A Hospital Infection Management Organization System
System
1. Hospital Infection Management Leadership Organization
(1) Organizational form:
1)Hospitals with more than 300 beds should establish a hospital infection management committee.
2)Hospitals with less than 300 beds should have a hospital infection management team.
(2) Composition:
Hospital infection management committee (group) generally set up a director (leader), by the vice president in charge of business; deputy director (deputy
group
leader) 1 to 2, respectively, by the director of the Hospital Infection Management Department, or by the director of the Department of Preventive Health Care, Director of the Department of Nursing. Committee
Members from the medical department, internal, external, gynecological, pediatric, infectious disease physicians, laboratory director, director of pharmacy, supply room nurse, hand
operation room nurse, the head of the General Affairs Department and other relevant personnel, the number of people depending on the size of the hospital, the nature of the task, the general Committee
Committee of not less than 10, the group of not less than 6 people is appropriate.
(3) tasks and responsibilities:
1) according to the "Chinese people's *** and the State Law on Prevention and Control of Infectious Diseases", "Disinfection Management Measures" as well as the provincial and municipal Ministry of Health
departments to prevent hospital infections of the relevant provisions of the hospital to develop hospital-wide control of hospital infections in the hospital's planning, the hygiene standards and management system.
2) monitoring of the incidence of hospital infections, timely detection of problems, put forward countermeasures, evaluation of the effectiveness of management, and research
improvement measures.
3)Responsible for the new facilities for the validation of hygiene standards.
4)Responsible for hospital infection management personnel training, provide technical advice.
5)Responsible for the required health authorities to fill in the hospital infection incidence monitoring form. In the event of an outbreak of epidemic, immediately
report to the higher authorities.
2. Hospital Infection Institution
(1) Institutional Setting:
Hospital Infection Management Department is the second level of hospital infection management, and is also the office of the Hospital Infection Management Committee. It is composed of full-time
personnel who are specifically responsible for the implementation of the various hospital infection programs.
Hospitals with less than 200 beds can set up an infection management team in the preventive health department or nursing department, composed of full-time staff.
(2) staffing:
1) hospital infection management department should have a director, deputy director, full-time physicians and nurse practitioners, full-time or part-time laboratory technician, and after
the appropriate professional training. Section director should have a senior technical title; as infection management physician, required to be a medical school
Public Health Department graduates or clinicians by specialized training; as infection management of the nurse practitioner, required to graduate from a formal nursing school, have extensive
clinical experience, by the specialized training of nurse practitioners and above.
2) According to the ratio of each person responsible for 250 beds with hospital infection monitoring nurse.
3)The Hospital Infection Management Section is administratively a functional section and operationally a medical section, with a dual nature. The medical and nursing staff of this section
are entitled to all the treatment of medical and nursing staff at the same level, such as promotion, nursing age, and health allowance.
(3) tasks and functions:
1) under the leadership of the dean and the Hospital Infection Management Committee (group), specifically responsible for the formulation of hospital-wide control of hospital infections plan
planning, and specific organization and implementation.
2)The implementation of the monitoring system, monthly monitoring, analysis, reporting morbidity and sterilization effect.
3)Investigate and analyze the hospital infection epidemic in a timely manner, report to the Hospital Infection Management Committee (group), and propose improvement
measures. The discovery of an outbreak of epidemic must be immediately reported to the Hospital Infection Management Committee, and at the same time report to the next level of health administration
Department.
4) Coordinate the hospital infection surveillance work of all departments in the hospital, and provide business and technical guidance and consultation.
5)Carry out thematic research on hospital hygiene management and promote new sterilization methods and preparations.
6)Carrying out on-the-job education on hospital infection for all staff, organizing training for surveillance personnel, and holding various types of lectures.
3. The hospital infection management team of each department
is the third-level management organization in the hospital infection management organization, consisting of the department (deputy) director, ward surveillance physician, head nurse and surveillance nurse
. Under the guidance of the hospital infection management department to do the infection management in the department.
