血液透析患者医院感染前瞻性目标监测及直接经济学损失评价研究
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摘要
研究背景：
医院感染是指发生在医院内的公共卫生事件,医院感染暴发给医疗安全和社会稳定造成严重影响。医院感染已经成为当今世界普遍关注的公共卫生问题,其难治性及较高的发生率和死亡率使之成为临床医疗工作中亟需解决的问题。医院感染不仅造成病人住院天数延长,增加了病死率,给病人健康和生命安全带来极大威胁,而且还影响一些高新技术的开展,如：器官移植和一些高难度手术往往由于难以控制医院感染而失败,造成医疗资源的浪费,直接经济学损失严重。因此,对医院感染开展前瞻性目标监测及直接经济学损失评价研究,研究发现医院感染的影响因素等潜在问题,研究制定并实施干预措施,避免医院感染的流行与暴发,为卫生行政部门和医院管理者制定相关法律法规和防控规章制度提供科学依据,意义重大。
临床资料研究显示,近年来慢性肾功能衰竭的患者越来越多,进行血液透析的患者也日益增多。在进行血液透析过程中,医院感染是其最常见的并发症,也是引起患者死亡的主要原因之一。在医院各科室感染发生率调查中,血液透析病房为感染高发科室,医院感染率高达14.2%～49.2%。2009年2月至2011年12月,国内几家医院先后发生了4起血液透析患者医院感染暴发事件,造成了严重的社会不良影响,引起卫生部门的高度重视。
文献资料研究显示,目前国内仅查到对血液透析患者医院感染相关因素进行回顾性调查研究与分析的文献。国外加拿大有关于血液透析患者医院血流感染的成本效益分析及预防和控制的研究,但是尚未检索到使用自行设计目标性监测调查表,采取前瞻性监测方法对血液透析患者医院感染影响因素进行调查和干预,并对其经济学损失进行评价研究的文献报道。
综上所述,本研究选择血液透析患者医院感染为研究对象,采用自行设计的目标性监测调查表,应用前瞻性监测方法对血液透析患者医院感染的影响因素和感染规律等进行全面系统地研究,对血液透析患者医院感染的直接经济学损失进行评价研究,研究提出针对性干预措施并组织实施,降低医院感染发生率,对避免医院感染的流行与暴发具有重要的现实意义。本研究具有极高的研究和应用价值。
研究目标：
本研究的总体目标是,通过前瞻性研究方法研究分析某省三级甲等医院血液透析患者的医院感染现状以及医院感染所致的直接经济学损失,发现医院感染的影响因素并针对影响因素提出干预性措施并实施,从而降低血液透析患者医院感染发生率,保障患者的医疗安全,减少患者的直接经济学损失,缩短血液透析患者的住院天数,提高患者的生活质量。具体目标包括：探明血液透析患者医院感染发生的现状、特点、医院感染部位及病原菌分布情况；分析医院感染发生的影响因素及感染环节；研究分析血液透析患者医院感染所致的直接经济学损失及其影响因素,并进行评价研究,以提高医院感染防控意识,减少卫生资源的浪费,为卫生行政部门和医院管理者制定相关法律法规和规章制度提供科学依据。
研究方法：
通过整群抽样的方法,对某省某三级甲等医院2008年1月1日至2012年12月31日日所有入住血液透析病房进行血液透析治疗的1184例患者进行前瞻性目标监测。由课题组成员填写自行设计的《血液透析患者医院感染前瞻性目标监测调查表》、《血液透析患者医院感染病例调查表》和《血液透析患者医院感染直接经济学损失调查表》,调查血液透析患者的一般资料、医院感染发生的现状以及患者的住院费用和住院天数等。通过卡方检验等方法分析各影响因素与医院感染的关系。利用logistic回归分析方法,将对医院感染具有显著意义的影响因素进行多元逐步回归分析。将发生医院感染的患者作为病例组,同期未发生医院感染的作为对照组,比较其住院费用和住院天数的差异,研究分析血液透析患者医院感染导致的直接经济学损失。所有数据采用SPSS19.0统计软件进行统计学处理。
研究结果：
1.研究样本共1184例患者,男794名,女390名；年龄最小12岁,最大89岁,平均年龄为(49.08-17.12)岁；60岁以下患者783例,60岁及以上患者401例。
2.在1184例血液透析患者中,有136例发生医院感染,医院感染发生率平均为11.49%。有151例次发生医院感染,医院感染例次发生率平均为12.75%。2008年至2012年血液透析患者医院感染发生率和医院感染例次发生率均呈逐年下降趋势。医院感染发生率从2008年的17.05%下降到2012年的6.14%。医院感染例次发生率从2008年的18.43%下降到2012年的7.58%。
3.在151例次医院感染中,下呼吸道感染发生最多,为61例次(占41.50%)；其次为上呼吸道感染,32例次(占21.19%)；导管相关感染发生26例次(占17.22%);泌尿道感染发生17例次(占11.26%),胃肠道感染发生5例次(占3.31%),其他感染发生10例次(占6.62%)。
4.在所有发生医院感染患者中共检出病原菌138株,革兰氏阴性菌67株(占48.55%),革兰氏阳性菌60株(占43.48%),真菌8株(占5.80%),病毒3株(占2.7%)。革兰氏阴性菌中以干燥奈瑟氏菌最多,革兰氏阳性菌中最常见的为草绿色链球菌,真菌中以白色念珠菌最多；病毒感染中以巨细胞病毒最多。
5.分析不同类别血液透析患者发生医院感染情况,通过卡方检验发现医院感染发生率在患者年龄、住院天数、透析天数、血红蛋白、体重指数、白细胞计数、尿量、置管部位、置管天数、社区感染情况和基础疾病等方面差异有统计学意义(P<0.05)而不同性别、住院季节的血液透析患者医院感染发生率差异无统计学意义(P>0.05)。
6.分析血液透析患者伴有不同基础疾病发生医院感染情况,通过卡方检验发现贫血、慢性肾小球肾炎、电解质紊乱以及类风湿性关节炎是医院感染发生的影响因素(P<0.05),而患高血压、糖尿病、心脏疾病、糖尿病肾病等疾病的患者医院感染发生率差异无统计学意义(P>0.05)。
7.医院感染影响因素的非条件logistic逐步回归分析结果显示年龄、基础疾病数量、置管部位、置管天数和尿量是医院感染发生的显著影响因素,差异有统计学意义(P<0.05)。
8.病例组(感染组)住院总费用最低为4044元,最高为255086元,中位数为32269元。对照组(非感染组)住院总费用最低为480元,最高为163718元,中位数为14872元,病例组大于对照组。中位数差值为17397元,即血液透析患者医院感染直接经济学损失为17397元。
9.比较病例组和对照组的各项住院费用发现,病例组的各项住院费用均高于对照组,差异有统计学意义(P<0.05)。在各项费用中,损失最多的为药物费,构成比为49.31%；其次为治疗费和化验费,其构成比分别为33.14%和8.34%,损失最少的为诊疗费,构成比为0.33%。
