Annual work plan for hospital infection management (I) 1. Improve the hospital infection management responsibility system, standardize and implement various rules and regulations.
In accordance with the Measures for the Administration of Hospital Infection and relevant national laws and regulations, improve the Hospital Infection Management Committee, further strengthen supervision, and carefully supervise the implementation of various rules and regulations. Effectively prevent and control the occurrence of hospital infection and ensure medical safety.
1, strengthening organizational leadership and establishing a sound hospital infection management system is an important prerequisite for preventing hospital infection.
2, to further improve the hospital infection management committee meeting system, at least once every six months, to study, coordinate and solve problems related to hospital infection management, hold special meetings at any time, give full play to the leadership and decision-making ability of the committee.
3. Further improve the multi-department cooperation mechanism of hospital infection management, actively carry out all the work of hospital infection management, actively cooperate with relevant departments, and coordinate with each other to make hospital infection management scientific and standardized.
4, clinical department hospital infection management team to strengthen management, timely monitoring all kinds of infections, take effective measures to reduce the incidence of nosocomial infection in undergraduate course room. Supervise and inspect the rational use of antibiotics by undergraduate doctors, strictly implement aseptic technical operation, implement disinfection and isolation and standard preventive measures to ensure medical safety.
Second, strict monitoring and supervision.
1. Hospital infection monitoring According to the diagnostic criteria of hospital infection, hospital infection is effectively monitored. Clinicians are required to master the diagnostic criteria skillfully and change the monitoring consciousness of medical staff on hospital infection. Summarize and analyze the monitoring data every month and feed it back to the department in time. Make a written report to the dean and the hospital infection management Committee every quarter, and give feedback to the medical staff of the whole hospital, and report and give feedback in time in special circumstances.
2. Monitoring of disinfection and sterilization effect: monthly monitoring of disinfection, sterilization and environmental sanitation, and regular and irregular random sampling monitoring of disinfectants used in clinical departments, medical staff's hands, object surfaces, indoor air and pressure steam sterilizers.
3, to carry out hospital pathogenic bacteria and drug resistance monitoring, regular feedback to clinical departments, to guide the clinical rational use of antibacterial drugs, improve the treatment level of hospital infectious diseases,
Third, strengthen the management of nosocomial infection in key departments.
1), all personnel should adhere to the rules of hand washing and strictly carry out aseptic operation before and after handling different patients or different parts of the same patient. Hand training once a month.
2) When all kinds of rescue articles and monitoring instruments are used in the conversion, the surface should be disinfected and cleaned, and all kinds of catheters, humidification bottles and oxygen masks should be disinfected and sterilized in a standardized manner.
3) Strengthen the monitoring and prevention and control measures for multi-drug resistant bacteria.
Four, strengthen the implementation of "hand hygiene standards"
Formulate and implement the hand hygiene management system for medical staff, and equip them with effective and convenient hand hygiene equipment and facilities. Strengthen the publicity, education and training activities of hand hygiene, enhance the awareness of preventing hospital infection, master the knowledge of hand hygiene, and ensure the effect of hand washing and hand disinfection.
Five, strengthen the occupational protection of medical personnel.
1, according to the Law on the Prevention and Control of Occupational Diseases and its supporting rules and standards, formulate the health protection system for medical personnel, clarify the competent departments and their responsibilities, and put them in place. Combined with the nature and characteristics of occupational exposure in our hospital, specific measures are formulated to provide targeted and necessary protective equipment to ensure the occupational safety of medical staff.
2. Strengthen the training of occupational exposure knowledge of employees in the hospital, conduct health check-ups for high-risk departments and medical staff in departments every year, strictly implement standard prevention, and do a good job in self-protection. When occupational exposure occurs, strictly follow the principle of occupational exposure treatment, and report, register, evaluate, prevent and treat and follow up regularly as required.
Six, to carry out hospital infection knowledge training, improve the understanding of hospital infection.
1. Strengthen the construction of hospital infection management team. Full-time hospital infection management personnel actively participate in the training courses of infection control and management, strive to improve their professional level and their own quality, and make hospital infection management institutionalized and standardized.
2, the hospital infection knowledge training for all employees to develop hospital infection knowledge training plan, implementation plan and specific measures, held all kinds of lectures and training at all levels. Pre-job training on hospital infection knowledge should be given to new employees, and they can only take up their posts after passing the examination. Through training, the majority of medical staff fully realize the importance of hospital infection, master the basic knowledge and skills of hospital infection, and promote the effective control of hospital infection.
Annual Work Plan for Hospital Infection Management (II) 1. Improve the management system and give full play to its 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, the hospital infection monitoring
1, medical record monitoring:
Control the infection rate and reduce the omission.
2. Environmental monitoring:
Regularly monitor the outpatient environment, air, clothing, hands of medical staff, disinfectants and sterile items.
3, disinfection and sterilization monitoring:
Monitor disinfectants used in general practice every day; 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 the 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.
Annual Work Plan for Hospital Infection Management (III) I. 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.
Annual Work Plan for Hospital Infection Management (IV) In order to improve the quality and safety of hospital medical treatment, reduce the spread of diseases and control the outbreak and prevalence of hospital infection, it is necessary to strengthen the management of hospital infection. Now a 20xx work plan for hospital infection management is formulated.
