70%-75%3 3 7 24propofol12
38 Care Bundle for Prevention of CLABSI (24) ~ ICURCC 01 02 03 04 1 1 2/ 3 4 5 1 1 2/ 3 4 5 1 1 2/ 3 4 5 2 1 2/ 3 4 5 2 1 2/ 3 4 5 2 1 2/ 3 4 5 3 1 2/ 3 4 5 3 1 2/ 3 4 5 3 1 2/ 3 4 5 4 1 2/ 3 4 5 4 1 2/ 3 4 5 4 1 2/ 3 4 5 5 1 2/ 3 4 5 5 1 2/ 3 4 5 5 1 2/ 3 4 5
CDC2008NHSN () 48 () 1 (1) 1 (2) 1 90mmHg 2 diphtheroids [Corynebacterium spp. not C. diphtheriae], Bacillus spp. [not B. anthracis], Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridians group streptococci, Aerococcus spp., Micrococcus spp. (3) 1 1 2 39
Care Bundle for Prevention of CLABSI 2 1 1 (1) (2) (3) 48 1 2 31CVC Double Lumen1 40
2007 Leapfrog Group 1,256 87% 35.4%[8] [9,10] CVC care bundle 41
Care Bundle for Prevention of CLABSI CVC care bundlecvc care bundle CVC care bundle 7 CVCCVC CVC CVC care bundlecvc care bundle 1 42
2011CDC [12] [13] 1980Donabedian [14] The Joint Commission,TJC Indicator Measurement System, IM System [15] 95% [16] 43
Care Bundle for Prevention of CLABSI 95% PDCA FOCUS-PDCA Finding Organize Clarity Understanding Selection Plan Do Check Action FOCUS-PDCA FOCUS-PDCA Finding 6W1H What Where When Whom 44
Which Who How Organize whom Clarity 90% 90% 1 2 45
Care Bundle for Prevention of CLABSI 3 Understanding Selection 1 2 3 (1) (2) (3) (4) 5 46
Plan 6W1H Do Check baseline rate 47
Care Bundle for Prevention of CLABSI Action PDCA 2009 ICU 200931ICU 3BICU13ICU CLABSI ICU ICUICU ICU 48
ICUCLABSI 3BICUCLABSI CLABSIICU 4044% CLABSI6.11 10006.11 3BICU 20099CLABSI 6.11 4.35 2009920107 3BICU ICU ICUCLABSI20096.11 2010 4.37 10.628.19.3 25.6 3BICU2012813 6BICUCLABSI 20104.25 20116.0 20128.55 201111 2% chlorhexidine gluconate CLABSI2012 CVC care bundle CVC care bundle benchmarking CLABSI 49
Care Bundle for Prevention of CLABSI 2011CVC care bundle Healthcare Failure Mode and Effects Analysis, HFMEA Team Resource Management, TRM CLABSI20121~38.55 20124~73.02 20128~102.93 5 hand hygiene2% chlorhexidine 100%100%CVC5.6 ICU7.2/19.6/23.2/ CLABSI201211~20132 2.84 CLABSI 1 CVC care bundle ICU 50
post graduate yearpgycvc PGYObjective Structured Clinical Examination, OSCE CVC PGY CVC 51
Care Bundle for Prevention of CLABSI 1-2 OSCE OSCE 3-4 CVC CVC 5-6 OSCE 5-12 DOPS OSCE OSCEPGY undergraduate year, UGYCVC PGY12CVCOSCE OSCE OSCE CVC CVCCVC 52
Direct Observation of Procedural Skills, DOPS PGY PGYCVC DOPS E-PortfolioGoogle e CVC1 OSCEPGYOSCE 1 A B C D DOPSPGY 53
Care Bundle for Prevention of CLABSI CDC 54
20 1 3 2 3 3 5 4 4 M PM NM 3 M. PM. NM. 3 1 0 1. 12 M. NM. 1 0 2. 2 M. PM. NM. 2 1 0 5 20 M.3 1) 2) 205 3) PM.M12 NM. 1) 2) 120 5 5 3 0 1. 1 M. NM. 1 0 2. 3 M. PM. 1) 2) NM. 3 1 0 55
Care Bundle for Prevention of CLABSI 5 5 6.1 4 6.2 7 18 5 M PM NM 5 20 M.2 1) 2) 205 PM.M12 NM. 1) 2) 120 5 5 3 0 4 M. PM. NM. 4 2 0 1. 122% chlohexidine M.3 1) 2% chlohexidine 1 2) 15 3) PM. 1) 2% chlohexidine 15 [-3~-5 2) -3 3) -4 NM. 1) 2) 2% chlohexidine 3) 2% chlohexidine 12 9~2 0 2. 6 M. NM. 6 0 5 20 M.2 1) 2) 205 PM.M12 NM. 1) 2) 120 5 5 3 0 56
