医疗质量控制指标

医疗质量控制指标 附件1 麻醉专业医疗质量控制指标 (2015年版) 一、麻醉科医患比 定义:麻醉科固定在岗,本院,医师总数占同期麻醉科完成麻醉总例次数,万例次,的比例。 计算: 麻醉科医患比=[麻醉科固定在岗,本院,医师总数/同期麻醉科完成麻醉总例次数,万例次,] ×100% 意义:反映医疗机构麻醉医疗质量的重要结构性指标之一。 二、各ASA分级麻醉患者比例 定义:根据美国麻醉医师协会(ASA)分级～对于接受麻醉患者的病情危重程度进行分级。各ASA分级麻醉患者比例是指该ASA分级麻醉患者数占同期各ASA分级麻醉患者总数的比例。 计算公式: 各ASA分级麻醉患者比例=[该ASA分级麻醉患者数/同期各ASA分级麻醉患者总数] ×100% 意义:体现医疗机构接诊不同病情危重程度患者所占比重～是反映医疗机构麻醉医疗质量的重要结构性指标之一。 三、急诊非择期麻醉比例 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 定义:急诊非择期手术所实施的麻醉数占同期麻醉总数的比例。 计算公式: 急诊非择期麻醉比例=[ 急诊非择期手术所实施的麻醉数/同期麻醉总数] ×100% 意义:反映医疗机构麻醉医疗质量的重要结构性指标之一。 四、各类麻醉方式比例 定义:各类麻醉方式比例是指该麻醉方式数占同期各类麻醉方式总数的比例。 计算公式: 各类麻醉方式比例= [该麻醉方式数/同期各类麻醉方式总数] ×100% 意义:体现医疗机构应用各类麻醉方式所占比重～是反映医疗机构麻醉医疗质量的重要结构性指标之一。 注:麻醉方式分为5类: ,一,椎管内麻醉:包括硬膜外麻醉～腰麻～腰硬联合麻醉～骶麻～鞍麻, ,二,插管全麻:包括支气管插管全麻～气管插管全麻～喉罩全麻～喉罩+气管插管全麻, ,三,非插管全麻, ,四,复合麻醉:包括插管全麻+椎管内麻醉～非插管全麻+椎管内麻醉,插管全麻+神经阻滞～非插管全麻+神经development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 阻滞～椎管内麻醉+神经阻滞, ,五,其他麻醉方式:包括神经阻滞～局麻强化MAC～其他。 五、麻醉开始后手术取消率 定义:麻醉开始是指麻醉医师开始给予患者麻醉药物。麻醉开始后手术取消率是指麻醉开始后手术开始前手术取消的数占同期麻醉总数的比例。 计算公式: 麻醉开始后手术取消率=[ 麻醉开始后手术开始前手术取消的数/同期麻醉总数 ] ×1000‰ 意义:体现麻醉性和管理水平～是反映医疗机构医疗质量的重要过程指标之一。 六、麻醉后监测治疗室(PACU)转出延迟率 定义:入PACU超过3小时的患者数占同期入PACU患者总数的比例。 计算公式: 麻醉后监测治疗室,PACU,转出延迟率=[ 入PACU超过3小时的患者数/同期入PACU患者总数 ]= ×1000‰ 意义:体现手术和麻醉管理水平～是反映医疗机构医疗质量的重要过程指标之一。 七、PACU入室低体温率 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the3 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 定义:PACU入室低体温是指患者入PACU第一次测量体温低于35.5?。PACU入室低体温率～是指PACU入室低体温患者数占同期入PACU患者总数的比例。体温测量的方式推荐为红外耳温枪。 计算公式: PACU入室低体温率=[ PACU入室低体温患者数/同期入PACU患者总数 ] ×100% 意义:反映围手术期体温保护情况～是反映医疗机构麻醉医疗质量的重要过程指标之一。 八、非计划转入ICU率 定义:非计划转入ICU是指在开始麻醉诱导前并无术后转入ICU的计划～而术中或术后决定转入ICU。非计划转入ICU率～是指非计划转入ICU患者数占同期转入ICU患者总数的比例。 计算公式: 非计划转入ICU率=[ 非计划转入ICU患者数/同期转入ICU患者总数 ] ×100% 意义:反映医疗机构医疗质量的重要结果指标之一。 九、非计划二次气管插管率 定义:非计划二次气管插管是指在患者术后气管插管拔除后6小时内～非计划再次行气管插管术。非计划二次气管插管development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 率～是指非计划二次气管插管患者数占同期术后气管插管拔除患者总数的比例。 计算公式: 非计划二次气管插管率=[非计划二次气管插管患者数 / 同期术后气管插管拔除患者总数] ×100% 意义:非计划二次气管插管提示在麻醉复苏阶段～对于拔管指征的掌握可能存在问～或者患者出现其它问题需要再次进行气管插管,是反映医疗机构麻醉质量管理和/或手术质量的重要过程指标之一。 十、麻醉开始后24小时内死亡率 定义:麻醉开始后24小时内死亡患者数占同期麻醉患者总数的比例。患者死亡原因包括患者本身病情严重、手术、麻醉以及其它任何因素。 计算公式: 麻醉开始后24小时内死亡率=[ 麻醉开始后24小时内死亡患者数/同期麻醉患者总数 ] ×100% 意义:麻醉开始后24小时内死亡与患者本身病情轻重、手术质量和麻醉质量等密切相关～是反映医疗机构医疗质量的重要结果指标之一。 十一、麻醉开始后24小时内心跳骤停率 定义:麻醉开始后24小时内心跳骤停是指麻醉开始后24小 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the5 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 时内非医疗目的的心脏停跳。麻醉开始后24小时内心跳骤停率～是指麻醉开始后24小时内心跳骤停患者数占同期麻醉患者总数的比例。患者心跳骤停原因包括患者本身病情严重、手术、麻醉以及其它任何因素。 计算公式: 麻醉开始后24小时内心跳骤停率=[麻醉开始后24小时内心跳骤停患者数 /同期麻醉患者总数]×100% 意义:麻醉开始后24小时内心跳骤停是围手术期的严重并发症～是反映医疗机构医疗质量的重要结果指标之一。 十二、术中自体血输注率 定义:麻醉中～接受400ml及以上自体血,包括自体全血及自体血红细胞,输注患者数占同期接受400ml及以上输血治疗的患者总数的比例。 