Annual work plan of department infection 1 With the strong support of hospital leaders and the active cooperation and help of various functional departments, the hospital infection management department earnestly practices the norms and systems of hospital infection management, based on the principle of seeking truth from facts and slowly and steadily, solves the existing problems step by step, grasps the key points according to the difficulty and importance of carrying out the work, and deepens, improves and improves them one by one. Hospital infection management is gradually standardized, which effectively controls the occurrence of hospital infection. Through the targeted detection of high-incidence hospital infection, the incidence of ventilator-associated pneumonia and surgical incision infection can be effectively reduced. The management level of hospital infection has been improved year by year, and the incidence of hospital infection has dropped from 2.27% in 20xx to 65,438 0.72% in 20xx, showing a downward trend year by year, which has made due contributions to ensuring hospital medical safety and promoting the double harvest of hospital social and economic benefits.
The standardized implementation of hospital infection management is a systematic project, which cannot be achieved overnight and needs long-term running-in. In view of this feature, the hospital infection management department has formulated a long-term plan for standardized management. The leading idea is not to rush for success, to seek truth from facts and to do the work step by step. Every step is strict, easy first, difficult later, and focused. First of all, seriously study the relevant laws and regulations of hospital infection management and related disciplines such as management, statistics and epidemiology, and keep up with the frontier progress of hospital infection at home and abroad. After thoroughly understanding the connotation of hospital infection management, combined with the actual situation of our hospital, we decompose the goals that need to be achieved, classify them according to the importance of the work, and do everything possible to solve the very important work as soon as possible to ensure the basic medical safety. Then according to the difficulty of the work, make a plan and complete it step by step.
In the first year, first of all, improve and perfect the hospital infection management organization.
Including the establishment of a new hospital infection management Committee, the establishment of part-time hospital infection management doctors and nurses in various departments, and the enrichment of hospital infection management staff. According to the requirements of the specification, the main framework of hospital infection management is established, and then the working methods and ideas are changed from the hospital infection management department, and the clinical departments are gradually influenced by the work of infection management personnel. Mainly took the following measures:
1. Establish a daily investigation system to obtain first-hand information in time.
Staff are required to go deep into clinical departments to investigate hospital infection cases every day. Design and determine the investigation route, and control the quality of the investigators to prevent them from not working hard in the department. Change the original mode of waiting for medical staff to report cases to the infection management department, and send staff to the department to receive the report form. This measure is convenient for medical staff to report cases in time and communicate with medical staff. Strengthen information exchange with clinical departments. To understand the problems existing in the work of our department and provide relevant guidance for the management of clinical hospital infection. A circular mechanism of "communication-feedback-communication-anti-spicy" has been initially established.
2. Clarify the internal division of labor in infection management department and inject the concept of clinical service.
As a supervisor, infection managers are often regarded as "withholding money" by clinical staff, and their hostility is obvious, so infection management stays at the level of coping. In order to reverse this situation, we should first refine the division of labor of the staff in the infection management department, so that everyone's responsibilities are clear. At the same time, we should establish a complaint mechanism in the clinical department to supervise the work of the staff in the infection management department, which will not only improve work efficiency, but also inject service awareness, actively improve the relationship with the clinical department, and strive to eliminate misunderstanding and hostility towards hospital infection management. Staff strengthen business learning, master business knowledge in depth, and change supervision and punishment into supervision and guidance. Guide clinical staff to better cooperate with hospital infection management.
After more than a year's efforts, the hospital infection management institution basically operates normally and has been recognized by the whole hospital. The working position of hospital infection management department in the hospital was initially established, and the clinical medical staff changed from hostility to initial approval, which laid a good foundation for further in-depth development of hospital infection management.
In the second year, the influence of hospital infection management department was further expanded and the management system was improved.
