2023 Infection Work Plan Part 1
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 of my department, my department according to the relevant documents and regulations, the development of the corresponding hospital infection control program is as follows:
First, improve the
First, improve the management system, play the role of the system.
1, in order to further strengthen the management of hospital infection, clear responsibilities, the implementation of the task, re-adjustment of clinical departments to enrich the infection monitoring group, improve the three-tier network management system.
2, the hospital infection management part of the Department of medical care quality inspection, the development of appropriate rewards and punishments.
3, the development of 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 infection rates and reduce underreporting.
2, environmental monitoring aspects; outpatient environment, air, clothing, medical staff hands, 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 strictly implement the triage system.
Fourth, the strict implementation of medical waste classification, collection, transportation and other systems to eliminate leakage events.
V. Multi-channel training to improve the awareness of medical staff hospital infection.
Six, the occurrence of nosocomial infection timely completion of the report.
VII, take a variety of forms of infection knowledge training: centralized training and morning meeting departmental training organic combination, increase the knowledge of medical staff of hospital infection, improve the awareness of hospital infection.
viii. Hand hygiene and occupational exposure protection issues into the focus of our hospital infection control work to strengthen hand hygiene and occupational exposure protection.
2023 Infection Work Plan Part 2
In recent years, due to the increasing complexity of diagnostic and therapeutic methods, the level of medical care continues to improve, the increase in chronic patients, the problem of hospital infections is also receiving more and more attention. Although the infection rate has been declining year by year, but how to reduce the hospital infection rate, improve the level of management, is an important topic of hospital quality management. Our hospital infection office will be in accordance with the "Hospital Infection Management Measures", "Disinfection Management Measures", "Medical Waste Management Regulations" and other key departments of the hospital key department management requirements, and effectively strengthen the management of hospital infection. The plan is as follows:
1, give full play to the role of the clinical department monitoring group, clinical department monitoring group in the department to play a role in guidance, supervision, coordination, monitoring, implementation. The hospital infection system needs this organization to implement, at the same time they are the site managers, is an important force in the control of infection link, the site of the illegal operation can be corrected in a timely manner. Practice has shown that as long as the clinical department monitoring group to play a good function, the hospital infection rate is significantly reduced.
2, according to the standard completion of the hospital's clinical departments environmental hygiene monitoring, sterilization effect, disinfectant, air, object surface and hand hygiene monitoring. All year round rotational sampling of clinical departments key departments key departments at least once every three months, general departments once every six months. UV lamp intensity monitoring in each clinical department once a quarter. Key monitoring key departments (operating room, maternity ward, neonatal, endoscopy room, hemodialysis, supply room, etc.) monthly inspection, supervision, rectification.
3. Adopt prospective monitoring methods to monitor cases of infection, and carry out targeted monitoring and current rate surveys. Check the hospital inpatient infection incidence rate line current rate survey. And do a good job in our hospital surgical incision, surgical site infection monitoring and analysis and tracheal catheter-related infection monitoring and analysis, to reduce the incidence of hospital infections, urging clinicians to report cases of hospital infections in a timely manner, to prevent outbreaks of hospital infections or epidemics.
4, arranged by the medical department or science and education of the hospital staff at all levels of hospital infection knowledge training. Increase the publicity of knowledge of hospital infection management to improve the importance of hospital infection management
Recognize. Specialized staff to participate in the hospital outside the hospital infection training one or two to enrich professional knowledge and skills, improve professional quality.
5, strengthen the medical staff hand hygiene supervision and management, promote hand hygiene in infection control in the important position, improve hand hygiene compliance. Monthly hand washing, hand hygiene sampling assessment, assessment results failed to be counted in the performance of the department.
6, with the Department of Laboratory for routine nosocomial infections, drug resistance rate and multi-drug resistant bacteria and bacterial spectrum survey, the results of the survey will be published every six months.
7, to strengthen the hospital sewage treatment and medical waste management supervision and management of standardized management.
8, the establishment of hospital infection monitoring, timely detection of problems to the hospital leadership and the person in charge of reporting and feedback, and put forward corrective comments. Quarterly on time to complete the "hospital infection newsletter".
