The pace of time will not stop, we are running non-stop into the new year, the annual summary of the work of the infectious disease doctors need to start up! No good person thrives without an overall review of the year's work. How do you write a great one for an infectious disease physician? In order to meet your needs, specially I have "Hospital Infection Management 2022 Annual Summary Report", I hope it will help you in your work and life.
Hospital infection management 2022 annual work summary report (Part 1)xx hospital infection work summary
First, the main work of the hospital infection management:
1, according to the requirements of the higher health administrative departments formulated xx hospital infection management work plan, the hospital infection knowledge of continuing education and training program; review the revision and additions to the hospital infection Prevention and control of quality inspection scoring standards, seriously study the Ministry of Health, "disinfection supply center management standards" and other six standards, to further improve and perfect the relevant hospital infection workflow.
2, strengthen the hospital infection prevention and control of quality supervision and management and continuous improvement, improve the quality of hospital infection management supervision and assessment mechanism, set up a part-time quality control team of hospital infections, monthly aseptic technology operations, medical waste management, hand hygiene, disinfection and isolation of the hospital infection control links of the quality of the regular self-inspection supervision and adhere to the self-inspection of the situation evaluation and analysis of the notification, supervise the clinical departments on the existence of problems in a timely manner to carry out the work of the hospital infection control. Clinical departments on the existence of problems in a timely manner to rectify, to ensure the healthy operation of the basic work of hospital infection management.
3, adhere to carry out key departments environmental microbiological monitoring and disinfectant use process monitoring, sterile goods sterilization effect monitoring, clinical disinfection and isolation work to play a substantial role in the inspection and supervision.
4, do a good job of hospital infection case monitoring and reporting:
(1) to carry out the key to regional hospital infection case monitoring, continuous ICU hospital infection targeted monitoring and network direct reporting.
(2) to do a good job of hospital infection outbreak epidemic monitoring and reporting and preventive control work, conscientiously implement the "hospital infection outbreak early warning report processing system", to strengthen the outbreak of hospital infections prospective monitoring, in March to investigate and deal with outbreaks of nosocomial infections in the upper respiratory tract early warning events, to assist the clinic to take the appropriate control measures, so that outbreaks of infections in a timely manner to get under control, did not cause the spread of the incident.
(3) carried out a hospital infection rate survey and network direct reporting, the survey rate of 97.6%.
5, do a good job of infectious disease hospital infection prevention and control work, do a good job of pre-screening and triage desk, isolation ward hospital infection prevention and control guidance, especially in the hand-foot-mouth disease, influenza A H1N1 prevention and control work, hospital infection control seriously implement the relevant spirit of the higher health administrative departments, seriously standardize the development of relevant work systems and processes, so that it meets the requirements of the prevention and control of hospital infections and to strengthen the relevant departments training and prevention and control supervision. The hospital has been working hard to develop the relevant work systems and processes to meet the requirements of hospital infection prevention and control, and to strengthen the training of relevant departments and prevention and control supervision.
6, to further strengthen the knowledge of hospital infection continuing education and training, hospital-wide training 4 times a year, each department to do the monthly intensive training for the staff of the section, to the hospital issued more than 1,000 copies of the training assessment questionnaire, the hospital infection knowledge training examination rate of 100%; for the current situation of our hospital infection management, organized by the Yichang City level of continuing education program for hospital infections training
7, hand hygiene management: the hospital implemented hand sanitizer hand washing, hand drying towel to do a person once a use a disinfection without secondary pollution, part of the key departments to implement the dry phone dry hands.
8, the key departments of the hospital infection management: the hospital has strengthened the key departments of the layout of the construction and improvement of the new blood purification room in recent years, purification ICU, laminar flow operating room, laboratory, gastroscopy room, and standardize the corresponding facilities and equipment, so that it reaches the requirements of the management of hospital infections, the center of the supply room is being prepared for the construction.
The Department of Hospital Sensory Nursing jointly implemented a monthly quality control supervision of the operating room and other key departments of the hospital.