The main tasks are:
(1) To do a good job of monitoring the hospital infection of patients hospitalized in this room. Attending physicians should report hospital infection cases to the Hospital Infection Management Department in the form of report cards within 24 hours
. Once an outbreak is detected, it must be reported immediately to the Department of Hospital Infection Management.
(2) To do a good job of disinfection, sterilization and isolation in this department to prevent exogenous infection.
(3) Observe the principle of rational use of antimicrobial drugs and do microbiological monitoring.
(4) Implement various disinfection and isolation and infection control systems.
(5) Implement in-service education on hospital infection for staff in this department.
Supervision and inspection
City and district health bureaus organize annual inspections, including:
1. Establishment of hospital infection management at all levels of relevant documents, training certificates, title certificates and other information.
2. The operation of the Hospital Infection Management Committee and the daily work of the Hospital Infection Management Department, such as meeting minutes, various
work records, hospital infection case monitoring, disinfection and isolation monitoring and other information.
3. Textual information on the work of various systems, annual plans, re-education and training for hospital infection control, listening to the work
reporting, and giving an evaluation of the effect.
Section II Hospital Infection Monitoring and Reporting System
System
1. Clinicians found that the patients under the management of hospital infections, must promptly fill out the "Hospital Infection Reporting Card (registration
table)", and within two days to report to the Hospital Infection Management Department or the corresponding functions. The hospital should report to the hospital infection management department or the corresponding functional department within two days. When discharged from the hospital, the diagnosis of the site of hospital infection should be filled in on the first page of the medical record in the column of "nosocomial infection
Name".
2. At least once every two days, the hospital infection staff will go down to the wards and microbiology room to check, collect and verify the infection cases. Confirmation
that the hospital infection to fill out the "hospital infection case registry".
3. The hospital infection staff weekly to the case room to check all the discharged medical records, found that the hospital infection cases should be underreported in a timely manner
Registration, and feedback to the underreporting department.
4. Each ward (department) to strengthen the self-inspection of environmental hygiene, regular monthly monitoring of seven specimens (sterilized items,
disinfected items, disinfectant in use, object surfaces, staff hands, air, ultraviolet lamps). Special departments to strengthen
Special items monitoring (eg: supply room to the autoclave monitoring, hemodialysis room to the dialyzer, dialysis fluid monitoring, etc.).
5. The hospital infection full-time nurse monthly microbiological monitoring of key wards (departments) (eg: supply room, hemodialysis room, operating room, maternity ward, love
baby area, surgical wards, custodial wards, treatment rooms, etc.), and quarterly monitoring of non-focused departments.
6. In order to effectively control hospital-acquired infections, hospital infection management staff should conduct monthly statistical and epidemiological analyses of hospital-acquired infections among hospitalized patients, including the hospital-acquired infection incidence rate, hospital-acquired infection
rate of all hospitals, the incidence of infections in all parts of the body, the hospital-acquired infection underreporting rate of all hospitals and departments, as well as the susceptibility to hospital-acquired infections, the risk factors, the risk factors, the risk factors, the risk factors, and the risk factors of hospital-acquired infections.
The statistics and analysis of hospital infection susceptibility factors,
distribution of hospital infection pathogens and results of drug sensitivity tests, and monitoring of hospital environmental hygiene and other items.
7. Hospital infection staff monthly statistical analysis of the results of timely feedback to the departments, and timely report to the competent
Dean and the relevant departments, such as the Medical Department, Nursing Department, and to help unqualified departments to find the reasons for the proposed control measures
8. Monthly medical meeting of the President in charge of the meeting should be informed of the hospital's hospital infections in the previous month, and put forward further
8. And put forward further
requirements.
9. A week found in the same ward (department), the occurrence of three cases of infection caused by the same pathogen, the ward should be reported to the hospital within 24 hours in a timely manner
Infection Management Department or the corresponding functional departments, and to do further identification of pathogens typing. If an outbreak of hospital-acquired infection is identified,
the hospital infection management department or the corresponding functional department should report to the hospital management committee or group within 24 hours,
simultaneously
reported to the next level of health administration. The hospital infection management committee (group) shall immediately convene an emergency meeting to formulate control
measures.
