1、Implementation of wet wipe cleaningYvonne Carter.Service Lead Nurse Infection Prevention and Control.The Royal Free London NHS Foundation Trust.消毒濕巾清潔方式的應(yīng)用消毒濕巾清潔方式的應(yīng)用 伊芳卡特小姐伊芳卡特小姐醫(yī)院感染控制與預(yù)防主任英國皇家自由醫(yī)院 - 英國國家醫(yī)療服務(wù)系統(tǒng)信托基金會Environmental contamination環(huán)境污染環(huán)境污染 Patients with infections are a source of environ

2、mental contamination. Increase risk for patients admitted into a room formerly occupied by infectious patient (Martinez JA et al (2003), Huang SS et al (2006), Drees M et al (2008) Some organisms shed for months after symptoms of infection have cleared eg, C.difficile, VRE. Some organisms require di

3、fferent cleaning products because they produce spores or are viruses resistant to routine disinfectants. Many organisms live for weeks or months in the environment, eg Acinetobacter sp. (Kramer et al (2006) Micro-organisms colonise everywhere: environmental surfaces, hands, skin and medical or care

4、devices and equipment.感染病人是環(huán)境污染的來源之一。住進有過感染患者的房間，會增加新進病人被感染的風(fēng)險。Martinez JA et al(2003), Huang SS et al (2006), Dress M et al(2008)。有些微生物在感染癥狀消失后可以匿藏數(shù)月之久，例如難辨芽胞梭菌和抗萬古霉素腸道球菌。對于產(chǎn)生孢子微生物或者是常規(guī)消毒劑無效的病毒，需要用不同的清潔消毒產(chǎn)品進行清潔。許多微生物能能在環(huán)境中存活數(shù)周甚至數(shù)月之久，例如不動桿菌。Kramer et al(2006)微生物定植無處不在：環(huán)境物體表面，手部，皮膚，醫(yī)療護理裝置等儀器設(shè)備。Changi

5、ng the culture of cleaning環(huán)境污染環(huán)境污染 What is the current process what do users think of it? Re-shape thinking what is the evidence for change What do I get out of it? How do I know this will work? How will patients benefit? OK make it clear make it simple.目前的清潔方式 - 清潔人員認(rèn)為這個方式怎么樣？重新改變思維 - 轉(zhuǎn)變的依據(jù)是什么？我該放棄

6、哪些陋習(xí)？我如何知道新的方式是有效的？對病患者有什么益處？可行的話 - 操作方法要清晰，簡單。4OPTIONS FOR CLEANING AND DISINFECTION清潔和消毒方式的選擇清潔和消毒方式的選擇Dont like mop and buckets water splashing everywhere, carrying heavy buckets.Did not know how often to change dirty water.Collecting mop, bucket, cloths and cleaning agent took a lot of time and

7、then time to put them away again.Complicated to know what to use for what purpose.Didnt know if cleaning product was working.Cloths often left marks or streaks across cleaned surfaces.Did not know how wet a cloth should be to ensure good coverage and contact time.Diluting chlorine tablets/powder. Of

8、ten got the wrong concentration.Did not like the smell of the cleaning products.Some products made the eyes and nose sting or weep.Cleaning agent was inhaled from spray bottles.Evaluation of current cleaning process對目前清潔消毒方式的評價對目前清潔消毒方式的評價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時。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

9、否真的起效。用抹布清潔消毒后通常會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吸入到體內(nèi)不喜歡地拖和水桶 - 水會到處濺潑，還要提著很重的水桶 broad spectrum: wide antimicrobial spectrumfast acting: rapidly kills short contact timeodourless: have a pleasant odour or no odoureconomical: not be too high i

10、n coststability: be stable in concentrated state and when dilutedone step removal of surface bio-matter and disinfectionsingle use - re-use encourages bacterial growthno transfer of bacteria while wipingEvidence what is the Ideal disinfectant?理想的消毒劑是什么？理想的消毒劑是什么？廣譜：廣譜：抗菌廣譜快速起效：快速起效：短接觸時間內(nèi)迅速殺滅無臭：無臭：清