计算公式: 术中自体血输注率=[麻醉中接受400ml及以上自体血,包括自体全血及自体血红细胞,输注患者数 /同期接受400ml及以上输血治疗的患者总数] ×100% 意义:自体血的应用可以显著降低异体输血带来的风险～是反映医疗机构医疗质量的重要结构性指标之一。 十三、麻醉期间严重过敏反应发生率 定义:严重过敏反应是指发生循环衰竭和/或严重气道反应development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre ,痉挛、水肿,～明显皮疹～需要使用肾上腺素治疗的过敏反应。麻醉期间严重过敏反应是指麻醉期间各种原因导致的严重过敏反应。麻醉期间严重过敏反应发生率～是指麻醉期间严重过敏反应发生例数占同期麻醉总例数的比例。 计算公式: 麻醉期间严重过敏反应发生率=[麻醉期间严重过敏反应发生例数 /同期麻醉总例数] ×1000‰ 意义:麻醉期间严重过敏反应是围手术期的严重并发症～是反映医疗机构医疗质量的重要结果指标之一。 十四、椎管内麻醉后严重神经并发症发生率 定义:椎管内麻醉后严重神经并发症～是指在椎管内麻醉后新发的重度头痛、局部感觉异常,麻木或异感,、运动异常,肌无力甚至瘫痪,等～持续超过72小时～并排除其他病因者。椎管内麻醉后严重神经并发症发生率～是指椎管内麻醉后严重神经并发症发生例数占同期椎管内麻醉总例数的比例。 计算公式: 椎管内麻醉后严重神经并发症发生率=[ 椎管内麻醉后严重神经并发症发生例数/同期椎管内麻醉总例数] ×1000‰ 意义:反映医疗机构麻醉医疗质量的重要结果指标之一。 十五、中心静脉穿刺严重并发症发生率 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the7 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 定义:中心静脉穿刺严重并发症是指由中心静脉穿刺、臵管引起的气胸、血胸、局部血肿、导管或导丝异常等～需要外科手段,含介入治疗,干预的并发症。中心静脉穿刺严重并发症发生率～是指中心静脉穿刺严重并发症发生例数占同期中心静脉穿刺总例数的比例。 计算公式: 中心静脉穿刺严重并发症发生率= [ 中心静脉穿刺严重并发症发生例数/同期中心静脉穿刺总例数]×1000‰ 意义:反映医疗机构麻醉医疗质量的重要结果指标之一。 十六、全麻气管插管拔管后声音嘶哑发生率 定义:全麻气管插管拔管后声音嘶哑～是指新发的、在拔管后72小时内没有恢复的声音嘶哑～排除咽喉、颈部以及胸部手术等原因。全麻气管插管拔管后声音嘶哑发生率～是指全麻气管插管拔管后声音嘶哑发生例数占同期全麻气管插管总例数的比例。 计算公式: 全麻气管插管拔管后声音嘶哑发生率= [ 全麻气管插管拔管后声音嘶哑发生例数/同期全麻气管插管总例数]×1000‰ 意义:全麻气管插管拔管后声音嘶哑是围手术期的严重并发症～是反映医疗机构麻醉医疗质量的重要结果指标之一。 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 十七、麻醉后新发昏迷发生率 定义:麻醉后新发昏迷是指麻醉前清醒患者麻醉手术后没有苏醒～持续昏迷超过24小时,昏迷原因可包括患者本身疾患、手术、麻醉以及其它任何因素～除外因医疗目的给予镇静催眠者。麻醉后新发昏迷发生率～是指麻醉后新发昏迷发生例数占同期麻醉总例数的比例。 计算公式: 麻醉后新发昏迷发生率=[ 麻醉后新发昏迷发生例数/同期麻醉总例数] ×1000‰ 意义:麻醉后新发昏迷是围手术期的严重并发症～是反映医疗机构麻醉医疗质量的重要结果指标之一。 附件2 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the9 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 重症医学专业医疗质量控制指标 (2015年版) 一、ICU患者收治率和ICU患者收治床日率 定义:ICU患者收治率是指ICU收治患者总数占同期医院收治患者总数的比例。ICU患者收治床日率是指ICU收治患者总床日数占同期医院收治患者总床日数的比例。同一患者同一次住院多次转入ICU～记为“多人次”。 计算公式: ICU患者收治率=[ICU收治患者总数 /同期医院收治患者总数] ×100% ICU患者收治床日率= [ICU收治患者总床日数 /同期医院收治患者总床日数]×100% 意义:反映全部住院患者ICU患者的比例及收治情况。 二、急性生理与慢性健康评分(APACHE?评分)?15分患者收治率(入ICU24小时内) 定义:入ICU 24小时内～APACHE?评分?15分患者数占同期ICU收治患者总数的比例。 计算公式: APACHE?评分?15分患者收治率(入ICU24小时内)= [ APACHE?评分?15分患者数/同期ICU收治患者总数]×100% development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 意义:反映收治ICU患者的病情危重程度。 注:具有信息化自动收集能力的医院建议直接提取APACHE?评分～并按照<10分～10-15分～15-20分～20-25分～>25分进行分层分析。 三、感染性休克3h集束化治疗(bundle)完成率 定义:感染性休克3h集束化治疗,bundle,～是指感染性休克诊断后3小时内完成:测量乳酸浓度,抗菌药物治疗前进行血培养,予以广谱抗菌药物,低血压或乳酸?4mmol/L给予30ml/kg晶体液进行目标复苏。感染性休克3h集束化治疗,bundle,完成率～是指入ICU诊断为感染性休克并全部完成3h bundle的患者数占同期入ICU诊断为感染性休克患者总数的比例。不包括住ICU期间后续新发生的感染性休克病例。 计算公式: 感染性休克3h集束化治疗,bundle,完成率= [ 入ICU诊断为感染性休克并全部完成3h bundle的患者数/同期入ICU诊断为感染性休克患者总数]×100% 意义:反映感染性休克的治疗性及诊疗能力。 