Infection work plan collection of 6
Life between heaven and earth, if a white horse passes by, suddenly, our work has entered a new stage, in order to have a better growth in the work, at this moment need to do a detailed plan for the next work. I believe that we are worried about writing a plan, right? The following is my collection of infection work plan 6, just for reference, we take a look at it.
Infection work plan Part 1
First, to strengthen the hospital infection management system, and according to the relevant national laws, regulations, rules and norms, routine requirements to carry out their work.
1, the hospital's various types of personnel prevention, control of hospital infection management knowledge and skills training, assessment, training and assessment at least once a quarter.
2, to further improve the rules and regulations on the prevention and control of hospital-acquired infections, and its implementation of inspection and guidance.
3, to further improve the hospital infection management team's responsibilities, and supervise its fulfillment.
Second, to strengthen the monitoring and supervision of hospital infections
1, monitoring, analyzing and feedback on hospital infections and their related risk factors, and put forward measures for the problem and guide the implementation.
2, investigation and analysis of the occurrence of hospital infections, analyze every six months, and report to the Hospital Infection Management Committee, actively take measures to control hospital infections, hospital infections occurring raw rate of 7%.
3, the hospital infection incident report and investigation and analysis, put forward control measures, and coordination and organization of relevant departments to deal with.
4, actively carry out hospital infection underreporting rate survey, quarterly survey, and the results of timely feedback to the Hospital Infection Management Committee and the relevant departments, underreporting rate should be 20%.
5, clinical departments, hospital infection management section in accordance with the "Hospital Infection Management Measures" requirements of the time limit for timely reporting of hospital infection cases to the higher authorities.
6, according to the "Hospital Infection Management Measures" requirements, do a good job of environmental hygiene, disinfection and sterilization effects and other monitoring.
7, the hospital infection management committee on the purchase of disinfection medicine, single-use medical and health supplies supervision and management of such supplies purchased by the hospital to audit the product copies of relevant documents to save.
8, the hospital's cleaning, disinfection and sterilization and isolation, aseptic technology, medical waste management and other work to provide guidance.
9, the infectious diseases of the hospital infection control work to provide guidance.
10, members of the Hospital Infection Management Committee actively participate in the Pharmacy Management Committee on the management of the clinical application of antimicrobial drugs.
Third, to strengthen the key departments of the supply room, maternity ward, operating room hospital infection management, in accordance with the relevant laws and regulations of the country system to develop the key departments of prevention, control of hospital infection system, and conscientiously implement, supervise.
Fourth, to improve the awareness of hospital infection control, strengthen the medical staff's own protection, to prevent hospital infections in the first place.
1, strengthen the medical staff's awareness of prevention and knowledge of relevant laws and regulations of the training efforts.
2, strictly require medical staff to implement aseptic technology operation, disinfection and isolation work system, hand hygiene, hand disinfection norms and mandatory management.
3, strictly require medical staff to implement standard precautions, try to avoid infection due to occupational exposure.
4, under the guidance and strong support of the Hospital Infection Committee, focusing on the clinical implementation of measures in the management of hospital infections, in order to manage the prevention and control of hospital infections by law, to prevent hospital infections in the first place.
Infection work plan Part 2
20xx Hospital Infection Office will be in accordance with the hospital's work objectives, conscientiously fulfill the function of management supervision, and strive to do a good job in the management of hospital infections.
I. Strengthen quality control, to eliminate the occurrence of outbreaks of hospital infection.
1, give full play to the role of the three-tier hospital infection management system, especially the role of the departmental surveillance team members, through the strengthening of hospital infection diagnostic standards training, the conscientious implementation of the hospital infection case reporting and monitoring system, and adhere to the "early discovery, early reporting, early control" principle, to eliminate the occurrence of hospital infection outbreaks. The company's website has been updated with the latest information about the company's website, including a list of its products and services.
2, the implementation of the hospital infection management meeting system, held quarterly meetings of the hospital hospital infection management committee to discuss and solve the difficult problems encountered in the management of hospital infection, summarize and arrange the work. Supervise the clinical departments to convene regular meetings of the departmental hospital infection management team to discuss and analyze the problems in the management of hospital infection in the department, to develop corrective measures, and actively rectify the situation.