10.分析血液透析患者不同医院感染部位的直接经济学损失发现,不同感染部位的病例组住院总费用均高于对照组,差异有统计学意义(P<0.05),并且多部位医院感染的病例组住院总费用高于单部位医院感染,直接经济学损失更大,为30946元。在单部位医院感染中,泌尿道医院感染所致的直接经济学损失最大,为23772元,其次为导管相关感染所致的经济学损失,为10257元。
11.比较不同年龄段的血液透析患者发生医院感染后直接经济学损失发现：不同年龄段患者医院感染所致的经济学损失不同,各年龄段病例组的住院总费用均高于对照组,差异有统计学意义(P<0.05),12-17岁血液透析患者发生医院感染后直接经济学损失最大,为74597元；其次为年龄大于60岁的血液透析患者,发生医院感染后直接经济学损失为22319元。
12.通过秩和检验分析病例组和对照组住院天数,结果显示病例组住院天数中位数为41天,对照组住院天数中位数为25天,两者差值为16天,差异有统计学意义(P<0.01),表明每例血液透析患者发生医院感染后延长住院天数16天。
13.比较不同感染部位血液透析患者发生医院感染后延长住院天数发现,不同感染部位病例组住院天数均比对照组的住院天数长,住院天数中位数差异均有统计学意义(P<0.05)。不同感染部位所致住院天数延长的时间亦不相同,但是发生多部位医院感染时,对患者住院天数影响最大,延长住院天数最长为35天。
14.分析不同年龄段病例组与对照组的住院天数差异发现：各个年龄段病例组住院天数均比对照组的住院天数长,病例组和对照组在各年龄段住院天数差异均具有统计学意义(P<0.05),12-17岁病例组与对照组住院天数中位数差值最大,为93天;其次为年龄大于60岁的病例组与对照组住院天数中位数差值为20天,即发生医院感染后延长住院天数20天。
结论与建议：
血液透析患者由于其自身免疫力低下、长期接受各种侵入性操作等,仍是医院感染发生的高危人群。本研究中血液透析患者医院感染发生率平均为11.49%,低于国内其他研究结果,并且2008年至2012年血液透析患者医院感染发生率呈逐年下降的趋势,但是血液透析患者年龄过大(>60岁)、基础疾病数量过多、多部位置管、临时置管、置管天数延长等是血液透析患者医院感染发生的影响因素。血液透析患者发生医院感染后各项住院费用都增加,尤其是药物费和治疗费；血液透析患者的住院天数延长。相比单部位感染,发生多部位感染患者的经济学损失更大。不同年龄段的血液透析患者发生医院感染后的经济学损失不同,12～17岁血液透析患者发生医院感染后直接经济学损失最大,老年患者发生医院感染后经济学损失次之。由此提出如下建议：
(1)在医院条件允许的情况下,尽量安排患者住单人间或双人间,尽可能避免使用多人房间,以防止呼吸道感染在病房内传播,可能会降低血液透析患者呼吸道感染的发生率。
(2)做好各种置管的维护,严格各项无菌操作,继续研究和制定降低相关导管感染的措施,提供循证医学的证据,向零感染的目标努力。
(3)利用本研究的成果,向广大医务人员和医院管理者宣传医院感染造成的危害和直接经济学损失,强化医务人员的医院感染防控意识,自觉地执行医院感染管理的规章制度。
(4)加强对医务人员进行医院感染方面的知识培训,继续做好医务人员手卫生工作,进一步提高洗手的依从性,避免院内交叉感染,降低医院感染的发生率。
(5)改善血液透析患者的营养状况,加强营养支持疗法,提高血液透析患者的血红蛋白含量和白细胞计数水平,纠正患者贫血状况,提高患者整体抗感染的能力。
(6)在患者病情允许的情况下适当控制血液透析患者的住院天数、透析天数以及置管天数,减少因为天数的延长导致医院感染发生的几率。
Background:
The nosocomial infection is a world's public health problem and the infection outbreak has a serious impact on medical security and social stability. The nosocomial infection is a world's public health problem and the refractory and higher incidence and mortality rates make it to be a clinical problem demanding prompt solution in the work. The nosocomial infection not only can prolong patients' hospitalization days increase patients' mortality rate, bring great danger to patients' health and safety, but also affect some high and new technology development, such as organ transplant and other difficult surgery. They often failed due to the nosocomial infection and result in a waste of medical resources and serious economic burden. Therefore, it is practical significant to conduct a prospective study on patients' nosocomial infection monitoring and evaluation of economic burden, to find the influence factors of nosocomial infection and formulate and implement interventions to prevent nosocomial infection outbreak, and provide the scientific basis for department of public health and hospital managers in the formulation of relevant laws and regulations and the prevention regulation.
