6. Implement the Guiding Principles for the Clinical Application of Antibacterial Drugs, and improve the level of rational clinical application of antibacterial drugs. Develop and improve the implementation rules for the clinical application of antibacterial drugs, and adhere to the graded use of antibacterial drugs. Carry out clinical drug monitoring, the implementation of antibacterial drug dosage dynamic monitoring and abnormal early warning, the excessive use of antibacterial drugs to timely intervention.7. Should be in accordance with the "Medical Waste Management Regulations", "medical waste management in health care institutions, medical waste management approach" of the provisions of the management of medical waste, with the conditions of centralized disposal, and the establishment of the loss of medical waste, leakage, proliferation and accidents of the emergency program. (II) Hospital infection prevention and control 1. Hand hygiene management 1.1 Equipped with hygienic hand hygiene facilities to actively create conditions for medical staff to provide good, convenient hand washing equipment and facilities, including general hand hygiene facilities and surgical hand disinfection facilities. General hand hygiene facilities include mobile water hand washing facilities, detergents, quick-drying hand sanitizers, etc., operating rooms, delivery rooms, disinfection and supply rooms and other key departments should be equipped with non-hand-touching faucets; surgical hand sanitizing facilities include hand-washing sinks, non-hand-touching faucets, hand-washing liquids and brushing tools, disinfecting liquids and sterile towels, timing devices, hand-washing processes and illustrative diagrams, etc. 1.1.1 The wards and diagnostic and therapeutic departments should have mobile water hand-washing facilities. 1.1.2 Hand-washing facilities should be actively created to provide good and convenient hand-washing equipment and facilities for medical personnel. 1.1.2 Use hand sanitizer with low irritation. 1.1.3 Equip hand drying articles or facilities to avoid secondary pollution. 1.1.4 When it is not convenient to wash hands, equip with quick hand sanitizer. 1.2 Basic requirements for hand hygiene management. 1.2.1 Hand hygiene management system should be formulated and implemented, and effective and convenient hand hygiene facilities should be equipped. 1.2.2 Regular training for the whole staff on hand hygiene should be carried out. Medical personnel should master hand hygiene knowledge and correct hand hygiene methods, and guarantee the effect of hand washing and hand disinfection.1.2.3 Guidance and supervision of hand hygiene work of medical personnel should be strengthened, and the compliance of hand hygiene of medical personnel should be improved.1.3 Hand washing and quick-drying hand disinfection1.3.1 Indications: When there is visible contamination of the hands with blood or other body fluids, the hands should be washed with soap and flowing water; when there is no visible contamination, it is appropriate to wash hands with soap and flowing water; and when there is no visible contamination of hands, it is advisable to wash hands with hand washing. When there is no visible contamination, it is appropriate to use quick-drying hand sanitizer to sanitize hands instead of hand washing. ① Before and after direct contact with each patient, when moving from the contaminated part of the same patient's body to the clean part. ② before and after contact with the patient's mucous membranes, broken skin or wounds, after contact with the patient's blood, body fluids, secretions, excretions, wound dressings, etc.. ③ Before and after putting on and taking off isolation gowns, and after removing gloves. ④Before performing aseptic operations and contacting clean, sterile items.
