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医护搭配，VAP无畏2016-06-27 SIFIC热点团队 SIFIC官微
前言
呼吸机相关肺炎（VAP）是最常见的院内感染之一，发病率 15% 左右。研究显示，VAP 与患者的死亡率增加、住院时间延长以及严重的经济负担密切相关。临床医生对VAP的主要防控工作是严格掌握使用呼吸机的适应证，严格执行正确的置管、撤管操作，而护理人员则是严格落实呼吸机相关性肺炎防控指引，加强护理。医疗、护理虽然是两个职业，但工作息息相关，不可分割，更没有孰重孰轻。只有医护紧密配合，携手合作，才能减少VAP的发生。
Greater Collaboration Between ICU Nurses and Physicians May Minimize VAP Risk ICU医护合作可以使VAP风险最小化 检索：刘金淑 译者：刘金淑
编写：陈志锦 审核：陈志锦
新闻发布：重症监护室(ICU),呼吸机相关肺炎预防研究
这是一张由美国胸科协会提供的呼吸机相关肺炎的影像图
2016年美国胸科协会国际会议上的一项研究表明，ICU医护之间的密切合作，有助于最大程度上减少呼吸机相关肺炎(VAP)发生的风险。
蒂娜凯利科斯塔博士就职于安阿伯市的密歇根大学护理学院和大学医疗政策和创新研究所，是一名注册护士，也是本研究主要作者，她说：“研究结果表明,护士的工作环境是VAP一项重要的预报器，并能调节ICU医生人手配置。”
该研究的作者写道，两个ICU特征，即一个更好的护士工作环境和一个封闭的ICU护士—医生配置模式（由一个特护医生领导管理所有病人的监护业务)与较低死亡率存在独立相关关系。然而,这些因素如何影响VAP，并未明了。
调查人员收集了2005、2006年两年25家 ICU重症监护护士的调查数据，对关键护士检查数据进行了二次单元层级分析。运用泊松多变量回归模型，调查人员模拟了VAP方面护士工作环境和ICU医生人员配置独立和联合作用效果。调查人员还对护士的工作环境和ICU医生配置进行了交互作用试验。
在25家ICU 866名护士当中，有462(53.5%)人参与了这项研究。21家 ICU (84%)归类为封闭式ICU，作者写道，“出人意料的是,我们的多变量分析显示,更好的护士工作环境，却显著增加了近6倍VAP风险。” 按照科斯塔博士解释，这一调查结果，可能是由于ICU团队成员的角色差异所致。
“护士提供病人插管后的VAP预防监护，但病人插管由内科医生完成。在临床工作中，我们没有考虑到医生人员配置情况,却误把更大的风险单独归咎于护士。我们的研究结果显示,护理和医生都有可能影响呼吸机相关肺炎发生的风险。”
独立分析表明，虽然封闭式ICU医生人员配置模式与VAP风险没有显著相关，但是护士工作环境和ICU医生人员配置与呼吸机相关肺炎存在显著性交互作用。
该显著性交互作用表明,对于开放式ICU，更好的护士工作环境可以使VAP风险最小化。但在封闭式ICU，反而增加了VAP的风险。这是因为在开放性ICU模式中,病人的监护是由若干医生管理的；除了更好的工作环境之外,开放式ICU医生的数量和类别可能会促使护士进行VAP标准化预防监护，从而将VAP的危险降到最低水平；但是在拥有更好工作环境的封闭式ICU里面，由于ICU医生更加关注VAP，护士的预防监护角度可能受到某种程度的削弱。
作者做出结论：“这项调查结果强调的一个新观点是，要将VAP风险降到最低，取决于培养ICU护理和医生之间的密切合作。” 资料来源:美国胸科学会
Greater Collaboration Between ICU Nurses and Physicians May Minimize VAP Risk
Posted in News, Intensive Care Unit (ICU), Vap Prevention, Research ,Print
This image shows ventilator-associated pneumonia or VAP. Courtesy of ATS
Greater collaboration between ICU nursing and medicine could help to minimize ventilator-associated pneumonia (VAP), according to a study presented at the ATS 2016 International Conference.
"Our results suggest that the nurse work environment is a significant predictor of VAP while controlling for ICU physician staffing," said lead study author Deena Kelly Costa, PhD, RN, from the University of Michigan School of Nursing and the Institute for Healthcare Policy and Innovation at the University of Michigan in Ann Arbor, Michigan.
Two ICU characteristics--a better nurse work environment and a closed ICU physician staffing model (where an intensivist leads and manages care of all patients)--have been independently associated with lower mortality, the study authors wrote. However, it has not always been clear how these factors together may influence VAP.
Investigators conducted a secondary unit-level analysis of critical care nurse survey data from 25 ICUs collected in 2005 and 2006. Investigators modeled independent and joint effects of the nurse work environment and ICU physician staffing on VAP using a Poisson multivariable regression model. Investigators also tested an interaction between the nurse work environment and ICU physician staffing on VAP.
From the 25 ICUs, 462 of 866 nurses (53.5%) participated in the study. Twenty-one ICUs (84%) were classified as closed ICUs, the authors wrote. "Surprisingly, in our multivariable analyses, a better nurse work environment was significantly associated with a nearly six-fold increase in VAP risk," the authors wrote. Dr. Costa explained that this finding may be due to differences in the roles of the ICU team members.
"Nurses provide preventive VAP care once a patient is intubated, but patients are intubated by physicians. Without taking into consideration the physician staffing model, we are misattributing greater risk to nurses alone when in clinical practice, and as our results suggest, both nursing and medicine have the potential to influence VAP risk. "
Although a closed ICU physician staffing model was not significantly associated with VAP risk in the independent analysis, there was a significant interaction effect between the nurse work environment and ICU physician staffing on VAP.
The significant interaction suggests that better work environments for nurses may minimize VAP risk in open ICUs but actually increase VAP risk in closed ICUs. In the open ICU model, several doctors manage patient care. The number and variety of physicians in open ICUs, in addition to better work environments, may encourage nurses to standardize VAP preventive care to minimize VAP risk. But in closed ICUs with a better work environment, nurses may play a less central role in VAP preventive care since there is more focused management from the ICU physicians.
"These findings highlight a novel view that minimizing VAP depends on cultivating organizational collaboration between ICU nursing and medicine," the authors concluded.
Source: American Thoracic Society
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图文编辑：周密
审稿：孙庆芬 赵静
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