某醫學中心2004-2007年全院醫療區手部衛生運動的推行方法及成果評估

Promotion and Achievement of a Hospital-wide Hand Hygiene Program Implemented During 2004-2007 at a Teaching Hospital in Taiwan

感染防治是病人安全及醫療職場安全的重要議題，其中簡易可行、有效且最合乎成本效益的方法，首推手部衛生。但臨床實務存在諸多問題，而使手部衛生一直處於「知易行難」的窘境。2003年SARS疫情後檢討，北部某2200床醫學中心決定針對手部衛生進行改善方案，本研究介紹四年來推動全院手部衛生運動之方法及成果。本活動依文獻查證於2003年10月進行先期調查，包括問卷、實地稽核及意見溝通，以暸解手部衛生無法落實的原因。在醫院高階主管重視和支持下，並依據全面品質管理理念，自2004年起以多元策略每年推動全院性手部衛生品管活動。以「認知」、「設備」、「行為」為主軸；進行乾洗手液試用及採購作業，提供多元的教育訓練（包含課堂演講、網路教學和測驗、實地抽評等），清潔區污染區劃分，製作不同形式文宣和海報，培訓種子同仁推動單位內部改善活動，長期的稽核監測，科部和單位的雙軌回饋賞罰機制。每年活動皆依計畫一執行一稽核一行動之循環模式運作，檢討前一年成效，因應不同時期所面臨的弱點，調整推動方法，並逐年提高目標值。2004-2007年經每年持續推動，各職別同仁的認知、設備、手部衛生確實率（應進行手部衛生時機且正確進行手部衛生之百分比）明顯僧加。全院手部衛生確實率由2004年43.3%逐年進步到2007年95.6%，與同時期醫療相關感染率的下降呈高度負相關（「r=-0.91, p=0.0128）。2007年科部間比較顯示進行內部品管改善方案之科部，其手部衛生確實率（96.5±6.2vs86.5±5.9, p=0.0075）及競賽總成績（85.7±3.2vs75.9±2.4 ,p<0.0001）皆高於未進行品管改善方案之科部。總結，全院手部衛生運動是實際可行的，主管的認同與支持及全員參與是影響品質改善成效的重要因素。而持續推動及逐年檢討改善，才能達到落實手部衛生並持續改善的目的。

Infection control is a vital issue for both patient safety and occupational health. The most feasible and fundamental component of infection control measures is hand hygiene. However, behavioral change in the target population remains a formidable obstacle, and the average level of compliance is low. After the outbreak of the severe acute respiratory syndrome (SARS) epidemic in 2003, we reviewed the strengths and weaknesses of infection control strategies for combating this disease, which had a very high morbidity and mortality in Taiwan. Our review highlighted the importance of hand hygiene. We also conducted an unannounced inspection of the hospital floors in December 2003. The results of tests revealed that compliance was only 16.6%. Hence, a hospital-wide hand hygiene program was implemented. With the strong support of the hospital administrators, we designed a multidisciplinary approach revolving 4 components (cognition, equipment, and behavior) based on the literature review, pilot study, and the concept of the total quality management. This program included promotion of the use of alcohol-based handrubs at the points of patient care; education through lectures, online selflearning materials, and resources for self-assessment; posters and reminders at various points of care; active participation for education and monitoring at unit levels; overt observation and verbal reminders by infection control nurses; periodic audit and performance feedback; and competitions and incentives at department, unit, and individual levels. The program was reviewed, revised, and promoted annually in accordance with the plan-do-check-action cycle. The overall compliance of hand hygiene increased gradually from 43.3% in 2004 to 95.6% in 2007, which was highly correlated with the reduction of the nosocomial infection rate (r = -0.91, p = 0.0128). In 2007, the departments with quality-improvement plans showed higher compliance rate of hand hygiene (96.5 ± 6.2 vs. 86.5 ± 5.9, p = 0.0075) and overall competition score (85.7 ± 3.2 vs. 75.9 ± 2.4, p < 0.0001) than those without. Active participation of the medical staff and strong support of administrators at the department/ unit level were associated with better and sustained effect for overall achievement of infection control.