Combined with the higher health administrative departments and our hospital infection control requirements, in order to improve the quality of our hospital infection management as the goal, my department according to the "Hospital Infection Management Code", "Disinfection Technical Specification" and "Infectious Disease Prevention and Control Act" and other relevant documents and regulations, to develop the corresponding hospital infection control program is as follows:
First, improve the management system, play the role of the system
1. To further strengthen the management of hospital infection, clear responsibilities, the implementation of the task, re-adjustment of the clinical departments to enrich the infection monitoring group, improve the three-tier network management system.
An outpatient nosocomial infection control team
Team leader
Deputy team leader:
Doctors nosocomial infection control members:
Nurses nosocomial infection control members:
2. Hospital infection management part of the Department of medical care in the quality of supervision, the development of the corresponding rewards and punishments.
3. Develop a monthly plan, weekly arrangements, the day focus on the implementation of the same time to do a good job of record-keeping.
Second, the hospital infection monitoring
1, medical records monitoring: control the infection rate and reduce underreporting
2, environmental monitoring; outpatient clinic environment, air, clothing, medical staff hand, disinfectant, sterile goods regular monitoring.
3, disinfection and sterilization monitoring: daily monitoring of disinfectant in use in the Department; monitoring of ultraviolet lamps in use, and the implementation of irradiation hours registration, regular replacement to ensure the quality of disinfection. Weekly self-inspection of disinfectants and disposable medical devices and items used in our department.
4, antibiotic use survey
Regularly check the use of antibiotics in the whole department to prevent the abuse of antibiotics.
3. Outpatient clinic strictly implement the triage system.
Fourth, the strict implementation of medical waste classification, collection, transportation and other systems to eliminate leakage incidents.
7, multi-channel training to improve the awareness of medical staff hospital infection.
viii, the occurrence of nosocomial infection timely completion of the report.
Nine, to take a variety of forms of infection knowledge training: centralized training and morning meeting departmental training organic combination, to increase the knowledge of medical staff of hospital infections, improve the awareness of hospital infection.
X. Hand hygiene and occupational exposure protection issues into the Department of hospital infection control work in the focus, to strengthen hand hygiene and occupational exposure protection.
Part II
In the new year, the hospital infection management will adhere to the policy of prevention, in order to strengthen the management of hospital infections, improve the quality of health care, to protect the safety of patients the goal of hospital infection management work seriously, specially formulated for the year 20xx hospital infection work plan is as follows:
A, strengthen the Education and training
1, the department organized a monthly hospital infection-related knowledge training, and make a good record.
2, the hospital sensory section of the hospital infection knowledge of the organization of two lectures throughout the year, taking a variety of forms of training for the whole staff, the examination paper to improve the awareness of medical staff to prevent hospital infection.
3, the implementation of pre-service training for new employees.
4, the hygienist medical waste collection and occupational protection knowledge training.
5, hospital sensory staff to participate in provincial and municipal hospital sensory continuing education training courses, in order to understand the province and the country's hospital infection management work development of new trends, new dynamics, to improve the level of infection management in our hospitals.
Second, the implementation of disinfection and isolation system, strengthen the effect of disinfection and sterilization monitoring and evaluation
1, the disinfectant used in various departments according to the performance of the timely replacement, timely disinfection and sterilization of instruments according to regulations, the qualification rate of 100%. Various catheters in use are sterilized and replaced according to regulations.
2, to strengthen the management of hand hygiene of medical staff, from time to time under the department to check the compliance of medical staff hand washing.
Third, to strengthen the monitoring of hospital infection, the implementation of hospital outbreak early warning report
1, strict "hospital surgical site management specification" implementation, monthly surgical incision infection monitoring.
2, give full play to the role of clinical surveillance management team, timely detection of hospital-acquired infections, the implementation of 24-hour reporting system.
3, clinical cases of hospital infection aggregation (3 cases of the same type) the implementation of hospital infection outbreak early warning report, analyze and investigate the source of infection, take effective measures to control the transmission pathway to prevent the occurrence of malignant hospital infection cases.
4, do a good job of occupational protection of medical personnel, each department will be each time the occurrence of occupational exposure and injury to the personnel reported to the Hospital Infectious Disease Branch, Hospital Infectious Disease Branch to do a good job of registering, protecting susceptible populations, and effective control of hospital-acquired infections.
Fourth, strict medical waste classification, collection, remote delivery, storage, transportation management, to eliminate leakage
1, medical waste according to the requirements of the classification placed, sealed, bag with a logo, out of the Department of registration, specialists to recover with a signature, sent to the medical waste storage place centrally placed.