Hospital infection management directly affects the hospital's medical safety, medical quality, medical and social benefits, reflecting the level of management of the hospital, but also an important symbol of the level of quality of medical ethics of hospital staff. At the same time, it also requires clinical departments to monitor the team members must improve their own business quality and technical level, and actively carry out their work, for which we must comprehensive measures to ensure that disinfection, sterilization, isolation to meet the predetermined requirements, in order to prevent and control the occurrence of hospital-acquired infections, so that the management of hospital infection is gradually standardized, systematized, scientifically, and the rate of hospital-acquired infections will be controlled at the lowest level.
2023 Infection Work Plan Part 3
First, hospital infection monitoring:
Adopt a prospective monitoring method, the incidence of infection of hospitalized patients throughout the hospital, monthly under the clinical monitoring of hospital inpatient hospital infection occurrences, and supervise clinicians to timely report cases of hospital infections, to prevent hospital infection outbreaks or Epidemic. Every six months, retrospective monitoring methods are adopted to investigate the underreporting rate of discharged patients. To reduce the underreporting of hospital infections, and gradually standardize the system of reporting hospital infections.
1, disinfection and sterilization effect monitoring and environmental hygiene monitoring
According to the "Disinfection Technical Specification" and "Hospital Infection Management Measures" requirements, the key departments of the air, object surfaces, staff hands, disinfectants, sterilizers, disinfection and sterilization of goods, such as disinfection and sterilization effect monitoring every month.
2, according to the "surgical site of hospital infection prevention and control of technical specifications" and "sterilization supply center infection prevention and control of technical specifications," the requirements of strict cleaning, disinfection and maintenance of operating room instruments.
Second, the rational use of antimicrobial drugs management:
According to the hospital's "reasonable use of antimicrobial drugs implementation rules and reasonable management of antimicrobial drugs", antimicrobial drugs implementation of hierarchical management. Quarterly surveys of inpatient antimicrobial drug use rate.
Third, urge the Department of Laboratory:
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.
Fourth, the hospital infection management knowledge training:
The hospital medical staff to carry out hierarchical hospital infection knowledge training, the main training content for the infection prevention and control of new developments, new methods, diagnostic criteria for hospital infections, antimicrobial drugs, the rational use of knowledge. The main training content for nursing staff is the knowledge of disinfection and isolation, the prevention and control of infection in the hospital and the classification and collection of medical waste. Cleaning staff work requirements, basic knowledge of disinfection and sterilization, cleaning procedures, personal protection measures and hand hygiene disinfection of health care workers.
V. Ward environmental hygiene and medical waste supervision and management:
Regular supervision of medical waste collection and disinfection treatment, supervision and management of the use of disposable medical supplies disinfection and disfigurement, recycling and incineration.
Sixth, infectious disease management:
In accordance with the requirements to improve the management of statutory infectious diseases and intestinal clinic, fever clinic management, to prevent underreporting of infectious diseases and epidemic. In particular, it is necessary to strengthen the monitoring and prevention of key infectious diseases. Eliminate the occurrence of epidemic spread due to underreporting of epidemics.
Seventh, the hospital renovation and expansion work:
Supply room, operating room renovation, should be strictly differentiated between the sterile area, clean area, contaminated area; contaminated items of cleaning, disinfection and sterilization must have a clear cycle of the route, can not be retrograde.
2023 Infection Work Plan Part 4
20xx year is our hospital is about to accept the "three A review", seeking development of the `critical year. At the same time, in order to further improve the management of hospital infection, to ensure medical safety. According to the "Hospital Infection Management", "Disinfection Technical Specification" and other relevant documents and regulations, under the leadership of the director in charge, this year, the main work is to do the following:
First, hospital infection monitoring
1, comprehensive monitoring: to take prospective monitoring methods, clinical monitoring of inpatient hospital infections occurring every month according to the plan, the incidence of hospital infection of the whole hospital patients statistics. At the same time, according to the monitoring results to determine whether the hospital infection aggregated cases, analyze and investigate the source of infection, to take effective measures to control the transmission channels, to prevent outbreaks or epidemics of hospital infections.
2, targeted monitoring
Continue to key departments in our hospital, key populations for targeted monitoring, including cesarean section surgery hospital infection target monitoring, oncology urinary tract intubation-related urinary tract infection monitoring, oncology vascular catheter-related bloodstream infection monitoring, nicu ventilator-related pneumonia monitoring, nicu vascular catheter-related bloodstream infection monitoring.
3, disinfection and sterilization effect monitoring and environmental hygiene monitoring
Quarterly monitoring of disinfection and sterilization effect on surfaces of objects, air, hands of staff, disinfectants, sterilizers, disinfected and sterilized items, etc. in key departments.
