提高急诊重症监护室患者痰标本送检率和阳性率的管理措施

The management measures for improvement the delivering and positive rate of sputum specimen in emergency ICU patients

目的探讨提高急诊重症监护病房（emergency intensive care unit，EICU）患者痰标本送检率和阳性率的管理措施。方法选取2015年7月至2016年2月入住新疆维吾尔自治区胸科医院EICU的肺部疾病患者206例。将2015年7月至10月的110例患者作为对照组，留取痰标本786例（份），采用早晨常规集中留取痰标本一次性送检的方法；将2015年11月至2016年2月的96例患者作为观察组，留取痰标本769例（份），通过全科护理人员系统学习留取痰标本知识、制定留取痰标本流程、医务人员（医生、护士、医技、护工）相互配合、护士长加强制度落实和流程监管等措施留取痰标本分次送检。两组均依照患者病情以患者自行咯出、气管插管吸痰、纤维支气管镜（简称“纤支镜”）吸痰3种方式采集痰标本，再依医嘱行痰涂片抗酸染色（简称“痰涂片”）、和（或）MTB培养、和（或）普通细菌培养的检测。实施4个月后，采用SPSSl7．0软件进行资料的统计和分析，两组患者痰标本送检率、不同检测方法采痰方式检出的阳性率、合格率的比较采用z。检验，以P〈0．05为差异有统计学意义。结果观察组、对照组的痰标本送检率分别为80．5％（769／955）、55．2％（786／1423），差异有统计学意义（χ^2=4．86，P=0．027）。两组采用痰涂片、MTB培养、普通细菌培养检测的阳性率均有提高[26．6％（115／432），19．7％（114／580）；46．7％（50／107），34．1％（46／135）；31．7％（73／230），21．1％（15／71）]，差异均有统计学意义（χ^2=3．99，P=0．046；χ^2=4．48，P=0．034；χ^2=6．25，P=0．012）。观察组和对照组患者不同方法（自行咯出、气管插管后吸出、经纤支镜吸出）采集痰标本的合格率[78．5％（386／492），60．0％（332／553）；97．8％（175／179），91．7％（132／144）；95．9％（94／98），95．5％（85／89）]和阳性率[24．6％（121／492），14．2％（79／553）；38．5％（69／179），37．5％（54／144）；49．0％（48／98），47．1％（42／89]比较，患者自行咯出的合格率与阳性率差异均有统计学意义（χ^2合格率=4．51，P=0.033；χ^2阳性率=3．99，P=0．046），而气管插管及经纤支镜采集痰标本患者的合格率差异均无统计学意义（χ^2插管=0.70，P=0．404；χ^2纤支镜=0．20，P=0.654）和阳性率（χ^2插管=0.56，P=0.453；χ^2纤支镜=0．05，P=0．821）。结论在EICU通过实施一系列痰标本留取改进措施，有助于提高痰标本的送检率和检测阳性率。

Objective To evaluate the management measures for of sputum specimen in emergency intensive care unit （EICU） patients. Improvement the delivering and positive rate Methods Two hundred and six patients with pulmonary disease admitted in the EICU of Xiniiang Uygur Autonomous Region chest hospital as research ob- ject during July 2015 to February 2016. All patients admitted during July 2015 to October 2015 as control group which 786 morning sputa were collected according to the original hospital management measure. All patients admitted during November 2015 to February 2016 as observation group which 769 morning sputa were collected according to the new hospital management measure. The new management measures were trained in all nurse staff of EICU for four months： The morning sputum which collected via sputum expectoration, sputum aspiration through tracheal cannula and sputum aspiration through bronchoscopy from all patients was performed with acid-fast staining, culture for mycobacterium tuberculosis （MTB） and other bacteria. The data was analyzed using SPSS software 17.0 for Windows. Delivering rate, positive rate and qualified rate in all patients were analy-zedwith Chi-square test. P〈0. 05 was considered as significant difference. Results The delivering rates of morning sputum were 80. 5% （769/955） and 55.2% （786/1423） with statistically significant difference （χ^2= 4.86, P= 0. 027）. The positive rates of acid-fast staining, euhure for MTB and other bacteria （26.6% （115/432）, 46.70/00 （50/107） and 31.7% （73/230）） in the observation group were higher than those （19.7% （114/580）, 34.1% （46/135） and 21.1%（15/71）） in the control group. The differences were statistically significant （χ^2 smear= 3.99,P= 0. 046;χ^2 culture for MTB= 4.48, P=0. 034;χ^2 culture for other bacteria= 6.25, P= 0. 012. ）. The qualified rates of sputum expectoration, sputum aspiration through tracheal cannula and sputum aspiration through hronchoscopy were 78.5% （386/492）, 97.8% （175/179）, and 95.9% （94/98） in observation group and 60.0% （332/553）, 91.7% （132/144）, and 95.5% （85/89） in the control group, respectively. The positive rates of the three ways collected sputum were 24. 6% （121/492）, 38. 5% （69/179）, and 49.0% （48/98） in the observation group and, and 14.2% （79/553）, 37. 5% （54/144）, and 47.1% （42/89） in the control group, respectively. The difference of qualified rate and positive rate of sputum expectoration in two groups was significant statistically （χ^2qualified rate = 4.51, P = 0. 033; χ^2positive rate= 3.99, P=0. 046）. However, the difference of qualified rate and positive rate of sputum aspiration through tracheal eannula and sputum aspiration through hronchoscopy in two groups was not significant （（χ^2tracheal cannula= 0. 70, P= 0. 404, χ^2bronchosoopy=0.20,P=0. 654 and χ^2tracheal=0.56,P=0. 453, χ^2bronchoscopy =0. 05, P=0.821）. Conclusion The new management measure for sputum collection is helpful to improve the rate of sputum delivering and positivity in the EICU.