The following reforms have been made to some management assessment indicators that are in line with reality and recognized by clinical medical staff, so as to make them closer to reality and be recognized by medical staff:
1. Improve the management assessment system and the continuing education system.
Cancel the management clause that used to assess departments according to the incidence rate (numerical value) of hospital infection, and change it to require that the incidence rate of hospital infection be lower than 10%, and deduct points when it exceeds 10%. However, when the hospital infection fails to report, and the party concerned is dealt with (deducted points), the department will deduct it from the assessment score (which will affect the rating of the department). Further rationalize the assessment system. On-the-job education on hospital infection was carried out for hospital staff according to hospital infection management standards, and the training on hospital infection management was included in the continuing education program. Conduct pre-job training for new employees. Incorporate the knowledge of hospital infection management into the "three basics" training and assessment of medical care. Through training and examination, the awareness and knowledge level of hospital infection management of medical staff have been improved, and the benign development of hospital infection management has been promoted.
2. Strengthen the management of hospital infection and introduce the "one-vote veto" system.
With the strong support of hospital leaders, the "one-vote veto" system is implemented for hospital infection management, that is, the departments with poor hospital infection management are cancelled to participate in the year-end "top three" departments and excellent and advanced qualifications. Further strengthen the status and authority of hospital infection management in hospital management.
3. Establish a daily reporting system to monitor the incidence of nosocomial infection in real time.
In order to find out the epidemic or outbreak trend and events of hospital infection in time, a daily report system of hospital infection cases was established, requiring staff to calculate and draw the incidence of hospital infection every day, draw a change curve, analyze the possibility of hospital infection through the change trend of the curve, respond in time, monitor the incidence of hospital infection, and initially realize the ability to deal with hospital infection events within 24 hours.
In the third year, while absorbing the experience of the previous two years, we will further strengthen the training of hospital infection management knowledge.
Especially for the personal protection of medical staff, in addition, the methods, skills and coordination of hospital infection management have been further deepened, which has made the hospital infection management work go up a storey still higher.
1. Strengthen hospital infection management and infectious disease prevention knowledge training.
With the cooperation of teaching and research section, medical department, nursing department and other relevant departments, 20 18 was designated as the training year of hospital infection management and infectious disease prevention and control knowledge, which further strengthened the training of medical staff. At the same time, we strengthened the contact with experts from Beijing and other places, sent full-time personnel to participate in national professional knowledge training courses, and brought back the contents of the training courses with modern means to train full-time personnel, which received good results.
2. Strengthen departmental cooperation and change "individual combat" into "group army combat".
Strengthen cooperation with nursing department, quality control room, medical department, teaching room, general affairs room, equipment room and clinical medical technology department, and fully incorporate hospital infection management into hospital quality management. The biggest benefit brought by multi-department cooperation is the timely communication of information, which eliminates some dead corners in previous work and some data that were difficult to obtain in time (the acquisition of data such as disinfectant dosage must rely on multi-department cooperation). Through the cooperation of departments, the quantitative data of hospital infection related materials were obtained and analyzed statistically. For example, according to the comparison between the number of inpatients in each department and the number of related disinfection products, we can find out which departments' disinfection products is obviously lower than the expected amount, and take targeted measures for supervision and management. This greatly improves the efficiency of hospital infection management department in finding and solving problems, and effectively promotes the in-depth development of hospital infection management.
3. Shorten the feedback period and find and solve problems in time.
Change the previous monthly and quarterly feedback mode to the weekly, monthly and quarterly feedback mechanism under the unified coordination of hospital quality control department. The director of the infection management department goes to the clinical department once a week to conduct supervision and training, and timely feeds back the problems found to the quality control room in the form of weekly summary, which is summarized by the quality control room and fed back to the hospital leaders at the morning meeting of the leading group every Monday. In the next week, we will go deep into the clinic, give feedback to relevant departments, urge improvement, and initially form a virtuous circle management model of "communication-feedback-improvement-communication-feedback-improvement".
4. Strengthen study and actively participate in various training courses related to hospital infection in China and the region.
Collecting the relevant information of hospital infection management, while enriching the professional knowledge of hospital infection, we should pay attention to collecting and learning the advanced experience of hospital management and even enterprise management, digest, improve and apply it to hospital infection management, further improve the level and ability of management and coordination, and make good preparations for hospital infection management in by going up one flight of stairs.
