How time flies! We will continue to write new poems and start a new journey. Making a good plan is a way to improve your work efficiency! So do you really know how to make a plan? The following is the annual work plan of the department for you. Welcome to reading. I hope you will like it.
Annual work plan of hospital infection in departments 1 1. Improve the department infection management responsibility system, standardize and implement various rules and regulations. In accordance with the Measures for the Administration of Hospital Infection and relevant laws and regulations, the responsibilities of the department infection control management team are clearly defined, and the responsibilities are earnestly performed, so as to supervise the staff of the department to implement the system and norms in the diagnosis and treatment operation, effectively prevent and control the occurrence of hospital infection and ensure medical safety.
1. The department infection control team should improve the department infection management system under the leadership of the team leader, which is an important prerequisite for preventing hospital infection.
2. The department infection control team should establish a meeting system to coordinate infection management related issues once every quarter. Have a meeting at any time if you have any questions, and give full play to the role of the infection control team.
3. The department infection control team should monitor all susceptible links in time, take effective measures to reduce the incidence of nosocomial infection in our department, supervise and inspect the rational use of antibacterial drugs by our doctors, strictly implement aseptic technical operation, and take various disinfection and isolation measures to ensure medical safety.
Second, strict monitoring and supervision.
1, hospital infection monitoring
According to the standards of hospital infection, effective infection monitoring requires clinicians to master the diagnostic standards, improve the awareness of hospital infection monitoring of medical staff, summarize and analyze the monitoring data every month, report them to the hospital infection management department, and make serious improvements according to the feedback information from the infection management department.
2, disinfection and sterilization
Monitor the disinfection and sterilization every month, and regularly and irregularly monitor the disinfectant used by the department, the hands of medical staff, the surface of objects, the air in the treatment room and the air in the monitoring room.
Random sampling monitoring.
3, cooperate with the hospital to carry out hospital infection and drug resistance monitoring.
Third, strengthen the management of nosocomial infection in key departments.
1, operating room, ① All staff members should dress neatly, wear isolation gown, and wear masks to change shoes, so as to reduce the flow of people and limit the number of visitors. (2) All personnel shall strictly carry out aseptic operation. ③ Special infection operation can only be performed in the infection operating room, and isolation and terminal treatment should be carried out according to the principle after operation.
2, strengthen the management of emergency patients, patients with low immunity and children or patients with special infection should be placed in a single room or classified according to the principle of isolation.
Fourth, strengthen the management of patients with indwelling catheter in our department, such as patients with tracheal intubation and patients with indwelling catheter.
Five, strictly implement the "hand hygiene standard" assessment system and the "medical staff hand hygiene management" system, equipped with effective and convenient hand hygiene equipment and facilities. Strengthen the publicity, education and training of hand hygiene, enhance the awareness of preventing infection, master the knowledge of hand hygiene, and ensure the effect of hand washing and hand disinfection.
VI. Protection of medical personnel
1. According to the Law on the Prevention and Control of Occupational Diseases, combined with the characteristics of occupational exposure in our department, we require hospitals to provide targeted and necessary protective articles for our department to ensure the occupational safety of medical staff.
2. Strengthen the training of occupational exposure knowledge, focusing on the self-protection of medical staff, followed by the principles and processes of dealing with occupational exposure.
Seven, to carry out hospital infection knowledge training, monthly organization department personnel training, improve the awareness of hospital infection.
Eight, antimicrobial drug management
1, strictly control the indications.
2. Reasonable treatment.
Supplementary terms:
According to the characteristics of our department, the prevention and control measures of hospital infection are as follows:
1, abide by hospital management rules and regulations, and strictly implement standard preventive measures;
2. In case of public emergencies, the department infection management quality control team is responsible for taking disinfection and isolation measures of undergraduate course room as required, and organizing the implementation;
3, supervise the department medical staff and interns, advanced students strictly implement aseptic operation procedures and disinfection and isolation system;
4. Implement standard prevention for all patients and isolate patients with special infection;
5. Every shift should take care of it every morning and evening, and change the contaminated clothes and sheets in time to avoid the bed unit being dirty and stained with blood. Towels for sweeping the bed and cleaning the bedside table should be disinfected with one towel for each bed. Soak in 1000mg/L chlorine-containing disinfectant after use, and clean it for later use.