四、感染性休克 6h集束化治疗(bundle)完成率 定义:感染性休克6h集束化治疗,bundle,～是指在3h集束化治疗,bundle,的基础上加上:低血压对目标复苏效果 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the11 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 差立即予以升压药,脓毒症休克或乳酸?4mmol/L容量复苏后仍持续低血压～需立即测量CVP 和 ScvO,初始乳酸高于2 正常患者需重复测量乳酸水平。感染性休克6h集束化治疗,bundle,完成率～是指入ICU诊断为感染性休克全部完成6h bundle的患者数占同期入ICU诊断为感染性休克患者总数的比例。不包括住ICU期间后续新发生的感染性休克病例。 计算公式: 感染性休克6h集束化治疗,bundle,完成率= [入ICU诊断为感染性休克全部完成6h bundle的患者数 /同期入ICU诊断为感染性休克患者总数]×100% 意义:反映感染性休克的治疗规范性及诊疗能力。 五、ICU抗菌药物治疗前病原学送检率 定义:以治疗为目的使用抗菌药物的ICU住院患者～使用抗菌药物前病原学检验标本送检病例数占同期使用抗菌药物治疗病例总数的比例。病原学检验标本包括:各种微生物培养、降钙素原、白介素-6等感染指标的血清学检验。 计算公式:ICU抗菌药物治疗前病原学送检率= [使用抗菌药物前病原学检验标本送检病例数 /同期使用抗菌药物治疗病例总数]×100% 意义:反映ICU患者抗菌药物使用的规范性。 六、ICU深静脉血栓(DVT)预防率 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 定义:进行深静脉血栓,DVT,预防的ICU患者数占同期ICU收治患者总数的比例。深静脉血栓预防措施包括药物预防(肝素或低分子肝素抗凝)、机械预防(肢体加压泵、梯度压力弹力袜等)以及下腔静脉滤器等。 计算公式: ICU深静脉血栓,DVT,预防率= [进行深静脉血栓,DVT,预防的ICU患者数 /同期ICU收治患者总数]×100% 意义:反映ICU患者DVT的预防情况。 七、ICU患者预计病死率 定义:通过患者疾病危重程度,APACHE?评分,来预测的可能病死率。患者死亡危险性,R,的公式:In,R/1-R,=-3.517+,APACHE?评分×0.146,+0.603 ,仅限于急诊手术后患者,+患者入ICU的主要疾病得分,按国际标准,。ICU患者预计病死率是指ICU收治患者预计病死率的总和与同期ICU收治患者总数的比值。 计算公式: ICU患者预计病死率=[ICU收治患者预计病死率的总和/同期ICU收治患者总数]×100% 意义:反映收治ICU患者的疾病危重程度～用来计算患者标化病死指数。 八、ICU患者标化病死指数(Standardized Mortality Ratio) development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the13 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 定义:通过患者疾病危重程度校准后的病死率～为ICU患者实际病死率与同期ICU患者预计病死率的比值。ICU实际病死率为ICU死亡患者数,包括因不可逆疾病而自动出院的患者,占同期ICU收治患者总数的比例～除外入院时已脑死亡～因器官捐献而收治ICU的患者。 计算公式: ICU患者标化病死指数=[ICU患者实际病死率/同期ICU患者预计病死率] ×100% 意义:反映ICU整体诊疗水平。 九、ICU非计划气管插管拔管率 定义:非计划气管插管拔管例数占同期ICU患者气管插管拔管总数的比例。 计算公式: ICU非计划气管插管拔管率=[非计划气管插管拔管例数/同期ICU患者气管插管拔管总数] ×100% 意义:反映ICU的整体管理及治疗水平。 十、ICU气管插管拔管后48h内再插管率 定义:气管插管计划拔管后48h内再插管例数占同期ICU患者气管插管拔管总例数的比例。不包括非计划气管插管拔管后再插管。 计算公式: ICU气管插管拔管后48h内再插管率= [气管插管计划拔development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 管后48h内再插管例数/同期ICU患者气管插管拔管总例数] ×100% 意义:反映对ICU患者脱机拔管指征的把握能力。 十一、非计划转入ICU率 定义:非计划转入ICU是指非早期预警转入～或在开始麻醉诱导前并无术后转入ICU的计划～而术中或术后决定转入ICU。非计划转入ICU率是指非计划转入ICU患者数占同期转入ICU患者总数的比例。非计划转入ICU的原因应进行分层分析(缺乏病情恶化的预警、麻醉因素和手术因素等)。 计算公式: 非计划转入ICU率=[非计划转入ICU患者数/同期转入ICU患者总数] ×100% 意义:反映医疗机构医疗质量的重要结果指标之一。 十二、转出ICU后48h内重返率 定义:转出ICU后48h内重返ICU的患者数占同期转出ICU患者总数的比例。 计算公式: 转出ICU后48h内重返率=[转出ICU后48h内重返ICU的患者数/同期转出ICU患者总数] ×100% 意义:反映对ICU患者转出ICU指征的把握能力。 十三、ICU呼吸机相关性肺炎(VAP)发病率 定义:VAP发生例数占同期ICU患者有创机械通气总天数的 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the15 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 比例。单位:例/千机械通气日。 计算公式: ICU呼吸机相关性肺炎,VAP,发病率(例/千机械通气日) = [VAP发生例数/同期ICU患者有创机械通气总天数] ×1000‰ 意义:反映ICU感控、有创机械通气及管理能力。 十四、ICU血管内导管相关血流感染(CRBSI)发病率 定义:CRBSI发生例数占同期ICU患者血管内导管留臵总天数的比例。单位:例/千导管日。 计算公式: ICU血管内导管相关血流感染,CRBSI,发病率(例/千机械通气日)=[CRBSI发生例数/同期ICU患者血管内导管留臵总天数] ×1000‰ 意义:反映ICU感控、血管内导管留臵及管理能力。 