DOI:
江苏卫生事业管理:2024,Vol.>>Issue(3):363-366
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某三级医院病案质量现状分析
叶 茜
(南京医科大学附属逸夫医院病案统计中心)
Pathogen Distribution and Drug Resistance of Nosocomial Infections in Pediatric,Obstetric and Gynecological Inpatients From 2019-2022
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中文摘要: 目的:通过对某三级医院病案质量现状的分析, 探讨提升医院病案管理的途径与方法。方法:用方便抽样法抽查某三级医院2023年上半年病案1 370份, 根据《江苏省住院病历质量评定标准》, 汇总本次抽查产生的病案质量问题, 将产生的缺陷问题分类编码, 通过分析这三类科室本次抽查产生的病案质量问题,了解该院病案质量现状。结果:1 370份病案中,问题病案926份, 占比68%;缺陷问题主要集中在病程记录和入院记录方面, 其中主要缺陷问题为病程记录不完整, 内容错误, 缺会诊记录, 缺阶段小结, 缺治疗记录以及生命体征、体格检查和查体错误。运用SPSS 21.0版本进行相关性分析和方差分析得出此次统计结果显著性P < 0.05,具有统计学意义。结论:针对该三级医院问题病案占比高和缺陷问题种类多的情况, 应充分发挥医院质控体系的作用, 做好患者信息收集和病案抽查质控的工作, 并定期开展病案质量方面的培训, 从而不断提升病案书写质量。
中文关键词: 病案质量  质量管理  三级医院
Abstract:Objectives:The investigation of pathogen distribution and drug resistance of nosocomial infection in pediatrics,obstetrics and gynecology is of great significance for the empirical treatment of nosocomial infection in women and children,and also provides a reference for the prevention and control of nosocomial infection. Methods:Patients admitted to the Department of Pediatrics,Obstetrics and Gynecology and diagnosed as nosocomial infection in our hospital from 2019-2022 were selected as research objects. Information on nosocomial infection rate and infection site in these three departments were collected,and bacteria were isolated and identified according to the methods in the National Clinical Examination Operating Procedures.VITEK-2Compact automatic bacterial identification instrument from France Biomeerieux and DL-96 automatic bacterial determination system from Zhuhai were used for bacterial identification and drug susceptibility tests,and the results were judged according to the standards of CLSI. Results:Among the 227,124 pediatric,obstetric and gynecological patients included in the study from 2019 to 2022,770 cases of nosocomial infection occurred,with an incidence rate of 0.34%. Among 770 patients with nosocomial infection,bacteremia and gastrointestinal infection were most common in pediatrics,accounting for 31.87% and 26.02% respectively. Other infections of the male and female genital tract and upper respiratory tract infections were more common in obstetrics,accounting for 15.98% and 14.79% respectively. In gynecology,abdominal(pelvic)cavity tissue and acute pelvic inflammation were more common,accounting for 24.32% and 23.94% respectively. A total of 458 strains of pathogens were isolated and cultured from 770 nosocomial infection patients. Staphylococcus epidermidis(S.epidermidis)and Klebsiella pneumoniae(K.pneumoniae)were the main pathogens in pediatrics,accounting for 23.12% and 20.10% respectively. In obstetrics,Escherichia coli(E.coli)and Enterococcus faecalis(E. faecalis)were dominant,accounting for 23.33% and 20.00% respectively. Escherichia coli(E.coli)was predominant in gynecology,accounting for 53.25%. Pediatric Klebsiella pneumoniae(K.pneumoniae)had no resistance to imipenem and meropenem,obstetric Escherichia coli(E.coli)had no resistance to imipenem and meropenem,gynecological Escherichia coli(E.coli)had 1.11% resistance to imipenem and meropenem,pediatric Staphylococcus epidermidis(S.epidermidis)had no resistance to vancomycin and linezolid,obstetric and gynecological Enterococcus faecalis(E. faecalis)had no resistance to vancomycin and linezolid. Conclusion:The incidence of nosocomial infection in pediatrics,obstetrics and gynecology during 2019-2022 was 0.34%,and the rate of nosocomial infection in pediatrics(1.17%)in our hospital was higher than that in obstetrics(0.12%)and gynecology(0.43%). The application rate of gynecological antibiotics was significantly higher than that of obstetrics,and non-combined use was the main factor,which resulted in a higher drug resistance rate of pathogens of nosocomial infections in gynecology than in obstetrics. Active monitoring of nosocomial infections in pediatrics,obstetrics and gynecology,and timely analysis and summary of the distribution and drug resistance of nosocomial infections have certain clinical guiding significance for judging nosocomial infections and the therapeutic use of antibiotics.
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叶 茜.某三级医院病案质量现状分析[J].江苏卫生事业管理,2024,35(3):363-366.
.Pathogen Distribution and Drug Resistance of Nosocomial Infections in Pediatric,Obstetric and Gynecological Inpatients From 2019-2022[J].Jiangsu Health System Management,2024,35(3):363-366.

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