李丽++张应先

[摘要] 目的 探討内审检查长效机制在改善医院感染管理现状中的价值。 方法 以重庆市綦江区人民医院相关科室和人员为研究对象，对其于2015年1～12月建立长效机制的内审检查，组成3个内审小组，每个组负责检查8～10个科室或护理单元，按照内审检查表完成现场审核。每个检查项目均以现场查看和现场访谈的方式进行检查，每个现场访谈的问题均规定访谈的对象和人数时间为期1年。对包括医院感染组织管理、手卫生、多重耐药菌管理、医院感染监测与暴发、消毒隔离、医疗废物管理、传染病疫情报告和职业暴露8个方面的制度、措施落实及工作人员对该项目知识知晓情况进行统计。 结果 实施内审检查前，现场查看项目及询问问题10 423个，正确6400个，正确率为61.4%；实施内审检查后，现场查看项目及询问问题13 008个，正确11 838个，正确率为91.0%；实施内审检查前后比较，差异有高度统计学意义（χ2=12.092，P<0.01）。实施内审检查前，仅组织管理、消毒隔离2个模块正确率超过了80%，最低的为职业暴露，正确率仅为26.0%；实施内审检查后，各个项目除疫情报告正确率为82.4%外，其余7个模块正确率均超过87%，其中多重耐药菌防控达到了97.0%；实施内审检查前后各项内容比较，差异均有统计学意义（P < 0.05或P < 0.01）。实施内审检查后总体效果改善明显（Z=9.450，P < 0.05）。各职别工作人员感控知识知晓率护士>医生>病房工人>保洁工人。实施内审检查后各职别医务人员感控知识知晓率较实施内审检查前有明显的上升，差异有统计学意义（P < 0.05或P < 0.01）。 结论 建立内审检查的长效机制，实施积极有效的监测系统，可以促进医院感染管理工作质量的持续改进，提高监测质量和效率。

[关键词] 内审检查；长效机制；医院感染管理

[中图分类号] R197.3 [文献标识码] A [文章编号] 1673-7210（2016）12（b）-0169-04

Value of long-term internal checking mechanism in improvement of management status of hospital infection

LI Li1 ZHANG Yingxian2▲

1.Department of Emergency Medicine， People's Hospital of Qijiang District in Chongqing City， Chongqing 401420， China； 2.Disinfection Supply Room， People's Hospital of Qijiang District in Chongqing City， Chongqing 401420， China

[Abstract] Objective To study the value of long-term internal checking mechanism in improvement of management status of hospital infection. Methods Related departments and personnel of People's Hospital of Qijiang District in Chongqing City were chosen as the research objects， a long-term internal checking mechanism was established from January to December 2015， which were composed by three internal checking groups， each group was responsible for checking of 8-10 departments or nursing units in accordance with the internal audit checklist. Methods of scene view and field interviewing were used in each inspection item. All questions of field interviewing were stipulated the interview objects and number of people， last for 1 year. Institution， measures for implementation and the staffs of knowledge about the project of 8 aspects including hospital infection management organization， hand hygiene， management of multi-resistant bacteria， hospital infection surveillance and outbreak， disinfection and isolation， medical waste management， report for infection diseases， occupational exposure were analzyed. Results Before the implementation of internal checking， nunbers of on-site check items and questions were 10 423， 6400 were correct， the accuracy rate was 61.4%. After the implementation of internal checking， nunbers of on-site check items and questions were 13 008， 11 838 were correct， the accuracy rate was 91.0%. Before and after the implementation of internal checking， the difference was statistically significant （χ2=12.092， P=0.000）. Before the implementation of internal checking， the accuracy rates of organization and management， disinfection and isolation were over 80%， the accuracy rate of occupational exposure was 26.0%， which was the lowest. After the implementation of internal checking， besides the accuracy rate of report of epidemic diseases was 82.4%， the accuracy rates of other items were all above 87%， while the management of multi-resistant bacteria had reached 97.0%. Before and after the implementation of internal checking， the differences of these items were all statistically significant （P < 0.05 or P < 0.01）. Compared with before the implementation of internal checking， after the implementation of internal checking the general effects had improved significantly （Z=9.450， P < 0.05）. The order of aware of knowledge about infection control was nurse >doctor >ward workers> cleaning workers. Compared with before the implementation of internal checking， after the implementation of internal checking the aware of knowledge about infection control in different job titles of medical workers had improved significantly （P < 0.05 or P < 0.01）. Conclusion To establish the long-term internal checking mechanism， implement effective monitoring system， can continuously improve the quality of hospital infection management， improve the monitoring quality and efficiency.

[Key words] Internal checking； Long-term mechanism； Hospital infection management

近年来，随着现代医学科学及医疗技术的不断发展，侵入型操作增加明显，大量广谱抗菌药物的应用使得耐药菌感染情况越来越严重，这一现状不仅增加了患者医院感染的风险，同时也给其治疗增加了难度，极大地威胁了医患安全，医院感染管理工作的重要性日益彰显[1-3]。如何……