十五、ICU导尿管相关泌尿系感染(CAUTI)发病率 定义:CAUTI发生例数占同期ICU患者导尿管留臵总天数的比例。单位:例/千导尿管日。 计算公式: ICU导尿管相关泌尿系感染,CAUTI,发病率(例/千机械通气日)=[CAUTI发生例数/同期ICU患者导尿管留臵总天数] ×1000‰ 意义:反映ICU感控、导尿管留臵及管理能力。 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 注:本重症医学专业医疗质量控制指标适用于包括 PICU、EICU、CCU等所有重症医学救治单元。 附件3 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the17 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 急诊专业医疗质量控制指标 (2015年版) 一、急诊科医患比 定义:急诊科固定在岗,本院,医师总数占同期急诊科接诊患者总数,万人次,的比例。 计算公式: 急诊科医患比= [急诊科固定在岗,本院,医师总数/同期急诊科接诊患者总数,万人次,]×100% 意义:反映医疗机构急诊医疗质量的重要结构性指标之一。 二、急诊科护患比 定义:急诊科固定在岗,本院,护士,师,总数占同期急诊科接诊患者总数,万人次,的比例。 计算公式: 急诊科护患比=[急诊科固定在岗,本院,护士,师,总数/同期急诊科接诊患者总数,万人次,]×100% 意义:反映医疗机构急诊医疗质量的重要结构性指标之一。 三、急诊各级患者比例 定义:急诊患者病情分级:?级是濒危患者～?级是危重患者～?级是急症患者～?级是非急症患者。急诊各级患者比例～是指急诊科就诊的各级患者总数占同期急诊科就诊患者总数的比例。 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 计算公式: 急诊各级患者比例=[急诊科就诊的各级患者总数/同期急诊科就诊患者总数]×100% 意义:反映医疗机构急诊医疗质量的重要结构性指标之一。 四、抢救室滞留时间中位数 定义:抢救室滞留时间是指急诊抢救室患者从进入抢救室到离开抢救室,不包括死亡患者,的时间,以小时为单位,。抢救室滞留时间中位数是指将急诊抢救室患者从进入抢救室到离开抢救室,不包括死亡患者,的时间由长到短排序后取其中位数。 计算公式: 抢救室滞留时间中位数=X, n 为奇数 (n+1)/2 抢救室滞留时间中位数=,X+X,/2～n为偶数 n/2n/2+1 注:n为急诊抢救室患者数～X为抢救室滞留时间。 意义:反映急诊抢救室工作量、工作效率的重要指标。 五、急性心肌梗死(STEMI)患者平均门药时间及门药时间达标率 定义:急性心肌梗死,STEMI,患者平均门药时间是指行溶栓药物治疗的急性心肌梗死,STEMI,患者从进入急诊科到开始溶栓药物治疗的平均时间。急性心肌梗死,STEMI,患者门药时间达标是指在溶栓药物时间窗,发病12小时,内～就诊的急性心肌梗死,STEMI,患者门药时间在30分钟内。 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the19 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 急性心肌梗死,STEMI,患者门药时间达标率是指急性心肌梗死,STEMI,患者门药时间达标的患者数占同期就诊时在溶栓药物时间窗内应行溶栓药物治疗的急性心肌梗死,STEMI,患者总数的比例。 计算公式: 急性心肌梗死,STEMI,患者平均门药时间达标率= [行溶栓药物治疗的急性心肌梗死,STEMI,患者的门药时间总和/同期行溶栓药物治疗的急性心肌梗死,STEMI,患者总数] ×100% 急性心肌梗死,STEMI,患者门药时间达标率= [急性心肌梗死,STEMI,患者门药时间达标的患者数/同期就诊时在溶栓药物时间窗内应行溶栓药物治疗的急性心肌梗死,STEMI,患者总数]×100% 意义:反映急诊绿色通道的效率。 六、急性心肌梗死(STEMI)患者平均门球时间及门球时间达标率 定义:急性心肌梗死,STEMI,患者平均门球时间是指行急诊PCI的急性心肌梗死,STEMI,患者～从进入急诊科到开始PCI的平均时间。急性心肌梗死,STEMI,患者门球时间达标是指在PCI时间窗,发病12小时,内～就诊的急性心肌梗死,STEMI,患者门球时间在90分钟内。急性心肌梗死,STEMI,患者门球时间达标率是指急性心肌梗死,STEMI,development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 患者门球时间达标的患者数占同期就诊时在PCI时间窗内应行PCI的急性心肌梗死,STEMI,患者总数的比例。 计算公式: 急性心肌梗死,STEMI,患者平均门球时间达标率=[行急诊PCI的急性心肌梗死,STEMI,患者的门球时间总和/同期行PCI的急性心肌梗死,STEMI,患者总数]×100% 急性心肌梗死,STEMI,患者门球时间达标率= [急性心肌梗死,STEMI,患者门球时间达标的患者数/同期就诊时在PCI时间窗内应行PCI的急性心肌梗死,STEMI,患者总数] ×100% 意义:反映急诊绿色通道的效率。 七、急诊抢救室患者死亡率 定义:急诊抢救室患者死亡是指患者从进入急诊抢救室开始72小时内死亡,包括因不可逆疾病而自动出院的患者,。急诊抢救室患者死亡率是指急诊抢救室患者死亡总数占同期急诊抢救室抢救患者总数的比例。 计算公式: 急诊抢救室患者死亡率= [急诊抢救室患者死亡总数/同期急诊抢救室抢救患者总数]×100% 意义:反映急危重症患者救治成功率。 八、急诊手术患者死亡率 定义:急诊手术患者死亡是指急诊患者接受急诊手术～术后 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the21 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 1周内死亡～除外与手术无关的原发疾病引起的死亡。急诊手术患者死亡率是指急诊手术患者死亡总数占同期急诊手术患者总数的比例。 计算公式: 急诊手术患者死亡率= [急诊手术患者死亡总数/同期急诊手术患者总数]×100% 意义:反映急诊手术救治成功率。 