10. Hospital infection specialists as well as the wards (departments) such as monitoring the sterilized items, disinfected items, disinfectant in use
and other substandard conditions should be found within 24 hours to find the cause, and reported to the Hospital Infection Management Committee (or the group) in a timely manner
developed
designed corrective measures.
Supervision and inspection
1. The hospital infection management team in each ward (department) should do a good job in the daily monitoring of hospital infections in the department.
2. The infection management function is responsible for the statistical leakage rate, the leakage rate should be <20%.
3. Establishment of disinfection and isolation team, monthly from time to time on the hospital's clinical departments for cleaning, disinfection, sterilization quality inspection.
4. Hospital infection outbreaks and epidemics found, the hospital must be in accordance with the provisions of the report by level, the failure to report will be investigated at all levels of the personnel concerned
responsibility.
Section III Disposable Medical Supplies Management System
System
1. Hospital Infection Management Department or the relevant management section should be the unit of disposable medical supplies, procurement, storage, issuance, use
and destruction of supervision and management of the implementation of the links to ensure that the quality of the product is qualified and the use of safety.
2. Medical and health units using disposable medical supplies, must be the provincial health administrative department issued by the "health
permit" and "production license" of the product. The package should indicate the approval number, factory name, batch number, disinfection method, disinfection
date and expiration date, with detailed instructions for use, the product preservation conditions and precautions for use.
3. Every time the equipment section purchases disposable medical supplies, it must carry out quality inspection and acceptance, so that the salesman's certificate, ordering contract, place of shipment and account number of remittance of payment are in line with the manufacturer, and check each batch of the product's certificate of conformity, date of disinfection, date of discharge from the
factory, and expiration date, and make a detailed registration and preservation.
4. The storage environment of disposable medical supplies should be kept clean and dry, and recontamination should be strictly prevented. Sterilization supply room is responsible for the issuance of disposable medical supplies, and make a detailed registration. Each department should set up a special cabinet for proper storage according to the purpose after receiving.
5. Clinical departments in the use of disposable medical supplies, should be carefully done before checking, where the packaging is damaged or expired products a
Law shall not be used. Doubts about the quality of the product, should stop using and timely report to the equipment section and hospital infection management, monitoring
the effect of disinfection.
6. disposable medical supplies after use, must be timely disinfection, disfigurement or incineration, for harmless disposal. Seriously
contaminated, should be stored separately from household garbage, sealed and then directly for incineration.
Supervision and inspection
1. Hospital Infection Management or the relevant management section of the quarterly purchase of disposable medical supplies equipment section of the "health license
Certificate" and "production license" and other checks, with provincial Health license rate must reach 100%, no substandard products.
2. Hospital Infection Management Department or the relevant management section of the quarterly inspection of the use of disposable medical supplies, whether to do
Timely disinfection, disfigurement or incineration.
3. Where the system does not require the purchase and use of unqualified disposable medical supplies according to the relevant provisions of the treatment, resulting in infection of the person to be held accountable
Responsibility.
4. The hospital infection department and the health epidemic prevention department each time to check the substandard items to trace the purchase channel, the purchasing staff
and the responsibility of the person in charge.
Section IV Disinfectant Management System
System
1. The Hospital Infection Management Committee is responsible for validating the use of varieties of disinfectants and determining the supply manufacturers. Acquisition of disinfectant or change of disinfectant
The manufacturer of disinfectant must be agreed by the Hospital Infection Management Committee before implementation.
2. Supply manufacturers should have the pharmaceutical sector and the provincial health administrative department issued by the "production license" and "health permit
certificate.
3. Each purchase of disinfectants, the Pharmacy Department must carry out quality inspection and acceptance, check each batch of disinfectant number of inspection certificate, approval
number, production lot number, concentration, expiration date and instructions for use, and make a detailed registration.
4. All kinds of disinfectants prepared by the hospital preparation room must be labeled with the approval number, production batch number, effective concentration and expiration date, and
after the quality inspection department to test and pass before being put into clinical use. The various disinfectants stored must reach their corresponding effective concentrations
and the monitoring results should be in line with national standards. Other departments shall not prepare and dilute disinfectants without authorization.