Clinical studies have shown that, in recent years, the number of patients with chronic renal failure is increasing and hemodialysis patients are increasing year by year. Nosocomial infection is the most common complication and main cause of death in hemodialysis patients. An investigation of the incidence of nosocomial infection of various departments in the hospital showed that, department of hemodialysis had high prevalence of infection and the incidence can be as high as14.2%-49.2%. There have already broken out four events about nosocomial infection with hemodialysis patients in several hospitals from February2009to March2010, which caused serious social impact and drawn great attention of the ministry of health.
Literature research indicated that domestic studies only focused on related factors of nosocomial infection in hemodialysis patients, most of which used retrospective investigation method. In Canada, some researchers paid attention to the cost-benefit analysis of nosocomial infection of hemodialysis patients and its prevention and control. There was yet no research that used the target monitoring method with the self-designed questionnaire to investigate the influencing factors of nosonomial infection of hemodialysis patients and evaluated the economic burden.
In conclusion, the study focusing on nosocomial infection of hemodialysis patients, used the self-designed target monitoring questionnaire and the prospective monitoring method to research comprehensively and systematically various factors, including the nosocomial infection's influencing factors, infection patterns and direct economic burden of hemodialysis patients. The study proposed and implemented the targeted intervention measures to reduce the incidence of nosocomial infection, which is of great practical significance to prevent nosocomial infection outbreak and has great value to application and research.
Research Objectives:
The objective of the study was to investigate the status of nosocomial infection of hemodialysis patients and its direct economic burden on a Three-level hospital by prospective target monitoring method, to find out the influencing factors and take intervention measures, to reduce the incidence of nosocomial infection and ensure the medical safety of hemodialysis patients, and to reduce the economic burden and shorten hospitalization days to improve patients'living quality. The specific objectives included:to investigate the current status, the characteristics, the site and pathogens distribution of nosocomial infection of hemodialysis patients; to analyze the correlation between the influencing factors and nosocomial infection; to study the direct economic burden and influencing factors, in order to improve the awareness of nosocomial infection prevention and reduce the waste of health resources, also to provide scientific basis for the administrative department of public health and hospital administrator to establish relevant laws, regulations and management rules.
Research Methods:
By cluster sampling, prospective target monitoring were taken on1184hemodialysis patients who suffered from uremia and were treated in department of hemodialysis on a Three-level hospital in Shandong Province from January1,2008to December31,2012. The questionnaire "The target monitoring investigation forms of hemodialysis patients","The nosocomial infection questionnaire of hemodialysis patients" and "The economic burden questionnaire of nosocomial infection of hemodialysis patients" of our own design were filled out by members of the research group. Various factors, including the general information of hemodialysis patients, the status of nosocomial infection, hospitalization expenses and hospitalization days were investigated. Chi-square test was used to analyze the relationship between the influencing factors and nosocomial infection. By logistic regression method, the significant influencing factors of nosocomial infection were included in multiple stepwise regression analysis. Patients with nosocomial infection were taken as case group and patients without nosocomial infection as control group, and hospitalization expenses and hospitalization days were investigated to analyze the direct economic loss of nosocomial infection. All the data were analyzed by Statistical Product and Service Solutions version19.0(SPSS19.0).
Research Results:
1. This study investigated1184patients,794male and390female patients aged between12and89years old, with an average age of (49.08±17.12),783patients were under60and401cases over60.
2. This study had investigated1184patients in department of hemodialysis from2008to2012,136patients and151cases suffered from nosocomial infection with an average infection rate of11.49%and an infection cases rate of12.75%. Both the infection rate and the infection case-rate of hemodialysis patients had shown a declining trend yearly from2008to2012. The infection rate dropped from17.05%in2008to6.14%in2012, and the infection case-rate from18.43%in2008to7.58%in2012.
3. In151infected cases, the infection site was mostly the lower respiratory tract with61infection cases and41.50%infectious rate, followed by upper respiratory infection,32infected cases and21.19%infectious rate.26cases (17.22%) suffered from catheter-related infections,17cases (11.26%) from urinary tract infection.5cases (3.31%) from gastrointestinal infection and10cases from other infections.