九、ROSC成功率 定义:ROSC,心肺复苏术后自主呼吸循环恢复,成功是指急诊呼吸心脏骤停患者～心肺复苏术(CPR,后自主呼吸循环恢复超过24小时。ROSC成功率是指ROSC成功总例次数占同期急诊呼吸心脏骤停患者行心肺复苏术总例次数的比例。同一患者24小时内行多次心肺复苏术～记为“一例次”。 计算公式: ROSC成功率=[ROSC成功总例次数/同期急诊呼吸心脏骤停患者行心肺复苏术总例次数]×100% 意义:反映急诊心肺复苏成功率。 十、非计划重返抢救室率 定义:因相同或相关疾病～72小时内非计划重返急诊抢救室患者总数占同期离开急诊抢救室,出院或转其他区域,患者总数的比例。 计算公式: development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 非计划重返抢救室率=[72小时内非计划重返急诊抢救 室患者总数/同期离开急诊抢救室,出院或转其他区域,患 者总数]×100% 意义:反映急诊医师对患者病情评估的准确性。 附件4 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the23 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 临床检验专业医疗质量控制指标 (2015年版) 一、标本类型错误率 定义:类型不符合要求的标本数占同期标本总数的比例。 计算公式: 标本类型错误率=[类型不符合要求的标本数/同期标本总数]×100% 意义:反映所采集标本的类型是否符合要求～是检验前的重要质量指标。标本类型符合要求是保证检验结果准确性的前提条件。 二、标本容器错误率 定义:采集容器不符合要求的标本数占同期标本总数的比例。 计算公式: 标本容器错误率=[采集容器不符合要求的标本数/同期标本总数]×100% 意义:反映用于采集标本的容器是否符合要求～是检验前的重要质量指标。 三、标本采集量错误率 定义:采集量不符合要求的标本数占同期标本总数的比例。 计算公式: 标本采集量错误率= [采集量不符合要求的标本数/同期development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 标本总数]×100% 意义:反映标本采集量是否正确～是检验前的重要质量指标。标本采集量不足或过多都可能影响检验结果。 四、血培养污染率 定义:污染的血培养标本数占同期血培养标本总数的比例。 计算公式: 血培养污染率= [污染的血培养标本数/同期血培养标本总数]×100% 意义:反映血培养过程是否操作正确～是检验前的重要质量指标。 五、抗凝标本凝集率 定义:凝集的标本数占同期需抗凝的标本总数的比例。 计算公式: 抗凝标本凝集率= [凝集的标本数/同期需抗凝的标本总数]×100% 意义:反映标本采集过程抗凝剂是否正确使用的情况～是检验前的重要质量指标。 六、检验前周转时间中位数 定义:检验前周转时间是指从标本采集到实验室接收标本的时间,以分钟为单位,。检验前周转时间中位数～是指将检验前周转时间由长到短排序后取其中位数。 计算公式: development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the25 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 检验前周转时间中位数=X, n 为奇数 (n+1)/2 检验前周转时间中位数=,X+X,/2～n为偶数 n/2n/2+1 注:n为检验标本数～X为检验前周转时间。 意义:反映标本运送的及时性和效率～检验前周转时间是保证检验结果准确性和及时性的重要前提。 七、室内质控项目开展率 定义:开展室内质控的检验项目数占同期检验项目总数的比例。 计算公式: 室内质控项目开展率=[开展室内质控的检验项目数/同 期检验项目总数]×100% 意义:反映实验室开展的检验项目中实施室内质控进行内部质量监测的覆盖度～是检验中的重要质量指标。 八、室内质控项目变异系数不合格率 定义:室内质控项目变异系数高于要求的检验项目数占同期对室内质控项目变异系数有要求的检验项目总数的比例。 计算公式: 室内质控项目变异系数不合格率= [室内质控项目变异 系数高于要求的检验项目数/同期对室内质控项目变异 系数有要求的检验项目总数]×100% 意义:反映实验室检验结果精密度～是检验中的重要质量指标。 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 九、室间质评项目参加率 定义:参加室间质评的检验项目数占同期特定机构,国家、省级等,已开展的室间质评项目总数的比例。 计算公式: 室间质评项目参加率=[参加室间质评的检验项目数/同 期特定机构已开展的室间质评项目总数]×100% 意义:反映实验室参加室间质评计划进行外部质量监测的情况～是检验中的重要质量指标。 十、室间质评项目不合格率 定义:室间质评不合格的检验项目数占同期参加室间质评检验项目总数的比例。 计算公式: 室间质评项目不合格率= [室间质评不合格的检验项目 数/同期参加室间质评检验项目总数]×100% 意义:反映实验室参加室间质评计划的合格情况～是检验中的重要质量指标。 十一、实验室间比对率(用于无室间质评计划检验项目) 定义:执行实验室间比对的检验项目数占同期无室间质评计划检验项目总数的比例。 计算公式: 实验室间比对率=[执行实验室间比对的检验项目数/同期无室间质评计划检验项目总数]×100% development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the27 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 意义:反映无室间质评计划的检验项目中实施实验室间比对的情况～是检验中的重要质量指标。 十二、实验室内周转时间中位数 定义:实验室内周转时间是指从实验室收到标本到发送报告的时间,以分钟为单位,。实验室内周转时间中位数～是指将实验室内周转时间由长到短排序后取其中位数。 计算公式: 实验室内周转时间中位数=X, n 为奇数 (n+1)/2 实验室内周转时间中位数=,X+X,/2～n为偶数 n/2n/2+1 注:n为检验标本数～X为实验室内周转时间。 