Work plan for infection in 2023 1

Combined with the requirements of the superior health administrative department and hospital infection control, in order to improve the quality of hospital infection management in our department, our department has formulated the corresponding hospital infection control scheme according to relevant documents and regulations as follows:

First, improve the management system and play a systematic role.

1, in order to further strengthen hospital infection management, clarify responsibilities, implement tasks, readjust and enrich the infection monitoring team in clinical departments, and improve the three-level network management system.

2. Hospital infection management has been added to the medical quality supervision in our department, and corresponding reward and punishment measures have been formulated.

3. Make monthly plans, weekly arrangements and daily priorities, and make records for the record at the same time of implementation.

Second, hospital infection monitoring.

1, medical record monitoring: control infection rate and reduce missed reports.

2. Environmental monitoring; Regularly monitor the outpatient environment, air, clothing, hands of medical staff, disinfectants and sterile items.

3, disinfection and sterilization monitoring: daily monitoring of disinfectants used in general practice; Monitor the ultraviolet lamp in use, register the irradiation time and replace it regularly to ensure the disinfection quality. Check the disinfectants and disposable medical instruments and supplies used in our department every week.

4. Antibiotic use survey: regularly check the use of antibiotics by general practitioners to prevent abuse of antibiotics.

Three, outpatient service strictly implement the triage system.

Four, strict implementation of medical waste classification, collection, transportation and other systems to prevent leakage.

Five, multi-channel training, improve the awareness of hospital medical staff.

Six, the occurrence of nosocomial infection report in time.

Seven, take various forms of infection knowledge training: organically combine centralized training with morning meeting department training to increase medical staff's knowledge of hospital infection and improve hospital awareness.

Eight, will hand hygiene and occupational exposure protection issues into the focus of infection control in our hospital, strengthen hand hygiene and occupational exposure protection.

Work plan for infection in 2023 II

In recent years, due to the complexity of diagnosis and treatment, the continuous improvement of medical level and the increase of chronic patients, hospital infection has attracted more and more attention. Although the infection rate is decreasing year by year, how to reduce the hospital infection rate and improve the management level is an important subject of hospital quality management. The infection management office of our hospital will strengthen the management of hospital infection according to the Management Measures for Hospital Infection, the Management Measures for Disinfection, the Regulations for the Management of Medical Waste and the management requirements of key departments of the hospital. The plan is as follows:

1, give full play to the role of clinical department monitoring group, and play the role of guidance, supervision, coordination, monitoring and implementation in the department. The hospital infection system needs to be implemented by this organization. At the same time, they are on-site managers and an important force in the control of infection links, and the illegal operations on site can be corrected in time. Practice has proved that as long as the monitoring team of clinical departments plays a good role, the hospital infection rate is obviously reduced.

2. According to the standard, complete the environmental health monitoring, sterilization effect, disinfectant, air, object surface and hand hygiene monitoring of clinical departments in the whole hospital. Spot-check three key clinical departments in turn throughout the year at least every three months 1 time, and general departments every six months 1 time. The intensity of ultraviolet lamps in clinical departments is monitored once every quarter. Key monitoring departments (operating room, delivery room, neonatal room, endoscopy room, hemodialysis room, supply room, etc.). ) conduct monthly inspection and supervise the rectification.

3. Prospective monitoring method was used to monitor infected cases, and targeted monitoring and epidemiological investigation were carried out. Check the infection rate of inpatients in the hospital and investigate the prevalence rate. And do a good job in the monitoring and analysis of surgical incision, surgical site infection and tracheal catheter-related infection in our hospital, reduce the occurrence of hospital infection, urge clinicians to report hospital infection cases in time, and prevent the outbreak or epidemic of hospital infection.

4, arranged by the medical department or science and education department for hospital staff stratified knowledge training of hospital infection. Strengthen the publicity of hospital infection management knowledge and improve the attention of employees to hospital infection management.

Know each other. Full-time staff attend one or two off-campus trainings to enrich their professional knowledge and skills and improve their professional quality.

5. Strengthen the supervision and management of hand hygiene of medical staff, popularize the important position of hand hygiene in infection control, and improve the compliance of hand hygiene. Hand washing and hand hygiene are assessed once a month, and the unqualified assessment results are included in the performance of the department.

6, cooperate with clinical laboratory to carry out routine hospital infection, drug resistance rate and multi-drug resistant bacteria and bacteria spectrum investigation, and publish the results every six months.

7. Strengthen the supervision and management of hospital sewage treatment and standardized management of medical waste.

8, the establishment of hospital infection monitoring, timely report and feedback to the hospital leaders and responsible persons, and put forward rectification opinions. Complete "Hospital Infection Newsletter" on time every quarter.