8 5 1. 3 A M. PM. 1) 2) NM. 1) 2) M PM NM B M. PM. 1) 2) NM. 1) 2) 3 2 0 2. 2 A M. PM. NM. 1) 2) B M. PM. NM. 1) 2) 2 1 0 57
Care Bundle for Prevention of CLABSI 9 5 10 12 11 3 M PM NM 5 M. 1) 2) 3 PM. 1) 3 2) 3 3) NM. 1) 2) 3) 5 3 0 1. 1 1 M. NM. 1 0 1. 2 2 M. NM. 2 0 1. 3 4 M.2% XylocaineCVP NM. 4 0 1. 4 guide wire 2. 5 M. NM. 5 0 3 M. PM. NM. 3 2 0 58
M PM NM 12 4 4 M.4 1) 2) 3) 4) 7 PM. 1) -1 2) -1 3) -1 4) 7-1 NM. 1) 2) 3) 4) 4 3~0 0 13 1 1 M.3 1) 2) 3) NM. 1) 2) 3) 1 0 14 2 2 (1) (2) (3) M. PM. NM. 2 1 0 59
Care Bundle for Prevention of CLABSI 15 16 17 5 3 8 M PM NM 520 M.2 1) 2) 205 PM.M12 NM. 1) 2) 120 5 5 3 0 3 M.X NM. 3 0 8 0 60
A 1 2 5 4 3 3 4 5 5 6 M PM NM 5 20 M.2 1) 2) 205 PM.M12 NM. 1) 2) 120 5 5 3 0 4 M. NM. 4 0 2 M. PM. NM. 3 1 0 5 M.7 NM. 5 0 1. 5 M. PM. NM. 5 3 0 2. 1 M. NM. 1 0 61
Care Bundle for Prevention of CLABSI 6 7 5 4 8 15 M PM NM 5 20 M.2 1) 2) 205 PM.M12 NM. 1) 2) 120 5 5 3 0 4 M. NM. 4 0 1. 4 M. PM. 1) 2) NM. 4 2 0 2. 8 M.2 1) 2% chlohexidine 1 2) 3) PM. 1) 2% chlohexidine -2~-4 2) -2 NM.2% chlohexidine 8 6~2 0 3. 3 M. NM. 3 0 62
9 10 B 5 5 1 10 2 5 M PM NM 5 M.3 1) 2) 3)7 PM. 1) -1 2) -1 3) 7-1 NM. 1) 2) 5 4~2 0 5 20 M.2 1) 2) 205 PM.M12 NM. 1) 2) 120 5 5 3 0 1. 8 M.5 PM. 5 NM. 1) 2) 5 3) 70-75%2% chlohexidine 8 6 0 2.2 M. NM. 2 0 524 5 0 63
Care Bundle for Prevention of CLABSI 64
TNIS2011 70-80% 2012-2013 201357 2014103 2012-2013 2% chlorhexidine 5 65
Care Bundle for Prevention of CLABSI 66
1.Stone PW. Hedblom EC. Murphy DM. Miller SB. The economic impact of infection control: making the business case for increased infection control resources. American Journal of Infection Control.2005;33(9):542-7. 2. Perencevich EN. Stone PW. Wright SB. Carmeli Y. Fisman DN. Cosgrove SE. Raising standards while watching the bottom line: making a business case for infection control. Infection Control and Hospital Epidemiology 2007;28(10):1121-33. 3. Edwards JR, Peterson KD, Banerjee S, et al. National Healthcare Safety Network(NHSN) report: Data summary for 2006 through 2008, issued December 2009. Am J Infect control 2009; 37:783-805. 4. Harbarth, S. The preventable proportion of nosocomial infections: an overview of published reports. J Hosp Infect. 2003;54:258-266. 5. Sheng WH, Wang JT, Lu DC, Chie WC, Chen YC, Chang SC. Comparative impact of hospital acquired infections on medical costs, length of hospital stay and outcome between community hospitals and medical centers. Journal of Hospital Infection 2005; 59(3):205-14. 6. http://www.ihi.org/ihi/topics/criticalcare/intensivecare/changes/ ImplementtheCentralLineBundle.htm. Access on Dec 9, 2010. 7. Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med 2006; 355:2725-2732. Health Care Quality. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. (Available on 67