Second, continue to carry out various hospital infection monitoring work
1, continue to carry out hospital infection environmental hygiene and disinfection and sterilization effect monitoring of the hospital's key departments, departments, such as maternity wards, operating theaters, disinfection and supply rooms, intensive care medicine, etc., the air, the surface of the object, the hands of the medical staff, the sterilized items, disinfected items, Sterilizers, disinfectants and pressure steam sterilizers are routinely monitored.
2. Continuously carry out targeted monitoring, including monitoring of ventilator-associated pneumonia, catheter-associated urinary tract infections in the intensive care unit, and monitoring of surgical site incision infections.
3, strengthen the hospital infection monitoring, hospital infection office full-time staff weekly in-depth clinical departments to collect information, monitoring, statistics on the incidence of hospital infections, to carry out a survey of hospital infection incidence rate once a year, to complete the statistics of hospital infections, summarize, analyze and report, and timely feedback to the clinical departments.
4, continued to carry out multi-drug-resistant bacteria monitoring by strengthening supervision, strengthen the awareness of each department of pathogenicity monitoring, improve the rate of delivery; timely record of microbiology laboratory positive results, early detection of multi-drug-resistant bacteria trends, the hospital's pathogenic bacteria resistance analysis, to provide a basis for rational clinical use of drugs.
Third, the hospital infection knowledge training, improve the awareness of hospital infection prevention and control
1, hospital infection management staff actively participate in the training courses on hospital infection control and management, and strive to improve the business level and their own quality, to improve the level of hospital infection management.
2, the development of hospital infection knowledge training program, held throughout the year hospital infection management knowledge training 4 times. For the training content, the knowledge of hospital infection management test 2 times. 20xx year plan to print a quarterly "hospital infection newsletter", publicize hospital infection management, feedback monitoring information. Through training, the majority of medical staff to master the basic knowledge and skills of hospital infection management, to promote the effective control of hospital infection.
Four, strengthen the medical staff hand hygiene
Implementation of the medical staff hand hygiene management system, to strengthen the hand hygiene of publicity, education, training activities, to enhance the awareness of the prevention of hospital-acquired infections, the monthly regular or occasional spot check medical staff hand hygiene knowledge mastery, the implementation of hand hygiene, hand sanitization to ensure that hand washing and disinfection effect.
Fifth, the rational use of antimicrobial drug management
Actively assist the Medical Department, Pharmacy Department to do a good job in the rational use of antimicrobial drug supervision and management, and do a good job of clinical, testing, pharmacy, and other departments of the role of the bridge between the laboratory to do a good job of monitoring the pathology of the work of the Department of Statistics quarterly statistics on the clinical departments of the first five hospital infections of the name of the microorganism and drug-resistant rate, and to the clinical departments to do a good job of the monitoring of the disease. The name and drug resistance rate, and drug resistance situation is analyzed, so as to provide more reliable security for the rational use of antimicrobial drugs for clinical.
Six, medical waste management institutionalization, standardization.
The Hospital Infectious Disease Office will give full play to the functions of supervision and inspection, business guidance, professional training, etc. On the basis of completing the daily supervision, we will strengthen the training on laws and regulations, professional technology, safety protection, and emergency treatment professional knowledge for medical staff, cleaners, and staff engaged in the collection, transportation, and storage of medical wastes, so as to prevent leakage and loss of medical wastes, and to make the medical waste management regulations and systems more effective. The hospital's medical waste management rules and regulations have been effectively implemented. design, according to the requirements of hospital infection management, do a good job in environmental hygiene, disinfection and sterilization effect, hand hygiene monitoring, supervision and management of disposable medical supplies, instruments, medicines, strengthen the management of medical waste and wastewater, the focus of the work is to strengthen the publicity of hand hygiene, the management of the rational use of antimicrobial drugs, targeted to put forward the control measures and guide the implementation of the key departments in the center of the infection of the key departments to carry out key supervision, and constantly Increase the key aspects of quality control and continuous quality improvement, thus effectively preventing and controlling the occurrence of hospital infections, no hospital infections and infectious disease outbreaks occurred throughout the year. Now the 2013 work summary is specifically reported as follows:
First, according to the hospital security production requirements to refine the quality of hospital infection management measures?