4. In all the patients of hospital mfection, a total of138pathogens were found.67Gram-negative bacteria (48.55%),60Gram-positive bacteria (43.48%),8fungi (5.80%) and3virus infections (2.7%). Neisseria meningitides were the most frequent finding in Gram-negative bacteria, streptococcus viridians in Gram-positive bacteria, Candida albicans in fungi and cytomegalovirus in virus infections.
5. According to the Chi-square test, the nosocomial infection rate was associated with many factors including ages, hospitalization days, dialysis days, hemoglobin, body mass index, white blood cells (WBC), urine volume, catheter site, catheter detaining time, community-acquired infection and underlying diseases the difference in which was statistically significant (P<0.05). Whereas, there was no statistical significance between patients with different gender and season (P>0.05).
6. The Chi-square test results showed that anemia, chronic glomerular nephritis, electrolyte disturbance and rheumatoid arthritis were influencing factors of nosocomial infection in hemodialysis patients (P<0.05). But there were no statistically significant differences on nosocomial infection rates of patients suffering from high blood pressure, diabetes, heart disease and diabetic nephropathy (P>0.05).
7. The results of multiple regression analysis showed that age, number of underlying diseases, catheter site, catheter indwelling time and urine volume were significant determinants of nosocomial infection with hemodialysis patients and the difference was statistically significant (P<0.05).
8. In infection group, the lowest total hospitalization expenses were4044yuan, the highest255086yuan and the median of total expenses were32269yuan. In control group, the lowest total hospitalization expenses were480yuan, the highest were163718yuan and the median of total expenses were14872yuan. The hospitalization expenses in infection group were higher than that in control group and the direct economic burden of nosocomial infection in hematodialysis patients was17397yuan.
9. The various hospitalization expenses of infection group were all higher than those of control group and the difference was statistically significant (P<0.05). Among various hospitalization expenses, medicine fees (49.31%) was the highest, about49.31%, followed by therapy fees (33.14%) and laboratory fees (8.34%) and the treatment fees were the lowest.
10. The total hospitalization expenses of infection group with different infection sites were higher than those of control group with a statistically significant difference (P<0.05). In comparison with single-site infection, the burden from multi-site infection was higher with30946yuan. In the single-site infection, the burden of urinary infection was highest, which took about23772yuan, followed by catheter-related infections, about10257yuan.
11. The economic burden varied from age. The total hospitalization expenses of case group of different ages were higher than those of control group with statistical significance (PO.05). Patients between12-17years old had the highest economic burden, about74597yuan, then followed by patients more than60years old, about22319yuan.
12. The hospitalization days were analyzed by Wilcoxon singned-rank test. The results showed that the median of hospitalization days of case group was41days and25days in control group. The difference was16days, which was statistically significant (P<0.05). It revealed that the hospitalization days of hemodialysis patient with nosocomial infection could be prolonged16days.
13. The prolonged hospitalization days of patients with different infection sites were analyzed and the results showed that the hospitalization days of case group with different sites were longer than those of control group and the difference on the median of hospitalization days was statistically significant (P<0.05). The prolonged hospitalization days varied from infection sites. The prolong time of Multi-site infection had the most impact on the prolonged time which was35days.
14. The prolonged hospitalization days of patients in different ages were analyzed. The results showed that the hospitalization days of case group were longer than those of control group, with a statistically significant difference on the median of hospitalization days (P<0.05). The difference of patients between12-17years old on prolonged hospitalization days was the longest and it was93days, then it was followed by patients more than60years old and the prolonged hospitalization days was20days.
Conclusions and Recommendations:
Although the average incidence of nosocomial infection in hemodialysis patients in the study was11.49%, lower than other relevant research results and the nosocomial infection rate of hemodialysis patients declined from2008to2012, hemodialysis patients were still at high risk of nosocomial infection due to their low immunity and long-term invasive operations. The influencing factors of nosocomial infection in hemodialysis patients include older age (higher than60years old), heavier underlying diseases, multi-site catheter, temporary catheter and extended catheter days. The occurrence of nosocomial infection can increase the hospitalization expenses, especially western medicine expenses and treatment expenses, and prolong the hospitalization days. The economic burden of multi-site infection is higher than that of a single site infection. The economic burden was different of hemodialysis patients in different age. Patients between12-17years old have the biggest economic burden, followed by elderly patients.
Recommendations:(1) Try to arrange the patients in a single or a double room and avoid a crowded room if the condition allowed, in order preventing the spread of respiratory infection in the ward, otherwise it may reduce the incidence of respiratory tract infection in hemodialysis patients.(2) Maintain all kinds of catheter and perform strictly aseptic operation, continue to study and formulate measures to reducing the risk of catheter related infection and to provide evidences of evidence-based medicine, to achieve the goal of "zero infection".(3) Promote the detriment and economic burden of hospital infection to the general hospital administrators and medical personnel according to the results of the study, to enhance the consciousness of nosocomial infection prevention in medical staff, and to enforce consciously the rules and regulations of nosocomial infection management.(4) Reinforce the training of medical staff on nosocomial infection and continue to carry out strict hand hygiene work of medical personnel, and improve the compliance of hand washing, to avoid nosocomial cross infection and reduce the incidence of nosocomial infection.(5) Improve the nutritional status of hemodialysis patients, strengthen nutrition support therapy, increase the level of HB and the amount of WBC, ameliorate anemia and enhance the immunity of patients against infection.(6) Control and shorten the hospitalization days, dialysis days and catherter days in hemodialysis patients with the permission of patients'conditions, to reduce the incidence of nosocomial infection caused by longer hospitalization days.