9, to further standardize the classification of medical waste collection management, medical waste management related systems and treatment process health
full, and standardize the implementation of the classification of collection, reasonable storage, focusing on rationalization of uncontaminated medical waste packaging, prohibit the mixing of medical waste with infectious, standardize the configuration of the collective infusion car medical waste containers and the standardized use of the hospital's medical waste containers; infectious medical waste, such as To do day-to-day clean and timely incineration, incinerator in the hospital has been smoke-free treatment; there are standardized new sewage treatment facilities, there are relevant management systems and responsibilities, a person in charge.
10, strengthen the management of multi-drug-resistant bacteria: the hospital has multi-drug-resistant bacteria disinfection and isolation measures and the implementation of the laboratory found multi-drug-resistant bacteria can be timely reported to the Hospital Infectious Disease Branch, Hospital Infectious Disease Branch timely feedback to guide the clinical departments to take disinfection and isolation measures, and multi-drug-resistant bacterial strains of the implementation of patient labeling management.
11, to strengthen the management of occupational exposure protection of medical personnel: improve the emergency plan for occupational exposure of medical personnel, treatment process, registration and reporting system, and can be the whole hospital medical staff related knowledge training, there are medical personnel occupational exposure of special preventive funds; medical personnel have occupational protection awareness, key positions corresponding to the availability of protective equipment (hats, masks, isolation suits, protective clothing, face masks, eye mask.), staff can correctly identify the occupational exposure of medical personnel, Rubber shoes, etc.), the staff can correctly use protective equipment.
12, disinfection of medicines and disposable medical supplies management: Hospital Infection Management Division of the purchase of disinfection of medicines and disposable medical supplies, storage and use of regulatory oversight, quarterly inspection guidance and analysis of the briefing.
13, conscientiously implement the hospital infection evaluation and analysis system, do a good job of statistical reporting of relevant information, and adhere to the regular convening of the hospital infection work conference, the occurrence of hospital infections, monitoring and evaluation of the hospital infection prevention and control measures to implement the implementation of the evaluation and analysis of the notification, and at the same time to carry out the monitoring of drug-resistant strains of bacteria, the rate of hospital infections sent to analyze the rate of pathogenicity of the cases, and the regular issuance of the Hospital Infection Newsletter
Second, there are problems with the hospital infection management department. >
Second, there are problems:
1, the hospital did not implement the centralized cleaning and disinfection supply, a few departments there are self-contained packages or daily diagnostic supplies section cleaning and disinfection of immersion, its cleaning facilities are not standardized, a small number of medical personnel disinfection methods and chemical disinfectants in place to master the use of disinfectants (disinfection and supply centers are in the pipeline).
2, medical personnel hand hygiene awareness to be further strengthened (infusion and injection, wound surgical dressing, critical checkups and other aspects of the quick-drying hand disinfectant are required to use hand disinfection), the hospital's quick-drying hand disinfectant purchased only 500 bottles a year, far from reaching the clinical norms of the demand for hand disinfectant, indicating that the actual operation of medical personnel is not the standardized implementation of the hand hygiene system.
Hospital Infection Management 2022 Annual Summary Report (Part 2)According to the hospital "safe production" and "quality management" requirements, improve the quality of hospital infection control and evaluation system, refine the quality of the hospital infection comprehensive goal Assessment standards, according to the comprehensive objectives of the supervision and feedback, comprehensive inspection and sorting out all aspects of the prevention and control of hospital infections, and seriously investigate the safety hazards, in order to ensure the safety of hospital infection, and effectively grasp the key departments of hospital infections, key parts, key links of the management, in particular, the operating room, disinfection and supply room, stomatology, gastroscopy, laboratory, and other key departments of the management of hospital infections; and the development of a Key parts, key links of the prevention and treatment of hospital infection measures, hospital infection routine supervision and guidance to prevent hospital infection outbreaks in the hospital.
