医院感染风险评估及COSO-ERM优化管理体系研究

Risk assessment of healthcare -associated infection and COSO-ERM optimization management system

摘要:

目的 对全院各临床科室进行医院感染风险评估，明确感染风险控制优先项目，应用企业风险管理整合框架(COSO-ERM)构建极高风险科室优化管理体系。 方法 根据2021年4—6月监测数据，2021年7月对某院37个临床科室进行风险识别、确立风险指标、赋予权重系数，从三个方面(即发生风险的可能性、后果严重程度、当前管理体系)对科室医院感染进行风险评估，再采用百分位数按普通科室和重症监护病房(ICU)系列科室分层进行风险评价，划分风险等级，对极高风险科室和项目采取风险控制措施，并构建COSO-ERM优化管理体系，评价风险评估前后效果。 结果 普通科室和ICU系列科室各评出极高风险科室1个，分别为神经外科和综合ICU。构建神经外科和综合ICU COSO-ERM优化管理体系，评价其干预效果，结果显示，与2021年4—6月风险指标值比较，2022年4—6月手卫生指标中的手卫生依从率和正确率均有所提高，各器械使用率有所降低，住院患者VAP发生率降低，差异均具有统计学意义(均P＜0.05)。 结论 神经外科和综合ICU为医院感染极高风险科室，应优先进行风险控制，构建风险优化管理体系有助于控制感染风险。

Abstract:

Objective To conduct healthcare -associated infection (HAI) risk assessment for each clinical department in the hospital, identify priority projects for infection risk control, and apply the integrated enterprise risk management framework (COSO-ERM) to build an optimized management system for extremely high risk departments. Methods According to the monitoring data from April to June 2021, risk identification, risk indicators establishment and weight coefficient assignment in 37 clinical departments in a hospital was carried out, and risk of HAI in the departments was assessed from three aspects (possibility of risk occurrence, severity of consequences, and current management system) in July 2021, percentile was adopted to conduct stratified risk assessment accor-ding to common departments and ICU departments, risk levels was determined, risk control measures for extremely high-risk departments and projects were taken, COSO-ERM optimization management system was built to evaluate the effect before and after risk assessment. Results General departments and ICU departments respectively rated one department with extremely high risk, namely neurosurgery and general ICU, COSO-ERM optimization management system of neurosurgery and general ICU were constructed respectively, intervention effect was evaluated. Compared with risk indicator value in April-June 2021, compliance rate and accuracy rate of hand hygiene in hand hygiene indicator improved, utilization rate of devices reduced, incidence of VAP in inpatients reduced in April-June 2022, differences were all significant (all P < 0.05). Conclusion Neurosurgery and general ICU are departments with extremely high risk of HAI, which should give priority to risk control, building a risk optimization ma-nagement system is conducive to infection risk control.