2, medical waste transfer orders filled out by specialized staff, and save the stub for inspection.
Part III
A hospital infection control
1, monthly to each department to monitor the occurrence of hospital inpatient hospital infection, urging clinicians to timely report cases of hospital infection to prevent outbreaks of hospital infections or epidemics.
2, monthly operating room, delivery room, hemodialysis room and other key departments of the air, object surfaces, staff hand, disinfectant, disinfectant, disinfectant and sterilized items, such as disinfection and sterilization effect and environmental hygiene monitoring once. Found unqualified place, strict rectification, until the monitoring results are qualified.
3, quarterly clinical departments, key departments to disinfection and isolation quality inspection, feedback on the results of the inspection, and put forward improvement measures.
4, according to this year's hospital infection monitoring and management requirements, with the national hospital infection monitoring and management training base, to carry out a cross-sectional survey of hospital infections.
Second, the application of antimicrobial drugs:
1, in accordance with the relevant provisions of the implementation of antimicrobial drugs graded management, regular investigation of the use of antimicrobial drugs in hospitalized patients.
2, to assist the Department of Laboratory Medicine regularly announced the hospital's top five infectious bacterial spectrum and its drug-resistant bacteria, for clinicians to provide a basis for the rational use of antimicrobial drugs.
Third, the management of infectious diseases:
1, daily collection of infectious disease report card, death medical diagnosis certificate, resident malignant tumor report card of each department of the hospital, and do a good job in the hospital outbreak report and death, tumor case report.
2, every day on the collection of infectious disease report card audit, to ensure that its content is complete and true.
3, after receiving the epidemic report card and death case report, in accordance with the specified time limit, through the national infectious disease epidemic surveillance information system for network direct reporting.
4, at the end of each month, access to the hospital's outpatient logbook for the month, in and out of the hospital registration, discharge medical records, radiology examination results and test results of positive results of the registry, found that the omission of timely replacement.
5, the monthly registration of deaths with the medical department approved, found that the omission of timely replacement.
6, conscientiously do a good job of the higher health administrative departments of the hospital's epidemic management, report the inspection work, with the disease prevention and control departments to do a good job of epidemic investigation.
Fourth, the supervision and management of medical waste
1, once a month to the hospital clinical support center inspection, supervise the implementation of medical waste classification, collection, delivery and other systems to avoid the loss of medical waste.
2, a monthly review of the medical waste handover register, found that the omission of timely fill.
V. Hand hygiene and occupational exposure protection
1, hand hygiene and disinfection included in the department of quality inspection projects, quarterly sampling of medical staff to carry out hand hygiene and disinfection technology assessment.
2, strengthen the knowledge of occupational exposure protection publicity and education to reduce the risk of occupational exposure.
3, after the occurrence of occupational exposure of medical personnel, strictly in accordance with the relevant provisions of the proper handling.
Sixth, hospital sensory knowledge training
1, this year, in collaboration with the medical education department to organize the new personnel for hospital sensory, infectious disease knowledge of pre-service training.
2, the level of the hospital's medical staff to carry out the knowledge of hospital infection training twice, to improve the level of knowledge of medical staff hospital infection.
Part IV
I. Organization, management and system construction
(a) to further strengthen the construction of the hospital infection management system: in accordance with the requirements of the evaluation of the three hospitals, combined with the actuality of the hospital, the proposed revision of the system of prevention and control of hospital infections and measures, focusing on the implementation of the new norms introduced by the state in the clinical approach, departmental hospital infection The main focus is on the implementation of the new norms issued by the state in the clinical practice, the departmental hospital-acquired disease performance assessment methods and rewards and punishments, hospital-acquired disease risk reporting and prevention and control methods, and the quality management of the logistics department cleaning.
(2) Reduce the burden and increase efficiency, to avoid the formality, false hospital-acquired forms and records. The proposed revision of clinically relevant hospital-acquired infection forms, as standardized, concise and effective as possible.
(C) adhere to the hospital infection management committee meeting at least twice a year, the meeting to solve the problem-oriented, clear responsibilities to ensure that the work is properly implemented, in place.
(D) to strengthen the hospital infection management and hospital infection three-level network management, give full play to the functions of the hospital infection office, supervise departmental managers to establish the "hospital infection prevention and control of the first person responsible for" awareness and "hospital infection high-risk" prevention and control awareness. The departmental performance appraisal program and related quality standards will be revised. At the same time, the managers of the key departments of hospital-acquired infections strengthen the awareness of the first person responsible for hospital-acquired infections prevention and control and the awareness of risk prevention and control of high-risk links, so as to prevent hospital-acquired infections from breaking out. At the same time to strengthen the hospital sensors and managers of hospital infection management knowledge training
(E) combined with the actual hospital, the proposed revision of the disinfection management team responsibilities and disinfection isolation quality standards, not a formality, to give full play to the functions of the disinfection management team.