11、新的氣味或無臭味經(jīng)濟：經(jīng)濟：不需要花費太高的成本穩(wěn)定性：穩(wěn)定性：穩(wěn)定的配液濃度比清潔和消毒一步到位一步到位一次性使用一次性使用：重復(fù)使用導(dǎo)致滋生細菌擦拭的時候不會產(chǎn)生細菌轉(zhuǎn)移不會產(chǎn)生細菌轉(zhuǎn)移Evidence for wet wipe cleaning what do I get out of it?使用濕巾清潔的依據(jù)使用濕巾清潔的依據(jù) - - 我該放棄哪些陋習(xí)？我該放棄哪些陋習(xí)？pre-measured dose of disinfectant on a wipe no dilution issues how muchpowder/tablets/water?use from clean to

12、 dirty and then throw awayuser friendly fast, grab a wipe and use.no mops, heavy buckets, rinse water, handling of dirty cloths.they are familiar to use baby wipes, picnic hand wipes.one step process clean away bio-matter and disinfect in one process.no sore eyes or nose no smell預(yù)先配比好濃度 無需稀釋 - 需要多少消

13、毒粉末，消毒片和水等問題。 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刺激眼睛或者鼻子 - 沒有氣味Wipes 濕巾:How will patients benefit?病患者如何受益病患者如何受益？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MRSA菌血癥Dru

14、g resistant organisms耐藥性微生物耐藥性微生物Current problems with multi - drug resistant Acinetobacter and Carbapenemase producing organisms. Klebsiella, E.coli, pseudomonas.Each organisms behaves in the same way as antibiotic sensitive species to disinfectants, so cleaning protocols remain the same.Disinfecta

15、nt wipes are just as effective against antibiotic resistant organismsCleaning should be made more strict to keep source of infection contained, but the products do not change.目前的問題在于多重耐藥性微生物的出現(xiàn)，例如：不動桿菌，產(chǎn)碳青霉烯酶腸桿菌，克雷伯桿菌，大腸桿菌，假單胞菌。與抗生素敏感株對消毒劑敏感一樣，每種微生物同樣對消毒劑敏感，所以需保持一樣的清潔方式。消毒濕巾對抗生素耐藥的微生物同樣有效。因此清潔操作應(yīng)該更加

16、嚴(yán)格控制感染源，清潔產(chǎn)品保持不變。Cost benefits成本效益成本效益 Each MRSA BSI costs around 10,000 to treat. Reduction from 98 cases to 1. - 98 cases costs 980,000. Each CDI case costs around 4,000 to treat每例MRSA血流感染病人的治療費用約1萬英鎊。從98例降至1例 - 98例總費用是98萬英鎊（相當(dāng)于人民幣980萬）。每例難辨芽胞梭菌感染病人的治療費用約4000英鎊（相當(dāng)于人民幣4萬元）。CDI rates not improving.a

17、ntibiotic policies and clinical practices recently reviewed.focus on environmental hygiene.traditional chlorine agents- not user-friendly.alternative effective product Sporicidal wipe.all patients over 2 years included in infection reporting.wipes introduced April 2008.April 2009 infections 72% lowe

18、r.cost per infection about 4,000, representing saving of 660.000. Cost benefits成本效益成本效益艱難梭狀芽孢桿菌感染率沒有升高。最近對抗生素政策和臨床實踐進行了審議。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2年的患者都被記錄在感染報告里。2008年4月份引進使用濕巾。2009年4月份感染降低了72%。每例感染花費約4000英鎊，這意味著節(jié)省了66萬英鎊?；计D難梭狀芽孢桿菌病例 - 2008年3月-2014年1月 單位：例Clear and simple簡單明了簡單明了 Sa

19、ve effort - one step - disinfectant wipes trap dirt and bacteria. Kills them as well as removes them no transfer from surface to surface. Save time - easy to use pick up a wipe and clean, then throw.簡化操作簡化操作 - - 一步到位-消毒濕巾能去除臟污及細菌。既能殺菌也能去除 - 不會讓細菌在物表之間轉(zhuǎn)移。節(jié)省時間節(jié)省時間 - - 使用方便 - 抽取一片濕巾進行清潔，清潔完畢丟棄即可。Clear

20、and simple簡明清楚簡明清楚 Save resources- Equipment and materials required;colour-coded bucket;colour-coded cloth;cleaning trolley;general purpose detergent / waterwarning signs.gloves and apronOrDisinfectant wipesgloves and apron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Making the ch

21、ange做出改變做出改變Introduce in a small way two wards identify any barriers easier to put right on small scale.One IPC nurse and manufacturers trainer on the wards each day to answer questions, demonstrate and train.Provide pocket size information sheet why wipes are beneficial: - easier to use - less time

