I. Purpose
To strengthen the management of hospital infections, effective prevention and control of hospital infections, to protect the safety of medical care and improve the quality of medical care.
Second, the scope of application
clinical, medical and technical departments.
Third, the responsibilities
1. Hospital infection control section (full-time staff, the same below) the main responsibilities:
(1) according to the national and regional health administrative departments of the hospital infection management regulations, standards, the formulation of hospital infection control planning, work plan, organization and development of hospitals and departments of hospital infection management rules and regulations, after approval, the specific organization, implementation, supervision and evaluation. The company is also responsible for the implementation, supervision and evaluation of the program.
(2) is responsible for the hospital at all levels and types of personnel to prevent and control hospital infection knowledge and skills training, assessment.
(3) is responsible for monitoring the incidence of hospital infections, regular supervision of hospital environmental hygiene, disinfection, sterilization effect, monitoring, timely summary, analysis of the monitoring results, found that the problem, the development of control measures, and supervise the implementation.
(4) the hospital occurred in the hospital infection epidemic, outbreaks of investigation and analysis, put forward control measures, and organize the implementation.
(5) Participate in the Pharmacy Management Committee on the management of the application of anti-infective drugs, to assist in the formulation of rules and regulations for the rational use of drugs, and participate in the supervision and implementation.
(6) Audit the purchase of sterilized medicines and disposable medical and hygienic supplies, and supervise their storage, use and disposal after use.
(7) Timely report the dynamics of hospital infection control to the supervisor and the hospital infection management committee, and inform the whole hospital.
2. Clinical departments to establish a hospital infection management team, consisting of the department director, head nurse and part-time monitoring of this section of the physician, nurse, under the leadership of the department director to carry out their work. Its main responsibilities are:
(1) responsible for the management of hospital infection in the room, according to the characteristics of hospital infection in the room, the development of management systems, and organization and implementation.
(2) monitor hospital infection cases and infection links, take effective measures to reduce the incidence of hospital infections in this room; when a trend of hospital infection epidemic is found, report to the Hospital Infection Management Division in a timely manner and actively assist in the investigation.
(3) Supervise and inspect the use of anti-infective drugs in this room.
(4) Organize training on the prevention and control of hospital infections in the department.
(5) Supervise the implementation of aseptic operation techniques, disinfection and isolation system in this room.
(6) To do a good job of hygienic management of hygienists, food dispensers, companions and visitors.
3. Medical staff should fulfill the following duties in the management of hospital infection:
(1) Strict implementation of aseptic technology operating procedures and other rules and regulations of hospital infection management.
(2) Master the principle of rational application of anti-infective drugs in the clinic, so as to achieve rational use.
(3) Master the diagnostic criteria of hospital infection.
(4) found cases of hospital infection, timely delivery of pathogenetic testing and drug sensitivity test, find the source of infection, infection pathway, control the spread, active treatment of patients, and truthfully fill out the form report; found that there is a trend of hospital infection epidemic, timely report to the Infection Management Division, and to assist in the investigation. The discovery of statutory infectious diseases, according to the provisions of the "Prevention and Control of Infectious Diseases Act" report.
(5) Participate in the prevention and control of hospital infection knowledge training.
(6) master the knowledge of self-protection, correctly carry out all technical operations, prevent sharp instrument stabbing.
Fourth, the work of the program
1. Reporting and control of hospital-acquired infections
( 1) When the emergence of hospital-acquired infections distributed cases, the attending physician should be timely to the head of the department of hospital-acquired infections monitoring
control team report, and fill out a form to report to the Department of Hospital Infection Management within 24 hours.
(2) The person in charge of the departmental surveillance team should, under the guidance of the Hospital Infection Control Department, promptly organize the treating physicians and nurses to find the cause of infection and take effective control measures.
(3) Hospital infections diagnosed as transmissible beam disease are reported and controlled according to the relevant provisions of the Infectious Diseases Prevention and Control Act.
2. Hospital infection epidemics, outbreaks of reporting and control
(1) hospital infection epidemics, outbreaks of reporting
① hospital infection epidemic trend, the hospital infection control section should be reported to the dean in charge of the 24 hours and the Medical Department, and inform the relevant departments.
② The investigation confirmed the emergence of hospital-acquired infections epidemic, the hospital should be reported within 24 hours to the local health administrative departments.
③ local health administrative departments to determine the hospital infection epidemic or outbreak, should be reported to the provincial health administrative departments within 24 hours, level by level; provincial health administrative departments received a hospital infection epidemic or outbreak of the report should be reported to the State Council within 24 hours of the health administrative departments.
