JCI标准下医院感染预防及控制质量持续改进的实践

Continuous quality improvement of healthcareassociated infection prevention and control based on Joint Commission International accreditation standards

摘要:

目的了解某院JCI评审期间医院感染率与手卫生依从率情况，评价JCI标准下医院感染控制措施实施效果。方法按该院JCI标准实施前（评审前）、启动过程中（围评审期）、通过JCI国际认证后（评审后）三阶段分组，比较不同阶段医务人员手卫生依从率、医院感染率、手卫生用品消耗量等指标的差异。结果全院医护人员的手卫生依从率由JCI标准评审前的74.99%，上升到围评审期的78.61%，再到评审后的90.95%，总体差异具有统计学意义（P<0.001）。JCI评审后全院各病区洗手液、快速手消毒剂消耗量均有增加；评审后，心内科、肿瘤血液科及全院医院感染发病率较评审前下降（P<0.05）,医院感染发病率较评审前也呈下降的趋势（P<0.05）。医护人员手卫生依从率与医院感染发病率呈负相关(r=-0.99，P<0.05)。 结论参照JCI评审标准，实时改进，可有效提高医护人员的手卫生依从率，降低医院感染发病率。

关键词:

JCI评审;标准;手卫生;医院感染

Abstract:

ObjectiveTo understand healthcareassociated infection(HAI) rate and hand hygiene compliance rate in a hospital during Joint Commission International(JCI) accreditation stage, and evaluate the implementation efficacy of HAI control measures based on JCI accreditation standards.MethodsThree groups were divided according to preimplementation (preaccreditation), initiation (periaccreditation), and postaccreditation (postaccreditation) of JCI standards, difference in hand hygiene compliance rate, HAI rate, and consumption of hand hygiene products among health care workers(HCWs) at different stages were compared.ResultsCompliance rate of hand hygiene among all HCWs increased from 74.99% before JCI accreditation to 78.61% during periaccreditation period, and then to 90.95% after the accreditation, the overall difference was statistically significant (P<0.001). After JCI accreditation, consumption of hand sanitizer and alcoholbased hand rub increased in all wards of the hospital, HAI rates in departments of cardiology and oncologyhematology as well as the whole hospital decreased (P<0.05), and HAI rates also showed a downward trend (P<0.05). Compliance rate of HCWs’ hand hygiene was negatively correlated with HAI rate (r=-0.99, P<0.05).ConclusionAccording to JCI accreditation standards, realtime improvement can effectively improve hand hygiene compliance rate of HCWs and reduce HAI rate.

Key words:

JCI accreditation; standard; hand hygiene; healthcareassociated infection