⑤After contact with the patient's surroundings and objects. ⑥ Before handling medication and meal preparation.1.3.2 Methods and Requirements ① Under running water, make the hands fully wet. ② Take an appropriate amount of soap (soap solution) and apply it evenly to the entire palm, back of the hand, fingers and finger joints. ③ carefully rub both hands for at least 15 seconds, should pay attention to cleaning all the skin of the hands, including the palm, finger cracks, back of the hand, finger joints, finger belly, fingertips, the specific operating procedures refer to the six washing techniques. ④ Thoroughly rinse the hands under running water, dry them, and take the appropriate amount of hand lotion for skin care.1.4 Surgical hand disinfection 1.4.1 Indication: surgical hand disinfection should be carried out before performing all surgeries; between the surgeries of those who do not agree, gloves are broken or hands are 1.4.2 Methods and requirements. All should wash hands first and then disinfect. ① Before washing hands, hand ornaments should be removed and nails should be trimmed, and the length of nails should not exceed the fingertips. ② Take the appropriate amount of detergent to clean hands, forearms and lower 1/3 of the upper arm, and rub carefully. When cleaning hands, attention should be paid to cleaning the dirt under the nails and the folds of the hand skin. ③ Rinse both hands, forearms and lower 1/3 of the upper arm with running water. ④ Dry both hands, forearms and lower 1/3 of the upper arm with a dry hand article. ⑤ Take an appropriate amount of hand sanitizer and apply it to each part of both hands, forearms and lower 1/3 of the upper arm and rub it carefully.26 Rinse both hands, forearms and lower 1/3 of the upper arm with running water, dry with a sterile towel, and put on gloves after applying an alcoholic hand sanitizer to sanitize the hands again. The amount of liquid to be taken from the hand disinfectant, the kneading time and the method of use follow the instructions for use of the product.1.5 Use of glovesWearing gloves stops the spread of bacteria and prevents serious contamination of the hands.1.5.1 Clean gloves should be worn when the hands of a patient in contact with the patient are likely to be contaminated, or when in contact with the patient's mucous membranes, blood, or bodily fluids.1.5.2 Staff members should wear clean gloves when carrying out surgical procedures, caring for immunocompromised patients, and carrying out invasive procedures that involve entry into a body cavity. Invasive operations should wear sterile gloves. 1.5.3 Precautions for the use of gloves ① After removing the gloves should wash their hands or disinfected hands disinfection. ② gloves can only be used as an auxiliary measure of hand hygiene, can not replace hand washing. ③ When the diagnosis and treatment activities are over or suspected glove breakage, as well as between the care of different patients should change gloves and hand washing or hand disinfection. ④ When caring for the same patient, changing gloves is required from touching the contaminated area to touching the clean area again. ⑤ Disposable gloves can only be used once, can not be washed and reused.2. Disinfection of medicines and equipment management system 2.1 Hospital infection management should be designated full-time and part-time personnel specifically responsible for the hospital disinfection, sterilization of medicines and equipment purchase, storage and use of supervision, inspection and guidance.
2.2 Purchasing department should be based on the hospital infection management special, part-time personnel review and approval of procurement, and in accordance with national regulations to check the required documents, monitor the quality of goods. 2.3 must establish and implement the disinfection, sterilization medicine and equipment purchasing and entry and exit registration system. 2.4 Establishment of disinfection equipment use of the registry, the registration of disinfection objects, disinfection time, operator and disinfection effect of regular monitoring results 2.5 The use department shall strictly implement the scope, methods and precautions for the use of disinfecting and sterilizing medicines and instruments; master the concentration, preparation method, disinfection target, replacement time and influencing factors of disinfecting and sterilizing medicines and instruments, and report any problems to the hospital infection management personnel or part-time personnel in a timely manner. 2.6 Prohibit the use of outdated, obsolete or unqualified disinfecting and sterilizing medicines and instruments. 3. One-time use Sterile medical supplies management system 3.1 The single-use sterile medical supplies used must be purchased uniformly, and the clinical departments shall not purchase and try on their own. Single-use sterile medical supplies can only be used for one time. 3.2 Hospital infection management specialists and part-time staff should conscientiously perform the supervision and inspection duties on the procurement management, clinical application and recycling of single-use sterile medical supplies. 3.3 Copies of three certificates of the purchased single-use sterile medical supplies, i.e., Medical Device Manufacturing License, Medical Device Product Registration Certificate, and Medical Device Business License should be submitted to the hospital infection management specialists and part-time staff, and should be kept in the hospital infection management specialists and part-time staff, and should be kept in the medical device business license. should be filed in the hospital infection management specialists and part-time staff, and establish a procurement registration system for single-use sterile medical supplies. 3.4 In the procurement of single-use sterile medical supplies, acceptance inspection must be carried out, in addition to the ordering contract, the delivery location and the account number for remittance of the payment should be the same as that of the production enterprise and the operating enterprise, and should also check the inspection certificate of the products in each box (package), the inner and outer packages should be intact, and the packaging and marking should meet the national standards. Labeling should be in accordance with national standards, imported products should have Chinese labels and instructions. 3.5 Should set up a one-time use of sterile medical supplies warehouse, the establishment of the entry and exit registration system, according to the expiration date of the successive storage in a cool, dry, well-ventilated shelves, prohibited and other items mixed, shall not be poorly labeled, damaged packaging, failure, moldy products issued to the clinical use of the 3.6 Clinical use of sterile disposable Medical supplies should be carefully inspected before the discovery of packaging and labeling does not meet the standards, packaging is damaged, more than the expiration date and the product is not clean, etc. shall not be used; if the use of pyrogenic reactions, infections, or other abnormalities occur, it should be immediately discontinued, and in accordance with the provisions of the detailed record of the scene, we must retain samples in a timely manner for testing, and timely to the medical management department and the hospital infection management of full-time and part-time staff report.
