Work plan for hospital infection 1 20xx years ago, under the unified leadership of the hospital, we strengthened active cooperation with the clinical laboratory, and conscientiously implemented the Measures for the Management of Hospital Infection, the Law on the Prevention and Control of Infectious Diseases in People's Republic of China (PRC), the Technical Specification for Disinfection, the Regulations on the Management of Medical Wastes, and the Management Specification for Disinfection Supply Centers.
In this regard, I, Kurt, have made a work plan for 20xx years, as follows:
First, the main objectives:
1, the training rate of college sense knowledge in another university is over 90%, and the qualified rate of training is 100%.
2, air, medical staff hands, object surface qualified rate of 98% or higher; The qualified rate of disinfectant in use is100%; The qualified rate of disinfection items reached 100%.
3. Missed diagnosis rate of nosocomial infection
4. Epidemic report of patients with infectious diseases100%; The timely rate is 98%;
5. The recovery rate of medical waste is 100%.
Second, the guarantee measures
(1) Strengthen education and training: the training of infection management knowledge will be included in the focus of this year's work, and all staff will be trained and papers will be distributed through various channels in the form of in-hospital lectures to improve the awareness of hospital infection prevention among medical staff. Train general practitioners on hospital infection knowledge every month.
1, every month, the department organizes hospital infection related knowledge training according to the undergraduate business development and completes it.
Record.
2. Actively participate in the hospital awareness knowledge education and training organized by the hospital, and incorporate the learning situation into the department assessment.
3, pre-job training for new employees, the main training content is eliminated.
The knowledge of virus isolation, the prevention and control of hospital infection, and the classified collection and treatment of medical waste make them integrate hospital awareness into their work.
4. Strengthen the training of nurses' disinfection and isolation knowledge, such as job requirements of nurses, basic knowledge of disinfection and sterilization, cleaning procedures and personal protective measures.
5, the implementation of personnel responsibilities at all levels, do a good job of isolation and protection, to avoid cross infection.
(2) Strengthen the monitoring and management of hospital infection.
1, give full play to the role of hospital quality control management team, and find problems and correct them in time through monthly quality control inspection.
2. According to the requirements of Technical Specification for Disinfection and Management Measures for Hospital Infection, the disinfection effect of air, object surface, staff hands, disinfectants, disinfectants and sterilized items in key departments should be monitored every quarter.
3. General practitioners are required to do a good job in occupational protection of medical staff, and those who have occupational exposure and injuries should be reported and registered to protect susceptible people and effectively control hospital infection.
4. Clean the air disinfection machine filter in use once a month.
(3) Strictly manage the classification, collection, transportation, storage and transportation of medical wastes to prevent leakage.
1. Medical wastes shall be classified and placed as required, sealed and transported, and the packaging bags shall be marked and registered when leaving the department. Designate a special person to collect and sign it, and send it to the temporary storage point of medical waste for centralized storage.
2, medical waste transfer form by full-time personnel to fill in, and save the stub for future reference.
Under the leadership of the nursing department and the infection control department, with the aim of serving patients and the working attitude of continuous improvement, we will further deepen and refine the management of hospital infection and infectious diseases, and effectively prevent and control the occurrence of hospital infection. According to the requirements of the xx version of the Standard Operating Procedures for Blood Purification of the Ministry of Health and the inspection and acceptance standards of the blood purification center of medical institutions in Shaanxi Province, and in combination with the key points and difficulties existing in the management of nosocomial infection and infectious diseases in the hemodialysis room of our hospital, 20xx is specially formulated.
First, strengthen organizational management and improve the management system of hospital infection and infectious diseases.
Objective: To strengthen the coordination ability between the hospital infection management committee and the leading group for infectious disease management, solve the related problems of hospital infection management and infectious disease management in time, and assess the implementation of key departments, key links and key processes of hospital infection and the implementation of intervention measures for infection risk factors. In case of hospital infection outbreak, unexplained infectious disease or special pathogen infection, clarify the responsibilities of relevant departments in preventing and controlling hospital infection and discuss other important matters related to hospital infection management.