4, bacterial drug resistance monitoring
Quarterly classification and summary of bacterial drug resistance data reported by the Department of Laboratory Medicine, to grasp the trend of bacterial drug resistance changes in the hospital, the hospital infection newsletter to inform the top five infections in the hospital bacterial spectrum and drug resistance rate.
5, the current rate of infection survey
Selected period of time to carry out a survey of the current rate of hospital infection, to understand the hospital infection, antibiotic use, microbial sent to the situation.
Second, improve the hospital infection management system
Every six months, a meeting of the Hospital Infection Management Committee was held to discuss the current problems and to propose preventive and control measures based on the existing problems. According to the latest requirements of hospital infection management, the hospital infection management system is revised in a timely manner. Supervise the corresponding departments to make timely revisions to the department's hospital infection management system.
Third, infection management knowledge training
Multi-channel training to improve the awareness of hospital infection prevention and control of health care workers. Quarterly training, training content includes:
1, disinfection and isolation knowledge, hand hygiene, medical waste classification, occupational exposure protection and other key hospital infection management content;
2, according to the country's new hospital infection-related documents to arrange for timely and appropriate training;
3, the pre-service training of the new staff;
4, cleaning staff of the Training includes work requirements, basic knowledge of disinfection and sterilization, cleaning procedures, personal protective measures and hand hygiene disinfection.
Fourth, medical waste management
Regular inspection of the hospital's medical waste classification, weighing, registration, handover, training of relevant personnel to prevent the loss of medical waste.
V. Strengthen academic exchanges on hospital infection management and carry out research on hospital infection.
Actively participate in the national and provincial organizations of the hospital infection management academic exchange activities, if possible, to complete the control of hospital infections related to the subject of research, and continue to apply for new subjects.
2023 Infection Work Plan Part 5
My department, under the leadership of the hospital leadership and the infection management committee, according to the "Hospital Infection Management Code", "Disinfection Technical Specification" and "Infectious Disease Prevention and Control Act" and other relevant documents and regulations, to formulate the appropriate plan for the control of hospital infections and to organize the implementation of timely monitoring of the effect of. Timely monitoring of the effect, timely revision of measures, so that the incidence of nosocomial infection in our hospital is controlled within a better range, no outbreaks of nosocomial infection epidemic. Now the main work of this year is summarized 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, in August this year, re-adjusted and enriched the Hospital Infection Management Committee, the infection monitoring team of the clinical departments, improve the three-tier network management system. In the work, encountered the need for multi-disciplinary coordination and cooperation, timely report to the competent leadership to solve the problem.
2. November in the Infection Management Committee under the initiative of the hospital leadership and support, hospital infection management part of the hospital to join the quality of medical care inspectors, the development of severe rewards and penalties.
Second, the hospital infection monitoring
I am responsible for monitoring the incidence of hospital infections throughout the hospital, regular supervision and monitoring of the hospital environment hygiene, disinfection, sterilization effects, timely summary and analysis of monitoring results, to find out the existence of risk factors for hospital infections, and to find effective prevention and control methods. Through monitoring-control-monitoring, ultimately reduce and control the occurrence of hospital infections and improve the quality of medical care.
1, medical records monitoring
Retrospective survey mode of hospital infection cases (in the case room to check the discharge medical records one by one, to prevent underreporting), a true understanding of the hospital infection rate of our hospital baseline. And at the same time used the form of prospective investigation, down the ward on the key patients throughout the treatment process of follow-up, close observation of the occurrence of hospital-acquired infections, not only to do the process of patient management, but also to the bedside doctor's continuous training, this work has received the desired effect, can be timely detection of hospital-acquired infections, to prevent outbreaks of hospital-acquired infections epidemic.
① infection rate monitoring: 242 people with hospital-acquired infections, the number of cases of infection 250 cases, the infection rate of 1.3%, to achieve the Department of Health requirements ≤ 8%.
② monitoring of the leakage rate: from November our hospital hospital infection management into the quality of medical care management, our leakage rate from 50% down to 16%. It meets the 20% required by the Ministry of Health.
