PDCA循环在持续改进多重耐药菌管理中的应用  

Application of PDCA cycle in multidrug-resistant organism management

作　　者：殷珺妹[1] 龙莉[1] 杨亚敏[1] 阚志超[1] 田洁[1] 张富玉[1] 

机构地区：[1]天津市第三中心医院感染管理科,天津300170

出　　处：《现代预防医学》2015年第12期2195-2196,2205,共3页Modern Preventive Medicine

摘　　要：目的运用PDCA循环加强某院多重耐药菌管理,提高MDRO相关制度落实情况,降低MDRO检出。方法收集资料分析现状,绘制鱼骨图找出多重耐药菌管理不到位的原因,针对原因制定持续改进计划,并采取修订相关制度、进行全员培训、加强巡查、随机提问、纳入考核等措施,检查评估执行的落实情况及效果,最后进行反馈总结,进入下一次PDCA循环。结果全员培训后,多重耐药菌相关知识的各项知晓率均提高到90%以上,较培训前有明显提高;PDCA循环实行后,医生对多重耐药菌病人开具隔离医嘱率(81.9%)和护士执行相应的消毒隔离措施率(88.5%)均较改进前(32.0%、38.0%)有明显提高;自PDCA实行后,该院多重耐药菌检出数呈不断下降趋势,月均MDRO检出数[(166.00+33.05)株]也较前[(221.20+38.50)株]有明显降低,差异均有统计学意义。结论应用PDCA循环持续改进,可有效提高多重耐药菌管理措施的落实,降低耐药菌检出。Objective This study aimed to improve the multidrug-resistant organism（MDRO） management and reduce the MDRO detection by the implementation of the PDCA cycle. Methods The related data was collected to draw the fishbone diagram. Schemes were then constructed for continuous improvement. The scheme included efforts of revising regulations, strengthening staff-training and inspection and so on. The performance of the scheme was then assessed and summarized before entering the next PDCA clycle.Results After the implementation of the PDCA cycle, the awareness rate of MDRO went above 90%, the rate of quarantineprescription and the rate of disinfection conducted by nurses increased from 32.0% and 38.0% to 81.9% and 88.5%, respectively.The number of detected MDRO per month decreased significantly from 221.20＋38.50 to 166.00＋33.05 after the application of PDCA cycle. Conclusion The application of PDCA cycle can effectively improve the MDRO management and reduce the number of MDRO.

关 键 词：PDCA循环 持续改进 多重耐药菌 

分 类 号：R197.3[医药卫生—卫生事业管理]