Hospital infection management directly affects the hospital's medical safety, medical quality, medical benefits and social benefits, reflects the hospital's management level, and is also an important symbol of the medical ethics quality level of hospital medical staff. At the same time, members of the monitoring team in clinical departments are required to improve their professional quality and technical level and actively carry out their work. Therefore, comprehensive measures must be taken to ensure that disinfection, sterilization and isolation meet the predetermined requirements, so as to prevent and control the occurrence of hospital infection, make the management of hospital infection gradually standardized, institutionalized and scientific, and control the hospital infection rate to the lowest level.

Work plan for infection in 2023 3

A, hospital infection monitoring:

Prospective monitoring method is adopted to monitor the incidence of nosocomial infection among inpatients in the whole hospital, monitor the occurrence of nosocomial infection among inpatients every month, and urge clinicians to report nosocomial infection cases in time to prevent the outbreak or epidemic of nosocomial infection. Retrospective monitoring method was used to investigate the rate of missing report of discharged patients once every six months. Reduce the omission of hospital infection, and gradually standardize the medical record reporting system of hospital infection.

1, disinfection and sterilization effect monitoring and environmental sanitation monitoring

According to the requirements of Technical Specification for Disinfection and Management Measures for Hospital Infection, the disinfection effect of air, object surface, staff hands, disinfectants, disinfectants and sterilized articles in key departments is monitored every month.

2. In accordance with the requirements of "Technical Specification for Hospital Infection Prevention and Control in Operating Places" and "Technical Specification for Infection Prevention and Control in Disinfection Supply Center", strictly do a good job in cleaning, disinfection and maintenance of operating room instruments.

Second, the rational use and management of antibacterial drugs:

According to the Detailed Rules for the Rational Use of Antibacterials and the Measures for the Rational Management of Antibacterials in our hospital, the antibiotics are managed at different levels. Investigate the utilization rate of antibacterial drugs in inpatients every quarter.

Three, supervision and clinical laboratory:

Regularly publish the spectrum of the top five infected bacteria and their drug-resistant bacteria in the hospital, so as to provide basis for clinicians to use antibiotics reasonably.

Four, hospital infection management knowledge training:

Training hospital medical staff on hospital infection knowledge at different levels. The main contents of the training are the new progress and methods of infection prevention and control, the diagnostic criteria of nosocomial infection, and the knowledge of rational use of antibacterial drugs. The main training contents for nursing staff are disinfection and isolation knowledge, prevention and control of hospital infection, and classified collection of medical waste. Job requirements of cleaning staff, basic knowledge of disinfection and sterilization, cleaning procedures, personal protective measures and hand hygiene and disinfection of medical staff.

Five, ward environmental sanitation and medical waste supervision and management:

Regularly supervise the classified collection and disinfection of medical wastes, and supervise and manage the disinfection, destruction, recovery and incineration of disposable medical supplies after use.

Six, infectious disease management:

Do a good job in the management of legal infectious diseases, intestinal clinics and fever clinics as required to prevent the omission and prevalence of infectious diseases. In particular, it is necessary to strengthen the monitoring and prevention of key infectious diseases. Put an end to the spread of the epidemic caused by the omission of the epidemic.

Seven, the hospital renovation and expansion work:

When the supply room and operating room are rebuilt, sterile area, clean area and polluted area should be strictly distinguished; Cleaning, disinfection and sterilization of contaminated materials must have a clear circulation route and cannot be reversed.

Work plan for infectious diseases in 2023 4

20xx is a crucial year for our hospital to accept the "three-level evaluation" and seek development. At the same time, it is also to further improve hospital infection management and ensure medical safety. According to the Management Measures for Hospital Infection, Technical Specifications for Disinfection and other relevant documents and regulations, under the leadership of the competent dean, we will mainly do the following work this year:

A, hospital infection monitoring

1. Comprehensive monitoring: Prospective monitoring method is adopted to monitor the incidence of nosocomial infection of inpatients every month as planned and count the incidence of nosocomial infection of patients in the whole hospital. At the same time, according to the monitoring results, we can judge whether there are clustered cases of nosocomial infection, analyze and investigate the source of infection, and take effective measures to control the transmission route to prevent the outbreak or epidemic of nosocomial infection.

2. Target monitoring

Continue to carry out targeted monitoring of key departments and key populations in our hospital, including targeted monitoring of nosocomial infection in cesarean section, urinary tract infection related to urinary catheter in oncology department, blood flow infection related to vascular catheter in oncology department, ventilator-associated pneumonia in nicu and blood flow infection related to vascular catheter in nicu.

