In order to further strengthen the management of hospital infection and ensure the medical quality and patient safety, according to the requirements of the superior health administrative department, the hospital infection inspection instructions were implemented, and the Measures for the Management of Hospital Infection were seriously implemented, from the aspects of hospital infection organization management, hospital infection monitoring, key departments (such as operating room, stomatology, treatment room, laboratory, etc.), high-risk factors in key departments, hospital-acquired case reporting and disposal, occupational exposure of medical staff, hand hygiene, and laboratory.
First,? Members of the organization? Team leader: Zhou Jianzhong
Deputy Team Leaders: He Qu and Lu
Members: department director, head nurse, team leader? The second is to further improve the management system and implement it:
Formulated various rules and regulations of hospital infection management (such as: hospital infection control system, sterilizer management system, disinfection and isolation system, hospital infection case registration and reporting system, infection control system, measures, workflow of key hospital departments, medical staff occupational exposure disposal process, medical waste management system and disposal process, hospital infection management inspection standards, etc. ), and asked the relevant personnel to study and implement seriously, improve the awareness of prevention, and reduce the incidence of hospital infection. The implementation of the regular and irregular supervision and inspection system of the department. Due to the attention of leaders, clear responsibilities at all levels and good operation, there has been no outbreak of nosocomial infection since the establishment of the hospital.
Third, strengthen the management of hospital sense in key departments:
1. Hospital leaders attach great importance to the management and supervision of key departments, and achieve "three areas", "three points" and "three channels" to ensure that articles are clean and not dirty (according to the process of recycling-sorting-cleaning-inspection and packaging-sterilization-storage-distribution);
The principle of air from clean to dirty. Three areas: contaminated area, clean area and sterile area. Three points: polluted recycled materials are separated from cleaning materials, primary washing is separated from fine washing, and unsterilized materials are separated from sterilized materials. The three channels: the dirt channel, the sterile goods channel and the personnel channel do not cross. ?
2. The hospital has no pressure steam sterilization equipment, and signed an outsourcing disinfection contract with Chengdu Jin Xin Psychiatric Hospital, with two-way signature registration. Adhere to the use of sterile package indicator tape and sterile package indicator card for self-monitoring and daily monitoring to ensure the quality of disinfection and sterilization.
3. Hospital infection monitoring has been effectively implemented, and there is a perfect monitoring system. Each department regularly monitors the number of bacteria in air, surface of objects, disinfectants in use, staff hands and sterile articles as required, and the hospital infection department randomly checks key departments to ensure the environmental quality of the hospital.
Fourth, do a good job in disinfection and isolation and infection monitoring in clinical departments:
1, strictly carry out disinfection and isolation work, strictly abide by aseptic operation technology, establish infection management and workflow in operating room, supply room and hospital, and clean disinfection process.
2, patient treatment and disposal adhere to one person, one needle, one tube, one use and one disinfection, the bed is wet-cleaned, one bed, one bedside table and one rag are disinfected, and the patient's bed unit is treated according to terminal disinfection after discharge.
3. Sterile articles in the treatment room shall be placed separately from disposable goods. After the aseptic goods are opened, record the opening time and disinfect the air with ultraviolet rays every day. Time accumulation, monitoring records. Air bacterial culture is done every quarter 1 time.
Fifth, strengthen the training of hospital awareness knowledge and improve the prevention and control awareness of hospital awareness of medical staff;
We have made a training plan for hospital awareness, paying special attention to publicity, education and training. Every year, new medical staff and hospital medical staff are trained and assessed on hospital infection, hand hygiene and epidemic prevention and control of infectious diseases.
Six, disposable goods management:
1. Hospital Infection Management Committee will perform supervision and inspection duties on the procurement, management and post-use treatment of disposable medical supplies.
2, where the purchase of disposable medical and health supplies for hospitals "three certificates" is complete, with disinfection and sterilization marks, production date, expiration date, product packaging meets the requirements.
3. There are "three certificates" of disposable articles and sterilized medical devices in the drug inventory, and a register is established. Goods are stored on cool, dry and well-ventilated shelves.
4, disposable medical supplies after use to destroy stereotypes, unified recycling, harmless treatment measures, and recorded.