6. The treatment room is responsible for turning on the ultraviolet light at noon 10-5 every day 1 hour, and keeping records of disinfection diseases at any time for special infections. Wipe the ultraviolet lamp with 75% alcohol twice a week (Tuesday and Friday), monitor and record the irradiation intensity every six months, and monitor it again, totaling 1000 hours.
7. The emergency class should clean and disinfect all kinds of rescue instruments and monitors in the department every day. After use, the surface should be cleaned and disinfected in time, and all kinds of pipes and digestion bottles should be disinfected in a standardized way.
8.9-4 Responsible for cleaning the dressing room disposal room every day, including cleaning the surfaces and floors of articles and cleaning the soaking bucket of toilet bowl.
9, to monitor the hospital infection cases and infection links, and take effective measures to reduce the incidence of hospital infection, found the epidemic trend of infection management department, and assist in the investigation.
10, strictly implement the hand hygiene system before and after each operation (the first two and the last three), wear gloves before touching blood and body fluids, and wash your hands immediately after taking off gloves to improve the compliance and accuracy of your hands;
1 1, the staff of each class are responsible for the hygiene and medical treatment of each room according to the contents of the department.
Classification and management of garbage. Supervise cleaning staff and personnel on duty to find and rectify in time. Monitor the air culture, object surface, hands of medical staff and disinfectant in each room of the first aid area every quarter and make analysis records;
/Kloc-Class 0/2 and Class 8-4 are responsible for cleaning the treatment room, including the used thermometers and tourniquets, and sending them away in time to dry for later use, so that one person can use them and disinfect them;
13, strictly implement the medical waste management system and do a good job in the training and assessment of hospital infection management and self-protection knowledge of department nurses.
14, mop management in ward corridor, toilet, office, treatment room and disposal room, clearly marked, dedicated to the area, hung to dry and disinfected regularly.
2. In the new year, hospital infection management will adhere to the policy of putting prevention first and strengthen hospital infection management.
In order to improve the quality of medical care and ensure the safety of patients, we should do a good job in hospital infection management. The hospital infection work of 202 1 needs to be further developed on the basis of 2020. Under the guidance of the Hospital Sensibility Office, the Medical Department and the Nursing Department, under the supervision of * * * *, formulated the 202 1 hospital infection related work plan according to the actual situation of the department. Details are as follows:
First, hospital infection learning
1, according to the requirements and regulations of the hospital infection office, mainly study the 100 questions that should be known about hospital infection, learn theoretical knowledge once every quarter, and make records to strengthen employees' reserve ability of hospital infection knowledge.
2. Implement pre-job training on hospital infection for new employees.
3. 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.
Two, to further standardize the hospital infection work content.
1. Strengthen the supervision and use of cleaning tools according to hospital regulations;
2. Strengthen doctors' compliance with the principles of clinical use of antibacterial drugs issued by the National Health and Family Planning Commission.
Clinical rational use;
3. Supervise and strengthen the compliance of employees with quick hand disinfection and running water hand washing after operation;
4. Strengthen the classified treatment and recycling of medical wastes; And save the stub for future reference.
5. Strengthen the use and monitoring of disinfectants; Change the alcohol in the immersion thermometer every day;
6. According to the requirements of the hospital, further standardize the use of one person and one belt;
7. Strengthen bacterial culture, hand culture, surface culture and ultraviolet lamp in hospital infection.
Monitoring and maintenance work;
8. Strengthen the management of consumables and use them in order of validity to avoid waste.
Phenomenon occurs;
9. Strengthen the disinfection of cotton balls on ECG surface, leads of ECG machine and cuff of sphygmomanometer;
10, strengthen the disinfection work in the prison area to avoid the occurrence of infectious diseases in the prison.
