消毒隔离持续质量改进评估体系的建立与应用效果评价

The establishment and application effects of disinfection continuous quality improvement evaluation system

目的探讨消毒隔离持续质量改进评估体系的建立与应用效果。方法成立消毒隔离持续质量改进评价小组,设计应用《消毒隔离持续质量改进评估表》对80个护理科室或部门进行每季度评估,比较2011年与2013年的消毒隔离质控分数与不良条目发生率等评价指标。结果 2013年消毒隔离质量分数在95分以上的比例从2011年的60.5%提高到77.1%,提高了16.6%(P<0.05)。2011年比2011年消毒隔离不良条数从9.7%下降到7%,下降了2.7%,有统计学差异(P=0.000)。2011年与2013年无菌操作的不良条目发生率最高,分别是39.4%和38.4%。其次是环境卫生和医疗废物的不良条数发生率分别排在第2位和第3位。无菌柜的不良条目发生率从2011年的l5.6%下降到2013年的9.4%,有统计学差异(P=0.021):冰箱的不良条目发生率从2011年的2.8%下降到2013年0%,有统计学差异(P=0.013);但是职业防护的不良条目发生率从2011年的0.8%升高到2013年的l5.2%,升高了14.4%,有统计学差异(P=0.000);其余条目无统计学差异。结论应用消毒隔离持续质量改进评估体系能提高消毒隔离的质控水平,达到持续质量改境进目的。

Objective：To investigate the establishment and application effects of disinfection continuous quality im-provement evaluation system. Methods：The group for disinfection continuous quality improvement evaluation system was established and evaluated all departments quarterly according to the table of ﹤Disinfection continuous quality improvement evaluation table﹥. And then the incidence of disinfection quality and bad items were summarized and compared between 2011 and 2013. Results：The score of disinfection quality greater than 95 in 2013 is 77. 1%,which has an enhancement of 16. 6% compared with that of 2011（60. 5%）. Further,the bad items in 2013 is 7%,which has a decrease of 2. 7%compared with that of 2011（9. 7%）. The incidence of aseptic operation is greatest among all items with 39. 4% abd 38. 4 in 2011 and 2013,respectively,then followed with environmental health and medical wastes. The incidences of bad items for aseptic tank decreased from 15. 6% in 2011 to 9. 4% in 2013,and for refrigerator decreased from 2. 8% in 2011 to 0%in 2013,however,the incidences of bad items for occupational protection increased from 0. 8% in 2011 to 15. 2% in 2013. All the differences are statistically significant（P ﹤0. 05）. Conclusions：The disinfection continuous quality im-provement evaluation system can improve the levels of quality constitutively.