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Am J Infect Control:接触隔离可有条件的取消手套的使用?

2018-05-28 李婧闻 SIFIC感染官微

接触隔离是指医务人员在接触明确或疑似被传染性微生物感染或定植的患者时采取的一系列措施,在接触这些患者时只使用标准预防是远远不够的。

接触隔离是指医务人员在接触明确或疑似被传染性微生物感染或定植的患者时采取的一系列措施,在接触这些患者时只使用标准预防是远远不够的。在实施接触隔离时,医务人员需穿戴个人防护用品(personal protective equipment, PPE),其中最常见的是非无菌手套和隔离衣。医务人员的手可以在同一病人的不同部位以及不同患者间传递微生物。

PPE试图减少医务人员在护理病人的过程中手部或衣物被污染的几率,从而减少致病微生物的传播。但是已有证据证明手套的使用和脱手套的动作会增加医务人员和患者被污染的风险。

在实施标准防护中时,66%的医务人员未在正确的时刻更换手套,82%的医务人员使用戴污染手套的手接触患者或患者区域至少一次。53%的患者在脱去PPE的过程中将污染他们的皮肤和衣物。但即便恰当的使用PPE,1.7%--4.2%医务人员的手仍将被污染。虽然手卫生是预防许多院内感染的重要措施,但仍有许多医务人员在使用手套的前后未清洁双手。

污染的未戴手套的手能在患者之间、患者区域之间传播微生物,而污染的手套表面其传播微生物的能力远远大于不戴手套的手。

戴手套的手一旦和任何表面发生接触后,其应立即被视为污染。世界卫生组织WHO有关手卫生的指南强调在接触患者后、操作后和接触病人环境后脱去手套的重要性,并强烈推荐接触隔离措施中使用手套,但是并未清楚地阐明手卫生的5个时刻里应如何对佩戴手套的手进行手卫生。将接触隔离与手卫生的5个时刻结合在一起对医务人员来说是一个巨大挑战。

医务人员在实施接触隔离时,所有的操作都需要佩戴手套,即使是在非暴露于患者液体的情况下。在我们的医院,我们正在尝试开展一项运动,称为“在接触隔离患者非体液血液、分泌物时请不要戴手套”。希望通过这项活动在不会接触到患者液体的情况下将戴手套从接触隔离的举措中去除。

本研究的目标是向医务人员证明在护理被耐甲氧西林金黄色葡萄球菌(MRSA)或耐万古霉素肠球菌(VRE)定植的患者时,手卫生能有效去除不戴手套的手的MRSA和VRE的污染。希望大家阅读本文后能有所收获。

从接触隔离的预防措施中有条件的取消手套的使用

手卫生的作用

摘要

背景:照护接触隔离患者的医护人员会暴露于不可预知的患者体液,常规手卫生能有效去除其未戴手套的手部的耐甲氧西林金黄色葡萄球菌(MRSA)和/或耐万古霉素肠球菌(VRE)。

方法:医护人员对已知定植或感染MRSA或VRE的患者进行常规临床护理后,使用含有酒精的手消毒剂揉搓双手或使用皂液和流动水清洗双手。

结果:对采自40名医护人员的240份样本进行检测:发现在与患者接触后按压3次手消液(0/80)或使用皂液和流动水清洗双手(0/80),MRSA或VRE培养均为阴性;在采集的120个样品中均未培养出VRE。按压2次手消液进行手卫生的培养中,有2个平板(2/40)培养均出1个MRSA的菌落。对采到2个阳性结果的医务人员,再次进行试验其结果均为阴性。

结论:我们发现即使医务人员在不戴手套的情况下进行普通的临床护理,与已知定植MRSA或VRE患者发生接触,正确的手卫生同样能有效去除手部的MRSA和VRE。改变接触隔离措施中有关手套使用的内容,当医务人员不会接触到患者体液、血液、分泌物时不需要戴手套,这可能会大大提高患者的安全。

方法

该项研究募集来自不同科室的医务人员共40位。医务人员在为MRSA或VRE感染或定植的患者实施护理操作时(不发生暴露于患者体液、血液和分泌物的操作)。我们将观察每位医务人员直到他们使用未戴手套的手接触患者及其患者环境。采集标本之前,医务人员将采用3种不同方法进行手卫生。然后将双手的10个指尖按压在预备好的平皿上15秒。

3种不同的手卫生方法:

