目的 探讨在国际医疗卫生机构认证联合委员会(JCI)理念指导下提高呼吸机相关性肺炎(VAP)集束化预防措施依从性对重症加强治疗病房(ICU)机械通气(MV)患者VAP发生率的影响,以及使用口护刷洗必泰的口腔护理效果.方法 采用前瞻性研究方法,选择2013年1月至2016年12月厦门大学附属第一医院重症医学科收治的MV患者为研究对象.在JCI理念指导下,将VAP预防临床护理实践分为4个阶段实施,以提升VAP集束化预防措施的依从性.2013年确定预防措施及加强教育;2014年强化以手卫生和床头抬高为主的依从性;2015年开展口护刷洗必泰与传统棉球洗必泰口腔护理对口腔卫生指标影响的对照研究,引入口护刷洗必泰口腔护理方案并提高依从性;2016年建立每日执行清单固化上述预防措施.通过医院和ICU两级的信息化软件统计VAP的年发生率,以每千通气日发生VAP病例数表示;并以2013年为基准1,计算各年份的VAP发生率比值(IRR).结果 研究期间共有2733例患者入住ICU,其中MV患者1403例;排除社区获得性肺炎(CAP)、吸入性肺炎、禁止背部抬高,以及资料不全、中途退出研究的患者94例,最终1399例MV患者纳入分析,总MV日11012 d,发生VAP患者94例.2013年至2016年ICU年VAP发生率呈逐年下降趋势,每千通气日发生VAP病例数分别为17.0、10.0、5.9、3.5例;以2013年为基准,2014年至2016年VAP的IRR值亦逐年下降,分别为0.59〔95%可信区间(95%CI)=0.35~0.98〕、0.35(95%CI=0.18~0.64)、0.21(95%CI=0.09~0.41),差异均有统计学意义(均P<0.05).2013年ICU患者床头抬高和手卫生依从性最低,分别为28.57%、54.29%;与2013年比较,2014年针对床头抬高和手卫生2个品管圈(QCC)项目的实施使其依从性显著提高,分别为82.35%、91.18%(均P<0.05);2015年针对年依从性最低的洗必泰口腔护理通过QCC进行改进,其依从性较2013年显著提高(87.10%比62.86%,P<0.05).与2013年比较,2016年除吸痰管无菌操作外,集束化治疗方案各项措施的依从性均显著提高〔每日唤醒和评估撤机为95.00%比71.43%,床头抬高至少30°为92.50%比28.57%,手卫生为97.50%比54.29%,洗必泰口腔护理6~8 h 1次为95.00%比62.86%,翻身拍背和体位引流为97.50%比80.00%〕,差异均有统计学意义(均P<0.05).与传统棉球洗必泰组(30例)比较,口护刷洗必泰组患者(30例)口臭、污垢残留和菌斑的发生率均显著降低(口臭为10.0%比40.0%,污垢残留为16.7%比70.0%,菌斑为3.3%比30.0%,均P0.05).结论 在JCI理念指导下实践集束化预防措施可有效降低VAP发生率;口护刷洗必泰口腔护理可有效改善口腔卫生.“,”Objective To observe the impact of improving the compliance of ventilator bundle on morbidity of ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients undergoing mechanical ventilation (MV) guided by context of Joint Commission International (JCI) settings, and to study the oral care efficacy of suction tube sponge brush. Methods A prospective study was conducted. The patients who needed MV admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Xiamen University from January 2013 to December 2016 were enrolled. In the context of JCI settings, necessary measurements were taken to enhance the compliance of ventilator bundle each year. In 2013, the preventive measures were set up and the education was strengthened. In 2014,the compliance of hand hygiene and bedside elevation was strengthened. In 2015, a control study was conducted to evaluate the effect between the traditional cotton dipped in chlorhexidine and the suction tube sponge brush rinsed with chlorhexidine on oral health impact parameters. The suction tube sponge brush rinsed with chlorhexidine oral care was introduced to improve compliance. In 2016, electronic bundle checklist for daily self-audits was conducted. The annually morbidity of VAP through the software of hospital and ICU was collected and calculated. The annual incidence of VAP was indicated by the VAP cases per 1000 MV days. Based on the VAP incidence rate in 2013 as 1, the VAP incidence-rate ratio (IRR) of each year was calculated. Results During the study period, a total of 2733 patients admitted to the ICU, including 1403 patients undergoing MV. Ninety-four of the 1403 patients with community-acquired pneumonia (CAP), aspiration pneumonia, back elevation ban, incomplete information, and withdrew from the study were excluded. 1399 patients undergoing MV were enrolled in the final analysis, with total MV days of 11012 days, and 94 patients occurred VAP. The annual incidence of VAP was progressively declined from 2013 to 2016, and the VAP cases per 1000 MV days were 17.0, 10.0, 5.9, 3.5 cases, respectively. Based on the VAP incidence rate in 2013, the IRR of VAP from 2014 to 2016 was also progressively declined, which was 0.59 [95% confidence interval (95%CI) = 0.35-0.98], 0.35 (95%CI = 0.18-0.64), and 0.21 (95%CI = 0.09-0.41), with statistical significance (all P < 0.05). In 2013, ICU patients had the lowest rates of bedside elevation and hand hygiene compliance, which were 28.57% and 54.29%, respectively. Compared with 2013, by the implementation of two quality control circle (QCC) projects for bedside elevation and hand hygiene, the rates of bedside elevation and hand hygiene compliance were improved significantly in 2014, which were 82.35%, 91.18%, respectively (both P < 0.05). In 2015, the compliance of chlorhexidine oral care which was the worst performed in 2014 had been improved by the method of QCC, and the rate of the compliance was significantly higher than that in 2013 (87.10% vs. 62.86%, P < 0.05). Compared with 2013, bundle compliance was significantly increased in 2016, except for the sterile operation of the suction tube [daily wake and weaning: 95.00% vs. 71.43%, bedside elevation for over 30°: 92.50% vs. 28.57%, hand hygiene: 97.50% vs. 54.29%, chlorhexidine mouth care once per 6-8 hours:95.00% vs. 62.86%, turned back and posture drainage: 97.50% vs. 80.00%], the differences were statistically significant (all P < 0.05). The incidences of bad breath, dirt residue and plaque were significantly lower in the group of oral care by using suction tube sponge brush with chlorhexidine (30 cases) compared with the group of traditional cotton pad with chlorhexidine (30 cases; bad breath: 10.0% vs. 40.0% %, dirt residue: 16.7% vs. 70.0%, plaque: 3.3% vs. 30.0%, all P 0.05). Conclusion Ventilator bundle can effectively reduce the morbidity of VAP in the context of JCI settings, and the oral care by using suction tube sponge brush and chlorhexidine can effectively improve oral hygiene.