3.7 The discovery of substandard products or products of doubtful quality, should immediately stop using, and promptly report to the drug supervision and management department, shall not be returned or exchanged. 3.8 Disposable sterile medical supplies after use, according to the State Council's "Regulations on the Management of Medical Wastes" regulations. 3.9 Orthopaedic internal fixation devices, pacemakers, intravascular catheters, stents and other implantable or interventional medical devices, must establish a detailed record of the scene in accordance with the requirements of the medical management department and hospital infection management specialists and part-time staff report. medical devices, detailed use records must be established. Necessary product tracking information should be recorded to enable product traceability. The barcode of the device should be affixed to the medical record.4. Disinfection and isolation work system 4.1 Disinfection and isolation management requirements for general wards 4.1.1 Do one bed and one towel to wet brush the bed, one cabinet and one rag to clean the bedside cabinet; after use, towels and rags are soaked in disinfectant solution and then washed and dried for spare parts or washed and autoclaved for spare parts, and the bed brushes are disinfected once a day. Sterile and non-sterile articles are placed separately and marked clearly.4.1.2 Wet cleaning is used for indoor and outdoor hygiene. Cleaning tools for offices, wards, dining rooms, toilets, etc. shall be strictly separated and hung. 4.1.3 Dosers shall accurately prepare all kinds of disinfectants, and the disinfectants for soaking all kinds of articles shall be replaced according to the requirements, and the concentration of all kinds of disinfectants and disinfectant effect shall be regularly monitored, and the disinfectants shall be replaced immediately if they are lower than the effective concentration. 4.1.4 There is a special cabinet for sterile articles in the ward, which is located at a distance of at least 20m from the ground, at least 5m from the wall, and at least 5m from the ceiling. Sterilized articles are marked with sterilization date and validity period, and autoclave sterilized articles are valid for 7 days under clean and dry condition; sterile articles placed in sterile containers are limited to be used for 24 hours once they are opened; after aseptic packages are opened, if the articles in the packages are exhausted at one time, they should be wrapped up in time in accordance with the original package order, indicating the date and time of opening, and they are valid within 12 hours. 4.2 Strictly observe the principles of aseptic technology operation when operating 4.2.1 Wash hands and wear masks before operation, and use rapid hand disinfectant to disinfect hand hygiene after each operation and care.4.2.2 All diagnostic and therapeutic articles in contact with the patient's sterile tissues should be sterilized before use. When using all sterile articles, the sterilization effect and sterilization period should be checked first, and whether the package is tight. 4.2.3 When taking sterile articles, they must be clamped with sterile holding forceps, and the non-sterile area should not be touched when using them. 4.2.4 When taking injections and treatments, sterile trays should be laid, and sterile trays should be laid with sterile trays. Sterile trays, sterile trays are limited to 4 hours after laying, the withdrawal of more than 2 hours can not be reused; intramuscular injection diluent is limited to 24 hours after opening; intravenous diluent is limited to the shift after opening (or 4 hours), the bottle cover is replaced at the same time.