④ hospital infections diagnosed as infectious diseases, in accordance with the relevant provisions of the "Law on the Prevention and Control of Infectious Diseases" report.
(2) the emergence of hospital infection epidemic or outbreak trend, the following control measures should be taken:
① Clinical departments must promptly find the cause, to assist in the investigation and implementation of control measures. ② hospital infection control department must be timely epidemiological investigation and treatment, the basic steps are:
A. Confirmation of epidemic or outbreak. Suspected of having the same type of infection to confirm the diagnosis of the case, calculate the rate of disease, if the rate of disease is significantly higher than the general incidence of hospital infections in the department or ward level in previous years, it is confirmed that there is an epidemic or outbreak.
B. Find the source of infection. Infected patients, contacts, suspected infectious agents, the environment, objects, medical staff and accompanying personnel to carry out etiological examination.
C. Find the factors that cause infection. Detailed epidemiologic investigation of infected patients and the surrounding population.
D. Develop and organize the implementation of effective control measures. This includes appropriate treatment of patients, proper sterilization, isolation of patients or even suspension of new patients if necessary.
E. Analyze the investigation data, the distribution of cases of departmental, population distribution and time distribution of description; analysis of the cause of the epidemic or outbreak, speculation on the possible sources of infection, infection pathway or infection factors, combined with laboratory results and the effect of control measures to make a comprehensive judgment.
F. Write an investigation report to summarize the experience and develop preventive measures.
③ The director in charge of the report, should promptly organize the relevant departments to assist the Hospital Infection Management Division to carry out epidemiological investigation and control work, and from human, material and financial resources to ensure.
④ When hospital infection epidemic or outbreak occurs in other hospitals, the region or the hospital should be similar potential risk factors for investigation and take appropriate control measures.
⑤ Hospital infections diagnosed as infectious diseases are managed according to the relevant provisions of the Infectious Diseases Prevention and Control Act.
3. Sterilization and isolation
(1) medical personnel must comply with the principle of sterilization, medical supplies into human tissue or sterile organs must be sterilized; contact with the skin and mucous membranes of the apparatus and utensils must be disinfected. Used medical equipment and articles should be decontaminated, thoroughly cleaned and then disinfected or sterilized; in particular, medical equipment and articles used by infected patients should be disinfected, thoroughly cleaned and then disinfected or sterilized. All medical devices should be disinfected or sterilized before overhaul.
(2) According to the performance of the items selected physical or chemical methods for sterilization. Heat-resistant, moisture-resistant items preferred physical sterilization method; surgical instruments and items, a variety of puncture needles, syringes, etc. preferred pressure steam sterilization; oil, powder, paste, etc. preferred dry heat sterilization. Heat-resistant items such as various catheters, precision instruments, artificial grafts, etc. can choose chemical sterilization method, such as ethylene oxide sterilization, etc., endoscopy can choose ethylene oxide sterilization or 2% glutaraldehyde immersion sterilization. Sterilization should be preferred to physical methods, can not be sterilized by physical methods of party selection of chemical methods.
(3) chemical sterilization or disinfection, according to different circumstances, respectively, choose sterilization, high-efficiency, medium-effective, low-effective disinfectants. The use of chemical disinfectants must understand the performance of the disinfectant, the role of the disinfectant, the use of methods, factors affecting the effect of sterilization or disinfection, etc., the preparation of attention to the effective concentration, and regular monitoring. When replacing the sterilizing agent, the container used to soak the sterilized items must be sterilized.
(4) formaldehyde gas sterilization with reference to the "Hospital Disinfection Technical Specification". Natural volatile fumigation method of formaldehyde fumigation box can not be used for disinfection and sterilization, and can not be used for the preservation of sterile items. Formaldehyde is not suitable for air sterilization.
(5) continuous use of oxygen humidification bottles, nebulizers, ventilator tubes, preterm baby warmer humidifier and other equipment, must be disinfected daily, end of use disinfection, dry storage. Humidification solution should be sterilized water.
(6) hand skin cleaning and disinfection should meet the following requirements:
① Hand washing equipment:
a. Wards and various diagnostic and treatment departments have mobile water hand washing facilities, with foot, elbow or inductive switches.
b. Soap should be kept clean and dry.
c. Optional paper towels, hand towels and other dry hands. Hand towels should be kept clean, dry and sterilized daily.
d. When it is not easy to wash your hands, you can use rapid hand sanitizer.