1 1. Do a good job in the inspection of the management and reporting of epidemic situation in the supervision places by the health administrative departments at higher levels.
Cooperate with disease prevention and control departments to do a good job in epidemic investigation.
Three, occupational exposure protection work
1, strengthen the propaganda of occupational exposure protection knowledge and reduce the risk of occupational exposure.
2. After the occupational exposure of medical staff occurs, it should be properly handled in strict accordance with relevant regulations.
Four, monthly group meeting and quality control
1. Every month, team members hold a meeting to discuss the focus of this month's work and the problems existing in the last month to deal with these problems.
2. According to the regulations of the hospital management office, quality control is carried out at the end of each month, and the existing problems are truthfully responded and recorded, and the corrective measures are written.
Verb (abbreviation of verb) analyzes and corrects the existing problems in 2020.
Analyze and judge the problems of last year in detail to avoid the recurrence of the same problems and reduce the incidence of hospital infection in by going up one flight of stairs in the new year.
Combined with the requirements of the higher health administrative department and the hospital infection control work, the annual work plan for hospital infection in three departments, in order to improve the quality of hospital infection management in our department, our department has formulated the corresponding hospital infection control plan according to the relevant documents and regulations such as Hospital Infection Management Standard, Disinfection Technical Standard and Infectious Disease Prevention Law, as follows:
First, improve the management system and give full play to the role of the system.
1. In order to further strengthen hospital infection management, clarify responsibilities, implement tasks, adjust and enrich the infection monitoring team in clinical departments, and improve the three-level network management system.
Outpatient hospital infection control team
Group leader
Deputy team leader:
Hospital infection control members are doctors:
Nurse nosocomial infection control members:
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 while implementing them.
Second, the 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. Investigation on the use of antibiotics
Regularly check the use of antibiotics by general practitioners to prevent the 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.
Seven, multi-channel training, improve the hospital awareness of medical staff.
Eight, the occurrence of nosocomial infection report in time.
Nine, 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.
X. Incorporate hand hygiene and occupational exposure protection into the focus of infection control in our hospital, and strengthen hand hygiene and occupational exposure protection.
4. In the new year, hospital infection management will adhere to the policy of putting prevention first, with the goal of strengthening hospital infection management, improving medical quality and ensuring patient safety, and earnestly do all the work of hospital infection management. Therefore, the work plan for nosocomial infection in 20xx years is formulated as follows:
First, strengthen education and training.
1, the department organizes hospital infection related knowledge training once a month, and makes records.
2. The hospital infection department organizes lectures on hospital infection knowledge twice a year, and carries out various forms of staff training and paper distribution to improve the awareness of hospital infection prevention of medical staff.
3. Implement pre-job training for new employees.
4. Conduct medical waste collection and occupational protection knowledge training for health workers.
5. Full-time staff of hospital infection participated in continuing education training courses on hospital infection held at provincial and municipal levels, and learned about the new trends and trends in the development of hospital infection management in the whole province and the whole country, so as to improve the level of hospital infection management.
Two, the implementation of disinfection and isolation system, strengthen the monitoring and evaluation of disinfection and sterilization effect.
1. Disinfectants used by various departments should be replaced on time according to performance, and instruments should be disinfected and sterilized in time according to regulations. The qualified rate is 100%. All kinds of catheters in use should be disinfected and replaced according to regulations.
2. Strengthen the management of hand hygiene of medical staff, and check the compliance of hand washing of medical staff from time to time.
Third, strengthen the monitoring of hospital infection and implement the early warning report of hospital epidemic situation.
1, strictly implement the "Hospital Operation Site Management Specification", and monitor the surgical incision infection every month.
2, give full play to the role of clinical monitoring management team, timely detection of hospital infection cases, a 24-hour reporting system.
3, clinical cluster hospital infection cases (3 cases of the same kind) the implementation of hospital infection outbreak warning report, analysis and investigation of the source of infection, take effective measures to control the route of transmission, put an end to the occurrence of malignant hospital infection cases.
