英國(guó)皇家自由醫(yī)院消毒濕巾的應(yīng)用經(jīng)驗(yàn)

ImplementationofwetwipecleaningYvonneCarter.ServiceLeadNurseInfectionPreventionandControl.TheRoyalFreeLondonNHSFoundationTrust.消毒濕巾清潔方式的應(yīng)用伊芳﹒卡特小姐醫(yī)院感染控制與預(yù)防主任英國(guó)皇家自由醫(yī)院-英國(guó)國(guó)家醫(yī)療服務(wù)系統(tǒng)信托基金會(huì)Environmentalcontamination

環(huán)境污染Patientswithinfectionsareasourceofenvironmentalcontamination.Increaseriskforpatientsadmittedintoaroomformerlyoccupiedbyinfectiouspatient(MartinezJAetal(2003),HuangSSetal(2006),DreesMetal(2008)Someorganismsshedformonthsaftersymptomsofinfectionhavecleared–eg,C.difficile,VRE.Someorganismsrequiredifferentcleaningproductsbecausetheyproducesporesorarevirusesresistanttoroutinedisinfectants.Manyorganismsliveforweeksormonthsintheenvironment,egAcinetobactersp.(Krameretal(2006)Micro-organismscoloniseeverywhere:environmentalsurfaces,hands,skinandmedicalorcaredevicesandequipment.感染病人是環(huán)境污染的來(lái)源之一。住進(jìn)有過(guò)感染患者的房間，會(huì)增加新進(jìn)病人被感染的風(fēng)險(xiǎn)。［MartinezJAetal(2003),HuangSSetal(2006),DressMetal(2008)］。有些微生物在感染癥狀消失后可以匿藏?cái)?shù)月之久，例如難辨芽胞梭菌和抗萬(wàn)古霉素腸道球菌。對(duì)于產(chǎn)生孢子微生物或者是常規(guī)消毒劑無(wú)效的病毒，需要用不同的清潔消毒產(chǎn)品進(jìn)行清潔。許多微生物能能在環(huán)境中存活數(shù)周甚至數(shù)月之久，例如不動(dòng)桿菌。［Krameretal(2006)］微生物定植無(wú)處不在：環(huán)境物體表面，手部，皮膚，醫(yī)療護(hù)理裝置等儀器設(shè)備。Changingthecultureofcleaning

環(huán)境污染W(wǎng)hatisthecurrentprocess–whatdousersthinkofit?Re-shapethinking–whatistheevidenceforchangeWhatdoIgetoutofit?HowdoIknowthiswillwork?Howwillpatientsbenefit?OK–makeitclear–makeitsimple.目前的清潔方式-清潔人員認(rèn)為這個(gè)方式怎么樣？重新改變思維-轉(zhuǎn)變的依據(jù)是什么？我該放棄哪些陋習(xí)？我如何知道新的方式是有效的？對(duì)病患者有什么益處？可行的話-操作方法要清晰，簡(jiǎn)單。4OPTIONSFORCLEANINGANDDISINFECTION

清潔和消毒方式的選擇Don’tlikemopandbuckets–watersplashingeverywhere,carryingheavybuckets.Didnotknowhowoftentochangedirtywater.Collectingmop,bucket,clothsandcleaningagenttookalotoftimeandthentimetoputthemawayagain.Complicatedtoknowwhattouseforwhatpurpose.Didn’tknowifcleaningproductwasworking.Clothsoftenleftmarksorstreaksacrosscleanedsurfaces.Didnotknowhowwetaclothshouldbetoensuregoodcoverageandcontacttime.Dilutingchlorinetablets/powder.Oftengotthewrongconcentration.Didnotlikethesmellofthecleaningproducts.Someproductsmadetheeyesandnosestingorweep.Cleaningagentwasinhaledfromspraybottles.Evaluationofcurrentcleaningprocess