③ Infection rate survey of 1751 sterile incisions in the whole hospital, there were 5 cases of infection, and the infection rate was 0.2%. The infection rate was 0.2%, which meets the requirement of ≤0.5% set by the Ministry of Health
2, the first time to carry out the survey of the current rate
In July, the department carried out a survey of the current rate of inpatient hospitalization. The survey has a hospital sensory department staff responsible for the survey time for three days, *** investigation of 399 patients in the hospital, the actual investigation rate of 98.8%. The survey results showed that the rate of nosocomial infection was 2.76%. Antibiotic utilization rate was 64.4%, and the delivery rate was 3.8%.
3, environmental monitoring
① The hospital environment sampling 366, 346 qualified, qualified rate of 94.5%. Among them, 243 samples were taken from high-risk departments, and 233 samples were qualified, with a qualification rate of 95.8%. General department sampling 133, qualified 128, qualified rate of 96.2%. Key departments hand hygiene sampling 144, qualified 142, qualified rate of 98.6%. For those who do not qualify, timely find the reasons and re-sampling.
③ County Health Supervision came to our hospital on the laminar flow operating room air monitoring sampling 9, qualified 8, qualified rate of 88%.
④ Dialysis fluid sampling for 180, qualified 180, qualified rate of 100%.
⑤ The air sampling method for the laminar flow operating room, labor and delivery room, icu put into use in October, for the first time to use the specific sampling requirements in the "Chinese people's *** and national standards for hospitals clean surgical department building technical specifications gb50333-20xx", the sampling results are in line with the requirements.
4, disinfection and sterilization monitoring
1. Monthly pre-vacuum autoclave effect monitoring of the disinfection room, according to the requirements of the national disinfection norms, b-d test every day, and monthly biomonitoring, to ensure the quality of autoclave disinfection and sterilization. The operating room of the rapid pressure steam sterilizer national sterilization norms require monitoring to ensure the quality of sterilization.
2. Monthly monitoring of disinfectants in use throughout the hospital: *** monitoring 246, qualified 246, qualified rate of 100%. And gradually cancel the surgical ward glutaraldehyde immersion disinfection, the use of pressure steam sterilization.
3. June on the use of ultraviolet lamps for monitoring, the first half of the *** monitoring 79, qualified 75, pass rate of 94.9%. To
4. The hospital used disinfectants and disposable medical devices and items for the record.
5. Antibiotic use survey
Two surveys were conducted throughout the year on the use of antibiotics in the hospital, and the first half of the antibiotic use rate was 80%. Among them, 29.1% for therapeutic use, 69.6% for prophylactic use. i class incision antibiotic use rate of 100%. The pathogenicity rate of patients using antibiotics was 11%; in the second half of the year, the antibiotic utilization rate was 64.4%. Therapeutic use was 30% and prophylactic use was 70%. category i incision antibiotic utilization was 100%. The pathogenicity rate of patients using antibiotics was 13.3%.
Third, to rule out outbreaks of hospital-acquired infections, for the clinical front line to solve the problem.
October 5 to October 8, in three days nicu reported found five cases of children with upper respiratory tract infection, suspected hospital infection outbreak. After the department's environmental hygiene monitoring and medical history investigation, we ruled out outbreaks of hospital-acquired infections, and confirmed the diagnosis of ceftazidime-induced drug fever.
Fourth, actively participate in the hospital building design
1. According to the Ministry of Health, "endoscopy cleaning and disinfection technology code of practice (20xx version)" requirements, with the hospital and the department to complete the reconstruction of the gastroscopy room, bronchoscopy room building.
2. In the new ward building, it is recommended to use inductive faucets, 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; proposed treatment rooms and pharmacy air disinfection of all the dynamic ultraviolet circulating wind sterilizer, also supported and to implement the use of.
3. Active participation in the design of the building and process of the new disinfection supply center.
4. According to the "Medical Waste Management Regulations" in Chapter III, Article 17 of the relevant provisions of the hospital's medical waste temporary storage site has been re-selected, and the specific program and architectural requirements were submitted to the hospital leadership, and was approved by the leadership of the hospital.
V. Strengthen the management of medical waste, standardize the system under the collection.
1. Contribute to the hospital's various departments to determine the medical waste generated by the Environmental Management Division of the specialized staff under the collection of the final implementation of the work, and to complete the collection of specialized staff to carry out the necessary laws, regulations and personal protection training. This makes the process of medical waste management more realistic and reduces the chances of contamination and injury to healthcare workers.
2. Redesigned the medical waste recycling register to facilitate recycling and archiving.
3. In August, our hospital received praise and affirmation from the higher authorities during the special inspection of medical waste by the county health supervision office.