According to the hospital "safe production" and "quality management" requirements, improve the quality control of hospital infections, refine the quality of hospital infections comprehensive objectives and assessment standards, according to the comprehensive objectives of the supervision and feedback, comprehensive inspection and sorting out of all aspects of the prevention and control of hospital infections. Hospital infection prevention and control of all aspects of the work, seriously checking the safety hazards, in order to ensure the safety of hospital infection, and effectively grasp the hospital infection of key departments, key parts, key links of the management, especially the injection room, stomatology, laboratory, inoculation room and other key departments of the management of hospital infections, and the development of key parts, key links of the prevention and control of hospital infections, the Department of Hospital Infection of the routine supervision and guidance, to prevent outbreaks of hospital infections. The company's website has been updated with the latest information on the latest news.
Second, according to the management requirements of infectious diseases to strengthen the hospital infection prevention and control of infectious diseases?
During the epidemic of hand-foot-mouth and human infection with H7N9 avian influenza, we further strengthened the management of key places such as the pre-screening and triage desk, fever clinic, etc., and conscientiously implemented the requirements of the hospital infection control of hand-foot-mouth and human infection with H7N9 avian influenza, intensified the prevention and control of hospital infection and standardized the work procedures, especially for the medical staff as well as the workforce, to strengthen the prevention and control of hand-foot-mouth and human infection with H7N9 avian influenza and other communicable diseases and self-protection. and other infectious diseases and the prevention and control of their own protection knowledge training, the strict implementation of 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 the epidemic work.
Third, environmental hygiene, disinfection and sterilization effects and hand hygiene monitoring?
The Hospital Infectious Disease Division of the department of the treatment room, laboratory, inoculation room disinfection sterilization effect monitoring, while strengthening the treatment room, stomatology, laboratory, inoculation room and other high-risk areas of the environmental hygiene monitoring and monitoring of hand hygiene of medical personnel. Important collection of air, object surfaces, hygienic hands, disinfectant, sterile items, the qualification rate of 100%.
Fourth, strengthen the management of medical waste to ensure environmental safety?
Hospital medical waste and sewage disposal in strict accordance with the "Medical Waste Management Regulations" and health administrative departments on the disposal of medical waste management regulations, requiring recycling personnel and clinical medical and technical departments to strictly handover, both sides signed, with a double layer of yellow medical garbage bags after closed transfer. The accountability system is implemented to avoid the loss of medical waste and ensure medical safety. Requirements for staff equipped with the necessary personal protective equipment, the clinical departments of medical waste disposal classification, handover registration records, medical waste temporary storage point in line with the requirements, in line with the ? Five precautions The company's website is a good place to find out more about the company's services, and to learn more about the company's services.
Fifth, hospital infection and infectious disease training and assessment
5 hospital infection and infectious disease knowledge training, including the center's medical staff and rural doctors. The contents of the training are: basic knowledge of hospital infection training, hand-foot-mouth disease disinfection and isolation knowledge training, human infection with H7N9 avian influenza hospital infection control and disinfection and isolation knowledge training, hand hygiene standard training for medical staff.
20xx work plan
A standardization and implementation of regulations
In accordance with the "Hospital Infection Management Measures" and the relevant state laws and regulations, to further increase the supervision and conscientiously supervise the implementation of regulations. Effectively prevent and control the occurrence of hospital-acquired infections to ensure medical safety.
Second, strengthen the organizational leadership, improve the hospital infection management committee, and play its decision-making ability
Hospital Infection Committee at least once every six months to convene a meeting to study, coordinate and resolve issues related to the management of hospital infections, and give full play to the committee's leadership and decision-making ability. The establishment of clinical departments hospital infection management team, supervision and inspection of undergraduate physicians rational use of medication and the rational use of antimicrobial drugs, the strict implementation of aseptic technical operations, the implementation of disinfection isolation and standard preventive measures, to protect the safety of medical care.