22、, effort and resources - proven reduction in infection rates小范圍引進新產(chǎn)品從兩個科室了解確認(rèn)目前存在哪些障礙和問題 -小規(guī)模試行能更容易予以糾正。一個感染預(yù)防控制護士和生產(chǎn)廠家的培訓(xùn)人員每天在科室回答醫(yī)護人員的問題，演示并進行培訓(xùn)。提供資料小冊子 - 為什么濕巾是有益的：更容易使用省時省力省資源證實能降低感染率Making the change做出改變做出改變 Support from manufacturer.installation of dispensersstaff training and repeat sessionse

23、-learning pack with tablets provided for usersposters and leaflets specific to each hospitalsponsorship for professional conferences and learningstudy day support, at local levelscientific research help in related IPC practice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)院量身定做的海報及宣傳單張專業(yè)

24、性會議及學(xué)習(xí)研討會等的贊助支持地方級醫(yī)院開展學(xué)習(xí)日與感染預(yù)防控制有關(guān)的科研協(xié)助Cleaning in practice清潔的實際操作清潔的實際操作 General principles:wipe all surfaces, including underneath - special attention to high touch points.clean top to bottom or clean to dirty.use overlapping S motion cover all areas.change wipes between surfaces.remove PPEs and w

25、ash hands.apply cleaned indicator tape or document.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。兩個物表之間的清潔要更換新的濕巾。脫下個人防護用品并洗凈雙手。物表清潔完畢后用清潔指示條帶或標(biāo)貼作標(biāo)記。S style cleaning “S”“S”形擦拭方式形擦拭方式High touch surfaces高接觸率物體表面高接觸率物體表面Cleaning who is responsible?清潔消毒清潔消毒 誰負(fù)責(zé)？誰負(fù)責(zé)？A Mat

26、rons Charter: 10 commitments:1 Keeping the NHS clean is everybodys responsibility.3Matrons will establish a cleanliness culture across their units.6 Cleaning routines will be clear, agreed and well-publicised.8 All staff working in healthcare will receive education in infection control.9 Nurses and

27、infection control teams will be involved in drawing up cleaning contracts, and matrons have authority and power to withhold payment.護士長憲章：護士長憲章：1010項承諾：項承諾：保持國家醫(yī)療服務(wù)體系下各個醫(yī)院的潔凈是每個人的職責(zé)。護士長在各自科室建立良好的清潔文化和制度。清潔消毒規(guī)范會清晰明了，經(jīng)過一致議定并公示出來所有在醫(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)。護士和感染控制團隊可參與起草清潔合同，護士長有權(quán)力控制款項支付。Cleaning- who i

28、s responsible清潔消毒清潔消毒誰負(fù)責(zé)？誰負(fù)責(zé)？ Clinical staff Domestic/cleaning staff Dedicated decontamination staff blood and body fluid exposure training - competence and understanding technical understanding electronic and medical equipment in patient use or routine cleaning in store room in food contact臨床醫(yī)護人員家政

29、機構(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)備病患者使用或儲物室例行清潔食品接觸方面49 Elements4949項物品清潔標(biāo)準(zhǔn)項物品清潔標(biāo)準(zhǔn)Cleaning frequencies清潔消毒頻率清潔消毒頻率Our Ward Cleaning Promise The Trust is committed to providing a clean and safe environment and wants to encourage patients and visitors feedback on every aspect of the clean

30、ing service. Programmed activities de-scaling ceiling vents window cleaning curtain changes deep cleaning信托基金會致力于提供一個清潔和安全的環(huán)境，并且鼓勵病患者及探訪者能夠為我們在清潔服務(wù)的每個方面提供寶貴意見。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Cleaning frequencies清潔消毒頻率清潔消毒頻率Standards標(biāo)準(zhǔn)標(biāo)準(zhǔn)All parts including underneath should be visibly clean with no

31、 blood and body substances, dust, dirt, debris or spillages.All wall surfaces including skirting should be visibly clean with no blood and body substances, dust, dirt, debris, adhesive tape or spillages.All parts of the bed (including mattress, bed frame, wheels and castors) should be visibly clean

32、with no blood and body substances, dust, dirt, debris, adhesive tape or spillages.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)標(biāo)準(zhǔn) Very high risk critical care, operatin