医院感染是指发生在医院内的公共卫生事件,医院感染暴发给医疗安全和社会稳定造成严重影响。医院感染已经成为当今世界普遍关注的公共卫生问题,其难治性及较高的发生率和死亡率使之成为临床医疗工作中亟需解决的问题。医院感染不仅造成病人住院天数延长,增加了病死率,给病人健康和生命安全带来极大威胁,而且还影响一些高新技术的开展,如：器官移植和一些高难度手术往往由于难以控制医院感染而失败,造成医疗资源的浪费,直接经济学损失严重。因此,对医院感染开展前瞻性目标监测及直接经济学损失评价研究,研究发现医院感染的影响因素等潜在问题,研究制定并实施干预措施,避免医院感染的流行与暴发,为卫生行政部门和医院管理者制定相关法律法规和防控规章制度提供科学依据,意义重大。
临床资料研究显示,近年来慢性肾功能衰竭的患者越来越多,进行血液透析的患者也日益增多。在进行血液透析过程中,医院感染是其最常见的并发症,也是引起患者死亡的主要原因之一。在医院各科室感染发生率调查中,血液透析病房为感染高发科室,医院感染率高达14.2%～49.2%。2009年2月至2011年12月,国内几家医院先后发生了4起血液透析患者医院感染暴发事件,造成了严重的社会不良影响,引起卫生部门的高度重视。
文献资料研究显示,目前国内仅查到对血液透析患者医院感染相关因素进行回顾性调查研究与分析的文献。国外加拿大有关于血液透析患者医院血流感染的成本效益分析及预防和控制的研究,但是尚未检索到使用自行设计目标性监测调查表,采取前瞻性监测方法对血液透析患者医院感染影响因素进行调查和干预,并对其经济学损失进行评价研究的文献报道。
综上所述,本研究选择血液透析患者医院感染为研究对象,采用自行设计的目标性监测调查表,应用前瞻性监测方法对血液透析患者医院感染的影响因素和感染规律等进行全面系统地研究,对血液透析患者医院感染的直接经济学损失进行评价研究,研究提出针对性干预措施并组织实施,降低医院感染发生率,对避免医院感染的流行与暴发具有重要的现实意义。本研究具有极高的研究和应用价值。
研究目标：
本研究的总体目标是,通过前瞻性研究方法研究分析某省三级甲等医院血液透析患者的医院感染现状以及医院感染所致的直接经济学损失,发现医院感染的影响因素并针对影响因素提出干预性措施并实施,从而降低血液透析患者医院感染发生率,保障患者的医疗安全,减少患者的直接经济学损失,缩短血液透析患者的住院天数,提高患者的生活质量。具体目标包括：探明血液透析患者医院感染发生的现状、特点、医院感染部位及病原菌分布情况；分析医院感染发生的影响因素及感染环节；研究分析血液透析患者医院感染所致的直接经济学损失及其影响因素,并进行评价研究,以提高医院感染防控意识,减少卫生资源的浪费,为卫生行政部门和医院管理者制定相关法律法规和规章制度提供科学依据。
研究方法：
通过整群抽样的方法,对某省某三级甲等医院2008年1月1日至2012年12月31日日所有入住血液透析病房进行血液透析治疗的1184例患者进行前瞻性目标监测。由课题组成员填写自行设计的《血液透析患者医院感染前瞻性目标监测调查表》、《血液透析患者医院感染病例调查表》和《血液透析患者医院感染直接经济学损失调查表》,调查血液透析患者的一般资料、医院感染发生的现状以及患者的住院费用和住院天数等。通过卡方检验等方法分析各影响因素与医院感染的关系。利用logistic回归分析方法,将对医院感染具有显著意义的影响因素进行多元逐步回归分析。将发生医院感染的患者作为病例组,同期未发生医院感染的作为对照组,比较其住院费用和住院天数的差异,研究分析血液透析患者医院感染导致的直接经济学损失。所有数据采用SPSS19.0统计软件进行统计学处理。
研究结果：
1.研究样本共1184例患者,男794名,女390名；年龄最小12岁,最大89岁,平均年龄为(49.08-17.12)岁；60岁以下患者783例,60岁及以上患者401例。
2.在1184例血液透析患者中,有136例发生医院感染,医院感染发生率平均为11.49%。有151例次发生医院感染,医院感染例次发生率平均为12.75%。2008年至2012年血液透析患者医院感染发生率和医院感染例次发生率均呈逐年下降趋势。医院感染发生率从2008年的17.05%下降到2012年的6.14%。医院感染例次发生率从2008年的18.43%下降到2012年的7.58%。
3.在151例次医院感染中,下呼吸道感染发生最多,为61例次(占41.50%)；其次为上呼吸道感染,32例次(占21.19%)；导管相关感染发生26例次(占17.22%);泌尿道感染发生17例次(占11.26%),胃肠道感染发生5例次(占3.31%),其他感染发生10例次(占6.62%)。
4.在所有发生医院感染患者中共检出病原菌138株,革兰氏阴性菌67株(占48.55%),革兰氏阳性菌60株(占43.48%),真菌8株(占5.80%),病毒3株(占2.7%)。革兰氏阴性菌中以干燥奈瑟氏菌最多,革兰氏阳性菌中最常见的为草绿色链球菌,真菌中以白色念珠菌最多；病毒感染中以巨细胞病毒最多。
5.分析不同类别血液透析患者发生医院感染情况,通过卡方检验发现医院感染发生率在患者年龄、住院天数、透析天数、血红蛋白、体重指数、白细胞计数、尿量、置管部位、置管天数、社区感染情况和基础疾病等方面差异有统计学意义(P<0.05)而不同性别、住院季节的血液透析患者医院感染发生率差异无统计学意义(P>0.05)。
6.分析血液透析患者伴有不同基础疾病发生医院感染情况,通过卡方检验发现贫血、慢性肾小球肾炎、电解质紊乱以及类风湿性关节炎是医院感染发生的影响因素(P<0.05),而患高血压、糖尿病、心脏疾病、糖尿病肾病等疾病的患者医院感染发生率差异无统计学意义(P>0.05)。
7.医院感染影响因素的非条件logistic逐步回归分析结果显示年龄、基础疾病数量、置管部位、置管天数和尿量是医院感染发生的显著影响因素,差异有统计学意义(P<0.05)。
8.病例组(感染组)住院总费用最低为4044元,最高为255086元,中位数为32269元。对照组(非感染组)住院总费用最低为480元,最高为163718元,中位数为14872元,病例组大于对照组。中位数差值为17397元,即血液透析患者医院感染直接经济学损失为17397元。
9.比较病例组和对照组的各项住院费用发现,病例组的各项住院费用均高于对照组,差异有统计学意义(P<0.05)。在各项费用中,损失最多的为药物费,构成比为49.31%；其次为治疗费和化验费,其构成比分别为33.14%和8.34%,损失最少的为诊疗费,构成比为0.33%。