Three strict monitoring and supervision of work
Sterilization effect monitoring monthly disinfection, sterilization, environmental hygiene monitoring of the clinical departments in use disinfectant, medical personnel's hands, the surface of the object, indoor air, autoclave sterilization kettle on a regular basis and from time to time random sampling monitoring. Problems are found to be rectified in time to improve the quality of medical care. Strictly control the room control, to ensure medical safety.
Fourth, strengthen the key departments of hospital infection management
All personnel should adhere to the rules of hand-washing, in dealing with different patients or different parts of the same patient before and after the need to wash their hands, and the strict implementation of aseptic operation. A variety of rescue items and monitoring instruments in the conversion of the use of the surface should be disinfected, cleaning, a variety of catheters, humidification bottles, oxygen masks, etc. should be standardized for disinfection and sterilization, must ensure medical safety.
V hospital infection and infectious disease knowledge training, improve the awareness of hospital infection
Development of hospital infection and infectious disease knowledge training program, implementation of the program and specific measures, held lectures and training. The new staff to carry out pre-service training on knowledge of hospital infection, and only after passing the examination can they take up their duties. Through training, the majority of medical staff fully recognize the importance of hospital infection work, master the basic knowledge and skills of hospital infection, and promote the effective control of hospital infection. Strengthening the training of all hospital staff on occupational exposure knowledge, providing annual health checkups for medical staff in high-risk departments and divisions, and strictly implementing standard precautions and self-protection for medical staff. When occupational exposure occurs, strictly follow the principles of occupational exposure treatment, reporting, registration, evaluation, preventive treatment and regular follow-up as required.
Six medical waste management institutionalization, standardization
Hospital Infectious Disease Division will give full play to the supervision and inspection, business guidance, professional Oh eh news, etc., in the completion of the daily supervision based on strengthening of medical staff, cleaners and engaged in the collection of medical waste, delivery, storage staff of the hair laws and regulations, professional and technical, safety and protection, as well as emergency treatment of professional knowledge training, to prevent leakage and loss of medical waste is the most important part of the medical waste. Medical waste leakage and loss, is the center of medical waste management rules and regulations are effectively implemented.
Infection work plan Part 4
A hospital infection monitoring:
Adopt prospective monitoring methods, the hospital inpatient infection incidence, monthly clinical monitoring of hospital inpatient hospital infection occurrences, urging clinicians to report hospital infection cases in a timely manner, to prevent outbreaks of hospital infections or epidemics.
Every six months to take a retrospective monitoring method, the discharge of patients for underreporting rate survey. Reduce hospital infection underreporting, and gradually standardize the hospital infection medical record reporting system.
3, 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.
4, 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 Medicine to regularly publish 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's medical staff to carry out hospital infection knowledge training at all levels, 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 knowledge of disinfection and isolation, prevention and control of hospital-acquired infections and 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, we should strengthen the monitoring and prevention of key infectious diseases. Eliminate the occurrence of epidemic spread due to underreporting of epidemics.
VII. Hospital reconstruction and expansion work:
Supply room, operating room reconstruction, should be strictly differentiated between the sterile area, clean area, contaminated area; contaminated items of cleaning, disinfection and sterilization must have a clear circulation route, can not be retrograde; walls, roofs should be smooth and flat, in order to facilitate cleaning and disinfection.
Infection work plan Part 5In order to actively cooperate with the overall work plan of our hospital, better implementation of the "Hospital Infection Management Measures", control and prevention of hospital infections, to protect the safety of medical care, improve the quality of medical care, especially the development of the implementation of this program:
First, improve the organization of hospital infection management in our hospitals, improve and strictly implement the various systems of hospital infection management. Hospital infection management to implement three-tier management. The hospital set up a hospital infection management committee, set up under the hospital infection management section, the clinical medical departments set up a hospital infection control team, by the director or deputy director of the head, each equipped with a monitoring physician and monitoring nurses, to fulfill their duties.
1, according to the personnel changes at any time to adjust the hospital infection monitoring organization, in order to better perform their respective duties, the hospital infection management work better.