First, further improve the system and measures of hospital infection control, continue to check the implementation of the system and measures in accordance with the requirements of the evaluation of "Dimethyl" hospital, supervise the infection quality of key departments such as operating room, supply room, delivery room, endoscopy, pediatrics, stomatology, laboratory and hemodialysis room, help control hospital infection, prevent and control the outbreak and prevalence of hospital infection, and regularly check and assess the quality of hospital infection links in various departments of the hospital.
Second, strengthen the training of hospital infection knowledge, and train hospital staff through various forms, so that the staff can understand and pay attention to the importance and necessity of hospital infection management, learn the relevant standards, laws and regulations of hospital infection, master the concepts and operations of disinfection, sterilization and aseptic technology, and the knowledge of "prevention and control" of hospital infection, and organize staff to take the hospital infection knowledge test 1-2 times.
Third, do a good job in the monitoring and management of hospital infection, including the health monitoring and effect evaluation of environment, air, sterile items and so on. , randomly check the health monitoring of key departments such as operating room, supply room and delivery room every month, urge departments to do a good job of disinfection, sterilization and isolation, monitor and evaluate the irradiation intensity of ultraviolet lamps in all departments of the hospital every six months, urge unqualified lamps and disinfectants to be replaced in time, and monitor the intensity of newly purchased lamps and lanterns, which are qualified.
Four, monthly statistics, summary of hospital infection cases in all departments of the hospital, urge clinical departments to report and summarize hospital infection cases, regularly understand the situation of the next department, check medical records for omission investigation, analyze and summarize hospital infection couples, report to the dean and the competent dean in time, report back to all departments of the hospital every quarter, conduct spot checks on outpatient prescriptions every month, check the use of antibiotics, and calculate the utilization rate.
Five, continue to strengthen the management of medical waste, often check and supervise the standardization of medical waste collection, classification and transportation. Standardize the treatment of medical wastes according to the Regulations on the Management of Medical Wastes and other laws and regulations.
Annual work plan for hospital infection management (V) In order to improve the quality of hospital infection management in our hospital, further improve the management of hospital infection and infectious diseases, and ensure the safety of medical care, a 20xx work plan is formulated:
A, hospital infection control:
1. Go to each department every month to monitor the occurrence of hospital infection among inpatients, and urge clinicians to report hospital infection cases in time to prevent the outbreak or prevalence of hospital infection.
2, every month to the operating room, delivery room, hemodialysis room and other key departments of air, surface, staff hands, disinfectants, disinfectants, disinfection and sterilization items such as disinfection effect and environmental hygiene monitoring once. Found unqualified, strict rectification, until the monitoring results are qualified.
3. Every quarter to clinical departments and key departments for a disinfection and isolation quality inspection, feedback the inspection results, put forward improvement measures.
4, according to the requirements of hospital infection monitoring and management this year, with the national hospital infection monitoring and management training base, to carry out cross-sectional investigation of hospital infection.
Second, the application of antibacterial drugs:
1, according to the relevant provisions of the implementation of hierarchical management of antibacterial drugs, regularly investigate the use of antibacterial drugs in inpatients.
2. Assist the clinical laboratory to regularly publish the spectrum of the top five infected bacteria and their drug-resistant bacteria in the hospital, so as to provide a basis for clinicians to use antibiotics reasonably.
Third, infectious disease management:
1, collect infectious disease report cards, death medical diagnosis certificates and residents' malignant tumor report cards from various departments of the hospital every day, and do a good job in reporting the epidemic situation, death and tumor cases in the hospital.
2. Check the collected infectious disease report cards every day to ensure that their contents are complete and true.
3, after receiving the epidemic report card and death report, according to the prescribed time limit, through the national infectious disease epidemic monitoring information system for network direct reporting.
4. At the end of each month, consult the outpatient log of the whole hospital this month, the registration of admission and discharge, the examination results of radiology department and the positive results register of clinical laboratory, and make up the report in time if there are any omissions.
5. Register the death cases with the medical department every month, and report the missing cases in time.
6, conscientiously do a good job in the hospital epidemic management, report and inspection work of the superior health administrative department, and cooperate with the disease prevention and control department to do a good job in epidemic investigation.
Four, medical waste supervision and management:
1, once a month to the hospital clinical support center for inspection, supervise the implementation of medical waste classification, collection, transportation and other systems, to avoid the loss of medical waste.
2. Check the medical waste transfer register once a month, and fill in any missing items in time.
Five, hand hygiene and occupational exposure protection:
1, hand hygiene disinfection will be included in the quality inspection items of the department, and hand hygiene disinfection technology inspection will be conducted for medical staff once every quarter.
2, strengthen the publicity and education of occupational exposure protection knowledge, reduce the risk of occupational exposure.
3. After occupational exposure of medical personnel, they should be properly handled in strict accordance with relevant regulations.
Six, hospital sense knowledge training:
1. This year, we cooperated with new medical and educational personnel and conducted pre-job training on hospital awareness and infectious disease knowledge.
2. Train the medical staff in the hospital twice in different levels to improve their hospital awareness knowledge.