4.2.5 All sterile supplies and thermometers, pulse pressure bands, hand pads, etc., limited to one person a use. 4.3 Infectious disease patients room door with isolation clothing and rapid hand disinfectant. According to the type of infectious diseases, respiratory isolation and digestive isolation are adopted respectively, and there are isolation signs; excreta and supplies of patients with infectious diseases should be disinfected; bed linen after patients' discharge and death should be disinfected according to the requirements. Attachment: monitoring standards environmental classification department air (3) physical surfaces (2) medical staff hands (2) sterile supplies in use disinfectant () Class I environment laminar flow operating room laminar flow ward ≤ 10 ≤ 5 ≤ 5 without any microorganisms ≤ 100 Class II environment general operating room, delivery room, neonatal room, preterm labor room, general protective isolation room, supply room aseptic area, burn wards, intensive care unit, hemodialysis ≤ 200 ≤ 5 ≤ 5 without any microorganisms ≤ 100 Ⅲ environment pediatric wards, obstetrics and gynecology examination room, injection room, dressing room, treatment room, supply room clean area, emergency department, laboratory, all types of general wards and rooms ≤ 500 ≤ 10 ≤ 5 without any microorganisms ≤ 100 Ⅳ environment infectious disease wards ≤ 500 ≤ 15 ≤ 5 without any microorganisms ≤ 100 Note: mothers and babies in the same room, pediatric wards The monitored surfaces, tableware and hands of medical personnel shall not detect Salmonella and other pathogenic bacteria, and pathogenic microorganisms shall not be detected in the sterilized articles.5 Medical waste management system5.1 Establish a medical waste management responsibility system, and set up full-time and part-time personnel in charge of the management.5.2 The temporary storage place of medical waste shall be reasonably sited, with obvious warning signs and safety measures such as rodent-proofing, mosquito and fly-proofing and anti-burglary, and be disinfected regularly to maintain a clean environment. 5.3 The department that produces medical waste should have a person in charge of registering, classifying, collecting, storing and transporting it in a closed place. 5.4 Medical personnel should bring back the medical waste after going out of the clinic, and it should not be left in the clinic and mixed with the domestic garbage. 5.5 The medical waste should be placed in a special package or closed container according to the category, and the handover registration should be carried out. The registration includes source, type, weight or quantity, handover time, disposal method, final destination and the signature of the person in charge, etc., and the registration information shall be kept for at least three years.5.6 The containers or collection bags for collecting medical wastes shall be uniformly labeled, and sharp wastes and highly polluted medical wastes shall be put into airtight, puncture-proof and seepage-proof containers or collection bags respectively in accordance with the provisions.5.7 Use special delivery tools to place the classified and subpackaged Medical waste shall be transported to the designated temporary storage place according to the specified time and route, and shall not leak, spill and pollute the environment. Medical waste temporary storage time does not exceed 2 days.
5.8 Medical waste management personnel should be trained in relevant laws and professional knowledge, safety and protection, and emergency treatment.6. Sharps injury prevention and emergency treatment High-risk operations for sharps injuries include: putting back the lancet, fiddling with needles, separating needles and syringes, and failing to discard needles in a timely manner or in close proximity, etc.6.1 Preventing Sharps Injuries6.1.1 Handle sharps carefully.6.1 .2 Do not recap syringes after use, use a single hand to hold the syringe to pick the cap on. 6.1.3 All used syringes, infusion needles and scalp needles are not separated and are placed directly into puncture-resistant sharps boxes. 6.1.4 Use safer tools and methods, e.g., use vacuum tubes and use protective gear when collecting blood intravenously.6.2 Emergency treatment of sharps injuries Operation of inadvertently by the patient's blood, blood products, body fluids, tissue fluids contaminated sharps injury, should immediately take relevant measures to prevent and control the infection of blood-borne diseases. 6.2.1 Immediately flush the wound with running water for 10 minutes; beside the wound from proximal to distal to gently squeeze, as far as possible to squeeze out the blood of the injury. Flush again with running water and soap solution. Local squeezing of the wound is prohibited.6.2.2 Disinfect the wound with 75% alcohol or 0.5% povidone-iodine after rinsing.6.2.3 Splash blood, body fluids, or contaminated fluids from medical wastes into the eye, immediately and repeatedly rinse the conjunctival sac with saline, and then immediately go to a specialist for further treatment.6.2.4 Report the case to the medical management department, the nursing department, and the hospital's infection management specialists or part-time staff, and seek medical help.6.2.5 Assist in completing the six-month follow-up of blood-borne diseases.6.2.6 Blood monitoring process for injured healthcare workers: when the source of exposure is (+) and the injured healthcare worker is (+) or (+), there is no need to be vaccinated or; when the injured healthcare worker is (-) who has not been vaccinated, he or she is to be vaccinated within 24h and vaccinated at 0 months, 1 month, and 6 months,. Surveillance,, 1 year. When the source of exposure is (+) and the injured healthcare worker is (-), after expert assessment, take prophylactic medication immediately and undergo medical observation for 1 year: check, liver function at 6 weeks, 3 months, 6 months and 12 months after stabbing.7. Occupational Protection and Reporting System for Blood-borne Diseases 7.1 Occupational Protection System 7.1.1 Adhere to the principle of standard prevention. All operations performed in this hospital are considered infectious operations. All sources of exposure to blood and body fluids contacted during operations are classified as potentially dangerous sources of infection, and occupational protection is actively done.7.1.2 Staff on duty are dressed in accordance with the requirements (work cap, white coat, mask, disposable gloves, protective goggles, protective mask if necessary, isolation gowns, isolation shoes, etc.). Completion of the operation or leave the work area should be timely removal of gloves, take off the work clothes, work cap, etc. It is strictly prohibited for staff to wear work clothes to enter the cafeteria, dormitory and out of the main door of the Hospital.