2, the implementation of the "disinfection specifications", with the quality of the departments to check the acceptance, do a good job of monitoring the hospital infection.
3, to further play the function of the infection management team, the indicators of serious and systematic monitoring, and will monitor the information reported on time, the monthly monitoring information to summarize, analyze, and find problems, and deal with them in a timely manner.
Second, to further strengthen the monitoring work. Under the leadership of the President, the assistance of the Laboratory and the hospital on the basis of existing conditions, in accordance with the "Hospital Infection Management Code" requirements, continue to do a good job in all monitoring work.
1, strengthen the monitoring of hospital infection cases.
(1) for hospitalized patients to take a prospective survey method for link quality control. And by summarizing and analyzing the information filled in by each monitoring group, calculating the infection rate and discovering the hospital infection . Most frequent sites, high-risk factors, etc., and take active preventive measures to reduce the rate of hospital infection and improve the quality of medical care. The hospital infection rate should be controlled at less than 8%, and the infection rate of one type of surgical incision site should be controlled at less than 1.5%.
(2) monthly random checks on the discharge medical records, the report of hospital infections and omissions to make a retrospective survey to calculate the omission rate, hospital infection omission rate must be controlled at less than 20%.
(3) monthly summary of the information, analyze, put forward measures to improve, and the results of timely feedback to the departments, to guide the clinical infection control work.
2, to strengthen the monitoring of the effect of disinfection and sterilization, sterilization pass rate of 100%. Problems are found in a timely manner to find the reasons and improve.
3, environmental hygiene monitoring.
(1) monthly air monitoring of key departments. Monitoring failed to find the reasons, analysis, improvement, until the standard. (Bacteriology of the material table and the hands of health care workers this year is expected to be able to do the Laboratory)
(2) Hospital Sensory Office of the quarterly sampling of key departments, the monthly operating room, supply room, delivery room, endoscopy room, stomatology and other departments to carry out inspections. Problems are found and feedback is given in time.
(3) Actively cooperate with the Yangquan disease prevention and control department to monitor the key departments of our hospital, find problems and timely analysis and feedback, put forward improvement measures.
(3) The departments continue to strictly implement the disinfection and isolation system, aseptic technology operating procedures, antimicrobial drug management system, medical waste disposal system and other rules and regulations, to reduce the incidence of healthcare-acquired infections and infections of healthcare workers.
Fourth, on-the-job education to strengthen the hospital staff to prevent and control hospital infection awareness. To create a hospital infection "zero tolerance" concept.
1, each section of the organization to study the new "Hospital Infection Management Measures", "Disinfection Technology Specification", "Antibacterial Drugs Clinical Application Guidelines", the Ministry of Health's newly promulgated regulations, documents, etc., to establish a sense of prevention of the standard, standardize their own behavior.
2, hospital infection knowledge training lectures and assessment in the hospital. 2 times a year, 2 times the examination.
3, the organization's new staff to learn about hospital infection-related knowledge and systems.
4 every year in November to do a survey of the rate of current patients.
Infection work plan Part 6
In the new year, under the specific guidance of the director in charge, monitoring as a technology, management as a means, training as a support, according to the "Shandong Province General Hospital Evaluation Standards and Implementing Rules" and the Ministry of Health issued the "Quality Miles" activities in 20xx program as a standard, for the 20xx years of the hospital infection management work in our hospitals deficiencies as well as the higher level of hospitals.
First, do a good job of hospital infection prevention and control of knowledge training and assessment
The hospital medical staff at all levels of hospital infection knowledge training, the development of a systematic training program, to take a variety of forms of training, full training and focus on the training of a combination of centralized and decentralized combination. Strive to achieve on-the-job personnel training rate of 90% or more, hospital infection knowledge test score of 85 or more; and through the bulletin boards, posters and other means of hospital infection knowledge propaganda. Medical staff are familiar with the hospital infection outbreak report and handling process, and gradually create a hospital infection "zero tolerance" concept, all-round, substantial control of hospital infection risk factors.
1. This year, hospital infection management staff to participate in the national, provincial and municipal health departments to organize the hospital infection learning to improve the class, the annual learning time of not less than 15 hours.