10.分析血液透析患者不同医院感染部位的直接经济学损失发现,不同感染部位的病例组住院总费用均高于对照组,差异有统计学意义(P<0.05),并且多部位医院感染的病例组住院总费用高于单部位医院感染,直接经济学损失更大,为30946元。在单部位医院感染中,泌尿道医院感染所致的直接经济学损失最大,为23772元,其次为导管相关感染所致的经济学损失,为10257元。
11.比较不同年龄段的血液透析患者发生医院感染后直接经济学损失发现：不同年龄段患者医院感染所致的经济学损失不同,各年龄段病例组的住院总费用均高于对照组,差异有统计学意义(P<0.05),12-17岁血液透析患者发生医院感染后直接经济学损失最大,为74597元；其次为年龄大于60岁的血液透析患者,发生医院感染后直接经济学损失为22319元。
12.通过秩和检验分析病例组和对照组住院天数,结果显示病例组住院天数中位数为41天,对照组住院天数中位数为25天,两者差值为16天,差异有统计学意义(P<0.01),表明每例血液透析患者发生医院感染后延长住院天数16天。
13.比较不同感染部位血液透析患者发生医院感染后延长住院天数发现,不同感染部位病例组住院天数均比对照组的住院天数长,住院天数中位数差异均有统计学意义(P<0.05)。不同感染部位所致住院天数延长的时间亦不相同,但是发生多部位医院感染时,对患者住院天数影响最大,延长住院天数最长为35天。
14.分析不同年龄段病例组与对照组的住院天数差异发现：各个年龄段病例组住院天数均比对照组的住院天数长,病例组和对照组在各年龄段住院天数差异均具有统计学意义(P<0.05),12-17岁病例组与对照组住院天数中位数差值最大,为93天;其次为年龄大于60岁的病例组与对照组住院天数中位数差值为20天,即发生医院感染后延长住院天数20天。
结论与建议：
血液透析患者由于其自身免疫力低下、长期接受各种侵入性操作等,仍是医院感染发生的高危人群。本研究中血液透析患者医院感染发生率平均为11.49%,低于国内其他研究结果,并且2008年至2012年血液透析患者医院感染发生率呈逐年下降的趋势,但是血液透析患者年龄过大(>60岁)、基础疾病数量过多、多部位置管、临时置管、置管天数延长等是血液透析患者医院感染发生的影响因素。血液透析患者发生医院感染后各项住院费用都增加,尤其是药物费和治疗费；血液透析患者的住院天数延长。相比单部位感染,发生多部位感染患者的经济学损失更大。不同年龄段的血液透析患者发生医院感染后的经济学损失不同,12～17岁血液透析患者发生医院感染后直接经济学损失最大,老年患者发生医院感染后经济学损失次之。由此提出如下建议：
(1)在医院条件允许的情况下,尽量安排患者住单人间或双人间,尽可能避免使用多人房间,以防止呼吸道感染在病房内传播,可能会降低血液透析患者呼吸道感染的发生率。
(2)做好各种置管的维护,严格各项无菌操作,继续研究和制定降低相关导管感染的措施,提供循证医学的证据,向零感染的目标努力。
(3)利用本研究的成果,向广大医务人员和医院管理者宣传医院感染造成的危害和直接经济学损失,强化医务人员的医院感染防控意识,自觉地执行医院感染管理的规章制度。
(4)加强对医务人员进行医院感染方面的知识培训,继续做好医务人员手卫生工作,进一步提高洗手的依从性,避免院内交叉感染,降低医院感染的发生率。
(5)改善血液透析患者的营养状况,加强营养支持疗法,提高血液透析患者的血红蛋白含量和白细胞计数水平,纠正患者贫血状况,提高患者整体抗感染的能力。
(6)在患者病情允许的情况下适当控制血液透析患者的住院天数、透析天数以及置管天数,减少因为天数的延长导致医院感染发生的几率。
Background:
The nosocomial infection is a world's public health problem and the infection outbreak has a serious impact on medical security and social stability. The nosocomial infection is a world's public health problem and the refractory and higher incidence and mortality rates make it to be a clinical problem demanding prompt solution in the work. The nosocomial infection not only can prolong patients' hospitalization days increase patients' mortality rate, bring great danger to patients' health and safety, but also affect some high and new technology development, such as organ transplant and other difficult surgery. They often failed due to the nosocomial infection and result in a waste of medical resources and serious economic burden. Therefore, it is practical significant to conduct a prospective study on patients' nosocomial infection monitoring and evaluation of economic burden, to find the influence factors of nosocomial infection and formulate and implement interventions to prevent nosocomial infection outbreak, and provide the scientific basis for department of public health and hospital managers in the formulation of relevant laws and regulations and the prevention regulation.