5. Strengthen communication and learn from the advanced experience of brother units.
The department has established an unwritten communication system, that is, it requires the staff of the department to warmly receive all the staff of the brother units who come to our hospital to visit and learn the experience of hospital infection management, and the relevant experience and knowledge should be unreserved, with the aim of strengthening contact and making common progress. The implementation of this measure not only contributed to the hospital infection management in our city, but also benefited us a lot. In the process of communication, I also learned the advanced experience of my brother units. At the same time, their valuable lessons also make our work less detours, and truly promote each other and improve together. At the same time, it also inspired the hospital infection management workers in our hospital-if you don't go against the current, you will retreat. Only continuous progress and innovation can effectively control the occurrence of hospital infection.
6. Targeted detection of high-incidence diseases in hospital infection.
A number of targeted tests including ventilator-associated pneumonia, surgical incision and indwelling catheter-related infection were carried out in 20xx. The targeted test of surgical incision infection significantly reduced the overall incidence of nosocomial infection in surgical patients. The development of targeted monitoring further effectively reduced the incidence of nosocomial infection.
After continuous research, exploration and repeated practice, our hospital has finally formed an effective hospital infection management model with practical characteristics and laws. Through the unremitting efforts of the whole hospital, the occurrence of hospital infection cases has been effectively controlled.
In practice, in line with the working attitude of seeking truth from facts and being steady and steady, don't rush for success, but solve the existing problems step by step. The incidence of nosocomial infection is decreasing year by year, and the quality of nosocomial infection management is improving year by year. In practice, we have also trained and trained a team of high-quality full-time hospital infection management personnel. It has made due contributions to the improvement of hospital medical quality.
In the new year, under the specific guidance of the dean in charge, with monitoring as the technology, management as the means and training as the support, according to the Evaluation Standards and Implementation Rules of General Hospitals in Shandong Province and the Quality Miles Activity Plan issued by the Ministry of Health in 20xx, aiming at the shortcomings of hospital infection management in our hospital in 20xx and the norms and requirements of infection prevention and control in superior hospitals, the department work plan for 20xx is formulated as follows.
First, do a good job in hospital infection prevention and control knowledge training and assessment.
Hospital medical staff were trained in hospital infection knowledge at different levels, a systematic training plan was formulated and various forms of training were adopted. All staff training should be combined with key training, and centralized training should be combined with decentralized training. Strive for the training rate of on-the-job personnel to reach over 90%, and the score of hospital knowledge test to reach over 85; And through publicity columns, posters and other ways to promote hospital common sense knowledge. Medical staff are familiar with the reporting and handling process of hospital infection outbreaks, and gradually establish the concept of "zero tolerance" for hospital infection, so as to comprehensively and substantially control the risk factors of hospital infection.
1. This year, the full-time staff of hospital infection management should participate in the hospital infection study upgrading class organized by the national, provincial and municipal health departments, and the annual study time should be no less than 15 class hours.
2. Newcomers, including interns, nurses and advanced students, should be trained in the basic knowledge of hospital infection for at least 3 hours.
3. Organize the medical staff of the whole hospital to seriously study the compilation of hospital infection management documents and hospital infection management rules and regulations issued by Weifang Municipal Health Bureau.
4. According to the specific conditions of different majors and different positions, professional training is carried out in stages and batches. The main training contents for clinicians are the new progress and methods of infection prevention and control, the diagnostic criteria of nosocomial infection, the knowledge of rational use of antibacterial drugs, and the basic knowledge of pathogenic microorganism monitoring. The main training contents for nursing staff are disinfection and isolation knowledge, prevention and control of hospital infection, and classified collection of medical waste.
5. Part-time staff in the whole hospital received theoretical training on basic knowledge of hospital sense, and took the exam 1-2 times.
6. Training the job requirements of cleaning staff, basic knowledge of disinfection and sterilization, cleaning procedures, personal protective measures and basic knowledge of hand hygiene and disinfection of medical staff 1-2 times.
7. New employees will make a study plan after taking up their posts, and carry out systematic training for three consecutive years according to the training plan of our college, and conduct closed-book examinations twice a year, with a passing rate of 100%. Those who fail the exam must make up the exam until they are fully mastered.