對(duì)目前清潔消毒方式的評(píng)價(jià)不確定多久換一次臟水。領(lǐng)取地拖，水桶，抹布和清潔消毒劑等物品很費(fèi)時(shí)。不清楚何種清潔消毒產(chǎn)品用作何目的。不清楚清潔消毒產(chǎn)品是否真的起效。用抹布清潔消毒后通常會(huì)有劃痕留在物體表面。不知道怎樣的濕度才能很好的覆蓋物體表面并起作用。含氯消毒片/粉末。濃度不能準(zhǔn)確配制。不喜歡當(dāng)時(shí)的清潔消毒產(chǎn)品的味道。一些清潔消毒產(chǎn)品刺鼻或刺眼清潔消毒劑可能會(huì)吸入到體內(nèi)不喜歡地拖和水桶-水會(huì)到處濺潑，還要提著很重的水桶broadspectrum:wideantimicrobialspectrumfastacting:rapidlykills–short‘contact’timeodourless:haveapleasantodourornoodoureconomical:notbetoohighincoststability:bestableinconcentratedstateandwhendilutedonestepremovalofsurfacebio-matteranddisinfectionsingleuse-re-useencouragesbacterialgrowthnotransferofbacteriawhilewipingEvidence–whatistheIdealdisinfectant?

理想的消毒劑是什么？廣譜：抗菌廣譜快速起效：短接觸時(shí)間內(nèi)迅速殺滅無(wú)臭：清新的氣味或無(wú)臭味經(jīng)濟(jì)：不需要花費(fèi)太高的成本穩(wěn)定性：穩(wěn)定的配液濃度比清潔和消毒一步到位一次性使用：重復(fù)使用導(dǎo)致滋生細(xì)菌擦拭的時(shí)候不會(huì)產(chǎn)生細(xì)菌轉(zhuǎn)移Evidenceforwetwipecleaning–

whatdoIgetoutofit?

使用濕巾清潔的依據(jù)-我該放棄哪些陋習(xí)？pre-measureddoseofdisinfectantonawipe–nodilutionissues–howmuchpowder/tablets/water?usefromcleantodirtyandthenthrowawayuserfriendly–fast,‘grab’awipeanduse.nomops,heavybuckets,rinsewater,handlingofdirtycloths.theyarefamiliartouse–babywipes,picnichandwipes.onestepprocess–cleanawaybio-matteranddisinfectinoneprocess.nosoreeyesornose–nosmell預(yù)先配比好濃度–無(wú)需稀釋-需要多少消毒粉末，消毒片和水等問(wèn)題。從干凈到臟擦拭，然后丟棄。方便使用-便捷，抽取一片即可使用。不需要使用地拖，拿著重的水桶，接自來(lái)水，還要處理臟污的抹布。清潔人員很熟悉使用方法–例如日常使用的嬰兒濕巾，戶外手部濕巾。清潔和消毒一步到位不會(huì)刺激眼睛或者鼻子-沒(méi)有氣味Wipes

濕巾:Howwillpatientsbenefit?

病患者如何受益？艱難梭狀芽孢桿菌-2008年3月份至2014年1月份數(shù)據(jù)英國(guó)皇家自由醫(yī)院MRSA2008-2014年感染數(shù)據(jù)MRSA菌血癥2005-203年數(shù)據(jù)單位：例單位：MRSA獲得者減少的目標(biāo)MRSA菌血癥總數(shù)可歸屬M(fèi)RSA菌血癥Drugresistantorganisms

耐藥性微生物Currentproblemswithmulti-drugresistantAcinetobacterandCarbapenemaseproducingorganisms.Klebsiella,E.coli,pseudomonas.Eachorganismsbehavesinthesamewayasantibioticsensitivespeciestodisinfectants,socleaningprotocolsremainthesame.DisinfectantwipesarejustaseffectiveagainstantibioticresistantorganismsCleaningshouldbemademorestricttokeepsourceofinfectioncontained,buttheproductsdonotchange.目前的問(wèn)題在于多重耐藥性微生物的出現(xiàn)，例如：不動(dòng)桿菌，產(chǎn)碳青霉烯酶腸桿菌，克雷伯桿菌，大腸桿菌，假單胞菌。與抗生素敏感株對(duì)消毒劑敏感一樣，每種微生物同樣對(duì)消毒劑敏感，所以需保持一樣的清潔方式。消毒濕巾對(duì)抗生素耐藥的微生物同樣有效。因此清潔操作應(yīng)該更加嚴(yán)格控制感染源，清潔產(chǎn)品保持不變。Costbenefits