意义:反映实验室工作效率～是实验室可控的检验中和检验后的重要质量指标。 十三、检验报告不正确率 定义:检验报告不正确是指实验室已发出的报告～其内容与实际情况不相符～包括结果不正确、患者信息不正确、标本信息不正确等。检验报告不正确率是指实验室发出的不正确检验报告数占同期检验报告总数的比例。 计算公式: 检验报告不正确率=[实验室发出的不正确检验报告数/ 同期检验报告总数]×100% 意义:反映实验室检验报告正确性～是检验后的重要质量指标。 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 十四、危急值通报率 定义:危急值是指除外检查仪器或试剂等技术原因出现的表明患者可能正处于生命危险的边缘状态～必须立刻进行记录并第一时间报告给该患者主管医师的检验结果。危急值通报率是指已通报的危急值检验项目数占同期需要通报的危急值检验项目总数的比例。 计算公式: 危急值通报率= [已通报的危急值检验项目数/同期需要 通报的危急值检验项目总数]×100% 意义:反映危急值通报情况～是检验后的重要质量指标。 十五、危急值通报及时率 定义:危急值通报时间,从结果确认到与临床医生交流的时间,符合规定时间的检验项目数占同期需要危急值通报的检验项目总数的比例。 计算公式: 危急值通报及时率= [危急值通报时间符合规定时间的 检验项目数/同期需要危急值通报的检验项目总数]× 100% 意义:反映危急值通报是否及时～是检验后的重要质量指标。 附件5 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the29 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 病理专业医疗质量控制指标 (2015年版) 一、每百张病床病理医师数 定义:平均每100张实际开放病床病理医师的数量。 计算公式: 每百张病床病理医师数=[病理医师数/同期该医疗机构实 际开放床位数]×100% 意义:反映病理医师资源配臵情况。 二、每百张病床病理技术人员数 定义:病理技术人员是指进行病理切片、染色、免疫组化及分子病理等工作的专业技术人员。每百张病床病理技术人员数～是指平均每100张实际开放病床病理技术人员的数量。 计算公式: 每百张病床病理技术人员数=[病理技术人员数/同期该 医疗机构实际开放床位数]×100% 意义:反映病理技术人员资源配臵情况。 三、标本规范化固定率 定义:标本规范化固定是指病理标本及时按行业推荐方法切开～以足量10%中性缓冲福尔马林充分固定。有特殊要development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 求者可使用行业规范许可的其它固定液。标本规范化固定率是指规范化固定的标本数占同期标本总数的比例。 计算公式: 标本规范化固定率=[规范化固定的标本数/同期标本总数] ×100% 意义:反映处理标本是否及时规范的重要指标。 四、HE染色切片优良率 定义:HE染色优良切片是指达到行业优良标准要求的HE染色切片。HE染色优良切片优良率～是指HE染色优良切片数占同期HE染色切片总数的比例。 计算公式: HE染色切片优良率= [HE染色优良切片数/同期HE染色切片总数]×100% 意义:反映病理科HE染色、制片质量的重要指标。 五、免疫组化染色切片优良率 定义:免疫组化染色优良切片是指达到行业优良标准要求的免疫组化染色切片。免疫组化染色优良切片优良率～是指免疫组化染色优良切片数占同期免疫组化染色切片总数的比例。 计算公式: 免疫组化染色切片优良率= [免疫组化染色优良切片数/同期免疫组化染色切片总数]×100% development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the31 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 意义:反映病理科免疫组化染色、制片质量的重要指标。 六、术中快速病理诊断及时率 定义:在规定时间内～完成术中快速病理诊断报告的标本数占同期术中快速病理诊断标本总数的比例。规定时间是指单例标本术中快速病理诊断报告在收到标本后30分钟内完成。若前一例标本术中快速病理诊断报告未完成～新标本术中快速病理诊断报告在收到标本后45分钟内完成。 计算公式: 术中快速病理诊断及时率=[在规定时间内完成术中快速病理诊断报告的标本数/同期术中快速病理诊断标本总数] ×100% 意义:反映病理科术中快速病理诊断及时率的重要指标。 七、组织病理诊断及时率 定义:在规定时间内～完成组织病理诊断报告的标本数占同期组织病理诊断标本总数的比例。规定时间是指穿刺、内窥镜钳取活检的小标本～自接收标本起～?3个工作日发出病理报告,其他类型标本自接收标本起～?5个工作日发出病理报告,需特殊处理、特殊染色、免疫组化染色、分子检测的标本～按照有关行业标准增加相应的工作日。 计算公式: 组织病理诊断及时率= [在规定时间内完成组织病理诊断报告的标本数/同期组织病理诊断标本总数]×100% development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 意义:反映病理科组织病理诊断及时率的重要指标。 八、细胞病理诊断及时率 定义:在规定时间内～完成细胞病理诊断报告的标本数占同期细胞病理诊断标本总数的比例。规定时间是指自接收标本起～?2个工作日发出细胞病理诊断报告,需特殊处理、特殊染色、免疫组化染色、分子检测的标本～按照有关行业标准增加相应的工作日。 计算公式: 细胞病理诊断及时率=[在规定时间内完成细胞病理诊断报告的标本数/同期细胞病理诊断标本总数]×100% 意义:反映病理科细胞病理诊断及时率的重要指标。 九、各项分子病理检测室内质控合格率 定义:分子病理检测室内质控合格是指检测流程及结果达到行业标准要求。各项分子病理检测室内质控合格率～是指各项分子病理检测室内质控合格病例数占同期同种类型分子病理检测病例总数的比例。 计算公式: 各项分子病理检测室内质控合格率=[各项分子病理检测室内质控合格病例数/同期同种类型分子病理检测病例总数] ×100% 意义:反映病理科分子病理诊断质量的重要指标。 