Clinical studies have shown that, in recent years, the number of patients with chronic renal failure is increasing and hemodialysis patients are increasing year by year. Nosocomial infection is the most common complication and main cause of death in hemodialysis patients. An investigation of the incidence of nosocomial infection of various departments in the hospital showed that, department of hemodialysis had high prevalence of infection and the incidence can be as high as14.2%-49.2%. There have already broken out four events about nosocomial infection with hemodialysis patients in several hospitals from February2009to March2010, which caused serious social impact and drawn great attention of the ministry of health.
Literature research indicated that domestic studies only focused on related factors of nosocomial infection in hemodialysis patients, most of which used retrospective investigation method. In Canada, some researchers paid attention to the cost-benefit analysis of nosocomial infection of hemodialysis patients and its prevention and control. There was yet no research that used the target monitoring method with the self-designed questionnaire to investigate the influencing factors of nosonomial infection of hemodialysis patients and evaluated the economic burden.
In conclusion, the study focusing on nosocomial infection of hemodialysis patients, used the self-designed target monitoring questionnaire and the prospective monitoring method to research comprehensively and systematically various factors, including the nosocomial infection's influencing factors, infection patterns and direct economic burden of hemodialysis patients. The study proposed and implemented the targeted intervention measures to reduce the incidence of nosocomial infection, which is of great practical significance to prevent nosocomial infection outbreak and has great value to application and research.
Research Objectives:
The objective of the study was to investigate the status of nosocomial infection of hemodialysis patients and its direct economic burden on a Three-level hospital by prospective target monitoring method, to find out the influencing factors and take intervention measures, to reduce the incidence of nosocomial infection and ensure the medical safety of hemodialysis patients, and to reduce the economic burden and shorten hospitalization days to improve patients'living quality. The specific objectives included:to investigate the current status, the characteristics, the site and pathogens distribution of nosocomial infection of hemodialysis patients; to analyze the correlation between the influencing factors and nosocomial infection; to study the direct economic burden and influencing factors, in order to improve the awareness of nosocomial infection prevention and reduce the waste of health resources, also to provide scientific basis for the administrative department of public health and hospital administrator to establish relevant laws, regulations and management rules.
Research Methods:
By cluster sampling, prospective target monitoring were taken on1184hemodialysis patients who suffered from uremia and were treated in department of hemodialysis on a Three-level hospital in Shandong Province from January1,2008to December31,2012. The questionnaire "The target monitoring investigation forms of hemodialysis patients","The nosocomial infection questionnaire of hemodialysis patients" and "The economic burden questionnaire of nosocomial infection of hemodialysis patients" of our own design were filled out by members of the research group. Various factors, including the general information of hemodialysis patients, the status of nosocomial infection, hospitalization expenses and hospitalization days were investigated. Chi-square test was used to analyze the relationship between the influencing factors and nosocomial infection. By logistic regression method, the significant influencing factors of nosocomial infection were included in multiple stepwise regression analysis. Patients with nosocomial infection were taken as case group and patients without nosocomial infection as control group, and hospitalization expenses and hospitalization days were investigated to analyze the direct economic loss of nosocomial infection. All the data were analyzed by Statistical Product and Service Solutions version19.0(SPSS19.0).
Research Results:
1. This study investigated1184patients,794male and390female patients aged between12and89years old, with an average age of (49.08±17.12),783patients were under60and401cases over60.
2. This study had investigated1184patients in department of hemodialysis from2008to2012,136patients and151cases suffered from nosocomial infection with an average infection rate of11.49%and an infection cases rate of12.75%. Both the infection rate and the infection case-rate of hemodialysis patients had shown a declining trend yearly from2008to2012. The infection rate dropped from17.05%in2008to6.14%in2012, and the infection case-rate from18.43%in2008to7.58%in2012.
3. In151infected cases, the infection site was mostly the lower respiratory tract with61infection cases and41.50%infectious rate, followed by upper respiratory infection,32infected cases and21.19%infectious rate.26cases (17.22%) suffered from catheter-related infections,17cases (11.26%) from urinary tract infection.5cases (3.31%) from gastrointestinal infection and10cases from other infections.
4. In all the patients of hospital mfection, a total of138pathogens were found.67Gram-negative bacteria (48.55%),60Gram-positive bacteria (43.48%),8fungi (5.80%) and3virus infections (2.7%). Neisseria meningitides were the most frequent finding in Gram-negative bacteria, streptococcus viridians in Gram-positive bacteria, Candida albicans in fungi and cytomegalovirus in virus infections.