Hospital Infection Management 2022 annual work summary report (Part 3)xx year hospital infection work summary
xx year in the hospital leadership of the importance and concern, our hospital infection team on the control of nosocomial infections have done a lot of work. Beginning with the implementation of the organization, to strict management system, to carry out the necessary clinical monitoring, etc., to take a variety of measures, so that our hospital hospital infection management gradually standardized, institutionalized, scientific, the hospital infection rate control at a low level. In order to further improve the management of hospital infection in the future, now the hospital's annual hospital infection control work is summarized as follows:
First, to strengthen the organization and leadership, to ensure that the smooth progress of hospital infection management Hospital infection management team business dean led by the Medical Department, the Department of Nursing part-time participation in the department in charge of the members of the team. Responsible for the hospital's infection control work, and guidance to the departments. The hospital infection team seriously grasp the daily work, regularly and irregularly supervise and inspect the nosocomial infection control work of each department, and collect and count the relevant data of the whole hospital. The implementation of the work of the layers, to ensure the smooth development of our hospital infection management.
Second, further improve the management system and implement
Hospital infection management system is to improve the foundation of hospital infection and an important guarantee, the development of a set of scientific and practical management system is very important. At the beginning of the year, according to the specific conditions of our hospital, revised the hospital work of the SOP; strengthen the construction of the system and learning, regular training and assessment of all health care personnel, and conscientiously carry out the implementation, improve the awareness of prevention, reduce the incidence of hospital-acquired infections; hospital sensory team to regularly check the implementation of the system, give full play to the role of constraints on the system, so that the work of the implementation of the practical.
Third, continue to grasp the clinical departments disinfection isolation, infection monitoring work
1, according to the SOP and the "Prevention and Control of Infectious Diseases Act", the hospital sensory team to strengthen the clinical departments disinfection isolation, infection monitoring work. Monthly inspections are conducted, and problems found are dealt with in a timely manner, which greatly reduces the possibility of nosocomial infections. In the year's disinfectant replacement and instrument
1 device soaking inspection, in addition to the occasional omission of some departments or incomplete records, instrument soaking and disinfectant preparation, replacement time are in line with the requirements.
2, the monitoring of the clinical department nursing staff's hand surfaces, object surfaces, air, disinfectants, the intensity of ultraviolet light, autoclave sterilization kit, etc., the pass rate reached 100%.
3, the hospital infection team staff regularly to the relevant departments to find out whether there are cases of nosocomial infection, there is no omission, misreporting and so on. Each section of the nosocomial infection cases found in a timely manner to register and report to the hospital infection team. After statistics, the rate of nosocomial function microbial culture is 100%, the annual incidence of nosocomial infection is 8%, down 1.1% from last year.
Fourth, good management of disposable supplies to ensure the medical safety of patients and prevent social pollution
In this year's purchase of disposable supplies, the hospital leadership to strengthen the management of this area, strict verification, check the quality. The hospital sentinel department and the warehouse custody is responsible for the purchase of disposable supplies for inspection, registration, good disposable supplies, disinfection medicine and equipment purchased at the gate, to prevent unqualified products into our hospital. In this year, none of the disposable products purchased by the hospital were unqualified. The hospital sensibility team inspects the single-use sterile medical supplies stored in the storehouse and each department once a quarter, and the nursing staff strictly checks them before use to prevent expired and invalid single-use supplies from being used by patients. As a result of strict control, there is not a single case of patients using unqualified sterile single-use medical supplies. For used disposables, each department has been insisting on disfiguring, sterilizing and recording. As a result, the rate of disfiguring and sterilizing empty disposable needles, infusion sets, urine bags, etc. in our hospital reaches 100%. Disfigured, sterilized single-use sterile medical supplies, designated by the Municipal Health Bureau special person recovery.
V. Strengthen the knowledge of hospital infection training, improve the awareness of the hospital staff to control nosocomial infections
Combined with the actual hospital, the hospital infection team organized the prevention of nosocomial infections of the special lectures, such as diagnostic criteria for hospital infections, the use of antimicrobials, the regulations on the treatment of medical accidents, disinfection, safety training, blood transfusion laws and regulations and blood transfusion of knowledge, etc., the hospital's medical staff
2 to prevent, protect, and prevent the use of blood transfusions. To improve the level of prevention and control of hospital infections in our hospital.