成本效益EachMRSABSIcostsaround￡10,000totreat.Reductionfrom98casesto1.-98casescosts￡980,000.EachCDIcasecostsaround￡4,000totreat每例MRSA血流感染病人的治療費(fèi)用約1萬(wàn)英鎊。從98例降至1例-98例總費(fèi)用是98萬(wàn)英鎊（相當(dāng)于人民幣980萬(wàn)）。每例難辨芽胞梭菌感染病人的治療費(fèi)用約4000英鎊（相當(dāng)于人民幣4萬(wàn)元）。CDIratesnotimproving.antibioticpoliciesandclinicalpracticesrecentlyreviewed.focusonenvironmentalhygiene.traditionalchlorineagents-notuser-friendly.alternativeeffectiveproduct–Sporicidalwipe.allpatientsover2yearsincludedininfectionreporting.wipesintroducedApril2008.April2009infections72%lower.costperinfectionabout￡4,000,representingsavingof￡660.000.Costbenefits

成本效益艱難梭狀芽孢桿菌感染率沒(méi)有升高。最近對(duì)抗生素政策和臨床實(shí)踐進(jìn)行了審議。注重環(huán)境衛(wèi)生。傳統(tǒng)的氯制劑-不方便使用。有效的替代產(chǎn)品-殺芽孢干巾。感染超過(guò)2年的患者都被記錄在感染報(bào)告里。2008年4月份引進(jìn)使用濕巾。2009年4月份感染降低了72%。每例感染花費(fèi)約4000英鎊，這意味著節(jié)省了66萬(wàn)英鎊。患艱難梭狀芽孢桿菌病例-2008年3月-2014年1月

單位：例Clearandsimple

簡(jiǎn)單明了Saveeffort-onestep-disinfectantwipestrapdirtandbacteria.Killsthemaswellasremovesthem–notransferfromsurfacetosurface.Savetime-easytouse–pickupawipeandclean,thenthrow.簡(jiǎn)化操作-一步到位-消毒濕巾能去除臟污及細(xì)菌。既能殺菌也能去除-不會(huì)讓細(xì)菌在物表之間轉(zhuǎn)移。節(jié)省時(shí)間-使用方便-抽取一片濕巾進(jìn)行清潔，清潔完畢丟棄即可。Clearandsimple

簡(jiǎn)明清楚Saveresources-Equipmentandmaterialsrequired;colour-codedbucket;colour-codedcloth;cleaningtrolley;generalpurposedetergent/waterwarningsigns. glovesandapron OrDisinfectantwipesglovesandapron節(jié)省資源設(shè)備和所需物品：有顏色標(biāo)記的垃圾桶有顏色標(biāo)記的抹布清潔小推車通用洗滌劑/水警告標(biāo)示牌手套及圍裙消毒濕巾手套及圍裙或者M(jìn)akingthechange

做出改變Introduceinasmallway–twowardsidentifyanybarriers–easiertoputrightonsmallscale.OneIPCnurseandmanufacturerstraineronthewardseachdaytoanswerquestions,demonstrateandtrain.Providepocketsizeinformationsheet–whywipesarebeneficial:

-easiertouse

-lesstime,effortandresources

-provenreductionininfectionrates小范圍引進(jìn)新產(chǎn)品–從兩個(gè)科室了解確認(rèn)目前存在哪些障礙和問(wèn)題-小規(guī)模試行能更容易予以糾正。一個(gè)感染預(yù)防控制護(hù)士和生產(chǎn)廠家的培訓(xùn)人員每天在科室回答醫(yī)護(hù)人員的問(wèn)題，演示并進(jìn)行培訓(xùn)。提供資料小冊(cè)子-為什么濕巾是有益的：更容易使用省時(shí)省力省資源證實(shí)能降低感染率Makingthechange

