Time flies, always passing unnoticed, we will usher in a new round of efforts, it is time to do a work plan for the next stage of their work, it is estimated that many people are thinking a lot, but will not write, the following is my collection of 2022 sense of control work plan (General 6), for your reference and reference, I hope it can help friends in need.
2022 sense of control work plan 1The implementation of the Ministry of Health "Hospital Infection Management Code", "Hospital Infection Diagnostic Criteria", "Disinfection Technical Specification" and "Hospital Classification Management Requirements" and other laws, regulations and rules, effective control of the occurrence of hospital infections, to strengthen the management of hospital infections, eliminate medical hazards, to ensure medical safety. In the new year focus on the following aspects of work:
First, strengthen the hospital infection "four rates" of monitoring, control work
1. Reduce the rate of hospital infections, improve the clinician's diagnosis of hospital infections in the medical records of the correct rate and accuracy of hospital infections and underreporting of the incidence of hospital infections to maintain a low level. low level. At the same time to do a good job of prospective medical records survey work, hospitalized patients running medical records hospital infection prospective investigation. Requirements for the department of hospital infection of running cases of timely diagnosis, timely reporting.
2. According to the requirements of the Quality Control Center for Hospital Infection of the Health Bureau: to do a good job of ⅰ, ⅱ type of surgical incision registration and investigation work. Surgical department ⅰ, ⅱ types of surgical incision registration, tracking and investigation.
3. Rational use of antimicrobial drugs, reduce the use of antimicrobial drugs, strengthen the management of the rational use of antimicrobial drugs, and conscientiously implement the "Guiding Principles for the Clinical Application of Antimicrobial Drugs", especially perioperative drugs and antimicrobial drugs grading and management, with the Medical Affairs Department **** with the work to be done.
4. Improve the rate of drug sensitivity test delivery, in order to prevent the production of drug-resistant strains, urge clinicians to infected patients need to use antibacterial drug treatment, in the use of antibacterial drugs before the retention of the corresponding specimens sent to the test. In order to more rational use of antimicrobials, to reduce the production of drug-resistant strains. Strive to increase the rate of delivery in 20xx.
Second, strengthen the standardization of the implementation of key departments
1. In accordance with the requirements of the National Ministry of Health "Hospital Infection Management Measures": the key departments, key links, key processes, risk factors, such as monthly monitoring, and planned target monitoring and routine monitoring, such as: operating room, supply room, hemodialysis, icu, sterile instruments and articles, stomatology, endoscopy, drug exchange and treatment of various departments. The company has also been working on the development of a new system for the treatment of patients with chronic illnesses.
2. High-risk departments, high-risk instruments and items to do monthly sampling for biological monitoring. Such as: operating room, sterile instruments and items; stomatology handpiece, dental drill, endoscopy room biopsy forceps and a variety of luminal scopes, acupuncture needles and sterilizing agents, disinfectants. Such as: glutaraldehyde, povidone-iodine, amyl iodine and so on.
3. The medium-risk instruments and items to do quarterly sampling for biomonitoring. Such as: gastroscopy, enteroscopy, tracheoscopy, laryngoscope, gynecological speculum and so on.
4. The nutritional cafeteria use cooked food board, cooked food knife quarterly salmonella culture. On the restaurant spare eating utensils such as: bowls, spoons, glasses, plates according to the season (May-October) to do E. coli monitoring.
5. Strengthen the monitoring of clinical treatment rooms using ultraviolet disinfection lamps. According to the requirements of the higher level to do Every six months to monitor 1 time, if necessary, at any time to monitor, found unqualified immediately replaced to ensure the effect of disinfection.
Third, to strengthen the knowledge of the prevention of hospital-acquired infections on the staff training
Prevention of hospital-acquired infections of publicity and training is to control hospital-acquired infections is an important work. Quarterly hospital infection prevention and control knowledge training will be carried out, such as antimicrobial drugs or disinfection and isolation of new knowledge lectures; strengthen the professional ethics education, requiring health care workers to have a high sense of responsibility, strict compliance with the operating procedures in the diagnosis and treatment process. In order to cooperate with the clinical control of multi-drug-resistant bacteria, in the new year, we will carry out the training of "multi-drug-resistant bacterial infection, hand hygiene, and the correct retention of specimens", and provide training lectures on hospital infections and disinfection and isolation for the trainees, interns, and new recruits. At the same time, we also provide training on disinfection, isolation and protection to the staff of the hospital. The company's website has been updated with the latest information on the latest developments in the field of hospital infection control.