3, disinfection and sterilization effect monitoring and environmental hygiene monitoring

Monitor the disinfection and sterilization effect of the surface, air, staff hands, disinfectants, disinfectants and disinfection and sterilization items in key departments every quarter.

4, bacterial drug resistance monitoring

Classify and summarize the bacterial resistance data reported by the clinical laboratory every quarter, grasp the trend change of bacterial resistance in the hospital, and report the bacterial spectrum and drug resistance rate of the top five infected bacteria in the hospital through hospital infection communication.

5. Prevalence survey.

Select the time to investigate the prevalence rate of nosocomial infection, and understand the nosocomial infection, antibiotic use and microbial test in the whole hospital.

Second, improve the hospital infection management system

A meeting of the Hospital Infection Management Committee is held every six months to discuss the existing problems and put forward preventive and control measures according to the existing problems. According to the latest requirements of hospital infection management, the hospital infection management system was revised in time. Supervise the corresponding departments to revise the hospital infection management system in time.

Three, infection management knowledge training

Multi-channel training to improve medical staff's awareness of hospital infection prevention and control. Organize training every quarter, including:

1, disinfection and isolation knowledge, hand hygiene, medical waste classification, occupational exposure protection and other key contents of hospital infection management;

2, according to the new national hospital infection related documents in a timely manner to arrange the corresponding training;

3. Pre-job training for new employees;

4. The training contents of cleaning personnel include job requirements, basic knowledge of disinfection and sterilization, cleaning procedures, personal protective measures and hand hygiene and disinfection.

Fourth, medical waste management.

Regularly check the classification, weighing, registration and handover of medical wastes in the hospital, and train relevant personnel to prevent the loss of medical wastes.

Five, strengthen the academic exchange of hospital infection management, carry out the research of hospital infection.

Actively participate in the academic exchange activities of hospital infection management organized by the state and the province, complete the relevant research on hospital infection control when conditions permit, and continue to apply for new topics.

Chapter V Work Plan for Infection in 2023

Under the leadership of hospital leaders and infection management committee, according to the relevant documents and regulations such as Hospital Infection Management Standard, Disinfection Technical Standard and Infectious Disease Prevention Law, our department formulated the corresponding hospital infection control plan, organized its implementation, monitored the effect in time, and revised the measures in time, so that the incidence of hospital infection in our hospital was controlled in a good range, and no hospital infection outbreak occurred. The main work this year is summarized as follows:

First, improve the management system and give full play to the role of the system.

1. In order to further strengthen hospital infection management, clarify responsibilities and implement tasks, the hospital infection management committee and the clinical department infection monitoring team were readjusted and enriched in August this year, and the three-level network management system was improved. At work, when there is a need for multi-department coordination, report to the competent leader in time to solve the problem.

2. 165438+ 10, with the initiative of the infection management committee and the support of hospital leaders, the hospital infection management department joined the medical quality inspector in our hospital and formulated severe reward and punishment measures.

Second, the hospital infection monitoring

Our department is responsible for monitoring the incidence of nosocomial infection in the whole hospital, regularly monitoring the environmental sanitation and disinfection and sterilization effect of the hospital, summarizing and analyzing the monitoring results in time, finding out the risk factors of nosocomial infection and looking for effective prevention and control methods. Through monitoring-control-monitoring, the occurrence of hospital infection is finally reduced and controlled, and the medical quality is improved.

1, medical record monitoring

Retrospective investigation mode of nosocomial infection cases (refer to the discharged medical records one by one in the medical record room to prevent missing reports), and truly understand the baseline of nosocomial infection rate in our hospital. At the same time, the whole treatment process of key patients in the lower ward was followed up in the form of prospective investigation, and the occurrence of hospital infection was closely observed, which not only managed the process of patients, but also provided continuous training for doctors in charge of beds. This work has achieved the expected results, which can find hospital infection cases in time and prevent the outbreak of hospital infection.

① Infection rate monitoring: 242 people were infected in hospital and 250 cases were infected. The infection rate was 65,438 0.3%, which met the requirement of ≤8% stipulated by the health department.

② Monitoring of missed report rate: From June 165438+ 10, our hospital incorporated hospital infection management into medical quality management, and the missed report rate dropped from 50% to 16%. Meet the requirements of the Ministry of health 20%.

③ To investigate the infection rate of 175 1 aseptic incision in our hospital, and 5 cases were infected, with an infection rate of 0.2%. It meets the requirement of ≤0.5% stipulated by the Ministry of Health.