(6) to strengthen multidisciplinary, multidepartmental communication, collaboration, and strive to establish multidepartmental cooperation, linkage mechanism; standardize the work of the department director, head nurse, hospital sensory doctors and nurses composed of hospital sensory management team, through the hospital sensory QQ group close communication, to solve the clinical hospital sensory prevention and control of the work of the doubts and difficulties.
(7) to strengthen the professionalism of the hospital infection office staff, set up the supervision of clinical, clinical service concept; efforts to cultivate the medical staff prudent and persistent spirit, to develop the habit of consciously abide by the norms of hospital infection, in order to effectively improve the basic level of sensory control. The Hospital Infectious Disease Office insists on a weekly section meeting, a quarterly preparation meeting before the quality control supervision, and a summary and analysis meeting after the quality control inspection.
Second, education and training
(a) full-time staff to participate in education and training
1, hospital sensory staff to participate in various types of training courses to enhance hospital sensory management skills.
2, to participate in the annual meeting or provincial academic exchanges to learn new developments.
3, participate in other meetings to exchange learning and experience.
4, the hospital sensory office to adhere to the weekly routine 1 hospital sensory learning and hospital sensory case discussion.
(2) targeted to the hospital infection of key departments, key departments, key populations of managers and hospital sensors hospital infection risk prevention and control training, to eliminate the high risk of hospital infection hidden danger, to eliminate hospital infection outbreaks. Doctors focus on training "hospital infection diagnosis", in order to achieve accurate reporting of hospital infection cases and reduce underreporting, multi-drug-resistant bacteria prevention and control; surgical medical staff focus on training "surgical site infection prevention and control", drug exchange and aseptic operation.
(C) held a provincial continuing education training, entitled "surgical site infection prevention and control", focusing on improving the surgical site infection prevention and control awareness and behavior of our surgical staff, to enhance the visibility of our hospital, while contributing to the city's hospital infection prevention and control work.
(D) hospital-wide knowledge training and assessment of various groups of people hospital infection
Strengthen the departmental management, sensory control doctors, sensory control nurses and other hospital infection knowledge and skills training, in order to play a supervisory and leading role in the department. For the hospital's poor compliance with hand hygiene, focus on strengthening hand hygiene training, while strict assessment, to develop hand hygiene habits.
(E) hospital sensory related knowledge courseware production and release
Hospital Sentinel Office after each training, for the department to provide an electronic version of the courseware, and in the hospital sentinel group release, to facilitate the organization of the department to learn and reference.
Third, hospital monitoring and quality control
Seriously do a good job of monitoring, hospital sentinel office quarterly I produced "hospital sentinel newsletter", so that the clinical timely information.
(a) comprehensive monitoring of hospital-acquired infections
1, hospital-acquired infections screening, confirmation and feedback
Strengthening of reported and suspected hospital-acquired infections screening efforts to reduce hospital-acquired infections underreporting of cases, and timely and underreporting of misreporting of feedback and communication with the doctor, and, if necessary, with the head of the Department of communication. To run the blue dragonfly hospital infection real-time monitoring system (new version), to increase the early warning function, improve information and data automation and work efficiency.
2, to improve the level of diagnosis of hospital-acquired infections, reduce underreporting
For the current part of the doctors hospital infection diagnostic standards are not clear, hospital infection information collection omission or disease record is too lagging, hospital-acquired infections underreporting cases, to carry out related work:
(1) to strengthen the clinician's diagnostic standards of hospital-acquired infections training, requiring bedside doctors to accurately, (1)Strengthen the training of clinicians in the diagnostic criteria of hospital infection, and require bedside doctors to accurately and timely record infection-related illnesses, and timely report cases of hospital infection. The company has been working on this project for over a decade and is looking forward to the next year's provincial education program, which will be held outside the hospital.
(2) to strengthen the hospital infection office personnel hospital infection diagnostic knowledge learning, improve the level of diagnosis, and more with clinicians (especially infectious diseases, ICU, respiratory doctors) to exchange learning and discussion.
(3) Encourage the department to really carry out the discussion of difficult cases of hospital infection, take the initiative to invite the hospital infection office, clinicians (especially infectious diseases, ICU, respiratory doctors) to participate in the performance of each time depending on the effect of encouragement to give additional points 2-6 points.