Fourth, to strengthen, supervise the implementation of the system of laboratory
1. Requirement of the laboratory bacteriological room quarterly on the hospital bacterial culture and scheduling and drug-resistant strains of bacteria summarized, to the Infection Branch feedback, the Infection Branch quarterly in the form of briefings in a timely manner to the clinical department feedback. Medical administration, pharmacy department, can be based on our hospital bacterial variation to guide doctors to the rational use of antimicrobial drugs.
2. Infection of the doctor will be the daily summary of the clinical departments of bacterial culture, drug sensitivity test cultured special drug-resistant bacteria and multi-drug-resistant bacteria: such as methicillin-resistant Staphylococcus aureus (mrsa), vancomycin-resistant enterococci (vre), the production of ultra-broad-spectrum β-lactamases (esbls) bacteria and multi-drug-resistant Acinetobacter baumannii. It is done to supervise the implementation of disinfection and isolation measures for such patients by the chief of each department and the head nurse. According to the bacterial culture, found in clinical departments within a week occurred in the same ward, three or more than three strains of the same species of homologous pathogens immediately investigate the causes of its occurrence, to find the source of infection, the infection pathway, to take effective control measures to prevent the spread of infectious agents and hospital infections outbreaks and epidemics.
V. Strengthen the special drug-resistant bacteria and multi-drug-resistant bacteria infected patients with the use of antimicrobial guidance
Strictly in accordance with the "guiding principles of clinical application of antimicrobial drugs, according to the characteristics of the pathogen variations and drug-resistant status quo, targeted strengthening of antimicrobial drugs and drug-resistant bacteria monitoring and management of the clinical use of antimicrobial drugs. To do a monthly summary of the drug sensitivity test feedback to the clinical departments, for clinicians to provide a reliable basis for the rational use of antimicrobials.
Six, to strengthen the awareness of workers on the protection of occupational exposure, prevention and treatment Do a good job on the missionary work of clinical medical staff, so that the staff of the prevention of occupational exposure attaches great importance to the prevention of occupational exposure to prevent the occurrence of occupational exposure.
VII, to strengthen the response to hospital infections and infectious disease outbreaks to deal with the implementation of monitoring measures, the implementation of our hospital "hospital infections and infectious disease outbreaks emergency response and monitoring measures" of the relevant plans to do:
1. closely with the hospital departments to carry out on-site analysis of the hospital infections and outbreaks of on-site analysis Events and outbreaks on-site analysis and investigation of timely triage of patients, disinfection site, remove the source of infection, cut off the transmission pathway, to protect health care workers, protection of susceptible groups, to take active and effective control measures, disinfection and isolation work, do a good job of disinfection of medical equipment and cotton fabrics, correctly dispose of medical waste, to eliminate the occurrence of cross-infection in the hospital, to ensure the safety of medical care.
2. Sampling of relevant specimens in a timely manner, timely delivery for technical analysis to determine and analyze the types of pathogenic microorganisms, and take appropriate control measures.
VIII, continue to strengthen the management of medical waste Regular and irregular inspection of medical waste classification, management, transfer, etc., found that the problem of timely communication with the integrated office.
IX, strengthen the laundry department cleaning, disinfection and isolation of the guidance and management Regularly to the laundry department to check, so that the laundry department staff to strictly implement the "laundry department of the hospital infection management system" issued by the Infection Division, the clinical infectious diseases patients used cotton fabrics, to do a person to collect, special car transport, first for the first disinfection, then washing. Then wash.
Ten, adhere to the inspection of disposable sterile medical devices and medicines to do every six months to the material section of the purchase of disposable sterile medical devices and items "three certificates" of the inspection and "no heat source" of the "monitoring report, inspection found that there is an expiration date. If any expiration date is found in the inspection, the competent department should be urged to replace them immediately. The pharmacy department and the pharmaceutical factory purchased intravenous fluids to do half a year check "no heat source monitoring report", for clinical medical safety.
XI, strengthen the infection management office staff of their own business learning, and constantly improve the level of professional knowledge, so that the infection control work of our hospital to a higher level.
2022 sense of control work plan 2First, the hospital sense of monitoring the implementation of standardized management
A variety of disinfectants practical, as well as a variety of pollutants items must be strictly in accordance with the "Disinfection Technical Specification" and "Medical Waste Management Regulations" and other regulations for the operation.