2. The prevalence rate was investigated for the first time.

In July, our department investigated the prevalence of inpatients. The investigation was conducted by the full-time staff of the hospital sensory department for 3 days. * * * 399 inpatients were investigated, and the actual investigation rate was 98.8%. The survey results show that the nosocomial infection rate is 2.76%. The utilization rate of antibiotics was 64.4%, and the inspection rate was 3.8%.

3. Environmental monitoring

① 366 environmental samples were taken from the whole hospital, and 346 samples were qualified, with a qualified rate of 94.5%. Among them, 243 samples were taken from high-risk departments, and 233 samples were qualified, with a qualified rate of 95.8%. The general department sampled 133, and qualified 128, with a qualified rate of 96.2%. Hand hygiene sampling in key departments 144, qualified 142, the qualified rate was 98.6%. For unqualified products, find out the reasons in time and re-sample.

③ The county health supervision office came to our hospital to monitor and sample 9 samples of air in laminar flow operating room, and 8 samples were qualified, with the qualified rate of 88%.

④ dialysate sample 180, qualified 180, qualified 100%.

⑤ The air sampling method of laminar flow operating room, delivery room and icu, which was put into use in June+10, 5438, adopted the specific sampling requirements in Technical Code for Building of Clean Operating Department of China People's Hospital (gb50333—20xx) for the first time, and the sampling results all met the requirements.

4, disinfection and sterilization monitoring

1. Monitor the effect of pre-vacuum pressure cooker in disinfection room every month. According to the requirements of national disinfection standards, b-d test is done every day and biological monitoring is done every month to ensure the disinfection and sterilization quality of pressure cookers. Monitor the requirements of national disinfection standard for rapid pressure steam sterilizer in operating room to ensure the sterilization quality.

2. Monitoring of disinfectant use in the whole hospital every month: * * 246 samples were monitored, and 246 samples were qualified, with the qualification rate of 100%. Gradually cancel glutaraldehyde immersion disinfection in surgical wards and adopt pressure steam sterilization.

In March and June, the ultraviolet lamps in use were monitored. In the first half of the year, 79 lamps were monitored, and 75 lamps were qualified, with a qualified rate of 94.9%. correct

4. Put on record the disinfectants and disposable medical instruments and supplies used in our hospital.

5, antibiotic use survey

The use of antibiotics in hospitals was investigated twice throughout the year, and the utilization rate of antibiotics in the first half of the year was 80%. Among them, 29. 1% was used for treatment and 69.6% for prevention. The utilization rate of antibiotics in type I incision was 100%. The pathogenic examination rate of patients using antibiotics was11%; The utilization rate of antibiotics in the second half of the year was 64.4%. Among them, 30% is used for treatment and 70% for prevention. The utilization rate of antibiotics in type I incision was 100%. The pathogenic examination rate of patients using antibiotics was 65438 03.3%.

Third, put an end to the outbreak of hospital infection and solve problems for the clinical front line.

From October 5th, 65438/kloc-0 to October 8th, 65438/kloc-0, nicu reported 5 cases of children with upper respiratory tract infection, which was suspected to be an outbreak of nosocomial infection. After environmental hygiene monitoring and medical history investigation in our department, we ruled out the outbreak of hospital infection and diagnosed it as drug fever caused by ceftazidime.

Fourth, actively participate in hospital architectural design.

1. According to the requirements of the Operating Specification for Endoscopic Cleaning and Disinfection Technology (20xx Edition) of the Ministry of Health, cooperate with hospitals and departments to complete the architectural renovation of gastroscope room and bronchoscope room.

2. When building a new ward building, it is suggested to use an induction faucet, and the key departments should be equipped with dry toilet paper, which has been approved by the hospital leaders and put into use. This measure has greatly improved the hand hygiene compliance of medical staff in our hospital; It is suggested that all the air disinfection in the treatment room and dressing room should adopt dynamic ultraviolet circulating air sterilizer, which has also been supported and put into practice.

3. Actively participate in the design of the new disinfection supply center building and technology.

4. According to the relevant provisions of Article 17 in Chapter III of the Regulations on the Management of Medical Wastes, the temporary storage place of medical wastes in our hospital will be relocated, and the specific scheme and construction requirements will be submitted to the hospital leaders for approval.

Five, strengthen the management of medical waste, standardize the collection system.

1. Promote the full-time staff of environmental management department to finally collect medical wastes generated by various departments in the hospital, and complete the necessary laws, regulations and personal protection training for full-time staff. It makes the management process of medical waste more realistic and reduces the chances of pollution and injury to medical staff.