2. The new staff, including interns, nurses, advanced students in the basic knowledge of hospital infection training, the time shall not be less than 3 hours.
3. Organize the hospital health care workers to department as a unit to seriously study the Weifang Municipal Bureau of Health issued a "compendium of documents on hospital infection management" and the various rules and regulations of hospital infection management.
4. For different professions and different positions of the specific situation of the personnel, phased in batches of professional training. The main training content for clinicians for infection prevention and control of new developments and new methods, hospital infection diagnostic standards, the rational use of antimicrobial drugs, knowledge of pathogenic microbial monitoring of basic knowledge, etc.; the main training content for nursing staff for disinfection and isolation of knowledge, the prevention and control of infection in hospitals and the classification and collection of medical waste.
5. Theoretical training and examination of basic knowledge of hospital infection for all part-time staff 1-2 times.
6. 1-2 times for the cleaning staff of the work requirements, basic knowledge of disinfection and sterilization, cleaning procedures, personal protective measures and hand hygiene and disinfection of health care workers and other basic knowledge training.
7. new workers on the job after the development of learning plans, in accordance with the hospital training program for three consecutive years of systematic training, closed-book exams twice a year, the pass rate of 100%, the exam failed must be remedial until it reaches a full grasp of so far.
Two, do a good job of comprehensive management of hospital infections and key monitoring
1. In a good job of comprehensive monitoring of the management of hospital infections on the basis of continuing to carry out targeted monitoring in accordance with the norms, focusing on the ICU catheterization caused by urinary tract infections, respiratory related pneumonia, vascular tube caused by the blood flow-related infections, surgical site infections, and so on.
2.
2. Clinicians should master the diagnostic criteria for hospital-acquired infections, and report cases of hospital-acquired infections to the Infection Management Department in a timely manner in accordance with the regulations 24h. Each department should establish and improve the diagnosis of hospital infection cases, registration, reporting, analysis and feedback system.
3. Strengthen the management of multi-drug-resistant bacteria infection cases, especially the management of key departments ICU, the discovery of infection cases, hospital infection department staff to the scene in a timely manner to understand the situation, to help find the reasons for the preventive measures taken to eliminate outbreaks of hospital-acquired infections.
4. For the discharge cases, the hospital infection department carries out random checks from time to time, and finds that the omission of cases, and immediately feeds back to the department to correct, so as not to omit the report, not good report. The annual hospital infection rate is controlled at about 1.5%, to prevent the occurrence of serious infections and outbreaks of epidemic events.
5. The key departments in accordance with the requirements of Shandong Province issued by the frequency of testing, monthly and quarterly environmental hygiene monitoring, monitoring results do not meet the requirements of the timely search for the reasons for the proposed corrective measures.
6. In November for the annual survey of the rate of present illness.
7. disinfectant and sterilizing agents in use: the Infection Management Section conducts quarterly biological monitoring spot checks. Each key department according to the test items, time requirements for microbiological monitoring records. Disinfectants and disinfected items can not detect pathogenic microorganisms; sterilizing agents and sterilized items can not detect any microorganisms.
8. Monitoring of various sterilizers
Pressure steam sterilization: physical monitoring, chemical monitoring and biological monitoring by the supply room. Physical monitoring is carried out per pot and recorded in detail. Chemical monitoring is carried out per package, pre-vacuum pressure steam sterilizer every day before sterilization B-D test, biological monitoring is carried out weekly. Physical, chemical and biological monitoring are conducted after new installation, overhaul and relocation of sterilizers and are qualified for use. Ethylene oxide gas sterilization: physical monitoring per pot, chemical monitoring per package, and biological monitoring per sterilized batch are performed by the supply room. Hydrogen peroxide plasma sterilization monitoring: the operating room is responsible for physical monitoring per pot, chemical monitoring per package, and biological monitoring once a day.
9. Ultraviolet disinfection: daily monitoring of the use of the department daily, lamp intensity monitoring is responsible for infection management section, the use of lamp irradiation intensity monitoring once every six months, its intensity shall not be less than 70 uW/cm2, the use of new lamps before the use of infection management section is responsible for the monitoring of irradiation intensity, shall not be less than 100 uW/cm2.