In the whole year of hospital infection control work, due to the hospital leadership attaches great importance to the guidance of the higher experts on our hospital, hospital infection team organization, guidance and the active cooperation of the departments, the work carried out relatively smoothly, and achieved good results. However, due to the late start of our hospital's nosocomial infection control work, there are still deficiencies, such as the diagnosis of nosocomial infection incidence cases, reporting, statistics and other aspects of the work is not enough, to be continuously improved and enhanced in the future. We believe that in the new year, as long as we continue to summarize the experience, learning, we will do a better job of nosocomial infection control.
xx year's hospital infection management work focus:
1, to strengthen the learning and training of medical staff. Such as hospital infection diagnostic standards, disinfection specifications, hand hygiene, rational use of antibiotics, HIV occupational protection;
2, each clinical department should organize learning to master the diagnosis of hospital-acquired infections, inspections, records and reporting procedures, etc., to improve the accuracy of the report of hospital-acquired infections, reduce underreporting;
3, to strengthen the microbial culture and drug sensitivity tests;
4, to strengthen the ultraviolet light Strength of monitoring;
5, medical waste management should be implemented in accordance with the requirements of the hospital medical waste management system;
6, the hospital sensory management team should be regular activities, do a good job of the relevant account book records, and rectification of existing problems.
xx
January 7
Hospital Infection Management Section 2022 annual work summary report (Part 4)Infection is divided into two kinds, medical infection, refers to bacteria, viruses, fungi, parasites and other pathogens invade the human body caused by the local tissue and systemic inflammatory response. Psychological infection is caused by some way of eliciting the same emotions and actions in others. It is essentially the transmission and exchange of emotions and has a large role in the interaction.
First, the hospital and the main work carried out by the hospital infection section
1, seriously study the "xx province medical hospital management review implementation rules", do a good job of creating a two-excellent review of the preparations for the inspection, according to the rules of the requirements for the development of the annual work plan, the annual training program, the workflow of hospital infections, collation and supplementation of the prevention and control of hospital infection regulations, quality control and management of all the rules and regulations, quality control and management of hospital infections. The company has been working to improve the hospital infection management system by organizing and supplementing the rules and regulations of hospital infection prevention and control management, and quality standards.
2, strengthen the supervision of the clinical departments of hospital infection prevention and control work, found that the problem of timely communication, timely guidance, timely improvement, especially for our medical staff on the classification of medical waste is not clear, a few clinicians aseptic operation is not in place and other phenomena such as repeated on-site supervision and correction, thoroughly clean up the dead ends of the work of hospital infection prevention and control, and really do the management of hospital infections, ` hospital-wide The company's management of hospital infection management is fully reflected in the standardization and unification of hospital infection management efforts.
3, strengthen and improve the environmental microbial bacterial monitoring work, the monitoring work and clinical work combined, pioneering the development of environmental dynamic bacterial monitoring, clinical disinfection and isolation work to play a substantial role in the inspection and supervision, in particular, take the initiative on the neonatal ward, mother and baby wards, neonatal warming box random sampling monitoring of the focus of the disinfection and isolation of the work of the environmental quality of the work of the region play a very good Supervision and prompt role.
4, to carry out key go to the regional hospital infection case monitoring, launched the icu hospital infection target monitoring.
5, do a good job in the hospital infection outbreak epidemic monitoring and reporting and preventive control work, 20xx Hospital Infectious Disease Branch developed a "clinical hospital infection outbreak early warning report system", to strengthen the outbreak of hospital infections prospective monitoring, implementation of this system, this year, x month, our hospital surgery two x type of surgical cut the spirit of the hospital, and seriously standardize the development of the relevant work system and process, so that it is the first time that the hospital outbreak of hospital infection outbreak. Related work systems and processes, so that it meets the requirements of hospital infection prevention and control, the first half of the hospital did not occur infectious diseases nosocomial infections, *** count to meet the higher inspection *** count.
7, to further strengthen the knowledge of hospital infection continuing education and training, hospital infection has been completed in the first half of the training, and part of the hospital training.
8, strengthen the clinical departments of hospital infection prevention and control measures to implement the supervision and assessment
adhere to the concept of continuous improvement of the work, found that the problem, timely research, timely communication, timely improvement, for the repeated correction of ineffective problems into the hospital quality control assessment scores, rewards and punishments; to do at any time to check the guidance, regular assessment and evaluation, and regularly to the departments to notify the assessment situation. On time and in accordance with the provisions of the higher authorities, hospital leaders, hospital quality control section to inform the relevant information.
