降低新生儿重症监护室极低出生体重早产儿抗生素使用时间的质量改进研究

A quality improvement project on reducing antibiotic use duration in very low birth weight preterm infants in the neonatal intensive care unit

摘要:

目的 应用质量改进的方法，制定降低新生儿重症监护室极低出生体重（very low birth weight, VLBW）早产儿抗生素使用时间的有效措施，以减少抗生素的使用。方法 以住院VLBW早产儿为研究对象，以2020年11月—2021年6月VLBW早产儿住院期间抗生素使用时间占住院时间百分比作为基线值，以降低抗生素使用时间占住院时间百分比为具体质量改进目标。应用帕累托图分析影响早产儿抗生素使用时间的因素。根据抗生素使用的各个环节构建关键驱动图，确定质量改进的关键环节和具体的干预措施。通过运行图监测VLBW早产儿抗生素使用时间占住院时间百分比的变化直至达到质量改进目标。结果 2020年11月—2021年6月VLBW早产儿抗生素使用时间占住院时间百分比在质量改进前为49%（基线值），设定质量改进目标为12个月内将该百分比降低10%。帕累托图分析显示影响早产儿的抗生素使用时间的主要因素为：抗生素使用不规范；无感染证据时未及时停用抗生素；中心静脉置管留置时间长；袋鼠式护理应用不足；肠内营养进程延迟。质量改进采取的干预措施包括：（1）制定败血症评估管理规范；（2）对医护人员进行关于早产儿抗生素合理使用的宣教；（3）查房时监督抗生素使用规范的执行性；（4）无明确感染表现且血培养阴性者，抗生素使用36 h后停止使用；（5）减少中心静脉置管及肠外营养时间，降低早产儿感染风险。控制图显示，随着干预措施的实施，VLBW早产儿抗生素使用时间占住院时间百分比由49%降低至32%，具有统计学意义。结论 应用基于统计原理、过程控制的质量改进工具及质量改进措施后，VLBW早产儿的抗生素使用时间可得到显著降低。

Abstract:

Objective To develop effective measures to reduce antibiotic use duration in very low birth weight (VLBW) preterm infants in the neonatal intensive care unit through quality improvement methods.Methods The study population consisted of hospitalized VLBW preterm infants, with the percentage of hospitalization time during which antibiotics were used from November 2020 to June 2021 serving as the baseline. The specific quality improvement goal was to reduce the duration of antibiotic use. Factors affecting antibiotic use duration in preterm infants were analyzed using Pareto charts. Key drivers were identified, and specific interventions were formulated based on the stages of antibiotic use. Changes in the percentage of antibiotic use duration were monitored with run charts until the quality improvement target was achieved.Results From November 2020 to June 2021, the baseline antibiotic use duration percentage was 49%, with a quality improvement target to reduce this by 10% within 12 months. The Pareto analysis indicated that major factors influencing antibiotic duration included non-standard antibiotic use; delayed cessation of antibiotics when no infection evidence was present; prolonged central venous catheter placement; insufficient application of kangaroo care; and delayed progress in enteral nutrition. The interventions implemented included: (1) establishing sepsis evaluation and management standards; (2) educating medical staff on the rational use of antibiotics for preterm infants; (3) supervising the enforcement of antibiotic use standards during ward rounds; (4) for those without clear signs of infection and with negative blood cultures, discontinued the use of antibiotics 36 hours after initiation; (5) reducing the duration of central venous catheterization and parenteral nutrition to lower the risk of infection in preterm infants. The control chart showed that with continuous implementation of interventions, the percentage of antibiotic use duration was reduced from 49% to 32%, a statistically significant decrease.Conclusions The application of quality improvement tools based on statistical principles and process control may significantly reduce the antibiotic use duration in VLBW preterm infants. Citation:Chinese Journal of Contemporary Pediatrics, 2024, 26(7): 736-742