內科病房MDROs病室清潔改善方案

本專案旨在提升內科病房多重抗藥性微生物（MDROs）病室清潔完整率，調查發現全院MDROs病室清潔完整率僅50.4%，醫院是抗藥性菌種傳播的大本營，深恐內科病房清潔不完整造成院內感染群突發，引發積極改善之動機。確立主要問題為：MDROs病室清潔之作業規範不周詳、清潔人員MDROs病室清潔知能不足、MDROs清潔相關硬體設備不完善、欠缺稽核制度等，經改善對策：修訂感控清潔作業規範及合約、拍攝本院清潔人員專用MDROs病室清潔教學影片製作教育訓練教材、舉辦清潔人員MDROs病室清潔教育訓練並培訓清潔種子教官、增修環境設備（清潔工作車定位及建置專屬清潔設備空間）、定期稽核。內科病房清潔人員MDROs清潔認知正確率由40.3%升至93.1%，內科病房MDROs病室清潔完整率由34.7%升至96.9%，改善期間未發生院內感染群突發。本專案印證清潔人員知能深深影響環境清潔成效，教育訓練與稽核是管理重點。

關鍵字

多重抗藥性微生物；病室清潔；院內感染

並列摘要

This project aims to improve the medical ward's completion rate of MDROs cleanse. According to investigations, the completion rate of ward's MDROs cleanliness is merely 50.4% in the whole hospital. The hospitals are the hotbed for multi-drug resistance organism. Therefore, in order to prevent nosocomial cluster infection, to improve relevant quality is essential. The possible fundamental causes could be: MDROs ward cleansing related regulations are not completed; the cleaning faculties for MDROs ward cleansing are not competent; MDROs cleaning facilities are not sufficient; shortage of regular supervision and so on. After management review, the following strategies for improvement was given: adjustment of rules and contract for infectious control as well as cleansing; producing relevant educational materials; holding training courses and seed instructors; augmenting environmental equipment (working vehicle positioning and provide exclusive cleaning equipment space); and periodic inspection. The cleaning faculty's comprehensive rate has hence elevated from 40.3% to 93.1%, medical ward's MDROs cleaning completion rate raises from 34.7% to 96.9%, no more episodes of nosocomial infection occurred during the improvement period. This project confirms that cleansing staff can profoundly influence the effectiveness of environmental cleanse, and educational training as well as auditing are the key points to management.