4, to do a good job of occupational protection of medical personnel, each department will report each personnel's occupational exposure and injury to the hospital infection department, and the hospital infection department will register to protect susceptible people and effectively control hospital infection.
Four, strict medical waste classification, collection, transportation, storage and transportation management, to prevent leakage.
1. Medical wastes should be classified and placed according to requirements, sealed, labeled in packaging bags, registered out of the department, recycled by special personnel and signed, and sent to the temporary storage place of medical wastes for centralized storage.
2, medical waste transfer form by full-time personnel to fill in, and save the stub for future reference.
Annual Work Plan for Hospital Infection in Departments 5 In order to improve the quality of hospital infection management in our hospital, further improve the management of hospital infection and infectious diseases, and ensure the safety of medical care, a 20xx work plan is formulated:
First, hospital infection control
1. Go to each department every month to monitor the occurrence of hospital infection among inpatients, and urge clinicians to report hospital infection cases in time to prevent the outbreak or prevalence of hospital infection.
2, every month to the operating room, delivery room, hemodialysis room and other key departments of air, surface, staff hands, disinfectants, disinfectants, disinfection and sterilization items such as disinfection effect and environmental hygiene monitoring once. Found unqualified, strict rectification, until the monitoring results are qualified.
3. Every quarter to clinical departments and key departments for a disinfection and isolation quality inspection, feedback the inspection results, put forward improvement measures.
4, according to the requirements of hospital infection monitoring and management this year, with the national hospital infection monitoring and management training base, to carry out cross-sectional investigation of hospital infection.
Second, the application of antibacterial drugs:
1, according to the relevant provisions of the implementation of hierarchical management of antibacterial drugs, regularly investigate the use of antibacterial drugs in inpatients.
2. Assist the clinical laboratory to regularly publish the spectrum of the top five infected bacteria and their drug-resistant bacteria in the hospital, so as to provide a basis for clinicians to use antibiotics reasonably.
Third, infectious disease management:
1, collect infectious disease report cards, death medical diagnosis certificates and residents' malignant tumor report cards from various departments of the hospital every day, and do a good job in reporting the epidemic situation, death and tumor cases in the hospital.
2. Check the collected infectious disease report cards every day to ensure that their contents are complete and true.
3, after receiving the epidemic report card and death report, according to the prescribed time limit, through the national infectious disease epidemic monitoring information system for network direct reporting.
4. At the end of each month, consult the outpatient log of the whole hospital this month, the registration of admission and discharge, the examination results of radiology department and the positive results register of clinical laboratory, and make up the report in time if there are any omissions.
5. Register the death cases with the medical department every month, and report the missing cases in time.
6, conscientiously do a good job in the hospital epidemic management, report and inspection work of the superior health administrative department, and cooperate with the disease prevention and control department to do a good job in epidemic investigation.
Four. Supervision and management of medical waste
1, once a month to the hospital clinical support center for inspection, supervise the implementation of medical waste classification, collection, transportation and other systems, to avoid the loss of medical waste.
2. Check the medical waste transfer register once a month, and fill in any missing items in time.
Five, hand hygiene and occupational exposure protection
1, hand hygiene disinfection will be included in the quality inspection items of the department, and hand hygiene disinfection technology inspection will be conducted for medical staff once every quarter.
2, strengthen the publicity and education of occupational exposure protection knowledge, reduce the risk of occupational exposure.
3. After occupational exposure of medical personnel, they should be properly handled in strict accordance with relevant regulations.
Six, hospital awareness knowledge training
1. This year, we cooperated with new medical and educational personnel and conducted pre-job training on hospital awareness and infectious disease knowledge.
2. Train the medical staff in the hospital twice in different levels to improve their hospital awareness knowledge.
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, ensure the occupational safety of medical staff, and gradually make the management of nosocomial infection more 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 specifications of hospital disinfection and isolation, 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.
Monitoring of lamp irradiation intensity: once every quarter, test with ultraviolet intensity irradiation indicator card.
Eight, regularly carry out hospital environmental health monitoring-medical staff's hands, 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.
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