Six, key departments, key parts of the hospital infection management
1. Quarterly sampling of key departments of infection management, found that the problem, take the initiative to communicate with the department head or head nurse and supervise the improvement.
2. Regularly check the central venous catheterization and indwelling urinary catheterization of patients every week, requiring medical staff to avoid unnecessary invasive operations according to the patient's specific condition, and to reduce the number of days the catheter remains in place.
3. After the incident of hepatitis C infection by hemodialysis occurred in the relevant hospitals, the Department of Hemodialysis timely self-correction and self-correction of the room, for the problems detected, put forward corrective measures and supervision. In July, the provincial hall of the hemodialysis room special inspection, our hospital hemodialysis room won the first place in the second level hospitals good results.
4. Disinfection supply center will soon be put into use, through the infection management committee, coordinated the development of the cssd and the operating room of the specific operating procedures for the handover of instruments between the revised cssd each area of responsibility and the standard operating procedures, as well as cleaning, disinfection and sterilization effect of the monitoring
5. Make full use of the network of resources through the website of the Department of Health to download the focus of the department, the focus of hospital infection sop, and down to the hospital. Infection sop, and issued to the corresponding departments and against the implementation.
Seven, multi-channel training to improve the awareness of medical staff hospital infection.
1. New employee training on the 50 new employees on the introduction to hospital infections, medical waste management knowledge training and assessment, the assessment rate of 100%; new interns, nurses, hospital infection knowledge training, so that they have a preliminary understanding of the hospital infection profile;
2. Morning meeting departmental training organic combination, increased the clinical medical staff's knowledge of hospital infection, improve hospital infection awareness.
3. August planning and organization of a "hand hygiene awareness month" activities. The theme of the activity is: "infection prevention and control," "hand" when the brunt. Through the promotional activities, so that everyone recognizes: hand washing is to prevent hospital infections is the most effective, the simplest, the most economical way; set up a correct concept, change the mode of behavior, to provide safe services.
Eight, the use of hospital infection monitoring and data reporting system software
In October, the Department for the first time to purchase the use of hospital infection software system, the hospital's case monitoring, environmental hygiene monitoring and targeting of the monitoring of data analysis, more intuitive science.
Although this year, the work of the Department has made great progress, but there are still some problems:
1. Clinical infection management team did not give full play to their role.
2. Infection monitoring results are not regularly routed to the clinical departments
3. Some clinical departments do not pay enough attention to hospital-acquired infections, the diagnosis of hospital-acquired infections of patients and the lack of analysis of the condition, the hospital infection registry can not be submitted in a timely manner.
4. The use of clinical anti-infective drugs is not standardized, especially in the perioperative period. The rate of pathogenicity of patients using antibiotics is extremely low, suggesting that the use of antibiotics in our hospitals is still misuse or abuse phenomenon.
The new year is approaching, our department will continue to carry out all the work, and for this year's problems, we hereby put forward the preliminary work plan for 20xx.
1. Give full play to the role of the three-tier surveillance network, according to the requirements of the sub-leaders and the Infection Management Committee, to develop the next phase of the control plan. Give full play to the role of the Clinical Infection Management Team and implement training and quality control checks in the department to individuals.
2. Establishment of the hospital infection newsletter: the number of infections in each clinical department, the number of omissions, the number of infections in class i incisions, and hygienic monitoring in the form of "Feedback Sheet" feedback to the clinical departments, the clinical departments to assess, and our department then follow up to check the results of improvement.
3. Do a good job of training in the diagnosis of hospital-acquired infections will be hospital-acquired infections diagnosis and the hospital doctors reported cases, the development of new training courseware, and organize learning.
4. Continue to carry out icu and orthopedic surgical site targeted monitoring, and will be related to the monitoring data to analyze, find out the weakness of infection control, the development of target monitoring plan, link intervention to ensure that the infection control program continues to be effectively implemented.
5. Disinfection supply center in January 20xx put into use, many links, the system needs to be further implemented. In particular, the process management of disinfection, sterilization and traceability system.
6. Develop a monthly plan, weekly arrangements, the day focus on the implementation of the same time to do a good job of record-keeping.
7. Cooperate with the Pharmacy Management Committee, according to the "Jiangsu Province hospital anti-infective drug use management norms", to participate in the rational use of anti-infective drugs in our hospital management.
8. The use of our hospitals to use the electronic medical records of the opportunity, the hospital sensory software loaded into the intranet, the implementation of paperless office.