2. Redesign the medical waste recycling register to promote recycling and archiving.

In March and August, our hospital was praised and affirmed by the higher authorities in the special inspection of medical waste carried out by our county health supervision office.

Six, key departments, key parts of hospital infection management

1. Spot check the infection management of key departments every quarter, find problems, actively communicate with the department director or head nurse and supervise the improvement.

2. Regularly check the situation of patients with central venous catheterization and indwelling catheter every week, and ask medical staff to avoid unnecessary invasive operation according to the specific situation of patients and reduce the days of indwelling catheter.

3. After the incident of hepatitis C infection caused by hemodialysis in related hospitals, our department conducted self-examination and self-correction in the hemodialysis room in time, put forward rectification measures and supervised the problems found. In the special inspection of hemodialysis room in provincial offices in July, the hemodialysis room in our hospital won the first place in the secondary hospital.

4. Disinfection supply center will be put into use soon. Through the Infection Management Committee, the specific operating procedures of handing over instruments between cssd and operating room were coordinated, and the responsibilities and standard operating procedures of each district of cssd and the monitoring of cleaning, disinfection and sterilization effects were revised.

5. Make full use of network resources, download the sop of hospital infection in key departments and key parts through the website of health department, and send it to the corresponding departments for comparison.

Seven, multi-channel training, improve the hospital awareness of medical staff.

1. New employee training: 50 new employees were trained and assessed on the knowledge of hospital infection and medical waste management, and the passing rate was100%; The newly admitted interns and nurses were trained in hospital infection knowledge, so that they had a preliminary understanding of the general situation of hospital infection;

2. Take various forms of infection knowledge training, organically combine centralized training with morning meeting department training, increase clinical medical staff's knowledge of hospital infection and improve hospital awareness.

Plan and organize "Hand Hygiene Publicity Month" in March and August. The theme of the activity is "prevention and control of infection, and" hands "bear the brunt". Through publicity month, we realized that hand washing is the most effective, simple and economical way to prevent hospital infection. Establish a correct concept, change behavior patterns, and provide safety services.

Eight, the use of hospital infection monitoring and data reporting system software.

From June+10, 5438, our department purchased and used the hospital infection software system for the first time, which made the data analysis of case monitoring, environmental health monitoring and target monitoring more intuitive and scientific.

Although the work of our department has made great progress this year, there are still some problems:

1. The clinical infection management team has not fully played its role.

2. The infection monitoring results are not regularly reported to the clinical department.

3. Some doctors in clinical departments do not pay enough attention to hospital infection, and the diagnosis and condition analysis of patients with hospital infection are insufficient, so the registration form of hospital infection cannot be submitted in time.

4. The clinical use of anti-infective drugs is not standardized, especially during perioperative period. The pathogenic examination rate of patients who use antibiotics is extremely low, suggesting that there are still cases of misuse or abuse of antibiotics in our hospital.

The new year is coming, and our department will continue to carry out all kinds of work, and in view of this year's problems, we specially put forward a preliminary work plan of 20xx.

1. Give full play to the role of the three-level monitoring network, and formulate the control plan for the next stage according to the requirements of the leaders in charge and the infection management committee. Give full play to the role of clinical infection management team, and implement the training and quality control inspection of departments to individuals.

2. Establish hospital-acquired communication: every quarter, the number of infected people, the number of missing reports, the number of Class I incision infections, and the hygienic monitoring of various clinical departments are fed back to the clinical departments in the form of feedback sheets, and the clinical departments are assessed, and our department will follow up and check the improvement results.

3. Do a good job in hospital infection diagnosis training. Combined with the diagnosis of nosocomial infection and the cases reported by doctors in our hospital, a new training courseware was formulated and the study was organized.

4. Continue to carry out targeted monitoring in icu and orthopedic surgery sites, and analyze relevant monitoring data to find out the weak links of infection control, formulate targeted monitoring programs, and carry out link intervention to ensure the sustained and effective implementation of infection control projects.

5. Disinfection supply center was put into use in 20xx 65438+ 10, and many links and systems need to be further implemented. In particular to a process management and traceability system for disinfection and sterilization.

6. Make monthly plans, weekly arrangements and daily priorities, and make records for the record while implementing them.

7. Cooperate with the Pharmaceutical Affairs Management Committee and participate in the rational use and management of anti-infective drugs in our hospital according to the management standards for the use of anti-infective drugs in hospitals in Jiangsu Province.

8. Taking advantage of the use of electronic medical records in our hospital, we installed hospital perception software on the intranet to realize paperless office.