Women and Children Health Care Institutions Infection Management Investigation on the Current Situation
江苏省医院协会医院管理创新研究课题（JSYGY-3-2023-363）
目的：了解分析妇幼保健机构感染管理部门配置及工作开展情况现状，并针对存在问题提出改进措施。方法：从江苏省内苏南、苏中、苏北地区妇幼保健机构分层抽样，对感染管理部门配置及工作开展情况进行问卷调查。结果：共纳入17份问卷，所有医疗机构均已成立院感委员会；76.5%的医疗机构院感委员会每年召开4次例会；94.1%的医疗机构医院感染管理部门独立设置。感染管理部门专职人员数量配置充足，院感专职人员以护理人员为主，占64.2%，学历以本科学历为主占75.5%，从事院感工作不满3年的占41.5%，高级职称人员占47.1%。93.3%的医院开展院感病例监测；57.1%的医院开展了手术部位感染目标性监测；设置新生儿监护室的医院100%开展了新生儿监护室医院感染目标性监测；设置重症监护室的医院71.4%开展了重症监护室（非新生儿）医院感染目标性监测；64.7%的医疗机构内检验科可自行开展微生物检测，其中81.8%的医院开展了多重耐药菌感染目标性监测；91.4%的医院开展了手卫生监测；80%的医院配备了信息化院感监测系统；94.1%的医院复用诊疗器械清洗、消毒和灭菌方式为消毒供应中心集中管理。结论：妇幼保健机构仍需完善医院感染管理三级组织，进一步优化专职人员专业结构，提升医院感染管理工作水平，促进妇幼保健机构医院感染管理高质量发展，确保医疗质量和医疗安全。
Objective：To analyze and understand the current situation of the allocation and work development of the infected management departments in women and children health institutions，and to propose the existing problems in women and children health institutions and the improvement measures. Methods：A questionnaire survey in the allocation and work development of infection management departments was conducted on the distribution and work of the infection management departments by stratified sampling of women and children health institutions in southern，central and northern Jiangsu Province. Results：A total of 17 questionnaires were included in the analysis of this survey：all health care institutions have established hospital awareness committees；76.5% of medical institutions hold four regular meetings every year；94.1% of medical institutions set up hospital infection management departments independently. The number of full-time staff in the infection management department is sufficient；Among the full-time staff with hospital sense，64.2% are still nursing staff，75.5% have bachelor’s degree，41.5% have been engaged in hospital sense work for less than 3 years，and 47.1% have senior professional titles. 93.3% of hospitals carried out nosocomial infection cases monitoring；57.1% of hospitals carried out targeted monitoring of surgical site infection；Hospitals with neonatal intensive care units have 100% implemented targeted monitoring of hospital infections in neonatal intensive care units. Targeted surveillance for nosocomial infections in intensive care units（non-neonatal）was conducted in 71.4% of hospitals with intensive care units；64.7% of the laboratories in hospital institutions can carry out microbial detection by themselves. Among them，81.8% of hospitals carried out targeted surveillance for multidrug-resistant bacteria infection；91.4% of hospitals carried out hand hygiene monitoring；80% of hospitals are equipped with information hospital sense monitoring system；94.1% of hospitals reuse medical instruments for cleaning，disinfection and sterilization by centralized management and delivery to the disinfection supply center. Conclusions：Women and children health care institutions still need to improve the three-level network organization of nosocomial infection management，the professional structure of full-time staff is not reasonable to further optimize，to improve the level of nosocomial infection management work，constantly promote the development of nosocomial infection management in women and children health care institutions，to ensure medical quality and medical safety.