方法1. 采用按压2下手消液(ABHR)进行手卫生

方法2. 采用按压3下手消液(ABHR)进行手卫生

方法3. 采用皂液和流动水进行手卫生

结果

整个试验共采集240份标本,其中包括120份MRSA和120份VRE,其中按压2下手消液后接种40个MRSA平板、40个VRE平板;按压3下手消液后接种40个MRSA平板、40个VRE平板;使用皂液和流动水洗手后接种40个MRSA平板、40个VRE平板。手采样包括接触MRSA阳性患者17位,MRSA和VRE均阳性11位,VRE阳性15位。来自2位医务人员的2次按压手消液的两块平板上均长出1个MRSA菌落(图1)。再次对这两位医务人员进行相同的测试,结果均为阴性。按压3次手消毒液和使用皂液和流动水的洗手培养的所有平板均未检出MRSA或VRE。

讨论

大部分指南推荐在接触患者体液、血液和分泌物时,或为实施接触隔离的患者进行护理时应佩戴手套。接触隔离防护措施中要求使用手套,这主要基于普遍共识和专家意见,而非高级别的证据。所以手套的使用被延伸到接触患者液体以外的操作范围。然而过早佩戴手套同时又过迟脱去手套,这大大提高病原菌传播的风险。

另外,污染的手套比污染的手传播病原菌的风险更高。因为戴手套的手的不太愿意洗手(其手卫生依从性低于平均值)。而指南强制要求使用手套,却没要求在不同操纵之间应更换手套并进行手卫生。

我们强烈要求更新手卫生5个时刻的框架,修改接触隔离指南中对手套的强制使用,当医务人员护理接触隔离患者时,如果不涉及接触患者的体液、血液和分泌物可以不佩戴手套。



原始出处:

Jain S , Clezy  K , McLaws  ML . Safe removal of gloves from contact precautions: The role of hand hygiene[J], Am J Infect Control.  2018, pii: S0196-6553

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    2018-05-30 FukaiBao
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    2018-05-29 龙胆草

    学习谢谢分享

    0

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    2018-05-29 1209e435m98(暂无昵称)

    学习了.谢谢分享

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1532055, encodeId=1db715320552b, content=<a href='/topic/show?id=782a543207d' target=_blank style='color:#2F92EE;'>#手套#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54320, encryptionId=782a543207d, topicName=手套)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=edd812309310, createdName=FukaiBao, createdTime=Wed May 30 14:07:00 CST 2018, time=2018-05-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319619, encodeId=599931961917, content=学习谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Nd44v3xHnnictn9UpctwtH62EPQ59TMdI9lnqHMgQ16nH7GmGCfpzicsHgjibYVk6vwSpXrC86gMibRkoaIzf5HwSz7/0, createdBy=78cc1691107, createdName=龙胆草, createdTime=Tue May 29 08:40:00 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319573, encodeId=8a163195e3c1, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Tue May 29 06:57:31 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319534, encodeId=950931953453, content=学了, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKcmgibQ4oCrK7Z6f4CvMcs4k7QUGCkhopcGxvxaBfVciadECSIwaRVttllIOEKumpEaRrq5PoOUxow/0, createdBy=e3bb2081203, createdName=哈哈869, createdTime=Tue May 29 06:20:20 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319517, encodeId=dda331951e57, content=学习学习.了解了解, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Tue May 29 05:31:48 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319512, encodeId=ae3831951234, content=好好好好好好好好, beContent=null, objectType=article, channel=null, level=null, likeNumber=101, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Tue May 29 05:14:48 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319489, encodeId=be7b319489df, content=学习了.谢谢分享., beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Mon May 28 23:47:50 CST 2018, time=2018-05-28, status=1, ipAttribution=)]
    2018-05-29 哈哈869

    学了

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1532055, encodeId=1db715320552b, content=<a href='/topic/show?id=782a543207d' target=_blank style='color:#2F92EE;'>#手套#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54320, encryptionId=782a543207d, topicName=手套)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=edd812309310, createdName=FukaiBao, createdTime=Wed May 30 14:07:00 CST 2018, time=2018-05-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319619, encodeId=599931961917, content=学习谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Nd44v3xHnnictn9UpctwtH62EPQ59TMdI9lnqHMgQ16nH7GmGCfpzicsHgjibYVk6vwSpXrC86gMibRkoaIzf5HwSz7/0, createdBy=78cc1691107, createdName=龙胆草, createdTime=Tue May 29 08:40:00 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319573, encodeId=8a163195e3c1, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Tue May 29 06:57:31 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319534, encodeId=950931953453, content=学了, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKcmgibQ4oCrK7Z6f4CvMcs4k7QUGCkhopcGxvxaBfVciadECSIwaRVttllIOEKumpEaRrq5PoOUxow/0, createdBy=e3bb2081203, createdName=哈哈869, createdTime=Tue May 29 06:20:20 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319517, encodeId=dda331951e57, content=学习学习.了解了解, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Tue May 29 05:31:48 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319512, encodeId=ae3831951234, content=好好好好好好好好, beContent=null, objectType=article, channel=null, level=null, likeNumber=101, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Tue May 29 05:14:48 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319489, encodeId=be7b319489df, content=学习了.谢谢分享., beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Mon May 28 23:47:50 CST 2018, time=2018-05-28, status=1, ipAttribution=)]
    2018-05-29 1dd8c52fm63(暂无匿称)