十、免疫组化染色室间质评合格率 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the33 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 定义:免疫组化染色室间质评合格～是指参加省级以上病理质控中心组织的免疫组化染色室间质评～并达到合格标准。免疫组化染色室间质评合格率～是指免疫组化染色室间质评合格次数占同期免疫组化染色室间质评总次数的比例。 计算公式: 免疫组化染色室间质评合格率=[免疫组化染色室间质评合格次数/同期免疫组化染色室间质评总次数]×100% 意义:反映病理科免疫组化染色质量的重要指标。 十一、各项分子病理室间质评合格率 定义:分子病理室间质评合格～是指参加省级以上病理质控中心组织的分子病理室间质评～并达到合格标准。各项分子病理室间质评合格率～是指各项分子病理室间质评合格次数占同期同种分子病理室间质评总次数的比例。 计算公式: 各项分子病理室间质评合格率=[各项分子病理室间质评合格次数/同期同种分子病理室间质评总次数]×100% 意义:反映病理科分子病理诊断质量的重要指标。 十二、细胞学病理诊断质控符合率 定义:细胞学原病理诊断与抽查质控诊断符合的标本数占同期抽查质控标本总数的比例。抽查标本数应占总阴性标本数至少5%。 计算公式: development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 细胞学病理诊断质控符合率= [细胞学原病理诊断与抽查质控诊断符合的标本数/同期抽查质控标本总数]×100% 意义:反映病理科细胞学病理诊断质量的重要指标。 十三、术中快速诊断与石蜡诊断符合率 定义:术中快速诊断与石蜡诊断符合是指二者在良恶性病变的定性诊断方面一致。术中快速诊断与石蜡诊断符合率～是指术中快速诊断与石蜡诊断符合标本数占同期术中快速诊断标本总数的比例。 计算公式: 术中快速诊断与石蜡诊断符合率= [术中快速诊断与石蜡诊断符合标本数/同期术中快速诊断标本总数]×100% 意义:反映病理科术中快速诊断准确率的重要指标。 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the35 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 附件6 医院感染管理质量控制指标 (2015年版) 一、医院感染发病(例次)率 定义:医院感染新发病例是指观察期间发生的医院感染病例～即观察开始时没有发生医院感染～观察开始后直至结束时发生的医院感染病例～包括观察开始时已发生医院感染～在观察期间又发生新的医院感染的病例。医院感染发病,例次,率是指住院患者中发生医院感染新发病例,例次,的比例。 计算公式: 医院感染发病,例次,率=[医院感染新发病例,例次,数/同期住院患者总数] ×100% 意义:反映医院感染总体发病情况。一般指月发病,例次,率和年发病,例次,率。 二、医院感染现患(例次)率 定义:确定时段或时点住院患者中～医院感染患者,例次,数占同期住院患者总数的比例。 计算公式: 医院感染现患,例次,率= [确定时段或时点住院患者中医院感染患者,例次,数/同期住院患者总数]×100% development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 意义:反映确定时段或时点医院感染实际发生情况～为准确掌握医院感染现状～判断变化趋势～采取针对性干预措施及干预效果评价提供基础。 三、医院感染病例漏报率 定义:应当报告而未报告的医院感染病例数占同期应报告医院感染病例总数的比例。 计算公式: 医院感染病例漏报率=[应当报告而未报告的医院感染病例数/同期应报告医院感染病例总数]×100% 意义:反映医疗机构对医院感染病例报告情况及医院感染监测、管理情况。 四、多重耐药菌感染发现率 定义:多重耐药菌主要包括:耐碳青霉烯类肠杆菌科细菌,CRE,、耐甲氧西林金黄色葡萄球菌,MRSA,、耐万古霉素肠球菌,VRE,、耐碳青霉烯鲍曼不动杆菌,CRABA,、耐碳青霉烯铜绿假单胞菌,CRPAE,。多重耐药菌感染发现率是指多重耐药菌感染患者数,例次数,与同期住院患者总数的比例。 计算公式: 多重耐药菌感染发现率=[多重耐药菌感染患者数,例次数,/同期住院患者总数]×100% 意义:反映医院内多重耐药菌感染的情况。 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the37 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 五、多重耐药菌感染检出率 定义:多重耐药菌检出菌株数与同期该病原体检出菌株总数的比例。 计算公式: 多重耐药菌感染检出率= [多重耐药菌检出菌株数/同期该病原体检出菌株总数]×100% 意义:反映医院内多重耐药菌感染的总体情况和某种特定菌种多重耐药菌感染情况。 六、医务人员手卫生依从率 定义:受调查的医务人员实际实施手卫生次数占同期调查中应实施手卫生次数的比例。 计算公式: 医务人员手卫生依从率=[受调查的医务人员实际实施手卫生次数/同期调查中应实施手卫生次数] ×100% 意义:描述医务人员手卫生实际执行依从程度～反映医务人员手卫生执行情况。 七、住院患者抗菌药物使用率 定义:住院患者中使用抗菌药物,全身给药,患者数占同期住院患者总数的比例。 计算公式: 住院患者抗菌药物使用率=[住院患者中使用抗菌药物,全身给药,患者数/同期住院患者总数]×100% development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 意义:反映医院内住院患者抗菌药物使用及管理情况。 八、抗菌药物治疗前病原学送检率 定义:以治疗为目的使用抗菌药物的住院患者～使用抗菌药物前病原学检验标本送检病例数占同期使用抗菌药物治疗病例总数的比例。病原学检验标本包括:各种微生物培养、降钙素原、白介素-6等感染指标的血清学检验。 计算公式: 抗菌药物治疗前病原学送检率= [使用抗菌药物前病原学检验标本送检病例数/同期使用抗菌药物治疗病例总数]×100% 意义:反映抗菌药物使用的规范性。 