陕西省医院感染管理体系现状调查及分析

Current situation of healthcare-associated infection management systems in Shaanxi Province

目的调查陕西省二级及以上医疗机构医院感染管理现状,分析发展趋势,提出改进建议。方法采用分层随机抽样方法抽取陕西省10个地市的170所二级及以上医院进行调查,调查时间为2016年5—6月。调查内容包括:医院的基本情况,医院感染管理情况以及医院感染相关监测情况等。结果共获取165所二级及以上医院的有效问卷资料,其中三级医院43所,二级医院122所。165所医院中90%以上医院感染管理组织机构及制度职责基本健全,但医院风险管理方面亟待加强,目前仅63.03%的医院完善了风险管理制度,66.06%的医院进行了风险评估。医院感染相关培训及效果反馈较好,分别为99.09%和88.41%。人员配置方面:88.48%的医院医院感染管理专职人员配备符合规范要求,但仅有34.55%的医院有人才培养计划。仅33.94%的医院有医院感染专项经费。医院感染监测方面:仅21.21%的医院已安装使用医院感染监测软件;监测项目开展情况:开展医院感染病例监测和环境卫生学监测的医院占90%左右;但开展重症监护病房和新生儿目标性监测的仅占34.55%和23.64%。结论陕西省医院感染管理组织结构健全,相关规章制度基本建立,基础监测项目普及;但风险管理意识有待加强,并存在专职人员配备及专业素质发展不均衡,信息化监测力度不够等问题。

Objective To investigate the current situation of healthcare-associated infection（HAI）management in secondary and above medical institutions in Shaanxi Province,analyze development trend,and put forward suggestions for improvement.Methods In May-June,2016,170 secondary and above hospitals in 10 cities were selected for surveying through stratified random sampling method.Survey content included basic situation of hospitals,HAI management,HAI monitoring,and so on.Results Available questionnaires were obtained from165 hospitals（43tertiary hospitals,and 122 secondary hospitals）.Of 165 hospitals,more than 90% have established HAI management organizations and regulations,but hospital risk management should be paid more attention,only 63.03% of hospitals perfected the risk management system and 66.06% conducted risk assessment.99.09% of hospitals implement training on HAI to all staff regularly and 88.41%conducted effective feedback.In the aspect of staff allocation,88.48% of the hospitals assigned enough professionals for HAI management,but only 34.55% have specific training programme for these personnel.Only33.94% of hospitals have special funds for HAI control;in the aspectof monitoring on HAI,21.21% of hospital installed and used HAI monitoring software;In the aspect of implementation of monitoring programme,about 90% of hospitals developed monitoring on HAI cases and environmental hygiene,but only 34.55% and 23.64% of hospitals conducted targeted monitoring on intensive care unit and neonatal intensive care unit respectively.Conclusion Organizational structure of HAI management in Shaanxi Province is perfect,relevant rules and regulations are basically established,basic monitoring projects are universal,but the awareness of risk management needs to be strengthened,professional allocation and professional quality development are both imbalance,informational monitoring is inadequate.