5. According to the Chi-square test, the nosocomial infection rate was associated with many factors including ages, hospitalization days, dialysis days, hemoglobin, body mass index, white blood cells (WBC), urine volume, catheter site, catheter detaining time, community-acquired infection and underlying diseases the difference in which was statistically significant (P<0.05). Whereas, there was no statistical significance between patients with different gender and season (P>0.05).
6. The Chi-square test results showed that anemia, chronic glomerular nephritis, electrolyte disturbance and rheumatoid arthritis were influencing factors of nosocomial infection in hemodialysis patients (P<0.05). But there were no statistically significant differences on nosocomial infection rates of patients suffering from high blood pressure, diabetes, heart disease and diabetic nephropathy (P>0.05).
7. The results of multiple regression analysis showed that age, number of underlying diseases, catheter site, catheter indwelling time and urine volume were significant determinants of nosocomial infection with hemodialysis patients and the difference was statistically significant (P<0.05).
8. In infection group, the lowest total hospitalization expenses were4044yuan, the highest255086yuan and the median of total expenses were32269yuan. In control group, the lowest total hospitalization expenses were480yuan, the highest were163718yuan and the median of total expenses were14872yuan. The hospitalization expenses in infection group were higher than that in control group and the direct economic burden of nosocomial infection in hematodialysis patients was17397yuan.
9. The various hospitalization expenses of infection group were all higher than those of control group and the difference was statistically significant (P<0.05). Among various hospitalization expenses, medicine fees (49.31%) was the highest, about49.31%, followed by therapy fees (33.14%) and laboratory fees (8.34%) and the treatment fees were the lowest.
10. The total hospitalization expenses of infection group with different infection sites were higher than those of control group with a statistically significant difference (P<0.05). In comparison with single-site infection, the burden from multi-site infection was higher with30946yuan. In the single-site infection, the burden of urinary infection was highest, which took about23772yuan, followed by catheter-related infections, about10257yuan.
11. The economic burden varied from age. The total hospitalization expenses of case group of different ages were higher than those of control group with statistical significance (PO.05). Patients between12-17years old had the highest economic burden, about74597yuan, then followed by patients more than60years old, about22319yuan.
12. The hospitalization days were analyzed by Wilcoxon singned-rank test. The results showed that the median of hospitalization days of case group was41days and25days in control group. The difference was16days, which was statistically significant (P<0.05). It revealed that the hospitalization days of hemodialysis patient with nosocomial infection could be prolonged16days.
13. The prolonged hospitalization days of patients with different infection sites were analyzed and the results showed that the hospitalization days of case group with different sites were longer than those of control group and the difference on the median of hospitalization days was statistically significant (P<0.05). The prolonged hospitalization days varied from infection sites. The prolong time of Multi-site infection had the most impact on the prolonged time which was35days.
14. The prolonged hospitalization days of patients in different ages were analyzed. The results showed that the hospitalization days of case group were longer than those of control group, with a statistically significant difference on the median of hospitalization days (P<0.05). The difference of patients between12-17years old on prolonged hospitalization days was the longest and it was93days, then it was followed by patients more than60years old and the prolonged hospitalization days was20days.
Conclusions and Recommendations:
Although the average incidence of nosocomial infection in hemodialysis patients in the study was11.49%, lower than other relevant research results and the nosocomial infection rate of hemodialysis patients declined from2008to2012, hemodialysis patients were still at high risk of nosocomial infection due to their low immunity and long-term invasive operations. The influencing factors of nosocomial infection in hemodialysis patients include older age (higher than60years old), heavier underlying diseases, multi-site catheter, temporary catheter and extended catheter days. The occurrence of nosocomial infection can increase the hospitalization expenses, especially western medicine expenses and treatment expenses, and prolong the hospitalization days. The economic burden of multi-site infection is higher than that of a single site infection. The economic burden was different of hemodialysis patients in different age. Patients between12-17years old have the biggest economic burden, followed by elderly patients.
Recommendations:(1) Try to arrange the patients in a single or a double room and avoid a crowded room if the condition allowed, in order preventing the spread of respiratory infection in the ward, otherwise it may reduce the incidence of respiratory tract infection in hemodialysis patients.(2) Maintain all kinds of catheter and perform strictly aseptic operation, continue to study and formulate measures to reducing the risk of catheter related infection and to provide evidences of evidence-based medicine, to achieve the goal of "zero infection".(3) Promote the detriment and economic burden of hospital infection to the general hospital administrators and medical personnel according to the results of the study, to enhance the consciousness of nosocomial infection prevention in medical staff, and to enforce consciously the rules and regulations of nosocomial infection management.(4) Reinforce the training of medical staff on nosocomial infection and continue to carry out strict hand hygiene work of medical personnel, and improve the compliance of hand washing, to avoid nosocomial cross infection and reduce the incidence of nosocomial infection.(5) Improve the nutritional status of hemodialysis patients, strengthen nutrition support therapy, increase the level of HB and the amount of WBC, ameliorate anemia and enhance the immunity of patients against infection.(6) Control and shorten the hospitalization days, dialysis days and catherter days in hemodialysis patients with the permission of patients'conditions, to reduce the incidence of nosocomial infection caused by longer hospitalization days.
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