Second, adhere to the hospital infection detection
1, fever clinic, intestinal clinic, gynecological examination room, operating room, and outpatient treatment room, monthly air culture.
2, fever clinic, intestinal clinic, gynecological examination room, operating room, and outpatient treatment rooms, quarterly by the Department of Sensory Control to carry out the table of material, hand, disinfectant sampling to do bacterial culture.
3, the clinics and treatment rooms of the ultraviolet lamp every six months for intensity testing.
Three strengthen the disinfection isolation link quality management
1, monthly by the Department of hospital monitoring group on a variety of disinfectant effective concentration, aseptic operation, disinfection isolation system implementation monitoring, inspection.
2, the disposable medical supplies for the special person special management, regular inspection.
Fourth, with the clinic doctors for the rational use of antimicrobial drugs
Fifth, to carry out on-the-job education of hospital sensory
1, the section of the new medical staff and cleaners to carry out the pre-service training
2, a monthly hospital sensory knowledge training
3, the organization's medical staff to participate in the hospital hospital knowledge training and examination.
Six, hospital infection monitoring indicators
1, disposable syringes, transfusions, blood transfusion devices after the use of the disfiguration rate of 100%.
2022 sense of control work plan 3In order to strengthen the management of hospital infections and infectious diseases, improve the quality of medical care, to ensure medical safety. According to the Ministry of Health, "Hospital Infection Management Measures" and grade hospital accreditation standards require the development of my department's work plan this year.
First, the control of hospital infections:
1, according to the "Hospital Infection Management Approach" to develop the "Hospital Infection Management Manual of Duolun County" to increase and improve the organizational system, hospital infection countermeasures, occupational infection countermeasures; preventive norms and emergency response plan and other content.
2, to strengthen infection control in key departments, develop and improve the work system work norms and processes and organization and implementation.
3, listen carefully to the hospital infection management organization in the clinical department management team's recommendations, so that it gives full play to its functions.
4, to carry out the hospital infection case reporting and monitoring work to ensure the accuracy of various types of information, do a good job of summarizing and evaluating the work.
5, efforts to do a good job of disinfection and isolation and aseptic monitoring, strict implementation of the "Disinfection Technical Specification", regular disinfection and sterilization monitoring work.
6, strengthen the supply room, stomatology, operating room, endoscopy room and other key departments of the hospital infection management.
Second, the management of infectious diseases
1, do a good job in the prevention and control of statutory infectious diseases and other infectious diseases, and improve the ability to respond to infectious diseases and public **** health emergencies.
2, to strengthen the reporting of fatal cases, reduce underreporting, improve the quality of reporting
3, to strengthen the registration of outpatient logs in various departments.
4, to further improve the referral of tuberculosis patients, improve the referral rate.
Third, the training work
The year will be the hospital infection management, infectious disease management, public **** health emergencies related to infection management knowledge as pre-service education, in-service education and training focus on the content, the organization of the relevant knowledge lectures.
Supply room power outage emergency measures:
1, the duty officer daily check the power switch and line, timely detection of problems, and timely report to the relevant personnel in charge of the hospital for maintenance and take appropriate measures.
2, such as power sector deployment or maintenance problems within a short period of time can not run in a timely manner to contact the relevant staff of the hospital to enable the hospital small power generation equipment.
3, notify the departments, will be in urgent need of disinfection items for registration.
4, in accordance with the order of urgency for disinfection and sterilization, with the normal operation of the work of the various departments procedures: immediately find the cause of contact with the relevant power sector, notify the departments to register the order, notify the person in charge of the hospital, and actively cooperate with the maintenance of the supply room flooding problem.
Emergency measures:
1, the duty officer daily check whether the water pipe is smooth or rupture, such as breakage in time to notify the hospital logistics staff for maintenance.
2, such as the occurrence of accidental water flow, with the supply room on duty to clean the room clean and timely normal work.
2022 sense of control work plan 4In order to further improve our hospital infection management, seriously implement the "Hospital Infection Management", "disinfection management approach" and other technical specifications, the development of our hospital in 20xx control of sensory work plan.
First, the first half of the year, the second half of the year held a hospital infection committee meeting to strengthen the organization and leadership of the hospital infection work, analysis and discussion of the work of the existing problems, and grasp the implementation.
Second, to strengthen the clinical departments disinfection, sterilization effect of monitoring, evaluation, and make records.