Second, do a good job in comprehensive management and key monitoring of hospital infection.
1. On the basis of comprehensive hospital infection management monitoring, we will continue to carry out targeted monitoring according to the specifications, focusing on monitoring urinary tract infection caused by indwelling catheter in ICU, ventilator-associated pneumonia, blood flow-related infection caused by angiostomy, and surgical site infection.
2. Clinicians should master the diagnostic criteria of hospital infection cases, find hospital infection cases, and report to the infection management department within 24 hours as required. All departments should establish and improve the system of diagnosis, registration, reporting, analysis and feedback of hospital infection cases.
3. Strengthen the management of cases of multi-drug resistant bacteria infection, especially in ICU of key departments. For the infected cases found, the staff of the hospital infection department should go to the scene in time to understand the situation, help find out the reasons, and take preventive measures to prevent the outbreak of hospital infection.
4. For the discharged cases, the sensory department of the hospital conducts spot checks. If any cases are found to be omitted, they will be immediately fed back to the department for correction, so as not to omit them, but to report them well. The annual hospital infection rate was controlled at about 65438 0.5% to prevent serious infection and epidemic events.
5. According to the requirements of testing frequency issued by Shandong Province, all key departments conduct environmental sanitation monitoring every month and quarter, find out the reasons in time if the monitoring results do not meet the requirements, and put forward rectification measures.
6. An annual prevalence survey was conducted in June from 5438+065438+ 10.
7. Disinfectants and disinfectants in use: The Infection Management Section conducts biological monitoring and spot checks every quarter. All key departments should make records of microbial monitoring according to the inspection items and time requirements. Disinfectants and disinfectants cannot detect pathogenic microorganisms; Sterilizers and sterilized articles cannot detect any microorganisms.
8. Monitoring of various sterilizers
Pressure steam sterilization: the supply room is responsible for physical monitoring, chemical monitoring and biological monitoring. Each tank shall be physically monitored and recorded in detail. Chemical monitoring is carried out in each package, B-D test is carried out every day before sterilization by pre-vacuum pressure steam sterilizer, and biological monitoring is carried out every week. Physical monitoring, chemical monitoring and biological monitoring should be carried out after the new installation, overhaul and relocation of the sterilizer, and it can only be used after it is qualified. Ethylene oxide gas sterilization: the supply room is responsible for physical monitoring of each pot, chemical monitoring of each package and biological monitoring of each sterilized batch. Monitoring of hydrogen peroxide plasma sterilization: the operating room is responsible for physical monitoring of each pot, chemical monitoring of each package and biological monitoring once a day.
9. Ultraviolet disinfection: the daily monitoring is carried out by the user department, and the lamp intensity monitoring is carried out by the infection management department. The radiation intensity of lamps in use shall be monitored once every six months, and its intensity shall be no less than 70uW/cm2. Before the new lamp is used, the infection management department is responsible for monitoring the radiation intensity, which should be no less than 100uW/cm2.
10. Various endoscopes: The Infection Management Section conducts spot checks on various endoscopes every quarter, and the user departments monitor them according to the standard time. After disinfection, biological monitoring shall be carried out on disinfection items such as endoscopes every quarter, and pathogenic microorganisms shall not be detected. Sterilized endoscopic biopsy forceps and sterilized articles must be monitored monthly, and no microorganisms can be detected. The endoscope room can be monitored at any time as required.
1 1. monitoring of dental instruments: the infection management department conducts spot checks every quarter, and the stomatology department conducts monitoring according to the standard requirements. Disinfectants (including sterilized items) are monitored biologically once every quarter, and disinfectants (including sterilized items) are monitored biologically once a month. Biological monitoring of rapid pressure steam sterilizer should meet the requirements of supply room.