Participants:
1, member of hospital infection management committee and member of leading group for infectious disease management.
2, the relevant department director, head nurse.
3. Full-time staff in the control and sensing department.
Specific requirements:
1, hold a meeting of the hospital infection management committee and the leading group for infectious disease management every quarter. Solve the problems in hospital infection management and infectious disease management, and put forward control and preventive measures for the existing problems.
2, according to the latest requirements of hospital infection management and infectious disease management, timely revision of hospital infection management and infectious disease management system.
3. In case of hospital infection outbreak, unexplained infectious diseases or special pathogen infection cases, hold a meeting in time to discuss relevant matters to prevent the outbreak.
Two, strengthen the training of hospital infection knowledge, improve the awareness of medical staff to prevent infection.
Objective: In order to make all kinds of medical staff at all levels in our hospital know the new knowledge and new ideas of hospital infection management in time, implement various rules and regulations and prevention and control measures of hospital infection management, explore the existing problems and solutions in hospital infection management, improve medical staff's legal awareness, reduce hospital infection rate and create zero tolerance of hospital infection.
Participants:
All kinds of medical staff at all levels, including newcomers, advanced students, interns, nurses, medical technicians and logistics personnel.
Main contents:
1, Measures for the Management of Hospital Infection, Technical Specifications for Disinfection, Regulations on the Management of Medical Waste, Measures for the Management of Medical Waste, Diagnostic Criteria for Hospital Infection, Hand Hygiene of Medical Staff, Disinfection and Isolation Technology, and Monitoring Specifications for Hospital Infection and other relevant laws, regulations and requirements.
2, hospital infection emergency management related knowledge training.
Specific requirements:
1, all medical personnel are trained twice, and the training content is assessed at least 1 time.
2, new hospital staff, trainers, interns, nurses pre-job training 1 time, the examination qualified rear can mount guard.
3. Monitoring physicians and nurses in clinical departments should be trained quarterly or hold special meetings 1 time.
4. Training of medical staff in relevant medical departments 1 time.
5, hospital nursing training 1 time, and evaluate the training content when necessary.
6, logistics personnel including medical waste collection, transportation, storage, laundry personnel and other related hospital infection management knowledge training once.
7, hospital infection emergencies and emerging infectious diseases emergency management knowledge instant training.
8, clinical and medical departments, hospital infection knowledge training once a month, the participants signed, training record registration is complete.
Three, strengthen the monitoring of hospital infection, deepen and refine the management of hospital infection.
Objective: According to the specific requirements of Technical Specification for Disinfection, Management Measures for Hospital Infection, Monitoring Specification for Hospital Infection, Manual Hygiene Specification for Medical Staff, etc. , do a good job in daily monitoring, daily inspection, monthly summary and quarterly report, and strive to control all indicators within the standard. Thoroughly carry out prospective and targeted hospital infection monitoring of inpatients, and do a good job in investigating the prevalence rate of inpatients every year. Deepen and refine the quality control standards of hospital infection, implement the prevention and control measures of hospital infection in key departments and key parts, and prevent and control the outbreak of hospital infection.
Participants: full-time staff of sensory control department, directors of clinical departments, head nurses, monitoring doctors, monitoring nurses, and microbiology laboratory staff.
Main contents:
1. Nosocomial infection case monitoring, including: nosocomial infection rate of inpatients, antibiotic utilization rate, surgical incision infection rate, nosocomial infection management of multi-drug resistant bacteria and nosocomial infection monitoring in ICU; To monitor patients with ventilator-associated pneumonia, urinary tract infection associated with indwelling catheter and blood flow infection associated with deep vein catheterization; Investigation on prevalence rate of nosocomial infection;
2, key departments (ICU, hemodialysis room, endoscopy room, operating room, supply room, stomatology, obstetrics, infectious diseases, etc. ) Hospital infection quality control.
