With the development of medicine and the change of medical model, hospital infection plays an important role in hospital management. Hospital infection is not only related to the health of both doctors and patients, but also affects the medical quality of hospitals. With the attention and concern of hospital leaders, various measures have been taken from organization and implementation to strict management system, which has gradually standardized and institutionalized the hospital infection management in our hospital. In order to further improve the management of hospital infection in the future, the hospital infection control work this year is summarized as follows:

First, strengthen organizational leadership; Ensure the smooth development of hospital infection management.

Hospital infection management organization is composed of three levels. Hospital infection management committee-hospital infection management department-hospital infection monitoring group of clinical department, with the business dean as the chairman, focuses on supplementing and adjusting the monitoring group personnel and clarifying the responsibilities of the system personnel at all levels. Hospital infection monitoring personnel at all levels have fulfilled the corresponding functions of hospital infection management, further improving the level of hospital infection management.

Second, carry out education and training as planned to improve the sense of control of the medical staff in the hospital.

(1) On June 25th, the hospital infection diagnosis standard was issued to the inpatient department and the emergency department, with a book for doctors and a review question. The monitoring team studied hard, and on July 6, the department closed the exam, which was invigilated by the hospital department, and ***26 doctors took the exam. Both are above 90 points.

(2) On July 12, medical, nursing and technical personnel, as well as new posts and interns, were trained in "Hand Hygiene Standards and Hospital Awareness Knowledge" and all passed the examination.

(3 3) 10/Oct.2 165438 was organized by the Medical Department, and the hospital sensory department trained medical, nursing and technical personnel in the new edition of the Technical Specification for Disinfection in Medical Institutions, with 85 participants, and finally passed the examination.

(4) The leaders of our hospital attached great importance to hospital infection control, sent the director of hospital infection department, the director of nursing department and the head nurse of operating room to participate in the training of infection knowledge teachers organized by Yangquan Health Bureau, and sent the supply room field to the "Disinfection Supply Center" of Yangquan First People's Hospital for training practice.

Third, the monitoring end:

(1) Assist the clinical laboratory to monitor the air disinfection effect of key departments every month, and other departments once every quarter.

(2) Physical and chemical monitoring of each pot in the supply room, and make records. Unqualified pots shall not be distributed.

(3) The ultraviolet lamp tube shall be monitored once every six months, and the unqualified lamp tube shall be replaced in time.

(4) Each department of hospital infection cases implements the system of zero monthly report, and the department of hospital infection goes deep into each department to investigate the omission every month. This year, * * * admitted 1766 people were infected with 6 people, the infection rate was 0.34%, the rate of missing report was 16%, the directional monitoring of clean surgical incision was 6 1 case, there were 0 cases of infection, and the first-class healing rate of clean surgery was 16%. 294 patients were monitored for catheter-related urinary tract infection, and the infection rate of 2 patients was 0.68%. The qualified rate of disinfection for conventional instruments is 100%, and the implementation rate of disinfection for one person, one needle and one tube is 100%.

(5) In June165438+1October 65438+May, the Municipal Center for Disease Control and Prevention conducted annual environmental sanitation and disinfection and sterilization effect monitoring on the key departments of nosocomial infection in our hospital.

(6 6) 10/Oct. 27th 165438 Investigation on the prevalence of inpatients. There were 29 inpatients and 28 people were investigated, and the actual investigation rate was 96.6%. The survey results show that the prevalence rate is 3.45%, the rate of missing report is 0%, and the utilization rate of antibacterial drugs is 72.4%, which is higher than the standard of 60% of the Ministry of Health.

(7) Collect and count the relevant data of hospital infection monitoring every month. Make monthly summary, quarterly feedback (quarterly briefing) and annual summary.

(8) Cooperate with the Department of Prevention and Care, pay a telephone call back to the hospitalized patients, ask for their opinions, and the satisfaction rate of% brings greetings to the patients, and at the same time, the cases of surgical incision infection can be found in time.

Fourth, strengthen the management of medical waste:

Cooperate with the Logistics Support Section to strengthen the daily supervision and inspection of medical waste, and ensure that the collection, classification, handover, registration and incineration of medical waste in our hospital are carried out in a standardized manner under the existing conditions, and there is no loss and leakage of medical waste. In particular, cooperate with the clinical laboratory to track and deal with each bag of expired blood, and no bag is lost to cause adverse events.

Five, the implementation of the system, check in place:

Do a good job in daily work, cooperate with the comprehensive target inspection of the hospital, refine the standards, report the inspection results at the regular meeting of the director of the department, and rectify the deficiencies.

Six, the management of occupational protection of medical staff:

Strengthen the safety management of medical staff to prevent occupational exposure such as sharp instrument injury. Starting with the use of hand hygiene and protective equipment, the occupational protection awareness of medical staff has been improved. Annual occupational exposure 1 case, no menstrual infectious disease infection. Existing problems:

1. According to the management standard of hospital disinfection supply center, the supply room of our hospital is in urgent need of replacement. The inspection of the superior department has been put forward many times, and the nursing department has also sent people to study it.

2. Construction of bacteria room in clinical laboratory.

3. Sewage treatment.

In a word, some hidden dangers of infection in our hospital are still very serious. We firmly believe that hospital infection control can be done well as long as leaders attach importance to it and our functional departments cooperate and perform their duties.