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目的了解二级及以上医疗机构医院感染管理现状,发现问题,提出改进对策。方法 2014年10月依据四川省卫生和计划生育委员会2011版《四川省综合医院评审标准》中“19.医院感染管理”评审标准,对18个二级及以上医疗机构医院感染管理工作进行现场督导考核。结果 18个医院的考核平均得分为(84.88±2.58)分,组织架构与制度流程合格率最高(83.33%),导管室合格率最低(33.33%)。结论 18个医院的医院感染管理得到了不同程度的重视,建立健全了医院感染管理组织架构,制定了较完善的规章制度和工作流程,但在重点部门和重点环节上的合格率仍很低,需及时更新管理理念,增加必要的感染控制设施设备、细化控制措施、制定预案流程和质量考核标准并有效执行。
Objective To understand the current status of nosocomial infection management in second-level and above medical institutions, find out the problems and propose countermeasures. Methods October 2014 According to the evaluation criteria of “19 Infection Management of Hospital” in the 2011 Sichuan Provincial General Hospital Accreditation Criteria of Sichuan Provincial Health and Family Planning Commission, the hospital infection management of 18 second-level and above medical institutions was conducted Site supervision and assessment. Results The average score of the examination in 18 hospitals was (84.88 ± 2.58) points, with the highest pass rate in organizational structure and system (83.33%) and the lowest pass rate in catheter room (33.33%). Conclusions Hospital infection management in 18 hospitals has been given different degrees of attention. The organization structure of hospital infection management has been established and improved, and better rules and regulations and workflows have been established. However, the pass rates in key departments and key links are still very low, It is necessary to update the management concept in time, increase the necessary infection control facilities and equipment, refine the control measures, formulate the preplan process and quality assessment standards and effectively implement it.