10. Various endoscopes: infection management section is responsible for the monitoring of various endoscopes each time. Management Section of the various endoscopes monitoring quarterly spot checks,
the use of departments in accordance with the standard requirements of time to monitor. Sterilized endoscopes, and other sterilized items, quarterly biomonitoring, shall not detect pathogenic microorganisms. Sterilized endoscopic biopsy forceps and sterilized items must be biomonitored on a monthly basis and no microorganisms must be detected. Endoscopy rooms may be monitored at any time as needed.
11. Dental instrument monitoring: quarterly sampling by the Infection Management Department, the Dental Department in accordance with the standard requirements for monitoring, disinfectants (including disinfected items) quarterly biomonitoring, sterilizers (including sterilized items) once a month for biomonitoring. Biological monitoring of rapid pressure steam sterilizers is required by the supply room.
12. Blood purification system: Infection Management Division quarterly spot checks, hemodialysis room monitoring according to standard requirements. Monthly monitoring of dialysis water, the total number of bacterial colonies must be <200cfu/ml. endotoxin quarterly monitoring, endotoxin <2EU/ml.
13. Environmental hygiene monitoring of key departments, its pass rate of 98.5%; a variety of sterilizers, disinfectants, disinfectants and sterilizers, disinfectants and sterilizers, medical supplies disinfected and sterilized to achieve a 100% pass rate;
14. "Infection control, hand when the brunt", hand hygiene is the most effective and economical measures to control hospital infections. According to the "medical personnel hand hygiene norms" requirements, further implementation of hand hygiene management system, promote "hand hygiene" concept, vigorously promote the importance of hand hygiene in infection control, actively implement hand hygiene facilities for the department, improve the implementation of hand hygiene compliance of health care workers, supervise the head nurse to receive hand sanitizers, hand sanitizers, hand sanitizers, on a monthly basis, as needed. The Department of Infectious Diseases recommends that hospitals improve hand hygiene facilities as soon as possible, and regularly supervise the hand hygiene work of medical staff for continuous quality improvement.
Three, to strengthen the management of medical waste
2 times a year on the cleaning staff for disinfection and isolation of knowledge and occupational protection training, so that it mastered the basic disinfection and isolation of the hospital knowledge. The whole process of classifying, collecting, packaging, transporting, and disposing of medical waste is subject to enhanced monitoring. Medical waste temporary storage station has a person to manage, record carefully, to do two-way signature, to prevent the occurrence of medical waste management mismanagement caused by a variety of hazards.
Four, single-use sterile medical supplies for the entire management
Infection Management Division ① monthly to the clinical departments for routine supervision and regular spot checks, and take samples to the supply department to request evidence, the documents must be complete and qualified, strict review of the supply manufacturers "four certificates" are complete; "whether or not"; and "the supply of medical supplies", "the supply of medical supplies", "the supply of medical supplies", "the supply of medical supplies", "the supply of medical supplies". "whether complete; ② strict warehouse management, in addition to the requirements of the specified put in place, inventory control at the minimum, to avoid the expiration of the use of disposable items; ③ to strengthen the use of infusion sets, syringes, catheters, etc. management, cleaning staff is responsible for the collection of delivery and preservation of strict registration by the Weifang City Medical Waste Disposal Center unified recycling of disposable sterile medical supplies use and disposal of qualified rate of 100 percent. The use of disposable sterile medical supplies and disposal of qualified rate of 100%.
Fifth, the focus of this year
1. Continue to strengthen the staff's understanding of the importance of hand hygiene, and try to improve the hand washing facilities in key departments, so that they try to meet the standard requirements.
2. The hospital's various departments on their own sterilization of the types of instruments, methods of mapping survey, the establishment of a basic file, the standardization of sterilization methods for instruments, can be used to high-pressure sterilization of surgical instruments do not have to glutaraldehyde immersion disinfection.
3. Continue to strengthen the monitoring and management of multi-drug-resistant bacteria, especially the monitoring and control of key departments and high-risk groups. The establishment of SOPs in line with the reality of our hospital.