九、I类切口手术部位感染率 定义:I类切口手术部位感染是指发生在?类,清洁,切口～即手术未进入炎症区～未进入呼吸、消化及泌尿生殖道～以及闭合性创伤手术符合上述条件的手术切口的感染～包括无植入物手术后30天内、有植入物手术后1年内发生的手术部位感染。I类切口手术部位感染率～是指发生I类切口手术部位感染病例数占同期接受I类切口手术患者总数的比例。 计算公式: I类切口手术部位感染率= [发生I类切口手术部位感染病例数/同期接受I类切口手术患者总数]×100% 意义:描述?类切口手术患者发生手术部位感染的频率,反 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the39 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 映医院对接受I类切口手术患者医院感染管理和防控情况。 十、I类切口手术抗菌药物预防使用率 定义:I类切口手术预防使用抗菌药物的患者数占同期I类切口手术患者总数的比例。 计算公式: I类切口手术抗菌药物预防使用率=[I类切口手术预防使用抗菌药物的患者数/同期I类切口手术患者总数]×100% 意义:反映I类切口手术患者抗菌药物预防用药使用及管理情况。 十一、血管内导管相关血流感染发病率 定义:使用血管内导管住院患者中新发血管内导管相关血流感染的发病频率。单位:例/千导管日。 计算公式: 血管内导管相关血流感染发病率= [血管内导管相关血流感染例次数/同期患者使用血管内导管留臵总天数]×1000‰ 意义:反映血管内导管相关血流感染情况和院感防控能力。 十二、呼吸机相关肺炎发病率 定义:使用呼吸机住院患者中新发呼吸机相关肺炎的发病频率。单位:例/千机械通气日。 计算公式: 呼吸机相关肺炎发病率=[呼吸机相关肺炎例次数/同期development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre 患者使用呼吸机总天数]×1000‰ 意义:反映呼吸机相关肺炎情况和院感防控能力。 十三、导尿管相关泌尿系感染发病率 定义:使用导尿管住院患者中新发导尿管相关泌尿系感染的发病频率。单位:例/千导尿管日。 计算公式: 导尿管相关泌尿系感染发病率= [导尿管相关泌尿系感染例次数/同期患者使用导尿管总天数]×1000‰ 意义:反映导尿管相关泌尿系感染情况和院感防控能力。 development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the41 downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre development in order to protect a host of attractions and historical sites, as well as to maintain the economic vitality of the downtown area. Figure 5.1-5 figure 5.1.4 Washington mass transit network to support implementation of effective transport demand management policies to reduce urban traffic congestion and public transport priority was in the early 1960 of the 20th century by the planners first proposed in Paris, France, and in Europe and other major cities to operate has been the formation of the rich content system. Public transport priority consists of two aspects: one is on the bus to help. ... 5.1-7 Park and ride systems 5.1.5 typical case Hong Kong-Japan Sapporo, Sapporo is a Japan Hokkaido central parts of cities, Japan's fifth largest city. Area of 1121km2 in the city, a population of 1.921 million. In addition is the administrative center of Hokkaido, Sapporo is Hokkaido's industrial and commercial center, in 1972, hosted the 11th Winter Olympic Games. 3 JR Sapporo rail transit line 3 metro and 3 tram lines, Sapporo in the urban development process combined with Center of construction of subway construction and residential development, and support the development of the region. Prior to 1971, Sapporo, Japan Hokkaido local Centre in the urban development process, in response to the rapid growth of the city centre traffic demand, building trams. 1981 years ago for holding the winter Olympic Games as an opportunity to start building connected to the venue and the city centre