摘要
目的：通过对持续质量改进在ICU医务人员手卫生管理中实施效果的探讨，来提高ICU医务人员手卫生依从性，从而减少医院感染的发生率，保证患者的安全。方法成立CQI小组，培训组员，应用PDCA循环原理和持续质量改进措施，调查目前质量现状，对存在的问题进行分析，找出原因；然后设定目标值（80%），制定改进措施。结果应用持续质量改进后，ICU医务人员总手卫生依从率和医生、护士手卫生执行率（94.3%，90.9%，95.6%）比改进前（76.3%，74.3%，79.5%）显著提高，差异均有统计学意义（P<0.01），且能较好的掌握手卫生时间。结论在医院ICU科室中应用持续质量改进进行手卫生管理，不仅加强了医务人员对手卫生的认识，而且提高了医务人员手卫生依从性。
Abstract
OBJECTIVE By exploring the effect of the application of continuous quality improvement (CQI) on the hand hygiene management of the ICU medical staff in order to improve their hand hygiene compliance, thus, reducing the rate of nosocomial infection and ensuring patient safety. METHODS Firstly, the CQI team was organized and trained, the current status was investigated by using the circulation of PDCA and CQI, the existing problems were analyzed to find out the reasons. Then, the target value of hand hygiene compliance was set to 80%, and improvement measures were employed. RESULTS The total hand hygiene compliance rate of ICU medical staff and the hand hygiene compliance of doctors and nurses(94.3%, 90.9%,95.6%) are significantly higher than the former rate(76.3%,74.3%,79.5%),and the differences have statistical significance(P<0.01), after the application of continuous quality improvement.CONCLUSION The application of continuous quality improvement of hand hygiene of the hospital ICU medical staff can significantly improve their awareness of hand hygiene and the hand hygiene compliance.
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