3, the use of sterile items management, including sterile items, disinfectants, disinfection equipment, pressure steam sterilization effect monitoring.
4. Strengthen the monitoring of mobile medical equipment in the hospital, including bronchoscope and laryngoscope.
5. Environmental health monitoring, including the monitoring of staff's hands, air, objects and ultraviolet lamps.
6. Management of medical wastes, including classification, collection, transportation, storage and registration of medical wastes.
7, to carry out hospital infection epidemic monitoring, and report to the administrative department of health within the prescribed time limit.
8, medical staff occupational protection, hand hygiene and disinfection and isolation technology.
Specific requirements:
1, do a good job in daily hospital infection case monitoring, and continue to carry out surgical site infection monitoring and ICU target monitoring; Isolation treatment of patients infected with multi-drug resistant bacteria; To evaluate the nosocomial infection of patients using ventilator, indwelling catheter and deep venous catheter. The key monitoring departments are: ICU, neurosurgery, neurology and urology. The prevalence rate of nosocomial infection should be investigated at least once.
2, every month for key departments, every quarter for general departments, a hospital infection quality control evaluation, monitoring the use of ultraviolet lamp once every six months. Timely feedback on existing problems and timely improvement. Each department should conduct self-examination once a month according to the quality control standard of hospital infection management, and require the quality control data to be complete.
3, key departments monthly, comprehensive departments quarterly environmental health monitoring and disinfection and sterilization effect monitoring. In the middle of each month, the infection control department conducts sampling monitoring on key departments and some clinical departments. Biological monitoring of sterilization effect of pressure steam in supply room, once a week, monitoring implants every time.
4, screening all mobile devices in various departments of the hospital, each department should do a good job of cleaning, disinfection, sterilization, transshipment and management of equipment according to the requirements of hospital infection management.
5, dynamic monitoring of hospital infection, actively intervene in clustered hospital infection cases, prevent and control the outbreak of hospital infection. All departments are required to report hospital infection cases in time and fill in the hospital infection case report register correctly.
6, monitoring do daily check, monthly total, monitoring results every quarter in the form of briefing feedback to the floor.
7, found in the hospital infection management monitoring security risks, timely report to the hospital infection management committee.
Four, combined with the actual situation, formulate our hospital infection prevention and control standard operating procedures (SOP).
Objective: According to the specific requirements of hospital infection management laws, regulations and norms, to refine, quantify and optimize the key points and difficulties in hospital infection management, so as to facilitate the operation and mastery of medical staff, better prevent and control the outbreak of hospital infection, and ensure the quality and safety of medical care.
Person in charge: Director of Sensory Control Department
Main contents:
1, prevention and control of nosocomial infection in key parts
2. Prevention and control of nosocomial infection in key departments
3. Basic methods of preventing and controlling nosocomial infection
4, occupational protection and biological safety
5. Collection and transportation of clinical microbial specimens
6. Management of clinical application of antibacterial drugs
7. Monitoring, prevention and control of drug-resistant bacteria
8, hospital environment cleaning, disinfection and monitoring
9, hospital infection case monitoring, etc.
Specific requirements:
1, xx years ago, before June, the Sense Control Department was responsible for formulating the Standard Operating Procedures (SOP) for Hospital Infection Prevention and Control and distributing it to relevant departments.
2, the department organized medical staff to study hard and comply with it.
Five, strengthen the management of infectious diseases, put an end to the phenomenon of missing and late reporting.
Objective: According to the specific requirements of the Law of People's Republic of China (PRC) on the Prevention and Control of Infectious Diseases and the Management Standard of Infectious Disease Information Reporting, do a good job in the management of infectious diseases, so as to keep the reporting rate of infectious diseases in our hospital at 100% and the timely rate at 100%.
Person in charge: epidemiologists and first-time doctors.
Main contents:
1, legal infectious disease registration, card collection and online direct reporting.
