Work plan of infection management 1

1. Strengthening the management of hospital infection

According to the relevant contents of hospital infection quality management in the Measures for the Management of Hospital Infection, the Norms for Hospital Infection Monitoring and the Detailed Rules for the Evaluation of Third-level Chinese Medicine Hospitals, and aiming at the problems existing in the inspection and evaluation of the Health Department of the Autonomous Region and the Health Bureau of Yinchuan City in 21xx, the assessment rules of each department will be further revised, and will be assessed at ordinary times according to the assessment rules.

2. Carry out monitoring of nosocomial infection

1. Carry out standardized prospective monitoring of nosocomial infection. Through inquiring the clinical case data of patients with high-risk factors, consulting the bacterial culture results in the laboratory and clinically visiting patients, we can find nosocomial infection cases in time, urge doctors to fill in hospital infection cards, and find clues of suspicious outbreaks in time.

2. Carry out targeted monitoring of surgical site infection, gradually standardize the monitoring of surgical site infection, and feed back information to clinical departments in time to provide reliable information for reducing surgical site infection.

3. Investigation on Clinical Application of Antibacterials

Based on the investigation on the use of antibiotics in inpatients, we tried to monitor the use of antibiotics in inpatients and the use of antibiotics in perioperative period.

4. Carry out a survey on the prevalence rate of nosocomial infection

Cooperate with the national survey on the prevalence rate of nosocomial infection in the national hospital infection monitoring and management training base for 21xx years. In August, a cross-sectional survey of nosocomial infection was conducted for 1 times in September, and the survey results were reported to the national training base for hospital infection monitoring and management.

5, carry out bacterial drug resistance monitoring

strengthen contact with clinical departments and clinical departments, timely find multi-drug-resistant bacteria infection, timely guide and supervise departments to take disinfection and isolation measures to prevent nosocomial infection and outbreak of multi-drug-resistant bacteria.

III. Summary of infection cases and reporting to the hospital infection base

Summarize the discharged cases according to disease classification and hospital infection statistics every month, and report the hospital infection monitoring report to the hospital infection base according to regulations.

Fourth, strengthen the control of hospital infection of multi-drug-resistant bacteria

For key departments and patients, we can find out the infection of multi-drug-resistant bacteria in time by inquiring the test results of bacterial culture in clinical departments, strengthen the supervision and guidance of the control measures of hospital infection of multi-drug-resistant bacteria in clinical departments, effectively control the hospital infection of multi-drug-resistant bacteria and prevent the outbreak of hospital infection of multi-drug-resistant bacteria.

5. Strengthen the monitoring and management of environmental hygiene, disinfection and sterilization effect

1. Monitor the bacterial content in key areas, including operating rooms, dressing rooms in treatment rooms, medical staff's hands, disinfection and sterilization articles and disinfectants and disinfectants in use, 1 times a month.

2. After disinfection and sterilization, gastrointestinal endoscopy, hysteroscopy, laparoscopy and stomatology instruments are monitored 1 times a month.

3. The intensity monitoring of ultraviolet lamps shall be conducted by the department once every six months and recorded, and shall be checked during the monthly assessment.

4. Monitor the concentration of test paper for disinfectants and disinfectants in use (randomly) at ordinary times and during monthly assessment.

assist in analyzing the causes of unqualified departments, put forward rectification measures and strengthen supervision and management.

VI. Strengthening the training of hospital awareness knowledge

1. Taking the department as the unit, the hospital awareness group will carry out the study of hospital awareness knowledge 1 times a month, and the examination will be conducted in the form of questions at the end of the month, so that the training of hospital awareness knowledge can be implemented.

2. Invited experts from other hospitals to come to our hospital and full-time management personnel of our hospital to give 1 lectures on the contents of the third-level hospital evaluation, prevention and control of nosocomial infection, and 1 special trainings on hand hygiene and nosocomial infection.

3. Complete the pre-job training on the knowledge of hospital infection prevention and control for interns, new recruits and other new hospital staff.

VII. Strengthen the management of disinfection medical instruments and supervise the quality of disposable medical supplies

Strengthen the audit of the relevant qualifications for purchasing disposable medical supplies.

VIII. Strengthen the supervision and guidance on the laundry room and sewage treatment

IX. Strengthen the management of medical waste

Strictly supervise all links of classified collection, transportation and centralized temporary storage of medical waste, and strictly prevent medical waste from mixing with domestic garbage to pollute the surrounding environment.

X. Standardizing the work of the supply room

According to the "Operating Specification for Cleaning and Disinfection Technology of Hospital Disinfection Supply Center", cooperate with the nursing department to further standardize the cleaning, disinfection and sterilization of hospital disinfection and sterilization items.

Xi. Outbreaks of nosocomial infection

If there is an epidemic or outbreak of infection, report it immediately and take active measures to prevent and control the spread of the disease.

Work plan of infection management Part 2

According to the Management Measures of Hospital Infection, the requirements of the inspection standard of 21xx provincial management year and the actual situation of our hospital, the work plan of prevention and control of hospital infection in 21xx was formulated.

1. according to the requirements of the latest national laws and regulations, improve and revise the rules and regulations of hospital infection management, and revise the 21xx hospital infection inspection and assessment standards.

2. hold quarterly meetings of hospital infection management Committee, hospital infection expert group and clinical application expert group to discuss decision-making related issues.

3. Training and assessment

1. Make a training plan.

2. Training scope: medical staff, managers, workers and new employees.

3. Training content: hospital infection management, disinfection technical specifications, new laws, regulations and rules and other related knowledge.