做出改變Supportfrommanufacturer.installationofdispensersstafftrainingandrepeatsessionse-learningpackwith‘tablets’providedforuserspostersandleafletsspecifictoeachhospitalsponsorshipforprofessionalconferencesandlearningstudydaysupport,atlocallevelscientificresearchhelpinrelatedIPCpractice生產(chǎn)廠家提供以下支持：安裝塑料方桶，用于放置濕巾醫(yī)護(hù)人員的培訓(xùn)和重復(fù)課程為清潔人員提供平板電腦等電子學(xué)習(xí)資料根據(jù)不同醫(yī)院量身定做的海報(bào)及宣傳單張專業(yè)性會(huì)議及學(xué)習(xí)研討會(huì)等的贊助支持地方級(jí)醫(yī)院開(kāi)展學(xué)習(xí)日與感染預(yù)防控制有關(guān)的科研協(xié)助Cleaninginpractice

清潔的實(shí)際操作Generalprinciples:wipeallsurfaces,includingunderneath-specialattentiontohightouchpoints.cleantoptobottomorcleantodirty.useoverlapping‘S’motion–coverallareas.changewipesbetweensurfaces.removePPEsandwashhands.apply‘cleaned’indicatortapeordocument.一般原理：用濕巾擦拭所有物體表面，包括物體底部–特別注意高頻接觸物表。由上至下或由干凈到臟進(jìn)行擦拭清潔。以“S”形走形擦拭，要有重疊擦拭的區(qū)域–覆蓋所有區(qū)域。兩個(gè)物表之間的清潔要更換新的濕巾。脫下個(gè)人防護(hù)用品并洗凈雙手。物表清潔完畢后用清潔指示條帶或標(biāo)貼作標(biāo)記。‘S’stylecleaning

“S”形擦拭方式Hightouchsurfaces

高接觸率物體表面Cleaning–whoisresponsible?

清潔消毒–誰(shuí)負(fù)責(zé)？AMatron’sCharter:10commitments:1KeepingtheNHScleaniseverybody’sresponsibility.3 Matronswillestablishacleanlinesscultureacrosstheirunits.6Cleaningroutineswillbeclear,agreedandwell-publicised.8Allstaffworkinginhealthcarewillreceiveeducationininfectioncontrol.9Nursesandinfectioncontrolteamswillbeinvolvedindrawingupcleaningcontracts,andmatronshaveauthorityandpowertowithholdpayment.護(hù)士長(zhǎng)憲章：10項(xiàng)承諾：保持國(guó)家醫(yī)療服務(wù)體系下各個(gè)醫(yī)院的潔凈是每個(gè)人的職責(zé)。護(hù)士長(zhǎng)在各自科室建立良好的清潔文化和制度。清潔消毒規(guī)范會(huì)清晰明了，經(jīng)過(guò)一致議定并公示出來(lái)所有在醫(yī)療衛(wèi)生領(lǐng)域工作的人員需接受感染控制的教育培訓(xùn)。護(hù)士和感染控制團(tuán)隊(duì)可參與起草清潔合同，護(hù)士長(zhǎng)有權(quán)力控制款項(xiàng)支付。Cleaning-whoisresponsible

清潔消毒–誰(shuí)負(fù)責(zé)？ClinicalstaffDomestic/cleaningstaffDedicateddecontaminationstaffbloodandbodyfluidexposuretraining-competenceandunderstandingtechnicalunderstanding–electronicandmedicalequipmentinpatientuseorroutinecleaninginstoreroominfoodcontact臨床醫(yī)護(hù)人員家政機(jī)構(gòu)/清潔人員專業(yè)清潔人員血液及體液溢漏培訓(xùn)-能力及理解力技術(shù)理解能力-電子和醫(yī)療設(shè)備病患者使用或儲(chǔ)物室例行清潔食品接觸方面49Elements

