持续质量改进对降低腹膜透析患者首年腹膜透析相关性腹膜炎发生率的作用  

Impact of continuous quality improvement on reducing the incidence of peritoneal dialysis-related peritonitis in patients within the first year of peritoneal dialysis initiation

作　　者：林建雄[1,2] 易春燕[1,2] 于晓丽[1,2] 张小丹[1,2] 吴晓凤[1,2] 阳晓[1,2] 毛海萍[1,2] 余学清[1,2] Lin Jianxiong;Yi Chunyan;Yu Xiaoli;Zhang Xiaodan;Wu Xiaofeng;Yang Xiao;Mao Haiping;Yu Xueqing(Department of Nephrology,the First Affiliated Hospital,Sun Yat-sen University,Guangzhou 510080,China;Key Laboratory of Nephrology,Ministry of Health,Guangzhou 510080,China)

机构地区：[1]中山大学附属第一医院肾内科,广州510080 [2]中山大学附属第一医院卫生部重点实验室,广州510080

出　　处：《中华肾脏病杂志》2020年第8期588-594,共7页Chinese Journal of Nephrology

基　　金：基金资助:国家重点研发项目(2016YFC0906101);广东省重点实验室运行经费(2017B030314019);广东省医学科学基金(A2019394);广东省科技计划(2017B020227006);广州市科技计划项目(201704020167)。

摘　　要：目的探讨持续质量改进(CQI)对降低首年腹膜透析相关性腹膜炎发生率的作用。方法纳入2006—2016年于中山大学附属第一医院新置管的维持性腹膜透析患者。入组患者按照置管时间分为4组:CQI前2006—2007年置管患者(A组),CQI后Ⅰ期2008—2010年置管患者(B组),CQI后Ⅱ期2011—2013年置管患者(C组),CQI后Ⅲ期2014—2016年置管患者(D组)。运用设计、实施、检验和应用(PDCA)四步法,改进首年腹膜透析相关性腹膜炎的处理和预防流程。所有患者随访12个月或随访至期间退出腹膜透析。采用Poisson检验比较CQI前后的腹膜炎发生率。结果本研究共纳入2383例腹透患者,其中A组、B组、C组、D组分别为346例、850例、688例、499例。患者年龄(47.1±15.8)岁,男性1409例(59.1%),糖尿病肾病者510例(21.4%),随访(10.9±2.8)个月。与A组相比,C组(CQIⅡ期)首年腹膜透析相关性腹膜炎总体发生率下降(0.156次/患者年比0.234次/患者年,P=0.020);亚组分析显示,CQI后各期首年革兰阳性菌腹膜炎发生率均下降(0.052、0.049、0.054次/患者年比0.104次/患者年,均P<0.05);革兰阴性菌腹膜炎发生率曾一过性上升,经进一步改进后亦有所下降(P>0.05)。Cox回归分析显示,CQI与首年革兰阳性菌腹膜炎的发生率独立相关(HR=0.526,95%CI 0.349~0.792,P=0.002)。结论应用CQI能有效降低腹膜透析首年革兰阳性菌腹膜炎的发生率。Objective To explore the effect of continuous quality improvement(CQI)on reducing the incidence of peritoneal dialysis(PD)-related peritonitis in patients within the first year of PD initiation.Methods The patients who received catheter placement from January 2006 to December 2016 in our hospital were enrolled in this study.All patients were divided into four groups:pre-CQI group patients who initiated PD treatment from 2006 to 2007(before CQI phase,group A),CQIⅠphrase patients who initiated PD treatment from 2008 to 2010(group B),CQIⅡphrase patients who initiated PD treatment from 2011 to 2013(group C),and CQIⅢphrase patients who initiated PD treatment from 2014 to 2016(group D).The method of plan,do,check and act(PDCA)was conducted to decrease the incidence of PDRP.All the patients were followed up for 12 months or until they withdrew from PD in this period.Poisson analysis was used to compare the incidence of PDRP among the groups.Results There were 2383 PD patients recruited in this study,including 346 cases in group A,850 cases in group B,688 cases in group C and 499 cases in group D,with an age of(47.1±15.8)years,among whom 59.1%of the patients were male,and 21.4%with diabetes.The follow-up time was(10.9±2.8)months.Compared with group A,the incidence of PDRP was lower than that in group C(0.156 episodes/patient year vs 0.234 episodes/patient year,P=0.020);the incidence of gram positive PDRP decreased(0.052,0.049,0.054 episodes/patient year vs 0.104 episodes/patient year,all P<0.05)in group B,C,D;the incidence of gram negative PDRP increased in group B,then decreased in group C and group D(all P>0.05).Cox regression analysis indicated that CQI was independently associated with the incidence of gram positive PDRP(HR=0.526,95%CI 0.349-0.792,P=0.002).Conclusion CQI can effectively reduce the incidence of gram positive PDRP in patients within the first year of PD initiation.

关 键 词：腹膜透析 腹膜炎 质量改进 

分 类 号：R692.5[医药卫生—泌尿科学]