7.1.3 When skin contact or possible contact with blood, blood products, body fluids, tissue fluids, mucous membranes or and suspected of being contaminated by direct contact with the environment, gloves should be worn, and the use of proper hand washing methods. 7.1.4 Estimated blood, body fluids splashing, splattering to the eyes, mouth, other mucous membranes or other parts of the body of the possibility of wearing goggles and anti- and anti-penetration masks; estimated that there are large areas of When there is a possibility of splashing blood or body fluids, isolation gowns or aprons with anti-permeability properties should also be worn. 7.1.5 Facilities, equipment, and environments that have come into contact with blood, body fluids, or infectious materials should be disinfected as soon as possible. 7.1.6 Prohibition of eating in workplaces where there is a possibility of exposure to blood, and food and beverages should not be placed in refrigerators in which infectious materials are placed. 7.1.7 Regulation of operating practices. Prohibit high-risk maneuvers that are likely to cause sharps injuries. It is prohibited to pass the end of the sharps directly to others; it is prohibited to put the used disposable syringe needle back into the needle cap; it is prohibited to manually disfigure used disposable syringes; it is prohibited to pick up broken glassware directly with hands in the workplace.7.1.8 When operating or as soon as possible after the operation, dispose of the used exposure source in the special medical waste classification and collection box, and put the sharps objects into a sharp objects collector in accordance with the national standard. 7.1.9 When performing invasive operations, make sure that there is sufficient light. 7.1.10 Nursing staff with skin wounds, dermatitis, or impaired integrity of the skin and mucous membranes (e.g., oral ulcers) should not participate in the direct treatment, care, or examination of patients with AIDS. 7.1.11 Medical staff should participate in occupational protection learning and master emergency treatment measures after occupational exposure. 7.1.12 The principle of graded protection for hospital infections: ① Basic protection applicable object: medical, nursing and technical personnel engaged in diagnosis and treatment in the infectious disease area of the hospital and areas other than fever outpatient (emergency) clinic. Protection equipment: white coat, work pants, work shoes, work hat and medical mask. Protection requirements: in accordance with the principle of standardized prevention of protection. ② strengthen the protection of the protection object: contact with blood, body fluids, excreta, secretions and other visible pollutants when the operation of medical, nursing, technical staff; into the infectious area of medical, nursing, technical staff; fever clinic during the epidemic, ward staff (medical, nursing, technical, labor, diligence); transfer suspected and clinically diagnosed patients, medical, nursing, technical staff and drivers. Dress code: on the basis of basic protection according to the degree of danger of diagnosis and treatment, use the following protective equipment: isolation gowns, protective goggles, surgical masks or N95 masks, gloves, masks, shoe covers and so on.
