成人外科加護病房應用Chlorhexidine漱口水行口腔護理是否可降低呼吸器相關肺炎發生率Effectiveness of oral care with chlorhexidine mouthwash on ventilator-associated pneumonia in the adult surgical intensive care unit

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2020-04-27 已刊登
新刊登 綜 整 預防/治療/介入類型

作  者

陳俊璋* 龔貞寧

實證知識類別

B 類:實證健康照護應用

PICO

治療/預防性問題

治療/介入措施

其他 other

科別

  • 重症護理 Critical Care Nursing
  • 臨床指引/實證照護成效 Clinical Guidelines/Evidence Based Outcomes

中文關鍵詞

Chlorhexidine 口腔護理 呼吸器相關肺炎

英文關鍵詞

Chlorhexidine oral care ventilator-associated pneumonia

機構名稱

奇美醫療財團法人奇美醫院

申請單位

外科加護病房

中文摘要

形成臨床提問:
形成臨床提問-探討使用含Chlorhexidine漱口水於口腔護理之效益? PICO-P:成人加護病房使用呼吸器病人、I:使用含Chlorhexidine漱口水、C:一般口腔護理、O:呼吸器相關肺炎感發生率。
文獻搜尋的方法與分析:
文獻搜尋的方法與分析-本文以PICO形成問題,採分層式搜索,依據P、I、C、O關鍵字(MeSH)及其同義字(Synonyms),運用布林邏輯中OR、AND,制定搜尋策略搜尋Cochrane database、Pubmed、CINAL等資料庫進行搜尋,以統合分析、系統性文獻回顧、隨機控制試驗文章為主。
文獻的品質評讀:
文獻的品質評讀-搜尋結果:英文文獻共67篇,排除與研究主題不相關文獻後,共評讀4篇文獻。採用2013年版的CASP、牛津大學實證醫學中心的臨床研究證據等級「Oxford Centre for Evidence- Based Medicine 2011 Levels of Evidence」作為評讀工具。
證據之臨床應用:
證據之臨床應用-運用實證知識轉譯之7步驟進行改善。研究設計為前後對照研究(Controlled before-and-after study),收案期間自2018 年 9 月 1 日至 2019 年 2 月 28 日及2019 年 4 月 1 日至 2019 年 9 月 30 日,研究地點採立意取樣,選擇南部某醫學中心之外科成人加護病房,介入期間以0.12-0.2% Chlorhexidine漱口水進行口腔護理。
成效評值:
成效評值-以本院感染控制中心統計報表為主,比較前後對照時間之呼吸器引起相關肺炎之發生率。2019 年 4 月 1 日至 2019 年 9 月 30 日,於0.12~0.2% chlorhexidine漱口水介入口腔護理後,本外科加護病房使用呼吸器人次共577人,共感染3人次。呼吸器相關肺炎發生率介入前為1.28% (7/545),介入後為0.52%(3/577),進行統計檢定後P值(>0.05),無顯著差異。
結論與建議:
本文探討0.12~0.2% chlorhexidine漱口水是否能降低呼吸器相關肺炎發生率,透過實證方法進行文獻評讀,篩選最終策略進行臨床應用。結果發現發生率於統計檢定上並無顯著差異。討論其影響因素可能與病人疾病狀況、氣管內管留置天數及護理人員技術執行缺失、漱口水濃度未達標準等相關。本文chlorhexidine漱口水介入時機多為放置氣管內管後,文獻建議預期性插管病人,應於插管前開始使用,未來可考慮推行至一般病房予預計手術中插管患者使用,提升口腔衛生護理品質,以降低呼吸器相關肺炎發生率。

英文摘要

Ask an answerable question (PICO):
Build up a clinical question: explore the benefits of using chlorhexidine mouthwash for oral care. PICO: P: adult patients using a ventilator in intensive care unit; I: chlorhexidine mouthwash; C: oral care; O: incidence of ventilator-associated pneumonia.
The Method and Analysis of Literature Review:
This article builds up a question with PICO and use the method of hierarchical search. According to the keywords (MeSH) and their synonyms. Using OR, AND in Boolean Logic to develop strategy to search the database of Cochrane, Pubmed and CINAL. Based on meta-analysis, systematic review, and randomized controlled trial articles.
Critical Appraisal:
Searching results: there are 67 articles in English. We excluded the topics that are not related. Finally, four articles were reviewed. Using the Critical Appraisal Skills Programme(CASP, 2013)and Oxford Centre for Evidence- Based Medicine 2011 Levels of Evidence as the appraising tool.
Clinical Application of Evidence:
Using 7 steps of empirical knowledge translation to improve the question.The study was designed as a pre-and post-test intervention. The study was started from September 1, 2018 to September 30, 2019. The study location was the surgical intensive care unit. During the intervention, 0.12-0.2% chlorhexidine mouthwash was used to replace initial oral care.
Evaluation of Effectiveness:
Compare the infection density of ventilator-associated pneumonia pre-and post-test intervention. According to the data from the infection control center in our hospital. During April 1, 2019 to September 30, 2019, there were 3 infections in our unit. The incidence of ventilator-associated pneumonia in the test group was lower than that in the control group. In the statistical analysis, the P value (> 0.05) showed non-significant.
Conclusions and Recommendations:
This article explores whether 0.12-0.2% chlorhexidine mouthwash can reduce ventilator-associated pneumonia or not. The statistical analysis was no significant difference. The influencing factors may include the days of ventilator use, disease severity, incomplete oral care operation methods and the concentration of mouthwash not reaching the standard. In this article, the timing of chlorhexidine mouthwash intervention is mostly after intubation. But the literature recommends that prospective intubation patients should be used before intubation. In the future, we will be implemented the chlorhexidine mouthwash to the preoperative patients in general wards. It is expected to improve the quality of oral care and reduce the incidence of ventilator-associated pneumonia.