Third, the new development of the control of sensory assessment rules, to complete the quality of the monthly examination, rewards and penalties are clear.
Fourth, strengthen the management of the infection section, improve the work system, process. Do a good job of isolation and treatment of infectious disease patients, and enhance the ability to deal with infectious disease epidemics history of public **** health emergencies.
V. Strengthen the supervision and inspection of key departments such as stomatology, supply room, endoscopy room, operating room, labor and delivery room.
six, complete the annual training of the Control and Sensory Section staff.
seven, to complete the year's pre-service training of new employees.
VIII, to complete the hospital infection related laws, regulations and a variety of Ministry of Health (Department, Bureau) temporary arrangements for various types of training.
2022 sense of control work plan 5In order to further implement the "Hospital Infection Management Measures", "second-class comprehensive hospital accreditation standards (20xx version) Implementation Rules", "Medical Waste Management Regulations", "Health and Planning Commission hand hygiene special work guidance program", "Health and Planning Commission special work guidance program for safe injections" and other relevant provisions, prevention and control of hospital infections, combined with my hospital The actual, do the following plan and organization and implementation.
First, the hospital infection management committee work plan
1, conscientiously implement the Health Planning Commission June 1, 20xx began to implement the 12 hospital infection new norms, the implementation of the "Hospital Infection Management Workbook (20xx revised)" in the hospital infection-related systems, processes, plans, hospital infection management committee members strictly fulfill the supervisory function. Members strictly fulfill their supervisory functions.
2, according to the prevention of hospital infections and hygiene requirements, review the architectural design of the new inpatient building, part of the construction of the sick bay and infectious disease outpatient building design, construction of the basic standards, basic facilities and workflow and comments.
3, according to the "Medical Waste Management Regulations", "Medical Waste Management Measures for Healthcare Institutions", "Centralized Disposal of Medical Waste Technical Specification", review and supervise the construction of temporary storage points so that the basic facilities and workflow in line with national standards.
4, held two meetings of the Hospital Sense Management Committee, in March 20xx, September to complete. In the event of urgent problems at any time.
5, the finalization of the Sensory Control Section 20xx work summary and 20xx work plan, and the implementation of the assessment.
6, the finalization of the hospital infection key departments, key links, key processes, risk factors and the interventions taken. Clearly the director of the department head nurse is the department responsible for the management of hospital infection, give full play to the role of the department hospital infection team.
7, coordinating the work of the hospital infection management team in each department, and timely completion of the hospital work.
8, to complete the directive tasks issued by the superior.
Second, carry forward the results of the second A, strengthen the multi-sectoral collaboration
1, with the Medical Department, Microbiology, Nursing Department collaboration, the implementation of the Baoji City Health Bureau "standardized specimen delivery and prevention and control of multi-drug-resistant bacteria," to promote the work.
2, perioperative (Ⅰ, Ⅱ, Ⅲ incision) management: collaboration with the Medical Department, Pharmacy Department, to strengthen the Ⅰ, Ⅱ, Ⅲ incision preoperative, postoperative antimicrobial drugs reasonable use, strengthen the management of surgical site infection.
3. Strengthen the implementation of disinfection and isolation system: collaborate with the Nursing Department, the Disease Control Section and the General Affairs Section to strengthen the cleanliness and disinfection of the patient rooms, treatment and examination rooms, and to implement the disinfection and isolation system, in order to reduce the colonization of multi-drug-resistant bacteria.
4. Collaborate with the Information Section to improve the hospital infection monitoring software, communicate and modify problems in a timely manner, and regularly publish infection dynamics and knowledge of prevention and control.
5, in collaboration with the Pharmacy Department, Medical Department, participate in the rational use of antibiotics, prevention of secondary infections occur.
6, in collaboration with the General Affairs Department and the Defense Department, to strengthen the management of medical waste and waste products, and strengthen the management of the janitorial guards to prevent the loss of medical waste or illegal trade.
7, in collaboration with the Procurement Division, to strengthen the management of disposable medical supplies and disinfection of medicine and equipment, and eliminate the use of substandard products in the hospital. And supervise their use, maintenance and after-use treatment.
Third, consolidate the results of the second review, and continue to improve the problem
1, improve the medical waste management missing
(1) the implementation of the Baoji Municipal Bureau of Health Bureau of Medical Waste Management "conference spirit, to strengthen the management of medical waste, and the development of the Baoji company and full-time medical waste collectors responsible for the contract with the penalties, in order to Clear duties to implement the responsibility.