49項(xiàng)物品清潔標(biāo)準(zhǔn)Cleaningfrequencies

清潔消毒頻率OurWardCleaningPromiseTheTrustiscommittedtoprovidingacleanandsafeenvironmentandwantstoencouragepatientsandvisitorsfeedbackoneveryaspectofthecleaningservice.Programmedactivitiesde-scalingceilingventswindowcleaningcurtainchangesdeepcleaning信托基金會(huì)致力于提供一個(gè)清潔和安全的環(huán)境，并且鼓勵(lì)病患者及探訪者能夠?yàn)槲覀冊(cè)谇鍧嵎?wù)的每個(gè)方面提供寶貴意見(jiàn)。我們的科室清潔承諾定期的清潔除垢天花板通風(fēng)口窗戶清潔窗簾更換深度清潔Cleaningfrequencies

清潔消毒頻率Standards

標(biāo)準(zhǔn)Allpartsincludingunderneathshouldbevisiblycleanwithnobloodandbodysubstances,dust,dirt,debrisorspillages.Allwallsurfacesincludingskirtingshouldbevisiblycleanwithnobloodandbodysubstances,dust,dirt,debris,adhesivetapeorspillages.Allpartsofthebed(includingmattress,bedframe,wheelsandcastors)shouldbevisiblycleanwithnobloodandbodysubstances,dust,dirt,debris,adhesivetapeorspillages.CommodesWallsBeds座便椅墻壁床所有部分（包括底部）看上去都應(yīng)當(dāng)干凈，無(wú)血液和身體物質(zhì)、灰塵、污垢、碎屑或溢出物。所有墻壁表面（包括踢腳線）看上去都應(yīng)當(dāng)干凈，無(wú)血液和身體物質(zhì)、灰塵、污垢、碎屑、膠帶或溢出物。床的所有部分（包括床墊、床架、床輪和腳輪）看上去都應(yīng)當(dāng)干凈，無(wú)血液和身體物質(zhì)、灰塵、污垢、碎屑、膠帶或溢出物。Standards

標(biāo)準(zhǔn)Veryhighrisk–criticalcare,operatingtheatresHighrisk–generalwardsSignificantrisk–laboratories,out-patientclinics98%95%85%下列提供三類“感染風(fēng)險(xiǎn)級(jí)別”的指標(biāo)：極度高風(fēng)險(xiǎn)-重癥監(jiān)護(hù)室，手術(shù)室高風(fēng)險(xiǎn)-普通病房顯著風(fēng)險(xiǎn)-實(shí)驗(yàn)室，門診Competenceassessment

能力評(píng)估explainthedifferencebetweencleaning,decontaminatingandsterilising.explaintheneedtophysicallycleanbeforechemicaldisinfection.explaintheusesofcleaninganddecontaminationagentsgenerallyinuse.demonstratehowandwhentouseUniversalandSporicidalwipes.explainthereasonbehind‘toptobottom’cleaningand‘cleantodirty’area

cleaning.解釋清潔，消毒，滅菌的不同之處。解釋為什么在化學(xué)消毒前要進(jìn)行物理清潔去污。解釋一般的清潔劑和消毒劑的使用方法。演示如何使用通用消毒濕巾和殺芽孢干巾。解釋“由上至下”“由干凈到臟”擦拭方式的原因。Trainingmethods

培訓(xùn)方法jointtrainingwithwardstaffandcleaningstaff

49elementsprovideacleaningproductthatisacceptabletousersandneedslittletrainingprovideequipmentandfurnishingsthatareeasilycleaned.visualdemonstrations–UVlightsystemadenosineTriphosphate(ATP)professionalpride–publicisecleaning

scoresatwardentrances與科室醫(yī)護(hù)人員和清潔人員進(jìn)行聯(lián)合培訓(xùn)49項(xiàng)物品清潔標(biāo)準(zhǔn)提供一個(gè)便于使用者使用，只需要進(jìn)行簡(jiǎn)單培訓(xùn)的清潔產(chǎn)品現(xiàn)場(chǎng)演示-紫外線手電筒培訓(xùn)系統(tǒng)三磷酸腺苷（ATP)職業(yè)自豪感-在各科室門口張貼清潔消毒審核分?jǐn)?shù)提供方便使用的設(shè)備和用具Trainingmethods