② washing finger signs:
a. Before and after contact with the patient, especially before and after contact with broken skin, mucous membranes and invasive operations.
b. Before and after the aseptic technique operation, before and after entering and leaving the isolation ward, ICU, mother and baby room, infectious
ward and other key departments, before and after wearing masks and putting on and taking off the isolation gown.
c. After contact with blood, body fluids and contaminated items.
d. After taking off gloves.
③ Hand washing method:
Carefully rub the palm, finger crevices, back of the hand, finger joints, finger bellies, fingertips, thumbs, and wrists with cleansing agent for 10 to 15 seconds, and then wash with running water.
④ Indications for hand disinfection:
a. Before and after entering and leaving the isolation ward, putting on and taking off the isolation gown.
b. After contact with blood, body fluids and contaminated items.
c. After contact with specific infectious agents.
⑤ Hand disinfection methods:
a. Rub hands with a quick hand disinfectant.
b. Soak hands in disinfectant.
⑥ Surgical hand brushing should be done with a brush dipped in detergent to brush the dirt from the nails, and wash both arms, dry them, and then brush or soak the hands with a hand disinfectant. Brush hands or soak hands time must meet the requirements. Specific methods see "hospital disinfection technical specifications".
(7) the ground should be cleaned and disinfected to meet the following requirements:
① The ground should be wet sweeping, keep clean; when there is blood, feces, body fluids and other contamination, it should be instantly mopped with chlorine disinfectant (1000ppm).
② mopping tools should be sterilized, washed and dried after use.
4. Management of disinfection equipment
(1) Hospital Infection Management Committee is responsible for the hospital's use of disinfection and sterilization equipment supervision and management.
(2) Infection Control Department in accordance with the relevant provisions of the state, specifically responsible for the hospital's disinfection and sterilization of the purchase
purchase, storage and use of supervision, inspection, guidance, and the existence of problems in a timely manner to report to the Hospital Infection Management Committee.
(3) Pharmacy should be based on clinical needs and the hospital infection management committee on the purchase of sterilization drugs and equipment for the validation of the procurement, in accordance with the relevant provisions of the State, check the necessary documents, supervise the quality of incoming products, and registration in accordance with the relevant requirements.
(4) the use of the department should accurately grasp the scope of use of disinfection and sterilization drugs and equipment, methods, precautions; to master the use of disinfection and sterilization of the concentration of the agent, the preparation method, the replacement time, factors affecting the effect of disinfection and sterilization, etc., found that the problem, and timely report to the Hospital Infection Control Section to be resolved.
5. Management of the application of anti-infective drugs
(1) The management of anti-infective drugs should meet the following requirements:
① Hospitals have a sound management system for the application of anti-infective drugs.
② The hospital anti-infective drug application rate statistics, and strive to control below 50%.
③ Laboratory and Pharmacy Department published every six months the main pathogenic bacteria and their drug sensitivity test results, and provide anti-infective drug information to clinical staff, to provide a basis for the rational use of anti-infective drugs.
④ Clinicians should improve the rate of sending relevant specimens for examination before the use of drugs, and according to the results of bacterial culture and drug sensitivity test, strictly grasp the indications and rationally select drugs; nurses should accurately execute the doctor's orders according to the pharmacological effects of various anti-infective drugs, contraindications for preparation and requirements for the preparation of the drugs, and observe the reaction of the patients after the use of the drugs, and cooperate with the physicians to do a good job in the retention and delivery of a variety of specimens for examination.
⑤ Hospitals should carry out monitoring of the clinical application of anti-infective drugs, including blood concentration monitoring and drug-resistant bacteria (such as methicillin-resistant Staphylococcus aureus [MRSA], vancomycin-resistant Staphylococcus aureus [VRSA] and vancomycin-resistant enterococci [VRE] and so on), in order to control the irrational application of anti-infective drugs and the emergence of drug-resistant strains of bacteria.
(2) the principle of rational application of anti-infective drugs:
① strictly grasp the indications and contraindications for the use of anti-infective drugs, close observation of the effect of the drug and the adverse reaction, rational use of anti-infective drugs.
② Strictly grasp the indications for the application of anti-infective drugs and preventive application.
③ Develop an individualized drug delivery program, pay attention to the dose, duration of treatment, and reasonable methods of drug delivery, interval time, route.
④ Closely observe the patient with or without bacterial dysbiosis, and timely adjust the application of anti-infective drugs.
⑤ Focus on pharmacoeconomics to reduce the cost of anti-infective drugs for patients.
(3) the rational application of anti-infective drugs:
① clear viral infections generally do not use antibacterial drugs.
② to fever cause unknown, and no signs of suspected bacterial infection, should not use anti-infective drugs. For those with serious conditions or bacterial infections that cannot be excluded, anti-infective drugs can be used as appropriate.