Eight, medical waste management:
The hospital infection management department has formulated the medical waste treatment process, established a medical waste register after use, and handed it over to the personnel of the disposal unit for treatment and double signing.
Hospital infection management self-inspection report
In accordance with the spirit of the instructions of higher authorities on carrying out special inspection of hospital infection, we thoroughly implement the Measures for the Administration of Hospital Infection, carefully find out the problems existing in the management, reporting and disposal of hospital infection in medical institutions, further strengthen the management of hospital infection, effectively prevent and control hospital infection and iatrogenic infection of infectious disease pathogens, drug-resistant bacteria, conditional pathogenic bacteria and other pathogenic microorganisms, enhance the prevention and control ability of hospitals, and ensure the health and life safety of people. The leaders of the hospital attached great importance to it, and the dean personally organized and implemented it. Self-examination and self-correction of hospital infection management have key points, parts and measures.
First, strengthen organizational leadership to ensure the smooth development of hospital infection management self-examination.
Clear responsibilities and division of responsibilities: each clinical department has a special person who is responsible for the monitoring of the department and reports the relevant situation to the hospital infection group on time. Due to the implementation of the work at different levels, the smooth development of hospital infection management in our hospital was ensured.
Second, seriously carry out self-examination and self-correction, and effectively implement hospital infection monitoring. The monitoring system of our hospital includes:
1. Because the hospital monitors air, objects and watches unconditionally, there is no hospital infection monitoring report.
2. Monitor disinfectants (alcohol, iodophor, dialdehyde, etc. ) Use it once a month.
3. Monitor the intensity of ultraviolet lamp once a month.
4. Monitor the pressure steam furnace (each sterilization package has a chemical indicator card) every month.
5. Disposable articles (syringes, infusion sets, etc.). ) after use, it is preliminarily soaked, and then it is uniformly recycled for a series of harmless treatments such as serious damage and incineration.
6 Operating room and delivery room, strictly distinguish clean area, semi-clean area and polluted area, and have corresponding supporting facilities. Facilities, workflow, medical instruments, appliances and personnel dress meet the requirements of the specification. ? Medical waste management:
1. Standardize and register the classified collection, transportation, temporary storage and destination of medical wastes. Code for management of storage, use and waste destination of disposable medical supplies.
2. Have relevant employees' occupational health and safety protection measures and knowledge training. ? Hand hygiene management:
1. There is a hospital hand hygiene system and specific implementation measures.
2. Spot check the hand hygiene knowledge of 5 medical staff, all of whom are familiar with hand hygiene knowledge. ?
3. Hand washing facilities meet the requirements. ? Through self-examination, we still have many problems:
1. The knowledge and control consciousness of hospital infection among employees are shallow, and the aseptic operation of individual medical staff is not strict enough.
2. Some departments are not equipped with disinfection hardware, and the concept of disinfection and sterilization needs to be strengthened.
3. The architectural design of operating room and delivery room is not reasonable enough.
4. The details of hospital infection control are not enough.
5. The hospital infection registration is incomplete, and some departments do not pay attention to filling in the hospital infection registration form.
6. Infectious disease card reporting lacks seriousness.
In view of the problems existing in our hospital, carefully analyze and find out the methods and measures to solve the existing practical problems:
1. Establish an organization, clarify responsibilities, assign responsibilities to people, and improve the system to bind people.
2. Go to the medical record room regularly to check the medical records, check whether the filling of hospital infection cases meets the requirements of superiors, and do a good job of leak detection and filling in hospital infection cases.
3. Formulate and implement various rules and regulations of hospital infection management, such as disinfection and isolation system, hospital infection case registration system, aseptic operation system and infectious disease reporting system. ?
4. Pay special attention to publicity and education, the training, cultivation and assessment of newly graduated medical staff, and the assessment of hospital infection management and infectious disease knowledge of medical staff in the whole hospital.
5. Carry out indoor and outdoor sanitary cleaning and rectify dead corners.
6. Do a good job in the registration of hospital infection related activities.
Third, further improve the management system and implement it? Hospital infection management system is the basis and important guarantee for doing a good job in hospital infection. It is very important to formulate and improve a scientific and practical management system to standardize the behavior of hospital staff and implement it seriously, which is very important to improve the awareness of prevention and reduce the incidence of hospital infection. Give full play to the binding role of the system, so that all work can be implemented.
