某三甲综合性医院多重耐药菌感染风险评估模型的构建与效果评价

Construction and effect evaluation of risk assessment model for multidrug-resistant organism infection in a “top three” general hospital

目的:观察多重耐药菌(MDRO)感染风险评估模型对医院MDRO感染防控的作用。方法:采用德尔菲法识别MDRO风险因素,建立MDRO感染风险评估模型,针对不同风险等级的科室及环节进行干预。从风险评估模型认定总风险指数不同的科室中分别随机抽取两组(每组2个)科室进行前瞻性和回顾性模型效果评价,同时对住院患者进行MDRO感染风险评估,确定高危患者进行重点监测干预,观察干预前后MDRO高风险环节措施依从率、MDRO检出率和MDRO发生率的变化;对353例住院患者采用MDRO感染风险评估模型判断MDRO感染可能性,绘制受试者工作特征曲线(ROC曲线),评估MDRO感染风险评估模型。结果:耐碳青霉烯类抗菌药物鲍曼不动杆菌感染高、中高、中、中低、低风险科室分别为10、10、10、9、10个,耐碳青霉烯类抗菌药物肠杆菌科细菌感染高、中高、中、中低、低风险科室分别为11、9、10、9、10个,耐甲氧西林金黄色葡萄球菌感染高、中高、中、中低、低风险科室分别为10、10、11、9、9个,多重耐药铜绿假单胞菌感染高、中高、中、中低、低风险科室分别为10、10、10、10、9个;MDRO高、中高、中、中低、低风险环节分别为7、7、6、7、6个。干预后,24 h内开具"接触隔离"医嘱、及时规范送检微生物学标本、预计明显接触时穿隔离衣、床单元清洁消毒≥2次/d、规范执行手卫生、MDRO患者未与各种置管开放伤口或者免疫抑制患者同病房和共用物品使用后及时消毒的依从率分别比干预前同期上升18.80%、11.90%、24.61%、27.43%、9.93%、11.47%、17.37%;前瞻性研究中干预组合计MDRO检出率及发生率分别比未干预组下降14.62%和1.86%,回顾性研究中试验组合计MDRO检出率及发生率分别比对照组下降17.74%和1.99%(P <0.05)。MDRO风险评估模型ROC曲线下面积为0.768,灵敏度63.33%,特异度75.28%。结论:MDRO感染风险评估模型具有较好的风险识别效度,可对MDRO的重点科室、环节及高危患者进行有效的识别。

Objective: To observe the effect of the risk assessment model for multidrug-resistant organism(MDRO)infection on prevention and control of hospital MDRO infection. Methods: Delphi method was used to identify the risk factors, and establish the MDRO risk assessment model. Intervention was adopted for departments and links with different risk levels. Two groups(two in each group) of departments were randomly selected from departments with different total risk indexes determined by risk assessment model to evaluate the effect of prospective and retrospective models. Meanwhile, MDRO infection risk assessment was carried out for hospitalized patients to determine the highrisk patients for focusing on monitoring and intervention. The changes of measure compliance rate in high-risk links of MDRO, MDRO detection rate and MDRO incidence before and after intervention were observed. MDRO infection risk assessment model was adopted in 353 hospitalized patients to assess the possibility of MDRO infection. The receiver operating characteristic curve(ROC curve) was then drawn up to evaluate the MDRO infection risk assessment model. Results: There were 10, 10, 10, 9 and 10 departments with high, medium-high, medium, medium-low and low risk of carbapenem-resistant Acinetobacter baumannii;11, 9, 10, 9 and 10 departments with high, medium-high,medium, medium-low and low risk of carbapenem resistant Enterobacteriaceae;10, 10, 11, 9 and 9 departments with high, medium-high, medium, medium-low and low risk of methicillin-resistant Staphylococcus aureus;10, 10, 10, 10 and 9 departments with high, medium-high, medium, medium-low and low risk of Multidrug-resistant Pseudomonas aeruginosa;and 7, 7, 6, 7 and 6 links with high, medium-high, medium, medium-low and low risk of MDRO. After intervention, the compliance rates of issuing “contact isolation” doctor’s order within 24 hours, timely and standardized submission of microbiological specimens for examination, expecting to wear isolation clothing for obvious contact,cleaning and disinfection of bed unit twice a day or more, standardizing hand hygiene, MDRO not sharing the same room with various catheterized or open wounds or immunosuppressed patients, and timely disinfection of common items after using compared with those before intervention in the same period rose 18.80%, 11.90%, 24.61%, 27.43%,9.93%, 11.47%, 17.37% respectively. In the prospective study, the detection rate and incidence of MDRO in intervention group decreased by 14.62% and 1.86% than in non-intervention group, respectively. In the retrospective study, the total detection rate and incidence of MDRO in experimental group decreased by 17.74% and 1.99% than in control group, respectively. The differences were statistically significant(P<0.05). The area under ROC curve of MDRO risk assessment model was 0.768, the sensitivity was 63.33%, the specificity was 75.28%. Conclusions: MDRO infection risk assessment model has good validity of risk identification, which can effectively identify the key departments, links and high-risk patients of MDRO.