2, cholera, avian influenza, tuberculosis, AIDS, AFP case monitoring and fever clinic, intestinal outpatient infectious disease management.
3, epidemic self-examination, analysis, summary and electronic documents and other information management.
4. Complete the network direct report of death case report card.
5, infectious disease management knowledge training. Including: report management of common infectious diseases and multiple infectious diseases, emergency management of public health emergencies and report management of new infectious diseases.
6, complete the mandatory tasks assigned by the superior leadership.
Specific requirements:
1. The epidemic specialist conducts self-examination on the outpatient log and the clinical department discharge register every day, collects infectious disease report cards in time, and completes the network direct report. Ensure that there is no omission of infectious diseases in our hospital.
2, do a good job in cholera, avian influenza, tuberculosis, AIDS, AFP case monitoring and fever clinic, intestinal clinic management.
3, the infectious disease report card number every month and save it after binding; Regularly analyze the epidemic situation and give feedback to the leading group of infectious disease management and related clinical departments in time.
4, infectious disease management knowledge training for more than six times. Trainers include: all clinicians, advanced students and interns. The new doctor must pass the exam before he can take up his post. Immediate training of sudden infectious diseases.
5. Ask the first-time physician to fill in the infectious disease report card and the death ratio report card in time, and improve the infectious disease report register.
6. Punish the departments and individuals that fail to report or conceal infectious diseases, and make records.
The third part of the hospital infection work plan conscientiously performs the management and supervision functions and strives to do a good job in hospital infection management.
1, give full play to the role of hospital sense management system, especially the role of hospital quality control team members. Through strengthening the training of hospital infection management system, let everyone know about the hospital infection management system and implement it seriously, so as to improve the cognition of each employee on hospital infection. Standardize operation and reduce the occurrence of hospital feeling.
2. Implement the system of hospital sensation meeting, hold a meeting of hospital sensation management committee every six months to study and solve the problems encountered in hospital sensation management, and summarize and arrange the work every six months. Analyze the causes of existing problems, formulate rectification measures and actively rectify them.
3. Continue to carry out hospital sense supervision.
(1) biological monitoring of hospital infection, air, object surface and hand hygiene monitoring of medical staff in key departments such as operating room, disinfection supply room, stomatology department, treatment room and dressing room.
(2) Strengthen the management of disposable consumables, and whether the manufacturer and the validity period meet the standards.
(3) Strengthen the hand hygiene management of medical staff, strengthen training, and conduct regular spot checks to understand the mastery of health knowledge of each medical staff.
(4) Medical waste management should be normalized and standardized, and medical personnel, cleaning personnel and staff engaged in medical waste collection, transportation and storage should be trained in laws and regulations, professional technology, safety protection and emergency treatment, so as to prevent the leakage and loss of medical waste and effectively implement various rules and regulations of hospital medical waste management.
In order to strengthen the prevention and control of nosocomial infection in our hospital, ensure the safety of patients, improve the quality of medical care, safeguard the occupational safety of medical staff, and make the management of nosocomial infection gradually scientific, systematic and standardized, combined with the actual situation in our hospital, the work plan of nosocomial infection management in 20xx is formulated as follows:
First, according to the laws, regulations and normative documents on nosocomial infection promulgated by the state and the Ministry of Health, we will constantly revise and improve the relevant systems, measures and processes for preventing and controlling nosocomial infection in our hospital.
Two, to carry out hospital infection prevention and control knowledge training and education.
This year, the hospital sensory department organized at least four hospital-wide trainings (once every quarter). This year, the hospital focused on training related knowledge such as disinfection and isolation, hand hygiene, occupational protection of medical staff, and classified disposal of medical waste. Each department formulates its own training plan according to the actual situation to improve the knowledge and professional level of all staff in preventing and controlling hospital infection.
Third, carry out hospital infection monitoring.
1, carry out comprehensive monitoring of nosocomial infection.
Medical staff in clinical departments find hospital infection cases in time, and doctors in clinical departments fill out report cards in accordance with the prescribed time limit and methods and report them to the hospital infection department.