Care Bundle for Prevention of CLABSI www.ihi.org) 9. How-to Guide: Prevent Central Line-Associated Bloodstream Infections (CLABSI). Cambridge, MA: Institute for Healthcare Improvement; 2012. (Available at www.ihi.org) 10.O Grady NP, Alexander M, Burns LA, et al: Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. 2011. 11.2011 201222175-188. 12.O'Grady NP, Alexander M, Burns LA, et al (2011, April 1). Guidelines for the Prevention of Intravascular Catheter-Related Infections. Available http:// www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf 13.2005115203.71.88.129/ genermed/course/9401.ppt 14.6.Donabedian Arediss.1998. The Definition of Quality and Approaches to its Assessment, Explorations in Quality Assessment and Monitoring Vol.1 Health Administration Press Ann ArborMichigan. 15. 2007;3:37-44 16.IHI(2011, April 6). Central Line Bundle Compliance. Available http://www. ihi.org/knowledge/pages/measures/centrallinebundlecompliancerate.aspx 68
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Care Bundle for Prevention of CLABSI 70
1. 2. CVCcentral venous catheterdouble Lumen Swan-Ganz PICCOpulse contour cardiac output 3. 4-1 2% Chlorhexidine 4-2 22% Chlorhexidine 5-1 5-2 6. 48 7-1 Tegaderm7 7-2 7 8. 2% Chlorhexidine 9. 10. 71
Care Bundle for Prevention of CLABSI 11. 1 2 3 4 5 72
14. 15. 16. 20 21~30 31~40 41~50 51~60 60 17. 11 133 355 510 10 18. 19. 20. 73
Care Bundle for Prevention of CLABSI Q1 A1 (1) (2) Q2 A2 Q12% Chlorhexidine A12% Chlorhexidine 2% Chlorhexidine SSIBSI Chlorhexidine2% Chlorhexidine Q2Port-A Port-A A2Port-A 74
Port-A Q3 A3 2 Q4 PPE A4PPE Q5 A5 Q6 A6 Q7CVC 75
Care Bundle for Prevention of CLABSI A7 3 3 Q8 A8 300152-180 10010-12 Q9 A9 2% chlorhexidine70%-75% Q10 A101 22 1 7 24 propofol12 Q11 A11 76
Q12 A12 Q1JCIXylocaine A1 Q2 A2 5 Q3 A3 Q4 A4 77
Care Bundle for Prevention of CLABSI Q1??? A1 59 810 Q2 A2 Q3 A3 - - Q4Port-A A448 Port-A 78
Q5 CLABSI2 CLABSI A5 (1) CLABSI (2) CLABSI 79
Care Bundle for Prevention of CLABSI 5 1 monitor 2Alarm 80
Opportunity Indication 1. 2.3. 4.5. Action Action IndicationOpportunityAction 81
Care Bundle for Prevention of CLABSI 9 61462a befhi 43 146 3 235 82
2 3 1Before touching a patient When Example 1 2 1 2Before clean/aseptic procedure 83
Care Bundle for Prevention of CLABSI When Example airways /A-V shuntdouble Lumen 1 2 3 2 3 84
When 2 Example 1 2 3 1 232 33 4 5 63 3 4After touching a patient 4 85
Care Bundle for Prevention of CLABSI 1 1 141 2 4 33 4 4 5After touching patient surroundings 5 When Example monitor 1 245 5 86
IV pumpiv 5IV pump 1 2 1 2 3 1 2 3 87
Care Bundle for Prevention of Central Line-Associated Bloodstream Infection /. - -. - -, 2015. 08. - - 016 ISBN 978-986-04-5749-0 1. 2. 419.6 104017057 Care Bundle for Prevention of Central Line-Associated Bloodstream Infection (CLABSI) 6 02-23959825 www.cdc.gov.tw 02-2931-1544 20158 450 (202) 022463-6590 (104)2091 (02)2518-0207 (100)160 (02)2368-3380 (110)11 (02)8789-3388 (400)6 (04)2226-0330 (407)240 (04)2705-5800 (408)1 (04)2385-3672 (640)1221 (05)534-8939 (800)290 07235-1960 (900)46-2 08732-4020 http://www.govbooks.com.tw http://www.wunanbooks.com.tw/ http://www.eslitebooks.com/ http://www.books.com.tw/ GPN 1010401624 ISBN 978-986-04-5749-0