3, hospital infection monitoring indicators and quality control system
Refinement of hospital infection monitoring indicators and quality control indicators, so that our hospital infection management quality indicators are up to the national health care commission hospital infection quality indicator requirements.
(1) hospital-acquired infection monitoring data and monitoring summary, hospital-acquired infection newsletters and other regular feedback to the clinical, published on the hospital website or hospital-acquired infection control group, necessity real-time, synchronized feedback, as far as possible, timely supervision and prevention and control.
(2) require departments to extract relevant data information involving their own departments in a timely manner, the hospital sensory team for data analysis and data use, continuous quality improvement.
4, to find, analyze the high risk of hospital outbreaks or hospital-acquired key departments to carry out hospital-acquired outbreaks of disposable drills and organize the relevant personnel to participate in the observation. Ensure that no hospital outbreaks occur throughout the year.
(B) Targeted monitoring
Strengthen the hospital sensory key departments, key departments and key links of hospital sensory management, through the hospital sensory risk assessment, timely detection of risk factors that may lead to the occurrence of hospital sensory events and effective prevention and control.
1, to strengthen the hospital infection management of the key departments, key departments and key links of hospital infection.
(1) Encourage departments to take the initiative to report "departmental risk assessment report and analysis to solve the problem" single, found that the risk point timely report hospital infection office, hospital infection office will be with the department *** with the analysis and solution. According to the norms of the hospital, the risk level and the effect of the solution, the Hospital Infectious Disease Office to supervise and discuss, depending on the risk level and the effect of the solution, each time to reward performance points 2-6 points.
(2) the hospital sensory office supervision found in the hospital sensory high-risk links, the department should make timely efforts to solve the improvement, such as the effect is significant, the progress is obvious, to give the progress award additional points, each time to reward the performance points 2-6 points.
2, strengthen the ICU, PICU, neonatal and other hospital infection prevention and control supervision.
3, continue to carry out surgical risk classification (NNIS classification) infection monitoring.
4, the development of adjustments to the surgical site targeted monitoring program:
Some surgeons need to update the concept of nosocomial infection prevention and control and knowledge, especially in surgical operations and dressing change operations in the concept of asepsis, instrument handling, hand hygiene and other aspects of the need to improve and enhance. The next step will be to focus on the training and assessment of surgical staff.
Continuing the monitoring of surgical site infections in craniotomy (cerebrovascular disease and brain tumor resection) is proposed to be discontinued due to the lack of significance of the monitoring of surgical site infections in obstetrics and the adjustment of the targeted monitoring program.
5, to carry out hospital-wide "three-tube" monitoring, especially ICU, PICU, CCU "three-tube" infection monitoring, to be added in the new system of three-tube monitoring data extraction, to avoid the inaccuracy of the manual reporting of data in the department, and at the same time to analyze and use the data to guide the clinical hospital infection prevention. The data will be used to guide the clinical hospital infection prevention and control work.
(C) hygiene monitoring
1, quarterly departmental air self-sampling: the key departments of hospital sensory treatment room, sterile goods storage room, mother and baby with the room, special requirements of the ward and other key air monitoring, requirements and guide the departmental staff to be cautious and rigorous, to avoid irregularities in the operation led to sampling meaningless and worthless.
2, monthly sterilization effect monitoring: such as operating rooms, endoscopy centers using endoscopes, as well as dialysis water and other hygienic sampling.
3, quarterly hygienic sampling: medical staff hands, surfaces, disinfection of endoscopes, disinfectant solutions in use.
4, according to the specification requirements, to be added according to the specification of the six-month sampling of the washroom, including personnel hands, surfaces and so on.
(D) presenting rate survey
In accordance with the requirements of the Provincial Center for Quality Control of Hospital Infections, continue to carry out the presenting rate survey in 2019, and carry out horizontal and vertical comparative analysis.
Fourth, bacterial drug resistance monitoring and management of multi-drug resistant bacteria
(a) continue to carry out hospital-wide monitoring of drug-resistant bacteria, and regularly publish data on the occurrence of hospital infection to the whole hospital.
(B) to strengthen the management of multi-drug resistant bacteria hospital infection
plans to hold two multi-drug resistant bacteria multi-departmental joint meeting, reflecting multi-departmental *** with the participation of the management of the cooperation mechanism, give full play to the function, increase the implementation of preventive and control measures to supervise the implementation of the strength of the regular analysis of multi-drug resistant bacteria hospital infection data, and regularly announced to the whole hospital in the various departments of multi-drug resistant bacteria hospital infection related situation.