The Department of Hospital Infection confirms and verifies the reported cases of hospital infection, collects the monitoring data in time, feeds it back to relevant departments, and works with relevant departments to formulate control measures to reduce the incidence of hospital infection.
2. Investigate the prevalence rate of nosocomial infection during the year.
Four, strengthen the prevention and control of nosocomial infection in respiratory tract, catheter-related urinary tract, skin and soft tissue and other major parts.
All clinical departments should check the implementation of relevant systems and measures, find problems in time and make improvements.
The hospital sensory department regularly visits various clinical departments to supervise, give timely feedback on existing problems and put forward rectification suggestions.
Five, the implementation of hand hygiene standards, compliance supervision and improvement.
Equipped with convenient hand hygiene equipment and facilities to provide necessary protection for hand hygiene. Conduct hand hygiene training and evaluation for all hospital employees.
Hospital sensory departments and departments regularly supervise, check, summarize and improve the standard hand washing.
Six, strengthen the supervision and guidance of hospital cleaning, disinfection, sterilization, hospital isolation, aseptic technology operation.
Strict implementation of aseptic technical operation specifications and disinfection and isolation system, disinfection work conforms to the Technical Specification for Hospital Disinfection and Isolation, which effectively cuts off the transmission route of exogenous infection and minimizes hospital infection caused by the spread of exogenous pathogens.
Seven, to carry out hospital disinfection and sterilization effect monitoring.
1, concentration monitoring of chemical disinfectants and disinfectants in use
Chlorine-containing disinfectant: once a day, use G- 1 disinfectant concentration test paper for quick and simple detection.
Glutaraldehyde: once a week, use glutaraldehyde concentration test paper for rapid monitoring.
2. Monitoring of bacterial contamination of disinfectants in use
Once a month, monitor the bacterial contamination of disinfectants and skin mucosa disinfectants in use.
3, pressure steam sterilization effect monitoring
Chemical monitoring: each package should be monitored, with a chemical indicator tape attached outside the package and a chemical indicator card inside the package.
4, ultraviolet lamp disinfection effect monitoring
Daily monitoring: including lamp service time and cumulative exposure time.
Lamp irradiation intensity monitoring: once every quarter, test with ultraviolet intensity irradiation indicator card.
Eight, regularly carry out hospital environmental health monitoring, medical staff hand, air, object surface monitoring.
Conduct routine monitoring on key departments such as operating room, laboratory, stomatology, endoscopy room and clinical department every month, analyze the causes of unqualified items and formulate improvement measures.
Nine, do a good job in the supervision and guidance of medical waste treatment.
Strictly implement the medical waste management system, collect and place medical waste according to the classification catalogue of medical waste, and it is strictly forbidden to mix medical waste with domestic garbage, and it is strictly forbidden to lose, leak, spread, transfer and trade medical waste.
The storage of medical waste shall be handed over to the centralized medical waste disposal unit for disposal in time, and the medical waste shall be registered.
Medical waste collection, transportation and storage personnel should be equipped with necessary protective equipment.
Ten, do a good job in the occupational safety protection of medical personnel, minimize the risk of occupational exposure, and ensure the safety of medical personnel.
To train and guide medical personnel on occupational safety protection knowledge; Provide necessary protective equipment for medical personnel; Medical personnel should register, report, evaluate and prevent occupational exposure in time.
Eleven, hospital infection prevention and control work quality evaluation and control.
The hospital infection department formulates the quality evaluation standard of hospital infection control in each department. According to this standard, the quality of hospital infection prevention and control in each department is evaluated, so as to control and manage the foundation, link and final quality, and continuously improve and improve the quality of hospital infection management.
Hospital infection department evaluates the quality of hospital infection in all departments and parts of the hospital every quarter, and conducts special supervision from time to time. Feedback the problems found in the inspection to the relevant departments of the hospital in time, make rectification within a time limit, and check and urge again until the rectification is in place.