上海市公立医院医院感染管理现状调查

 目的 调查上海市市级公立医院医院感染管理现状，并提出改进建议。方法 采用问卷对39所上海市市级公立医院的分管副院长和医院感染管理部门负责人进行专家访谈。专家访谈内容主要包括市级公立医院医院感染管理部门组织体系建设情况、医院感染管理部门人才配备情况、制度建设情况、医院感染管理工作实施过程中的困难以及亮点等。结果 39所市级公立医院中有37所（94.9%）设置了医院感染管理委员会，建立了完备的市级医院感染管理体系并开展相应工作职责。30所（76.9%）医院的医院感染管理委员会的部门成员构成符合要求，主任委员由医院院长或医疗副院长担任的有38所（97.4%）。有37所（94.9%）市级公立医院设置了独立的医院感染管理部门，31所（79.5%）医院的医院感染管理部门由医疗副院长直接管理，28所（71.8%）定位为职能部门。39所市级公立医院平均每239张床位配备1名医院感染管理专职人员，符合规范要求，但在不同医院间存在差异。医院感染管理部门负责人专业方向主要为临床医学（59.0%），感染管理专职人员的专业方向主要为护理学（41.9%）。39所市级公立医院医院感染管理工作亮点主要是能够采用个性化和多样化的培训方式（100.0%）、建立医院感染病例监测预警机制（89.7%）、实行感染防控网格化管理和MDT多学科协作管理模式（87.2%）等；建设难点主要集中在员工发展前景受限及晋升难（41.0%）、医院经费投入不够（33.3%）、岗位人员待遇低（23.1%）等问题。结论 市级医院需要健全医院感染管理组织建设，完善医院感染管理体系，优化医院感染管理队伍培养机制，落实人员晋升激励措施，加大医院感染管理经费投入，保障科学规范资源配置，不断推进医院感染管理水平的科学化、精细化和规范化。

Current status of healthcare-associated infection management in public hospitals in Shanghai City

Objective To investigate the current status of healthcare-associated infection (HAI) management in municipal public hospitals in Shanghai City, and put forward suggestions for improvement. Methods Questionnaires were used to interview deputy directors in charge of 39 municipal public hospitals and heads of HAI management departments of 39 municipal public hospitals in Shanghai City. The content of interview mainly included the organizational system construction of HAI management departments of municipal public hospitals, assignment of professionals and system construction of HAI management departments, difficulties and highlights in the implementation of HAI management, etc. Results 37 (94.9%) of the 39 municipal public hospitals have set up HAI mana-gement committees, established a complete municipal HAI management system and carried out corresponding work responsibilities. The composition of the department members of HAI management committees of 30 hospitals (76.9%) met the requirements, 38 hospitals (97.4%) appointed medical directors or medical deputy directors as chairman of HAI management departments. 37 (94.9%) municipal public hospitals have set up independent HAI management departments, 31 hospitals (79.5%) had HAI management departments directly managed by medical deputy director, and 28 hospitals (71.8%) were as functional departments. 39 municipal public hospitals had an average of one full-time HAI management professionals for every 239 beds, which met the standard requirements, but there were differences among different hospitals. The professional direction of heads of HAI management departments was mainly clinical medicine (59.0%), professional direction of full-time infection management professionals was nursing (41.9%). The highlights of HAI management in 39 municipal public hospitals were mainly the adoption of personalized and diversified training methods (100.0%), establishment of HAI case monitoring and early warning mechanism (89.7%), implementation of HAI control grid management and multi-disciplinary team (MDT) collaborative management mode (87.2%), etc.; the construction difficulties mainly focus on the limited development prospect and difficult promotion of employees (41.0%), insufficient fund investment from hospital (33.3%), and low income of HAI management professionals (23.1%), etc. Conclusion Municipal hospitals need to improve the construction of HAI management organization, improve HAI management system, optimize the training mechanism of HAI management team, implement staff promotion incentive measures, increase the fund investment in HAI management, ensure scientific and standardized resource allocation, and constantly promote the scientific, refinement and standardization of HAI management level.