Fifth, hand hygiene management
Our hospital medical staff hand hygiene compliance is too poor, the correct rate is low, and the national three hospitals and three A review requirements gap is large, medical staff hand hygiene concepts and behaviors need to focus on improving. As a next step, it is suggested that the hospital should consider placing a hand hygiene information system in the key departments of hospital sensory to supervise and count the implementation of hand hygiene. According to the "three general hospital accreditation standards implementation rules" and "hand hygiene norms", to strengthen the hospital's various groups of people hand hygiene training and assessment, increase hand hygiene management efforts, training, rewards and punishment.
(a) Surgical hand disinfection monitoring and management
Hospital Infectious Disease Office, Medical Department, Nursing Department, Quality Control Office, etc. from time to time every week through the hospital infection of the real-time monitoring system *** with the view of the operating room and the hospital infection of the focus of the monitoring department of the implementation of surgical handwashing, and, if necessary, to ask the leadership of the hospital to supervise. If the surgical hand washing is not standardized immediately communicate with the person in charge of the department, require immediate rectification and incorporate into the assessment.
(B) the hospital hand hygiene compliance supervision
1, departmental self-examination of the implementation of hand hygiene, the requirements of real, and quarterly analysis of hand hygiene trends, serious implementation, continuous improvement.
2, hand hygiene special investigation team quarterly compliance survey, feedback to the hospital survey data, analyze the reasons, and require improvement to improve hand hygiene compliance and correct rate.
3, ATP fluorescence monitoring of clean hands, bacterial monitoring of sterilized hands.
4, to be in the world hand hygiene day (May 5) to carry out hospital sensory knowledge contest and hand hygiene to implement the evaluation, publicity activities, hand hygiene awareness in the hospital again to strengthen.
Six, hospital infection quality control inspection
(a) to revise the clinical quality control checklist, and strive to standardize, concise, practical.
(b) quality control inspection: hospital sensory staff from time to time each month on the clinical and medical departments to carry out hospital sensory quality control random inspection, to achieve full coverage of the hospital every quarter.
(C) the inspection process found problems, real-time feedback and require immediate rectification. If necessary, require the department to submit a written rectification, the hospital sensory office again to supervise the improvement of the situation.
(4) hospital sensory office monthly summary analysis of the quality control situation, the score is included in the department performance appraisal, at the same time in the hospital sensory group publicity, the annual summary of the score according to the rankings of the public, the top ten alternative hospital sensory advanced group; after the five departments, hospitals, the other first, the assessment of excellence a vote of veto. After ten of the department personnel, hospital sensory advanced individual one vote to veto.
(E) focus on strengthening the management of disinfection supply center. Disinfection supply center is the heart of the hospital, is an important department of hospital infection prevention and control, the supply room management within the operating room has been difficult and weak points. Due to management and equipment factors, elective surgical instruments should be standardized to the lower Jiangbei elimination supply center unified processing, otherwise the safety hazard, the requirements of instrument processing to ensure that its quality and transit intact, timely.
(F) focus on strengthening the logistics service support system and cleaning and cleaning quality management. Poor logistics management function and workers poor service consciousness, elimination of supply center equipment transfer can not meet the clinical emergency needs, washing room workers management and quality standards can not meet the hospital infection norms and clinical needs. The operating room, supply room, ICU, dialysis room and other key departments need to be strengthened. Workers cleaning awareness and behavior is poor, no sense of responsibility, cleaning tools need to be improved and added, should strengthen the hospital cleaning quality management, improve the assessment methods and increase management efforts.
VII, other work
(a) the strict implementation of the hospital's decisions and regulations, to complete the Commission, the quality control center, the hospital's directive work and temporary tasks.
(b) focus on coordination with the departments, with the functional departments, with the sister hospitals and the higher hospitals related to the relationship between the departments, to maintain the image and reputation of the hospital, for the development of the hospital's hospital management work to lay a good foundation of resources.
(C) of the hospital's new construction, remodeling, expansion projects to audit, good hospital security.
(d) Participate in the hospital consultation and examination, and put forward recommendations for the prevention and control of hospital infection.
(E) audit and management of sterilized medicines and disposable medical devices.
(F) to guide the lower level of medical institutions hospital infection work, and play a good role in leading the regional medical center in the south of Sichuan.
(7) hospital infection information system can not meet the requirements of hospital infection prevention and control, hospital infection related data can not be extracted or does not match, part of the data still need to be reported by the department and manual statistics, there is a gap between the hospital infection information system from many tertiary hospitals, need to be updated and improved, to be supplemented with relevant early warning functions.