目的 通过实证调查,验证医院感染主动监测系统对提高综合医院医护人员手卫生依从性的效果。方法 医院感染主动监测系统应用期间,将医院十个科室纳入调查现场,对上述现场医护人员手卫生依从率进行跟踪监测,对纳入调查的科室医护人员进行“手卫生知识知晓率”、“七步洗手法规范率”的考核评估,同时采用“管理模式认可度调查问卷”了解医护人员对该系统改善手卫生管理的满意度。结果 经该监测系统的阶段性应用,2019年1、2季度纳入调查现场的医护人员手卫生依从率分别为72.43%、88.24%,显著较上年度同期(该系统投入应用前)提升明显,差异有统计学(均P<0.05)；最新一期的医护人员手卫生知识知晓率、七步洗手法规范率分别为82.72%和76.84%,显著高于该系统投入应用前的48.16%和53.31%,差异有统计学意义(均P<0.05)；医护人员“管理模式认可度调查”的结果显示,多数人员对该系统在手卫生管理中的作用持肯定态度,五项评估内容的积极评价率均超过80%。结论 配置医院感染主动监测系统并构建与其配套的手卫生监管策略,可极大地促进手卫生监测管理的效率和水平,对提高医护人员手卫生依从性具有重要价值。

[Abstract] : Objective To verify the effect of active nosocomial infection monitoring system on improving the hand hygiene compliance of medical staff in general hospital through empirical investigation.Methods During the application of the active hospital infection monitoring system, ten departments of the hospital were included in the investigation site, and the hand hygiene compliance rate of the medical staff on site was monitored. The "awareness rate of hand hygiene knowledge" and "standard rate of seven-step washing technique" were assessed and evaluated.At the same time, the "management mode recognition questionnaire" was used to understand the satisfaction of the medical staff on the improvement of hand hygiene management by the system.Results After the phased application of the monitoring system, the hand hygiene compliance rates of medical staff included in the survey sites in the first and second quarters of 2019 were 72.43% and 88.24%, respectively, which were significantly higher than the same period of the previous year (before the system was put into application), with statistical differences (all P<0.05).The awareness rate of hand hygiene knowledge and the standard rate of seven-step washing technique of medical staff in the latest period were 82.72% and 76.84%, respectively, which were significantly higher than 48.16% and 53.31% before the system was put into use, with statistical significance (all P<0.05).The results of the "management mode recognition survey" of medical staff showed that most of them held a positive attitude towards the role of the system in hand health management, and the positive evaluation rate of the five evaluation contents was more than 80%.Conclusion The allocation of hospital infection active monitoring system and the construction of hand hygiene monitoring strategy can greatly promote the efficiency and level of hand hygiene monitoring and management, and it is of great value to improve the hand hygiene compliance of medical staff.

内蒙古医科大学高等教育教学改革研究项目（NYJXGG2019024）