9, to further strengthen the management of medical waste classification collection and treatment, after the use of disposable items recycling rate of 100%, the waste of medical waste incineration 100%, focusing on the inspection of domestic waste and medical waste classification and separation, medical sharps, infectious waste treatment.
10, conscientiously implement the hospital infection evaluation and analysis system, do a good job of statistical reporting of relevant information, adhere to the regular convening of the hospital infection work conference, the occurrence of hospital infections, monitoring and evaluation of the hospital infection prevention and control measures to implement, etc., evaluation and analysis of the notification, and at the same time to carry out the monitoring of drug-resistant strains of bacteria, the rate of hospital infections sent to analyze the rate of pathogenetic cases, the regular issuance of the Hospital Infection Newsletter
Second, the main problems of hospital infection work and next year's work focus
1, the target monitoring work is not perfect.
2, the hospital medical waste classification collection and treatment facilities need to be improved (garbage cans, bags).
3, hand washing facilities need to be improved (faucets, hand sanitizer, etc.).
Hospital Infection Management 2022 annual work summary report (Part 5)20xx year, hospital infection management work in the hospital under the correct leadership of the strong support, the hospital infection department actively work to further improve the implementation of the hospital infection organization network, strict management system, to carry out the necessary monitoring and inspection work. Hospital departments cooperate strongly, the nursing department effectively grasp the department disinfection and isolation technology operation, aseptic technology operation and inspection and assessment, clinical departments timely and carefully fill out and report the department of hospital infection cases, the hospital infection department do a good job of monitoring and analysis of hospital infection cases, and guidance to the clinical departments to control hospital infections. Through the above work, in 20xx, our hospital hospital infection cases ****5 cases, hospital infection rate of 0.9%, no hospital infection outbreak epidemic, effective control of hospital infection at a lower level.
A sound organization, the development and improvement of hospital infection management rules and regulations
In March of this year, the hospital adjusted the hospital infection committee, a sound hospital infection quality control management system at the hospital level. According to the "Hospital Infection Management Measures", "Disinfection Technical Specification", "Chinese People's *** and State Infectious Disease Prevention and Control Law", "Disinfection Management Measures", "Medical Waste Management Measures for Healthcare Institutions", "Endoscopic Cleaning and Disinfection Technical Specification", "Infectious Disease Information Reporting Management Specification" and other relevant laws, regulations, norms, regulations, combined with the actual situation of the hospital to revise the hospital's management of hospital infections, infectious disease The company's management system, responsibilities, measures, processes, and so on.
Second, for the hospital infection weak link, strengthen the hospital infection quality control
Further improve the hospital infection quality control and evaluation system, developed a hospital infection quality comprehensive goal assessment standards, according to the comprehensive goal of supervision and feedback, comprehensive inspection and combing of all aspects of hospital infection prevention and control work, seriously The company's main goal is to prevent the spread of hospital-acquired infections, and to ensure the safety of hospital-acquired infections, and to ensure the management of key hospital-acquired infections, especially in the operating room, labor and delivery room, laboratory, treatment room, and emergency department.
Three, according to the management requirements of infectious diseases, to strengthen the hospital infection prevention and control of infectious diseases
To further strengthen the management of internal medicine outpatient, fever outpatient (emergency) clinic and other key places, conscientiously implement the requirements of the hospital infection control of infectious diseases, to increase the efforts of the prevention and control of hospital infection and standardize the work procedures, especially for the whole hospital medical staff, to strengthen the knowledge of the prevention and control of infectious diseases and their own protection. Infectious disease prevention and control and self-protection knowledge training, the strict implementation of the hospital infection prevention and control and personal protection measures to prevent the occurrence of hospital cross-infection, and actively cooperate with the relevant departments, *** with the prevention and control of epidemics.
