风险评估联合PDCA改善医院感染管理效果研究

目的 探讨应用风险评估联合PDCA循环法改善医院感染管理的效果，以及对医院感染相关指标的影响。方法 根据2017年风险评估的结果和分析，利用PDCA循环法落实针对某院各临床科室的共性及个性干预措施，2019年再次进行风险评估，并比较两次风险评估结果。结果 2019年风险评估显示，绝大部分科室都处于中等风险水平，高风险科室为产科、神经外科、新生儿科。2019年极高风险科室减少1个，中风险科室增加1个；神经外科由极高风险降为高风险，产科升为高风险科室，重症医学科及神经外科ICU仍然为极高风险科室。与2017年各项监测数据相比，2019年手卫生依从率及正确率明显提高，医院感染发生率、MDRO医院感染发生率明显降低，差异均有统计学意义(均P<0.05)。结论 通过风险评估联合PDCA循环法，关注重点科室、重点环节及因素，持续有效推进医院感染管理工作，可降低医院感染发生率。

Effect of risk assessment combined with PDCA cycle on improving healthcare-associated infection management

Objective To explore the effect of applying risk assessment combined with plan-do-check-action (PDCA) cycle method to improve the management of healthcare-associated infection (HAI) and its impact on relevant HAI indexes. Methods According to risk assessment results and analysis in 2017, PDCA cycle method was used to implement the common and individual intervention measures for each clinical department in a hospital, risk assessment was conducted again in 2019, two risk assessment results were compared. Results The risk assessment in 2019 showed that most departments were at a medium risk level, the high-risk departments were obstetrics, neurosurgery, and neonatology. In 2019, the number of extremely high-risk departments dropped by one and the number of medium-risk departments increased by one; department of neurosurgery dropped from extremely high-risk to high-risk, obstetrics upgraded to high risk department, department of critical care medicine and neurosurgery intensive care unit (ICU) were still extremely high risk departments. Compared with the monitoring data in 2017, the compliance rate and accuracy rate of hand hygiene in 2019 improved significantly, incidence of HAI and multidrug-resistant organism (MDRO) HAI reduced significantly, differences were all statistically significant (P<0.05). Conclusion Through the risk assessment combined with PDCA cycle method, focusing on key departments, key links and factors, as well as continuous and effective promotion of HAI management, incidence of HAI can be reduced.