    学习学习.了解了解

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1532055, encodeId=1db715320552b, content=<a href='/topic/show?id=782a543207d' target=_blank style='color:#2F92EE;'>#手套#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54320, encryptionId=782a543207d, topicName=手套)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=edd812309310, createdName=FukaiBao, createdTime=Wed May 30 14:07:00 CST 2018, time=2018-05-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319619, encodeId=599931961917, content=学习谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Nd44v3xHnnictn9UpctwtH62EPQ59TMdI9lnqHMgQ16nH7GmGCfpzicsHgjibYVk6vwSpXrC86gMibRkoaIzf5HwSz7/0, createdBy=78cc1691107, createdName=龙胆草, createdTime=Tue May 29 08:40:00 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319573, encodeId=8a163195e3c1, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Tue May 29 06:57:31 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319534, encodeId=950931953453, content=学了, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKcmgibQ4oCrK7Z6f4CvMcs4k7QUGCkhopcGxvxaBfVciadECSIwaRVttllIOEKumpEaRrq5PoOUxow/0, createdBy=e3bb2081203, createdName=哈哈869, createdTime=Tue May 29 06:20:20 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319517, encodeId=dda331951e57, content=学习学习.了解了解, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Tue May 29 05:31:48 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319512, encodeId=ae3831951234, content=好好好好好好好好, beContent=null, objectType=article, channel=null, level=null, likeNumber=101, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Tue May 29 05:14:48 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319489, encodeId=be7b319489df, content=学习了.谢谢分享., beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Mon May 28 23:47:50 CST 2018, time=2018-05-28, status=1, ipAttribution=)]
    2018-05-29 yjs木玉

    好好好好好好好好

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=1532055, encodeId=1db715320552b, content=<a href='/topic/show?id=782a543207d' target=_blank style='color:#2F92EE;'>#手套#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54320, encryptionId=782a543207d, topicName=手套)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=edd812309310, createdName=FukaiBao, createdTime=Wed May 30 14:07:00 CST 2018, time=2018-05-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319619, encodeId=599931961917, content=学习谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Nd44v3xHnnictn9UpctwtH62EPQ59TMdI9lnqHMgQ16nH7GmGCfpzicsHgjibYVk6vwSpXrC86gMibRkoaIzf5HwSz7/0, createdBy=78cc1691107, createdName=龙胆草, createdTime=Tue May 29 08:40:00 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319573, encodeId=8a163195e3c1, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Tue May 29 06:57:31 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319534, encodeId=950931953453, content=学了, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKcmgibQ4oCrK7Z6f4CvMcs4k7QUGCkhopcGxvxaBfVciadECSIwaRVttllIOEKumpEaRrq5PoOUxow/0, createdBy=e3bb2081203, createdName=哈哈869, createdTime=Tue May 29 06:20:20 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319517, encodeId=dda331951e57, content=学习学习.了解了解, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Tue May 29 05:31:48 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319512, encodeId=ae3831951234, content=好好好好好好好好, beContent=null, objectType=article, channel=null, level=null, likeNumber=101, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Tue May 29 05:14:48 CST 2018, time=2018-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319489, encodeId=be7b319489df, content=学习了.谢谢分享., beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Mon May 28 23:47:50 CST 2018, time=2018-05-28, status=1, ipAttribution=)]
    2018-05-28 惠映实验室

    学习了.谢谢分享.

    0

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接触隔离是指医务人员在接触明确或疑似被传染性微生物感染或定植的患者时采取的一系列措施,在接触这些患者时只使用标准预防是远远不够的。在实施接触隔离时,医务人员需穿戴个人防护用品(personal protective equipment, PPE),其中最常见的是非无菌手套和隔离衣。

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