33、g theatres High risk general wards Significant risk laboratories, out-patient clinics98%95%85%下列提供三類“感染風(fēng)險級別”的指標(biāo)：極度高風(fēng)險 - 重癥監(jiān)護室，手術(shù)室高風(fēng)險 - 普通病房顯著風(fēng)險 - 實驗室，門診Competence assessment能力評估能力評估explain the difference between cleaning, decontaminating and sterilising.explain the need to physically clean before ch

34、emical disinfection.explain the uses of cleaning and decontamination agents generally in use.demonstrate how and when to use Universal and Sporicidal wipes.explain the reason behind top to bottom cleaning and clean to dirty 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

35、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。Training methods培訓(xùn)方法培訓(xùn)方法joint training with ward staff and cleaning staff 49 elementsprovide a cleaning product that is acceptable to users and needs little trainingprovide equipment and furnishings that are easily cleaned.visual demonstrations UV light systemadeno

36、sine Triphosphate (ATP)professional pride publicise cleaning scores at ward entrances與科室醫(yī)護人員和清潔人員進行聯(lián)合培訓(xùn)49項物品清潔標(biāo)準(zhǔn)提供一個便于使用者使用，只需要進行簡單培訓(xùn)的清潔產(chǎn)品現(xiàn)場演示 - 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Training methods培訓(xùn)方法培訓(xùn)方法public and patient pressurepatient lead assessment of care environment (PLA

37、CE) with external verifiermock PLACE assessments by IPC practice-educators and senior trust staffPLACE scores publicised publicly on PLACE website for the world to seehospital of choice來自公眾和病患者的壓力以患者為首，聯(lián)合第三方，進行護理環(huán)境評估（PLACE）由感染預(yù)防控制部門進行模擬的護理環(huán)境評估- 由教員和信托基金會高級職員進行。評估得分會張貼在該評估網(wǎng)站上讓所有的人都能查閱選擇醫(yī)院Patient info

38、rmation患者資訊患者資訊Leave infections at home If you have had an infection, make sure you are completely well before visiting anyone in hospital. Cover any wounds. Cleanse your hands carefully and often Wash your hands if they are soiled. Use the alcohol hand rub when you enter and leave a ward and use th

39、e bedside rub after close contact with patients. There are signs showing you how to use them - or ask staff. Let staff know when the supplies are running low. Dont clutter Help staff to keep areas clean by not bringing in lots of clutter and by taking away things that are not required. 感染了，請留在家感染了，請

40、留在家如果你獲得感染，確保徹底痊愈了方可進入醫(yī)院探訪。包扎好所有傷口。經(jīng)常勤洗手經(jīng)常勤洗手雙手臟污時要進行清洗。進入和離開病房的時候使用酒精手消液，和病患者距離接觸過后使用病床旁邊的手消液。有使用方法說明 - 或者可以咨詢醫(yī)護人員。手消液剩余不多的時候請告知醫(yī)護人員。 不添亂不添亂幫助醫(yī)護人員保持清潔區(qū)域的整潔，不亂放雜物，帶走不需要的物品。Training methods培訓(xùn)方法培訓(xùn)方法 Link nurses and practice educators - train ALL staff nurses, cleaners, therapists, doctors, porters. -

41、twice weekly walk-about - scheduled rotational working in wards dedicated PE during outbreaks. - IPC Forums focus on legal duty of care - dedicated training in EVERY ward for new cleaning products聯(lián)絡(luò)護士和實操教員培訓(xùn)所有醫(yī)護人員 - 護士，清潔工，治療師，醫(yī)生，護工每周兩次巡視當(dāng)醫(yī)院感染爆發(fā)時，科室要輪班工作，并注意帶上個人專用防護用品感染預(yù)防控制論壇 - 關(guān)注法律規(guī)定的“護理義務(wù)”每個新的清潔產(chǎn)品

42、都要對每個科室進行專門培訓(xùn)Training methods培訓(xùn)方法培訓(xùn)方法 IPC and cleaning Champions Champion badges for inspirational staff awards for best ward cleaning scores, individuals and teams demonstrating best practice. competitions with prizes target new starters培訓(xùn)感控成員，參與清潔冠軍活動以冠軍徽章來激勵醫(yī)護人員為得到最高分的科室提供獎勵，由個人和團體展現(xiàn)最優(yōu)秀的清潔方式。引入競賽與獎勵以新入門者為目標(biāo)Training methods培訓(xùn)方法培訓(xùn)方法 rapid response team practical and fast response to cleaning issues Helpdesk 24 hour phone line for cleaning and maintenanceservice annual Deep Clean makes it e