使用含CHG敷料是否能降低留置中心靜脈導管病人之血流感染率Whether chlorhexidine gluconate dressing can reduce the central line-associated bloodstream infection of patients with indwelling central venous catheter

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2020-03-10 已刊登
新刊登 綜 整 預防/治療/介入類型

作  者

劉羽紋 呂婧希* 陳雅惠 蔡佩臻

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

感染性疾病 Infectious Diseases

科別

  • 感染/傳染性疾病護理 Infectious / Communicable Disease Nursing
  • 傷口照護/造口/失禁照護護理 Wound Care / Ostomy / Continence Care Nursing
  • 臨床指引/實證照護成效 Clinical Guidelines/Evidence Based Outcomes

中文關鍵詞

CHG敷料 中心靜脈導管 血流感染

英文關鍵詞

chlorhexidine gluconate dressing central venous catheter bloodstream infection

機構名稱

長庚醫療財團法人林口長庚紀念醫院

申請單位

護理部

中文摘要

形成臨床提問:
中心靜脈導管相關血流感染(Central line-associated bloodstream infection, CLABSI)是造成醫療照護相關感染的首因,近幾年被列為提升病人安全工作的目標之一,然在推行組合式照護措施下,卻無法讓血流感染率降為零。各研究對使用chlorhexidine gluconate(CHG)敷料來預防CLABSI的成效不一,故本文以實證方式來驗證CHG敷料於降低CLABSI的效益性,故形成臨床問題為:「使用含CHG敷料是否能降低留置中心靜脈導管病人之血流感染率?」。
文獻搜尋的方法與分析:
透過PICO建立關鍵字及同義字,以布林邏輯原則,於Cochrane library、Embase、PubMed、CEPS華藝中文電子期刊進行搜尋,共得344篇文獻,依納入及排除條件篩選後,選定1篇隨機對照試驗研究及2篇系統性文獻統合分析,以CASP針對有效性、重要性及應用性評析,並依據2011年Oxford證據分類標準來進行等級分類。
文獻的品質評讀:
CASP針對3篇文獻之有效性、重要性及應用性評讀,證據等級依Oxford標準評定介於Level 1-2。3篇文獻皆比較CHG敷料與其它敷料對預防CLABSI的成效,但3篇結論對CHG敷料預防CLABSI的看法存爭議:第1篇結論指出Chlorhexidine gluconate-impregnated (CGI)浸漬敷料可降低CLABSI (p=.022),第2篇亦是認同CHG敷料能降低血流感染率(p=.004),第3篇則指出無足夠證據顯示CHG敷料較OP site(p=1.00)敷料能更有效防止血流感染發生。
證據之臨床應用:
以實證步驟為基礎,透過專案方式進行問題改善,選定本院移植加護中心為推行地點、肝移植術後有留置中心靜脈導管病人為收案對象,收案時間自2018年4月至2019年8月,將收案對象分為兩組進行比較,介入期間以CHG敷料替代OP site照護中心靜脈導管傷口。
成效評值:
自2018年10月至2019年3月,CHG敷料介入後,CLABSI發生率由7.58‰降為2.83‰、下降63%,而2019年4月至8月之維持期期間則感染人次0位,無血流感染發生。
結論與建議:
CHG敷料能有效降低CLABSI感染率、降低醫療成本支出、減少護理師換藥頻率。希望此實證結果能提供其它醫療單位做參考,也建議能將CHG敷料納入組合式照護模組中,期能達成零容忍目標。

英文摘要

Ask an answerable question (PICO):
Central line-associated bloodstream infection (CLABSI) is the first cause of health care-associated infection. It has been listed as one of annual patient safety goal in recent years. However, CVC bundle care has been implemented strictly, the bloodstream infection rate is unable to be zero. Studies results of the effectiveness of chlorhexidine gluconate (CHG) dressing in CLABSI prevention are inconsistent. The purpose of this study is to evaluate the effectiveness of CHG dressing in reducing the rate of CLABSI. The answerable question is: can CHG dressing reduce the central line-associated bloodstream infection of patients with indwelling central venous catheter?
The Method and Analysis of Literature Review:
Through Boolean logic, the study keywords and synonyms of PICO were searched on Cochrane library, Embase, PubMed and CEPS. Totally 344 literatures were obtained. After screening, one randomized controlled trial study and two systematic review with meta-analysis were selected. These three research evidences were critically appraised for validity, importance, and practicability through CASP and graded according to Oxford Center for Evidence-based Medicine 2011 Level of Evidence.
Critical Appraisal:
The CASP evaluates the validity, importance and practicability of these 3 studies. The evidence level were Level 1-2 according to the Oxford standard. The 3 studies were aimed at comparing the effectiveness of CHG dressing to other dressings on CLABSI prevention. But the conclusions were inconsistent. The first study is believed that CGI impregnated dressing can reduce the bloodstream infection rate (p=.022), and the second study also agrees that CHG dressing can reduce bloodstream infection rate (p = .004). The third study indicates that there is not enough evidence to show that CHG dressing is more effective in preventing bloodstream infection than OP site (p=1.00).
Clinical Application of Evidence:
The study was a project to improve the problems through evidence-based steps at a transplant center. Patients in this center with indwelling central venous catheter after liver transplantation were recruited into the study from April 2018 to August 2019. The subjects were divided into two groups. During the intervention, the central venous catheter wound care was dressed with the CHG dressing instead of OP site.
Evaluation of Effectiveness:
From October 2018 to March 2019, the rate of CLABSI after application of CHG dressing decreased from 7.58‰ to 2.83‰, a decline rate of 63%. What’s more, the bloodstream infection rate was zero during the maintenance period from April to August 2019.
Conclusions and Recommendations:
After using CHG dressing, we found that it can effectively reduce the rate of CLABSI, the medical costs, and the frequency of changing wound dressing. The result can provide a reference for medical institutions. It is also recommended to incorporate CHG dressing into the CVC care bundle, and it is expected that the goal of zero-tolerance will eventually be achieved.