(2) and the Department of Pathology cooperation to draw up a chemical waste disposal registration form, requiring the use of waste 95% alcohol, 3% hydrogen peroxide, xylene, formaldehyde, etc. and the disposal of waste for the handover of the registration, the hospital section of the implementation of the supervision and inspection; and Shaanxi Xintiandi Medical Waste Disposal Company to sign a contract for the disposal of hazardous chemical wastes.
(3) to the medical waste temporary storage point equipped with refrigerators, specializing in the preservation of cases of sexual waste and placenta, and signed a contract with the crematorium, regular incineration of pathological waste.
(4) Revision of the roadmap for the collection of medical waste and the process of classifying and treating medical waste, and the production of eye-catching signs for the new temporary storage points to standardize the temporary storage of various types of medical waste.
2, the implementation of hand hygiene in the third year of continuous improvement program
(1) hand hygiene facilities set up and supplies configuration qualification rate of ≥ 80%, the key departments of hand hygiene facilities set up and supplies configuration qualification rate of 100%;
(2) hand hygiene training of medical personnel coverage of 100%; hand hygiene knowledge ≥ 90%;
(3) hand hygiene for medical staff compliance Rate of hand hygiene ≥ 60%, hand hygiene correct rate ≥ 75%, of which, the focus of the department compliance rate and correct rate of 75% and 90% or more;
(4) in-depth analysis of the correlation between the use of hand hygiene products and supplies and the rate of compliance with hand hygiene, to explore the use of hand hygiene products and supplies in line with the actual norms;
(5) the implementation of the Department of the good incentives and notification of commendation.
(6) Formulate a summary report and develop a continuous improvement program for the next 3 years.
3, to strengthen the management and monitoring of high-risk factors
(1) organization of key departments in charge, the use of enumeration, brainstorming, score method of risk assessment of hospital infections, hospital infections by the risk of high and low sequential order, to determine the priority or high-risk items and the development of targeted control plans and measures.
(2) key departments, such as the supply room, stomatology, hemodialysis, neonatology, operating room, intensive care medicine, endoscopy room, neurosurgery, etc. require the strict implementation of the department's hospital infection management system, to strengthen the cleanliness and disinfection of the instruments, environment, and surfaces of the objects; key populations, such as the critical, the elderly, neonates, radiotherapy and other patients in a timely manner to detect and report cases of hospital infections in order to take preventive and control measures; key groups, such as critical, elderly, newborn, radiotherapy and other patients in a timely manner. Take preventive and control measures; key parts, respiratory tube, indwelling urinary catheter, deep arterial vein tube, surgical sites, etc. to strengthen the implementation of relevant infection norms and measures; hospitals and departments to strengthen the inspection, the existence of problems in a timely manner to analyze and rectify.
(3) the use of tracking method, PDCA, cause and effect diagrams and other quality management tools, regularly or randomly on the implementation of a variety of systems and measures to check, through the phenomenon to see the essence of the problem to achieve the purpose of finding problems to solve the problem.
(4) Strengthen the monitoring of the effect of disinfection and sterilization, quarterly testing of sterilized instruments, disinfectant in use, disinfected items, to ensure that the quality of disinfection and sterilization is up to standard, to ensure medical safety.
(5) the implementation of the quarterly hospital infection quality assessment feedback sheet, half a year to produce a "hospital infection newsletter" a period of time, the content of which includes the quality of the sensory control supervision, the monitoring indicators, hand hygiene, the implementation of key parts of the infection measures, etc..
Four, play "real-time sensory control monitoring software" role, target monitoring full coverage
1, continue to carry out in the Department of Neurosurgery, "hospital-acquired pulmonary infection" monitoring, specialists are responsible for, and regularly go to the hospital district to guide and supervise the implementation of "hospital-acquired pulmonary infection" cluster preventive and control measures, "hospital-acquired pulmonary infection", "hospital-acquired pulmonary infection" cluster preventive and control measures. The hospital-acquired lung infection" cluster prevention and control measures to reduce the incidence of lower respiratory tract infections in neurosurgery patients.
2, continue to implement the early warning mechanism for the prevention and control of multi-drug-resistant bacteria, the implementation of disinfection and isolation system, a person is responsible for the daily computer "real-time case monitoring" or go to the microbiology room to learn about the MDRO detection situation, and regularly go to the hospital district to guide and supervise the implementation of the early warning, bedside card marking, isolation of the doctor's orders, the standard precautions to prevent cross-infections. The company's website is a great source of information on cross-infection.