③ Correctly grasp the indications for perioperative prophylactic application of anti-infective drugs and the course of treatment.
④The application of anti-infective drugs before the timely and correct retention of clinical specimens.
⑤ Strictly control the skin and mucous membrane localization of anti-infective drugs.
⑤ Strictly control the topical use of anti-infective drugs on skin and mucous membranes.
6. Management of single-use sterile medical supplies. (See "disposable supplies, goods storage and monitoring management system")
7. Hospital infection monitoring
(1) Hospital infection case monitoring
① Hospitals must carry out hospital infection monitoring of patients to grasp the incidence of hospital infection, the most common site, the most common departments, high-risk factors, pathogens, characteristics and resistance to drugs, etc., in order to provide a scientific basis for the control of hospital infections. The hospital infection monitoring.
② The hospital should take a prospective monitoring method for comprehensive monitoring.
③ The hospital infection control section of the monthly monitoring information is summarized, analyzed, quarterly written report to the President, the hospital infection management committee, feedback to the hospital medical staff, monitoring information properly stored. Special circumstances timely reporting and feedback.
④ The hospital should evaluate the monitoring information every year, and carry out the investigation of hospital infection underreporting, the sample size of the investigation should be not less than 10% of the number of patients monitored annually, and the underreporting rate should be less than 20%.
⑤ The incidence of hospital infection in hospitals with 100 to 500 beds should be less than 8%; the infection rate of one type of incision surgical site should be less than 0.5%.
(2) Sterilization and disinfection effect monitoring
① Hospitals must regularly monitor the effect of disinfection and sterilization. Sterilization pass rate must reach 100%, unqualified items are not allowed to enter the clinical use department. Monitoring method see "Hospital Sterilization Technical Specification".
② disinfectants in use, sterilization agents, biological and chemical monitoring should be carried out.
Biological monitoring: disinfectants quarterly, the bacterial content must be <100cfu/ml, no pathogenic microorganisms shall be detected; sterilizing agent monthly monitoring, no microorganisms shall be detected.
Chemical monitoring: should be based on the performance of disinfection, sterilization agent regular monitoring, such as chlorine disinfectants should be monitored daily, the monitoring of glutaraldehyde should be no less than once a week. Disinfection and sterilization items should be monitored for disinfection and sterilization effects at the same time, and no pathogenic microorganisms should be detected in the disinfected items, and no microorganisms should be detected in the sterilized items.
③ Pressure steam sterilization: process monitoring, chemical monitoring and biological monitoring must be carried out.
Process monitoring per pot, and detailed records; chemical monitoring per package, surgical packages are still required to carry out chemical monitoring of the central part; biological monitoring monthly, new sterilizers must be biomonitoring before use, qualified before use; the proposed use of new packaging containers, placement, exhaust and special sterilization process, must also be biomonitoring, qualified before use.
④ ultraviolet disinfection: daily monitoring, ultraviolet lamp irradiation intensity monitoring and biological monitoring should be carried out.
Daily monitoring includes lamp application time, cumulative irradiation time and the user's signature; new and in-use ultraviolet lamps should be irradiation intensity monitoring, the irradiation intensity of the new lamp shall not be less than 100μW/cm2, the use of lamps shall not be less than 70μW/cm2, irradiation intensity monitoring should be every six months;
Biological monitoring is necessary to carry out, the sterilized Natural bacteria in the objects or air should be reduced by more than 90.00%, and the killing rate of artificially infected bacteria should reach 99.90%.
⑤ All kinds of sterilized endoscopes (such as gastroscopes, enteroscopes, laryngoscopes, tracheoscopes, etc.) and other sterilized articles should be monitored quarterly, and no pathogenic microorganisms should be detected.
⑥ a variety of sterilized endoscopes (such as laparoscopes), biopsy forceps and sterilized items, must be monitored monthly, no microorganisms shall be detected.
⑦ Medical supplies that enter the human sterile tissues, organs or contact with broken skin, mucous membranes and medical supplies that contact the skin, mucous membranes, should be in line with the "Hospital Disinfection Hygiene Standards" (GB15982-1995) in the provisions. The monitoring method is described in "Hospital disinfection health standards" (GB15982-1995).
(3) environmental hygiene monitoring
① Environmental hygiene monitoring, including monitoring of air, object surfaces and health care workers hand.
② hospitals should be monthly operating rooms, intensive care wards, maternity wards, supply room sterile areas, treatment rooms, dressing rooms and other key departments for environmental hygiene monitoring. When there is an epidemic of hospital infections, suspected of being related to hospital environmental health factors, timely monitoring.