医疗新技术新项目院感审查流程化管理实践探索  

A practical exploration of process management of hospital infection review for new medical technologies and projects

作　　者：杨璐 朱越献[1] 王敏芳 丁黎敏[1] 叶文怡 干铁儿[1] YANG Lu;ZHU Yuexian;WANG Minfang;DING Limin;YE Wenyi;GAN Tieer(The First Affiliated Hospital of Zhejiang Chinese Medical University(Zhejiang Provincial Hospital of Chinese Medicine),Hangzhou,Zhejiang 310006,China)

机构地区：[1]浙江中医药大学附属第一医院(浙江省中医院)医院感染管理科,浙江杭州310006 [2]浙江中医药大学附属第一医院(浙江省中医院)医院医务部,浙江杭州310006

出　　处：《中华医院感染学杂志》2025年第6期956-960,共5页Chinese Journal of Nosocomiology

基　　金：浙江省卫健委科技计划基金资助项目(2021KY820);浙江省医院协会医院管理软科学研究基金资助项目(2020ZHA KEB314)。

摘　　要：目的对医疗新技术新项目的医院感染管理(以下简称“院感”)审查流程化管理实践进行总结,为其他医疗机构提供参考依据。方法收集浙江省中医院2018-2023年院感审查的新技术新项目相关资料,对审查流程和管理实践进行总结。通过构建医疗新技术新项目的医院感染管理评价指标、开展院感审查流程化管理,对可能带来的感染风险进行评估,明确相应的感染防控措施,对已经实施的新技术新项目进行追踪闭环管理。结果629项医疗新技术新项目进行了院感审核和追踪闭环管理,其中医技药499项(占比79.33%)、护理130项(占比20.67%)。审核结果中606项为同意(占比96.34%)、14项为修改后同意(占比2.23%)、3项为重审后同意(占比0.48%)、6项不同意(占比0.95%)。风险评估中5项为高风险项目(占比0.79%)、624项为低风险项目(占比99.21%),审核通过的项目在临床应用追踪中未发现严重医院感染或感染聚集事件。结论该实践从源头上控制了医院感染风险,进一步规范了新技术新项目的临床应用,为促进医疗机构新技术新项目规范化应用提供参考。OBJECTIVE To summarize the procedural management practice of hospital infection review for new medical technologies and projects so as to provide references for other medical institutions.METHODS The data with the respect to review of new technologies and projects were collected from Zhejiang Provincial Hospital of Chinese Medicine between 2018 and 2023,and the process of review and management practice were summarized.The potential risk for infection was evaluated by establishing the evaluation indexes for nosocomial infection management of new technologies and projects and conducting procedural management of the review so as to make clear of the corresponding prevention and control measures.The tracking closed-loop management was carried out for the new technologies and projects that have been already implemented.RESULTS Totally 629 items of new medical technologies and projects were involved in the review and tracking closed-loop management,including 499(79.33%)medical technologies and pharmacy-related projects and 130(20.67%)nursing.The result of review showed that there were 606(96.34%)items with'approval',14(2.23%)items with'approval after revision',3(0.48%)items with'approval after reexamination',and 6(0.95%)items with'disapproval'.The result of risk assessment indicated that there were 5(0.79%)items of high-risk projects and 624(99.21%)items of low-risk projects.There was no severe nosocomial infection or infection cluster incident during the tracking of clinical application of the approved items.CONCLUSION The risk of nosocomial infection has been controlled from the origin through the practice,which further standardizes the clinical application of the new technologies and projects and provides evidence for normalized application of the new technologies and projects in the medical institutions.

关 键 词：医疗新技术 医疗新项目 院感审查 评价指标 

分 类 号：R197.3[医药卫生—卫生事业管理]