Four, continue to pay special attention to the disinfection and isolation of clinical departments, infection monitoring.
Hospitals strengthen disinfection and isolation and infection monitoring in clinical departments. Check regularly and irregularly, and handle problems in time when found. When infectious patients are found, they should register and report the epidemic situation in time. Toxic, harmful and infectious sewage and dirt must be disinfected. In addition to strict disinfection of reusable items, our hospital has also improved the utilization rate of disposable sterile medical supplies, greatly reducing the possibility of hospital infection.
Invalid disposable items, etc. Used by patients. Due to strict control, no patients used unqualified disposable sterile medical supplies. For used disposable products, all departments have always insisted on destruction, disinfection and recording. Therefore, the destruction rate of disposable empty needles, infusion sets and urine bags in our hospital reached 100%.
Six, strengthen the training of hospital infection knowledge, improve the awareness of hospital staff to control hospital infection.
Combined with the actual situation of our hospital, we organized training on medical accident handling regulations, disinfection and safety knowledge. And train the medical staff in the hospital to prevent and control hospital infection, so as to enhance their awareness of preventing and controlling hospital infection. Improve the level of prevention and control of nosocomial infection in our hospital. We believe that as long as we constantly sum up experience and learn with an open mind, we will do a better job in hospital infection control.
Hospital nosocomial infection self-examination report
In accordance with the spirit of instructions from higher authorities, we will thoroughly implement the Measures for the Management of Hospital Infection, carefully find out the problems existing in the management, reporting and disposal of hospital infection in medical institutions, further strengthen the management of hospital infection, effectively prevent and control infectious disease pathogens and iatrogenic infections, enhance the ability of hospital prevention and control, and ensure people's health and life safety. The leaders of the hospital attached great importance to it, personally organized it and paid close attention to its implementation. From establishing organizations, perfecting systems and responsibilities to front-line inspectors, hospital infection management, self-examination and self-correction should be carried out comprehensively, standardized and scientifically.
First,? Strengthen organization and leadership to ensure the smooth development of hospital infection management.
Hospital infection management team was established in our hospital:
Responsible for the control of the whole hospital in the hospital sense group headed by the secretary, and guide the lower departments. Earnestly do a good job in daily work, regularly and irregularly supervise and inspect the hospital infection control in all subjects, collect and count the relevant data of the whole hospital, and report to the hospital leading group. Each clinical department has a special person who is responsible for the monitoring of the undergraduate course, and reports the relevant situation to the hospital infection group on time. .
Second, seriously carry out self-examination and self-correction.
After several self-inspections, we still have many problems:
(1) employees have little knowledge and awareness of hospital infection control. ?
(2) Some departments are not equipped with disinfection hardware. ?
⑶ Hospital infection control system is not comprehensive. ?
⑷ The details of hospital infection control are not enough.
5] hand hygiene is not in place.
[6] Endoscopic room equipment is not up to standard and disinfection is unqualified.
(7) Hospital infection case report is not timely (the doctor's diagnosis of hospital infection is not clear enough.
Being needle knife room management is not in place, department staff infection control consciousness is weak. ?
Pet-name ruby abortion room management is not in place, department staff infection control consciousness is weak. ? In view of the problems existing in our hospital, the hospital infection management team analyzed them one by one and tried to find ways and measures to solve the existing practical problems:
(1) Establish an organization with clear responsibilities, and the responsibility lies with people. ?
⑵ Improve and perfect the system to bind people.
(3) Improve hand hygiene facilities, conscientiously implement hand hygiene standards, raise awareness, and conduct regular hand hygiene monitoring.
⑷ Make a training plan for hospital infection to improve employees' ideology. ?
5] Carry out indoor and outdoor sanitation and cleaning.
[6] do a good job in the registration of hospital infection-related activities, improve the purchase of basic items in various subjects, and ensure the normal operation of hospital infection control.
Through medical training once, doctors can master the diagnostic criteria of hospital infection, report it in time, improve records and effectively control hospital infection.
⑻ Endoscopic room should be built according to standardization, soft endoscope should be decontaminated as required, and enteroscopy, stomach meridian and laryngoscope should be included in the key monitoring scope. Ensure patient and medical safety.