3, four quarters to carry out the infection rate survey, timely grasp of the hospital infection rate, incidence rate, specimen delivery rate and antibiotic use rate, for the prevention and control of hospital infections to provide a scientific basis.
4, ICU to carry out ventilator-associated pneumonia, catheter-related urinary tract infections, blood catheter-related bloodstream infections in the monitoring of the three tubes, the implementation of the three key parts of the infection management process and preventive control measures.
5, different weight neonatal hospital infection monitoring, specialists are responsible for, regularly go to the ward to implement neonatal hospital infection prevention and control measures.
6, hospital infection case monitoring, specialists are responsible for the daily computer "real-time case monitoring", every day to urge doctors to deal with infection early warning information, found that the hospital infection hidden danger, timely treatment and notification.
Fifth, strengthen the knowledge of infection control training
1, continue to carry out hospital infection prevention and control capacity building tour
In order to closer to the clinical work, service in the clinic, to promote the implementation of sense of control measures, continue to focus on the characteristics of the different key departments of the sense of control and prevention of disease focus on the step-by-step intensive care unit, neonatal, endoscopy room, hemodialysis room, neurosurgery, and the prevention and control of disease. In order to further serve the clinical work and promote the implementation of sense control measures, we will continue to focus on the sense control characteristics and disease prevention focus of different key departments, and step by step to the intensive care unit, neonatology, endoscopy, hemodialysis, neurosurgery, and laboratory to explain the interpretation of the new norms of hospital-acquired infections, hospital infection standard prevention, multi-drug-resistant bacterial prevention and control, occupational protection against blood-borne diseases, catheter-related infections, hospital-acquired pulmonary infections, prevention of surgical site infections, hand hygiene, and commonly used instrument cleaning and inspection methods. The first is to make a presentation on the subject, and the second is to make a presentation on the subject.
2, clinicians, nursing, medical technology and janitorial staff training
(1) Physicians, nursing and medical technology staff training this year, focusing on the interpretation of the new norms of hospital infection released by the industry, disinfection and isolation of knowledge, hand hygiene, medical personnel occupational health, medical waste disposal and multi-drug-resistant bacteria in the prevention and control of hospital infections in the training time of not less than 4 hours.
(2) work cleaning staff training focuses on daily cleaning and disinfection of patient rooms, disinfectant configuration, cleaning utensils partition use, medical waste classification and disposal methods, personal protection methods and other training.
(3) the form of training and assessment methods
① Quarterly by the Department of hospital monitoring team leader to organize the department staff to carry out hospital sensory-related knowledge learning, quality control assessment based on the department's learning records to ask questions, the Sensory Control Section spot checks, the end of the quarter and the Department of the performance appraisal linked.
② training organized by the hospital, invited provincial and municipal experts to our hospital for the whole hospital medical staff to carry out "multi-drug-resistant bacterial infection prevention and control and the rational application of antimicrobial drugs," a lecture.
3, full-time staff training
(1) full-time staff to participate in the national and provincial hospital infection management knowledge training time of not less than 16 hours, in order to grasp the latest information on the prevention and control of hospital infection dynamics.
(2) the establishment of the Department of sensory control learning program, every Saturday morning, every Monday afternoon by the Department of quality control officer to organize the main lecture or self-study, learning content for the hospital infection-related laws and regulations, grade hospital accreditation should be aware of the handbook should know, 24 medical channel, people assured that the model hospital network, sensory control PIUS, Shanghai International Hospital Infection Control Forum, sensory control books and other content.
(3) rotating selection of key department heads, monitoring doctors and nurses, to participate in the provincial and municipal short-term training courses 1 ~ 2 times a year.
2022 sense of control work plan 6First, strengthen quality control, to eliminate the occurrence of outbreaks of hospital infections
1, give full play to the role of the three-tier hospital infection management system, in particular, the role of members of the departmental surveillance team to strengthen the diagnostic standards of hospital infections through the training of hospital infection diagnostic standards, and conscientiously implement the reporting of hospital infections and monitoring system
1, adhere to the "early detection, monitoring," and the "hospital infection" system.
