中医院病区院感管理指标体系构建研究  

Construction of a Healthcare-associated Infection Management Quality Evaluation System in Traditional Chinese Medicine Hospital Ward

作　　者：雷晓婷[1] 芮丽 戴正香[1] 林红[1] 孙慧 LEI Xiaoting;RUI li;DAI Zhengxiang;LIN Hong;SUN Hui(Department of healthcare-associated infection management,Jiangsu provincial hospital of TCM,Affiliated Hospital of Nanjing University of TCM;Medical General Office,Zidong District,Nanjing,Jiangsu 210029)

机构地区：[1]江苏省中医院、南京中医药大学附属医院感染管理办公室 [2]紫东院区医疗综合办公室,江苏南京210029

出　　处：《江苏卫生事业管理》2024年第2期161-166,共6页Jiangsu Health System Management

基　　金：江苏省医院协会医院管理创新研究课题(JSYGY-2-2020-95)。

摘　　要：目的:构建适合三级中医院普通病区的医院感染管理质量评价指标体系,以全面、客观评价病区医院感染防控工作。方法:通过梳理病区医院感染管理相关标准规范、查阅文献及研究小组讨论,初步拟定病区医院感染管理指标内容与定义。采用2轮改良德尔菲专家咨询法,函询收集全国22家三级中医院院感专家意见,确立指标体系。用AHP层次分析法计算各级指标的权重,肯德尔协调系数(Kendall’s W)评价专家对指标设置意见的协调性。结果:构建了共包含11个一级指标、66个二级指标及定义的指标体系,AHP判断矩阵满足一致性检验(CR值=0.000)。一级指标中,“诊疗用品处理”“标准预防与职业暴露”“医院感染报告与监测”“医院感染高风险环节防控”“传染性病原体与多重耐药菌相关感染防控”5项权重度最高,均为0.0931。两轮函询后,Kendall’s W一级指标为0.225,二级指标为0.186,P值均<0.01。结论:研究构建的病区医院感染管理指标体系,专家意见协调一致性高,可作为中医院病区感染管理与防控工作开展与评价的参考。Objective:To construct a quality evaluation index system of healthcare-associated infection(HAI)management in ward of tertiary traditional Chinese medicine hospitals,so as to comprehensively and objectively evaluate the prevention and control of hospital infection in the ward.Methods:The contents and definitions of indicators was drew up initially by sorting out the relevant standards and specifications of HAI management,reviewing the literature and discussing in research group.Two rounds of modified Delphi method were used to collect the expert opinions from 22 tertiary traditional Chinese medicine hospitals in China,and establish the index system.The weight of indicators at all levels were determined using AHP analytic hierarchy process.Kendall’s W is used to evaluate the coordination of experts’opinions on indicator settings.Results:A TCM hospital infection management index system was constructed,which includes 11 primary indicators and 66 secondary indicators.The AHP judgment matrix met the consistency test(CR=0.000).Among the first level indicators,“Dispose of medical equipment and articles”,“Standard prevention and occupational exposure”,“HAI monitoring and reporting”,“Prevention and control of high-risk process”,and“Prevention and control of communicable disease and MDRO”have the highest weight,all of which were 0.0931.The Kendall’s W of 11 first-level indicators was 0.225,and that of second-level index was 0.186(both P<0.01).Conclusion:The constructed index system for HAI management in wards has high coordination and consistency of expert opinions,and which provide guidance and reference for HAI management in traditional Chinese medicine hospitals.

关 键 词：中医院 病区 医院感染 质量评价体系 

分 类 号：R197.3[医药卫生—卫生事业管理]