(9) Strengthen the concept of aseptic operation of doctors in the needle knife room and abortion room, train them, improve the facilities and equipment in the needle knife room, and conduct spot checks, inspections and supervision on a regular basis. ? Third, further improve the management system and implement it.
Hospital infection management system is the basis and important guarantee for doing a good job in hospital infection. A set of scientific and practical management system has been formulated, and the systems of hospital infection management, disinfection and isolation of various departments, hospital infection report, discussion of critical death cases, special case referral and sewage treatment have been improved. Standardize the behavior of hospital staff. Strengthening the system construction and research, and conscientiously implementing it are extremely important to improve the awareness of prevention and reduce the incidence of hospital infection. Give full play to the binding role of the system, so that all work can be implemented. ?
Fourth, strengthen the disinfection management of disinfection room.
The logistics department often checks the indoor walls and ceilings to keep them smooth, without cracks and falling ash. Disinfection room layout is reasonable, and "three areas" should be adhered to. "Three separate". ? Three areas: contaminated area, clean area and sterile area. ? 3. Separation: separation of waste recovery and net distribution;
Primary washing is separated from fine washing;
Separate unsterilized articles from sterilized articles;
In the process of pressure steam sterilization, we insist on using the indicator tape outside the package and the indicator card inside the package for self-monitoring, which ensures the quality of disinfection and sterilization and carries out biological monitoring.
Five, continue to pay special attention to the disinfection and isolation of clinical departments, infection monitoring. ?
1. According to the Law on the Prevention and Control of Infectious Diseases, the Measures for the Administration of Disinfection and the Regulations on the Administration of Hospital Infection, the hospital has strengthened the disinfection isolation and infection monitoring of clinical departments. Check once every half a month, and handle problems in time when found. When infectious patients are found, they should register and report the epidemic situation in time. Toxic, harmful and infectious sewage and dirt must be disinfected. In addition to strict disinfection of reusable items, the utilization rate of disposable sterile medical supplies is improved and the possibility of hospital infection is greatly reduced. In the disinfection solution replacement and equipment soaking inspection, except for occasional omissions or incomplete records in individual departments, the time for equipment soaking and disinfection solution preparation replacement meets the requirements.
2. Monitor the hand surface, object surface, air, disinfectant, ultraviolet intensity and pressure steam sterilization package of nurses in clinical departments.
4. Hospitals should do well in environmental hygiene, indoor hygiene, personal hygiene and food hygiene, strengthen health publicity and education for patients, and create a clean, quiet, comfortable and safe medical environment for patients.
Six, the management of disposable supplies, to ensure the medical safety of patients, to prevent social pollution.
When purchasing disposable products, strengthen the management in this respect and strictly verify and check the quality. Hospital leaders and warehouse keepers are responsible for checking and registering the purchased disposable articles, ensuring the purchase of disposable articles and sterilized medical devices and preventing unqualified products from entering our hospital. The storage management of disposable sterile medical supplies was strengthened, and they were stored off the ground and off the wall as required. Check the disposable sterile medical supplies stored in the warehouse and various departments once every quarter, and the nursing staff should strictly check them before use to prevent the expired disposable supplies from being used by patients. For used disposable articles, all departments have always insisted on destroying, disinfecting and recording, and severely criticized individual phenomena that were not destroyed and immediately replenished during spot checks. The disinfection rate of disposable empty needles, infusion sets and urine bags in our hospital reached 100%.
Seven, strengthen the training of hospital awareness knowledge, improve the consciousness of hospital staff to control hospital infection.
Combined with the actual situation of our hospital, the hospital infection committee decided to organize lectures, disinfection and safety knowledge training, blood transfusion related laws and regulations and blood transfusion knowledge learning in the second half of the year, and train the medical staff in the hospital on hospital infection prevention and control to enhance their awareness of hospital infection prevention and control. Improve the level of prevention and control of nosocomial infection in our hospital. However, due to the late start of nosocomial infection control in our hospital, there are still some shortcomings in the diagnosis, reporting and statistics of nosocomial infection cases, which need to be improved and perfected in the future. We believe that as long as we constantly sum up experience and learn with an open mind, we will do a better job in hospital infection control.