5. After receiving the disinfectant solution, the department should be stored in a neat, dark and light place, and should be sealed immediately after opening each time to avoid evaporation and staining
dyeing, which will affect the disinfection effect. Containers containing disinfectant must be sterilized before use. Before the use of disinfectant must be two people
more than check the concentration, expiration date, date of delivery and retrieval date, and have a signature record.
6. Clinical staff should understand the performance of various disinfectants, the role of effective concentration, time of action, the use of the method and the impact
factors, and strictly in accordance with the degree of disinfection and sterilization of items required to select the appropriate disinfectant and disinfection methods, shall not be changed without
change. In case of quality problems, the use should be stopped and promptly reported to the Hospital Infection Management Department and the Preparation Room.
7. The Hospital Infection Management Department is responsible for supervising the purchase and preparation of disinfectants and guiding the clinical use of various disinfectants. Monthly monitoring
The disinfection effect of disinfectants in use should be monitored. Clinical disinfectants that do not meet the Hospital Disinfection Health Standards must be stopped immediately
.
Supervision and inspection
1. Hospital Infection Management Department or the relevant management section quarterly inspection of the Pharmacy Department purchased disinfectants, holding provincial health license rate
must reach 100%, the preparation of disinfectants must be quality control, marked with the approval number, production lot number, concentration, expiration date, no
qualified products.
2. The Hospital Infection Management Department or the relevant management section conducts monthly inspections of the disinfectant in use, whether it is in line with the "Hospital Disinfection
Hygiene Standards", and whether there is any use of unqualified disinfectants.
3. Municipal and district health epidemiological departments are responsible for regular testing of special disinfectants, and the results will be returned to the hospital concerned.
4. Anyone who does not follow the above system of purchase, preparation and use of disinfectants for dereliction of duty, in accordance with the relevant provisions of the treatment, resulting in nosocomial infections
according to the circumstances of the serious treatment.
Section V. Hospital sewage, waste management system
System
1. Hospitals should have sewage treatment facilities, and a person responsible for management.
2. Hospital sewage discharge must meet the standards.
3. Inorganic waste should be concentrated at a fixed point and removed regularly for external transportation.
4. Organic waste should be incinerated. Incinerator should be responsible for the management, and work records.
5. Incinerator emissions should be in line with national environmental standards.
Supervision and inspection
1. On-site inspection of sewage treatment facilities, whether there is a person in charge of management, daily disinfection work records, daily residual chlorine and quarterly disinfection
effective or not.
2. On-site inspection of organic waste collection and incineration process.
3. The incinerator should be managed by a person, the equipment should be in good working order and the work record is complete. Incinerator emissions should be in line with national
environmental standards.
Section VI hospital infection on-the-job education and training system
System
1. Professionals in the hospital infection department must strengthen the on-the-job education to improve the business quality of hospital infection specialists, the monthly section
Organized within the department of business learning once a quarterly lecture on the topic of once a year to go out to study.
2. Training for hospital infection monitors. By
each clinical department selects physicians and nurse practitioners with practical work experience and prestige to serve as hospital infection monitors, and the Hospital Infection Department
conducts regular business training for them.
3. Do a good job of re-education of knowledge of hospital infection,
annual popularization of knowledge of hospital infection for the entire hospital medical staff, to strengthen the awareness of hospital infection prevention. Training methods can be used
study hospital infection management documents, books or handouts, watch the hospital infection control teaching video, invited experts to give lectures
, academic reports, hospital infection knowledge test.
4. Anyone who is a chief resident in a clinical department or is about to be promoted to attending physician should go to the hospital infection department for a short period of one week.
5. Newly assigned to the hospital's health care personnel in the pre-service education program should receive training in hospital infection knowledge, without training shall not be on duty
6. Targeted to carry out a variety of professional training courses for other personnel training. Such as antibiotic classes for doctors, nurses sterilization
poisoning and sterilization classes, administrative staff hospital infection management classes, cleaning training courses for cleaners.
Supervision and inspection
Hospitals regularly check each year, item by item, the various records of the hospital infection department professionals and other types of personnel in-service education.
The above information is for reference only!