2, further improve the hospital infection management committee meeting system, at least once every six months to study, coordinate and solve problems related to the management of hospital infections, encountered problems at any time to convene a special meeting, give full play to the committee's leadership and decision-making ability. Discussions to 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, and formulate corrective measures, and actively rectify the situation.
Second, continue to carry out the hospital infection monitoring work
1) All staff should wear special uniforms, change shoes, wear a hat inside, minimize the flow of people, strict control of people into the room, visitors should wear a visiting clothes, shoe covers, wear a hat inside.
2) All personnel should adhere to the rules of hand washing, in dealing with different patients or the same patient to get different parts of the front, after all must wash their hands, strict implementation of aseptic operation. Hand culture once a quarter.
3) Each patient used sphygmomanometer, stethoscope, bedside articles, oxygen supply and suction device can not be cross-used with others. Patients must be thoroughly cleaned and sterilized after leaving the room before they are given to others to use.
4) A variety of rescue items and monitoring equipment in the switch to use, the surface should be disinfected, cleaned, a variety of catheters, humidification bottles, oxygen masks, etc. should be standardized for disinfection and sterilization.
5) Strengthen the monitoring of multi-drug resistant bacteria and preventive and control measures.
6) clean surgery after surgery patients admitted to the ICU to take protective isolation measures.
Third, to carry out training in hospital infection knowledge, improve the awareness of hospital infection prevention and control
1, hospital infection management staff actively participate in the hospital infection control and management training courses, and strive to improve their business level and quality, to improve the level of hospital infection management. Make the hospital infection management institutionalized, standardized.
2, the hospital infection knowledge of the whole training to develop hospital infection knowledge training program, the implementation of the program and specific measures to organize various types of lectures and training at all levels. The new staff, advanced training students, interns for pre-service training in hospital infection knowledge, assessment and qualification before taking up their duties. Through training, so that 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.
Four, strengthen the key departments of hospital infection management
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 hospital infection management. Sound hospital infection management responsibility system, standardization and implementation of the rules and regulations in accordance with the "Hospital Infection Management Measures" and the relevant state laws and regulations, improve the hospital infection management committee, and further increase the supervision, seriously supervise the implementation of the rules and regulations. Effectively prevent and control the occurrence of hospital infections, to ensure medical safety.
V. Targeted monitoring
1, ventilator-associated pneumonia and morbidity.
2, central venous catheter-related bloodstream infection incidence.
3. Incidence of urinary tract infections associated with indwelling urinary catheters.
4. Incidence of surgical site infections by infection risk index.
Sixth, strengthen the implementation of the implementation of "hand hygiene norms" to develop and implement the medical staff hand hygiene management system
equipped with effective and convenient hand hygiene equipment and facilities, to strengthen the publicity of hand hygiene, education, training activities, to enhance awareness of prevention of hospital infections, to master the knowledge of hand hygiene, to ensure that the effect of handwashing and disinfection of the hand.
Seven, strengthen the medical staff of occupational protection
1, in accordance with the "Prevention and Control of Occupational Diseases Act" and its supporting regulations and standards, the development of health protection system for medical personnel, clear authorities and their responsibilities, and implementation of in place, combined with the nature of occupational exposure to the characteristics of the hospital to formulate specific measures, to provide targeted, necessary protective equipment, safeguard the medical staff of occupational exposure. The hospital has been able to develop specific measures to provide targeted and necessary protective equipment to ensure the occupational safety of medical personnel.
2, to strengthen the hospital staff to get knowledge of occupational exposure training, high-risk departments and departments of medical staff to provide annual health checkups, medical staff to strictly implement the standard precautions, do a good job of self-protection. When occupational exposure occurs, strictly follow the principles of occupational exposure treatment, according to the requirements of reporting, registration, evaluation, preventive treatment and regular follow-up.
Eight, 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, do a good job of clinical, testing, pharmacy and other departments to bridge the gap between the work of the testing department to do a good job of monitoring the etiology of the work of the clinical department every six months to count the first five of the hospital infections in the name of the microorganism and drug-resistant rate, and to the hospital infection of microbes The name and resistance rate of the top five pathogenic microorganisms of hospital infection in clinical departments are counted every half a year, and the drug resistance situation is analyzed, so as to provide a more reliable safety guarantee for the rational use of antimicrobial drugs in clinics. Strengthening and deepening the management of clean surgical incisions for the preventive use of antimicrobial drugs, and strengthening and improving the correct understanding of clinicians on the prevention of postoperative infections.