3 tight protection protection object: invasive operations, such as respiratory infectious disease patients for tracheal intubation, incision suction. Protection requirements: on the basis of enhanced protection, the use of masks. 7.2 Reporting system 7.2.1 Occupational exposure occurred, should be implemented as soon as possible emergency measures, and within 30 minutes to the director of the section or the head nurse report, the director of the section or the head nurse should be reported to the medical management department, hospital infection management specialists, part-time staff and the Department of Nursing in 2h, the source of the exposure to the patient for the positive or suspected, should be reported to the medical management department within 1h after the occurrence of the exposure. Within 1h report to the medical management department, hospital infection management specialists, part-time staff and the nursing department. 7.2.2 Report to the higher authorities, including the time and place of the injury, what was injured, how deep the wound is, on-site treatment measures, medical treatment measures, treatment records, medication records.
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Communicable Disease and Hospital Infection Management Job Responsibility System
Communicable Disease and Hospital Infection Management Job Responsibility System
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1. To conscientiously implement the "Chinese People's *** and the State Law on Prevention and Control of Infectious Diseases", "Chinese People's *** and the State Law on Prevention and Control of Infectious Diseases Implementation Measures", the strict management of infectious diseases, strict control of infectious disease transmission and epidemic.
2. patients with infectious diseases, should establish a system of registration of infectious diseases, infectious diseases by a person responsible for the management of infectious diseases, disinfection and disposal in accordance with the relevant provisions of the State; patients with suspected infectious diseases should be left in the observation room isolation observation.
3. The excreta and used articles of patients with infectious diseases shall be disinfected according to the requirements; they shall not be taken out of the infectious disease area (room) without disinfection; the used clothes of the patients shall be disinfected before being sent for washing.
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4. When a suspected or confirmed case of statutory infectious disease is found, the epidemic shall be reported to the county (city or district) CDC in a timely manner according to the time limit for reporting statutory infectious diseases, and shall not be omitted, withheld, re-reported, or misreported. The discovery of outbreaks must be reported immediately
5. Infectious disease report registration form, report card and related records should be accurate and complete, and according to the requirements of the summary, statistics, reported, archived for inspection, pay attention to confidentiality. Epidemic administrators should be checked in a timely manner, check the omission, late reporting, misreporting, and proofreading.
Two, hospital infection management
(a) hospital infection management system
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1. To conscientiously implement the "Chinese People's Republic of China*** and the State Infectious Disease Prevention and Control Act", "Chinese People's Republic of China*** and the State Infectious Disease Prevention and Control Act Implementation Measures" and "Hospital Infection Management Measures," and so on, to strengthen the hospital infection management. Hospital infection management is an important responsibility of the dean, to establish and implement the hospital infection management responsibility and accountability system.
2. To be in accordance with the "Hospital Infection Management Measures" of the relevant provisions of the actual situation, combined with the institution, the system and the implementation of the institution's hospital infection management countermeasures, measures, evaluation of the effectiveness of the monitoring and reporting system and the relevant workflow, to determine the clinical prevention and reduction of hospital infections focus on the management of the project, and as an important element of quality management of health care, regular or irregular supervision and inspection.
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3. Regular assessment of medical staff's knowledge and techniques of disinfection and isolation and the completion of hospital infection control indicators will be included in the department's medical quality management and regular assessment, and regularly informed to the medical staff and management.
4. Establish an on-the-job training and education system for hospital infection management, and regularly publicize and educate the staff of the hospital on the prevention of hospital infection.
5. To standardize the management of disinfection, sterilization, isolation and medical waste, strict aseptic technique operation, disinfection and isolation work system, to strengthen the infectious disease department, stomatology, operating room, neonatal room, delivery room, catheterization room, clinical testing department and disinfection of the supply room and other key departments of the hospital infection management and monitoring.
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6. Implement the Guiding Principles for the Clinical Application of Antimicrobial Drugs, and improve the level of rational clinical application of antimicrobial drugs. Formulate and improve the implementation rules of clinical application of antibacterial drugs, and adhere to the graded use of antibacterial drugs. Carry out clinical drug monitoring, the implementation of antibacterial drug dosage dynamic monitoring and abnormal warning, the excessive use of antibacterial drugs to timely intervention.
7. Should be in accordance with the "Medical Waste Management Regulations", "medical waste management in health care institutions," the provisions of the management of medical waste, the conditions to be centralized disposal, and the establishment of medical waste loss, leakage, proliferation and emergency response to accidents.
(2) the prevention and control of hospital infection