Fourth, according to the hospital infection management requirements, do a good job of retrospective investigation of cases
20xx, the hospital *** discharged patients 5456, of which 2205 surgical discharges, medical discharges 2,596 discharges, obstetrics and gynecology discharges 655, of which surgical infection cases **** 3, the incidence of infection was 0.14%; internal medicine hospital infection cases have 1 case, the incidence of infection is 0.038%; obstetrics and gynecology hospital infection infection has 1 case, the incidence of infection is 0.15%; traditional Chinese medicine, Pentacenter, anus and intestines hospital infection incidence rate are 0%.
Fifth, grasp the environmental hygiene, sterilization effect and hand hygiene monitoring
In order to standardize the hospital's disinfection work, to prevent nosocomial infections, the hospital infection department to strengthen the sampling and monitoring of nosocomial infections, commissioned by the county CDC on the hospital's focus on the effect of disinfection monitoring, and at the same time, strengthening of operating rooms, maternity wards, nursing and other high-risk areas. At the same time, the hospital has strengthened the monitoring of environmental hygiene in high-risk areas and the monitoring of hand hygiene of medical staff. The air in all clinical departments, medical technology departments and outpatient clinics of the hospital has been monitored, and the pass rate reaches 100%.
Six, strengthen the management of medical waste
Hospital Sensory Department continue to improve the rules and regulations, clarify the duties of medical waste management personnel, the implementation of the accountability system, to strengthen the management of medical waste and routine supervision, found that the problem of timely rectification and feedback. Our hospital medical waste classification, collection, storage, packaging, transportation, handover, etc. to achieve standardized management, to prevent hospital infection outbreaks caused by poor management of medical waste. Redesigning the medical waste recycling registration form to facilitate recycling and archiving. The hospital's medical waste storage site has been re-sited and reconstructed. The process of managing medical waste is more realistic and reduces the chance of contamination and injury to healthcare workers.
VII, strengthen the hospital infection training and assessment
Four hospital infection knowledge training, including the entire hospital medical staff, ****118 people, the training content is: ① hospital infection basics training, ② the guiding principles for the clinical application of antimicrobial drugs, interpretation of multi-drug-resistant bacteria hospital infection prevention and control of the technical guide ( trial), ③ medical waste, the hospital infection prevention and control of the technical guide ( trial). (Trial), ③ medical waste disposal, ④ diagnostic criteria for hospital infection cases, hand hygiene standards for prevention, interpretation of the "second B hospital" hospital infection standards.
Through the training, the whole hospital medical staff and workers pay attention to the hospital infection. Medical staff aseptic operation awareness has been enhanced, and strive to do everyone to "aseptic concept, aseptic operation".
VIII. Management of disinfectant and single-use sterile medical supplies
In order to strengthen the management of disinfectant and single-use sterile medical supplies, the Department of Infectious Diseases carries out routine supervision and regular spot checks on their use. The sampling of sterilized medicines and single-use sterile medical supplies is done once a quarter, by sampling from the clinical departments and requesting certificates from the material storehouse. The results are complete, all qualified.
Nine, actively involved in the hospital building design
In the new ward building, it is recommended to use sensor taps, key departments equipped with hand drying paper, hospital leadership agreed and has been implemented in place, put into use. This measure has greatly improved the hand hygiene compliance of our medical staff. It is recommended that all air disinfection of the treatment room and pharmacy all use suspended ultraviolet disinfection machine dynamic ozone air disinfection machine, which suspended ultraviolet disinfection implementation is not in place, will be further improved, and strive for the implementation of the various departments.
Ten, although my section has done a lot of work, but there are still many problems:
1. Hospital infection link quality needs to be further strengthened.
2. Clinical infection management team has not yet fully realized its role.
3. The results of infection surveillance should be regularly fed back to the clinical departments.
4. Some doctors in clinical departments still do not pay enough attention to nosocomial infections, and there is a lack of diagnosis and analysis of patients' conditions related to nosocomial infections, and hospital infection registries cannot be submitted in a timely manner.
5. The clinical departments of medical staff asepsis concept, hand hygiene knowledge still need to be strengthened.
The new year is approaching, our department will continue to carry out all the work, and for this year's problems, and constantly improve and improve. Continuously summarize the experience, learning with an open mind, and strive for the "Second B Hospital" passed successfully.