培訓(xùn)方法publicandpatientpressurepatientleadassessmentofcareenvironment(PLACE)withexternalverifiermockPLACEassessmentsbyIPCpractice-educatorsandseniortruststaffPLACEscorespublicisedpubliclyonPLACEwebsitefortheworldtosee‘hospitalofchoice’來(lái)自公眾和病患者的壓力以患者為首，聯(lián)合第三方，進(jìn)行護(hù)理環(huán)境評(píng)估（PLACE）由感染預(yù)防控制部門進(jìn)行模擬的護(hù)理環(huán)境評(píng)估-由教員和信托基金會(huì)高級(jí)職員進(jìn)行。評(píng)估得分會(huì)張貼在該評(píng)估網(wǎng)站上讓所有的人都能查閱選擇醫(yī)院Patientinformation

患者資訊Leaveinfectionsathome

Ifyouhavehadaninfection,makesureyouarecompletelywellbeforevisitinganyoneinhospital.Coveranywounds.Cleanseyourhandscarefullyandoften

Washyourhandsiftheyaresoiled.Usethealcoholhandrubwhenyouenterandleaveawardandusethebedsiderubafterclosecontactwithpatients.Therearesignsshowingyouhowtousethem-oraskstaff.Letstaffknowwhenthesuppliesarerunninglow.Don’tclutter

Helpstafftokeepareascleanbynotbringinginlotsofclutterandbytakingawaythingsthatarenotrequired.感染了，請(qǐng)留在家如果你獲得感染，確保徹底痊愈了方可進(jìn)入醫(yī)院探訪。包扎好所有傷口。經(jīng)常勤洗手雙手臟污時(shí)要進(jìn)行清洗。進(jìn)入和離開(kāi)病房的時(shí)候使用酒精手消液，和病患者距離接觸過(guò)后使用病床旁邊的手消液。有使用方法說(shuō)明-或者可以咨詢醫(yī)護(hù)人員。手消液剩余不多的時(shí)候請(qǐng)告知醫(yī)護(hù)人員。不添亂幫助醫(yī)護(hù)人員保持清潔區(qū)域的整潔，不亂放雜物，帶走不需要的物品。Trainingmethods

培訓(xùn)方法Linknursesandpracticeeducators-trainALLstaff–nurses,cleaners,therapists,doctors,porters.-twiceweeklywalk-about

-scheduledrotationalworkinginwards–dedicatedPEduringoutbreaks.

-IPCForums–focusonlegal‘dutyofcare’

-dedicatedtraininginEVERYwardfornewcleaningproducts聯(lián)絡(luò)護(hù)士和實(shí)操教員培訓(xùn)所有醫(yī)護(hù)人員-護(hù)士，清潔工，治療師，醫(yī)生，護(hù)工每周兩次巡視當(dāng)醫(yī)院感染爆發(fā)時(shí)，科室要輪班工作，并注意帶上個(gè)人專用防護(hù)用品感染預(yù)防控制論壇-關(guān)注法律規(guī)定的“護(hù)理義務(wù)”每個(gè)新的清潔產(chǎn)品都要對(duì)每個(gè)科室進(jìn)行專門培訓(xùn)Trainingmethods

培訓(xùn)方法IPCandcleaningChampionsChampionbadgesforinspirationalstaffawardsforbestwardcleaningscores,petitionswithprizestarget‘newstarters’培訓(xùn)感控成員，參與清潔冠軍活動(dòng)以冠軍徽章來(lái)激勵(lì)醫(yī)護(hù)人員為得到最高分的科