12. blood purification system: the infection management department conducts spot checks every quarter, and the hemodialysis room monitors according to the standard requirements. Monitoring dialysis water every month, the total number of bacterial colonies must be
13. Environmental sanitation monitoring in key departments, with a qualified rate of 98.5%; All kinds of sterilizers, disinfectants, disinfection and sterilization articles and medical supplies have reached the disinfection and sterilization qualification rate of100%;
14. Hand hygiene is the most effective and economical measure to control hospital infection. In accordance with the requirements of "Medical Staff Hand Hygiene Standard", further implement the hand hygiene management system, popularize the concept of hand hygiene, vigorously publicize the importance of hand hygiene in controlling infection, actively implement hand hygiene facilities in departments, improve the compliance of medical staff, and urge head nurses to receive hand disinfectants and hand disinfectants as needed every month. The hospital sensory department suggested that the hospital should improve the hand hygiene facilities as soon as possible, regularly supervise the hand hygiene work of medical staff and carry out continuous quality improvement.
Third, strengthen the management of medical waste.
Conduct disinfection and isolation knowledge and occupational protection training for cleaning staff twice a year, so that they can master the basic disinfection and isolation knowledge of the hospital. Strengthen the monitoring of the whole process of medical waste classification, collection, packaging, transportation and disposal. Medical waste temporary storage station is managed by special personnel, carefully recorded and signed in two directions to prevent various hazards caused by poor management of medical waste.
Four, the whole process management of disposable sterile medical supplies.
(1) conduct routine supervision and regular spot checks on clinical departments every month, and take samples to the supply department for evidence collection. All certificates must be complete and qualified, and strictly review whether the supplier's "four certificates" are complete;
(2) Strict warehouse management, in addition to placing corpses as required, keep the inventory to a minimum to avoid the expiration of disposable goods;
③ Strengthen the management of used infusion sets, syringes and various catheters. Full-time cleaning personnel are responsible for the collection, transportation and storage, and strictly registered, which will be recycled by Weifang Medical Waste Disposal Center. The qualified rate of disposable sterile medical supplies is 1.000%.
Verb (abbreviation of verb) annual key work
1. Continue to strengthen the awareness of all employees on the importance of hand hygiene, do their best to improve hand washing facilities in key departments, and try their best to meet the standard requirements.
2. Investigate the types and methods of self-disinfection and sterilization instruments in all departments of the hospital, establish basic files, standardize the disinfection and sterilization methods of instruments, and sterilize surgical instruments that can be autoclaved without glutaraldehyde soaking.
3 continue to strengthen the monitoring and management of multi-drug resistant bacteria, especially in key departments and high-risk groups. Establish SOP in line with the actual situation of our hospital.
3 According to the requirements of the superior health administrative department and hospital infection control, in order to improve the quality of hospital infection management in our department, according to the relevant documents and regulations, our department has formulated the corresponding hospital infection control plan as follows:
First, improve the management system and play a systematic role.
1, in order to further strengthen hospital infection management, clarify responsibilities, implement tasks, readjust and enrich the infection monitoring team in clinical departments, and improve the three-level network management system.
2. Hospital infection management has been added to the medical quality supervision in our department, and corresponding reward and punishment measures have been formulated.
3. Make monthly plans, weekly arrangements and daily priorities, and make records for the record at the same time of implementation.
Second, hospital infection monitoring.
1, medical record monitoring: control infection rate and reduce missed reports.
2. Environmental monitoring; Regularly monitor the outpatient environment, air, clothing, hands of medical staff, disinfectants and sterile items.
3, disinfection and sterilization monitoring: daily monitoring of disinfectants used in general practice; Monitor the ultraviolet lamp in use, register the irradiation time and replace it regularly to ensure the disinfection quality. Check the disinfectants and disposable medical instruments and supplies used in our department every week.
4. Antibiotic use survey: regularly check the use of antibiotics by general practitioners to prevent abuse of antibiotics.
Three, outpatient service strictly implement the triage system.
Four, strict implementation of medical waste classification, collection, transportation and other systems to prevent leakage.
Five, multi-channel training, improve the awareness of hospital medical staff.
Six, the occurrence of nosocomial infection report in time.
Seven, take various forms of infection knowledge training: organically combine centralized training with morning meeting department training to increase medical staff's knowledge of hospital infection and improve hospital awareness.
Eight, will hand hygiene and occupational exposure protection issues into the focus of infection control in our hospital, strengthen hand hygiene and occupational exposure protection.