4. training time: train the relevant knowledge of hospital infection according to the classification of personnel, reaching 6 class hours per year and 3 class hours before work for on-the-job personnel.

5. In addition to organizing training, we will focus on exams and give appropriate rewards to achieve the purpose of promoting learning.

6, full-time staff to participate in national, provincial and municipal training.

IV. Monitoring work:

(1) Hospital infection case monitoring: comprehensive and comprehensive monitoring

1. Gradually cancel retrospective investigation, focus on prospective investigation, and conduct self-report by doctors, laboratory results, fever, use of antibacterial drugs, interventional operations (such as catheterization, intravenous catheterization), critically ill patients, long-term hospitalized patients, and so on. Based on the monitoring data of retrospective investigation in previous years, the comparison and analysis are made with the data obtained now.

2. Target monitoring: Continue to carry out icu target monitoring, summarize it every month and give timely feedback.

3. through the above monitoring, the hospital infection cases can be found in time, so as to avoid the phenomenon of missing reports and find out the hidden danger of epidemic in time.

4. Summary items: monthly summary of infection rate, first-class incision infection rate, site infection rate, hospital infection sample submission rate, positive rate, etc.

5. Feedback method: send emails to department directors and monitoring doctors every month, and use quality control meetings and online feedback.

(2) Environmental hygiene monitoring, disinfection effect monitoring:

1. Monitor the air, glutaraldehyde, dialysis system, autoclave and endoscope in key departments such as operating room, supply room, obstetrics and gynecology department, pediatrics department, dialysis room and icu once a month, and monitor the salmonella and pathogens on the surface of objects, ventilators, gynecology and pediatrics department. The Hospital Sense Office is responsible for statistics, summary and analysis of all monitoring results, and puts forward rectification requirements for the problems found.

2. Negotiate with the clinical laboratory, and plan the routine or epidemiological investigation of hospital infection to carry out the classified monitoring of bacteria in the air and surface of icu, nicu, operating room and other departments.

(3) Other monitoring related to hospital infection:

1. Monitoring of susceptible population, high-risk factors and infection sites of hospital infection. Supervise and inspect the risk factors of lower respiratory tract infection, such as sputum aspiration (21xx has been changed to disposable materials in October, avoiding operational pollution) and disinfection of ventilator.

2. Strengthen the supervision and management of venous catheterization, and implement the management measures of venous catheterization to avoid the occurrence of vascular related infection.

3. Monitor the residual liquid of fever reaction caused by transfusion and blood transfusion, investigate the transfusion reaction, and take preventive measures for suspicious situations found.

4. Strengthen the inspection of daily work, be good at discovering dangerous goods and dangerous links used by various departments, and monitor the uncertain disinfection effect or possible infection risk factors.

(4) Supervise the clinical pharmacy to formulate the monitoring system of antibacterial drugs, carry out the related monitoring of antibacterial drugs, and temporarily continue the retrospective investigation and rationality evaluation of the rational use of antibacterial drugs by the Hospital Sense Office, and intervene to achieve the purpose of standardizing the rational use of antibacterial drugs in clinical practice.

(5) Drug resistance monitoring should be carried out by the bacteria room of the clinical laboratory, and the monitoring results should be summarized and analyzed to guide the rational clinical experience in drug selection. The hospital infection office emphasizes the clinical improvement of the inspection rate of infected specimens and the correct rate of collecting specimens. According to the summary results of drug resistance monitoring, the rate of community infection samples is low, and the next step is to improve the sample collection rate, especially the sampling rate of patients who use drugs for treatment. Check the sampling rate of therapeutic drugs,

5. Various management work:

(1) Strengthen the work of the hospital infection management team in the department, require a meeting once a month, analyze and discuss the self-examination and rectification of the hospital infection management in the department, and keep records of work and meetings, so as to strengthen supervision and inspection.

(2) Implement the "Disinfection and Isolation Measures for Multi-drug-resistant Bacteria Infection", check the monitoring results of the bacteria room every day, and supervise and inspect the clinical disinfection and isolation work and medication of patients infected with mrsa, vre and other multi-drug-resistant bacteria.

(3) promote the implementation of the "hand hygiene system". Hand washing steps, drying methods, soap, hand sanitizer, faucet, pool quick-drying hand disinfectant, etc.

(4) The implementation of enzyme washing of endoscopes and instruments in all departments of the hospital.

(5) Carry out in-depth review of disposable medical supplies and disinfection products, and truly review before purchasing.

(6) medical waste management: strictly implement the medical waste management system, strengthen inspections such as classification and collection, urge the standardized construction of temporary storage points for medical waste, strengthen the recycling management of disposable medical supplies, and control the supervision and inspection of illegal trading.

(7) management of key departments: strengthen the implementation and inspection of hospital infection management system and disinfection and isolation system in the whole hospital, including outpatient service, emergency treatment, ward, medical technology and logistics, especially the management of clean operating room, hemodialysis, oral cavity, baking room, endoscope, urology, and obstetrics and gynecology outpatient endoscopes, instruments and autoclaves.

(8) Strengthen the management of hospital infection of infectious diseases: Strengthen the prevention and control of human avian influenza in winter, and regularly check whether the fever clinic, intestinal clinic, fever pre-examination and triage office, registration room, pediatric, emergency and respiratory departments have correct procedures for receiving patients with fever, consultation and screening.

(9) occupational exposure protection: strengthen the occupational health and safety education of staff, strengthen the management of occupational exposure protection and the registration, inspection, observation and emergency treatment after occupational exposure, and negotiate with cdc of Pipeline Bureau to handle the free emergency injection of hepatitis B positive exposure.

(11) Pay attention to the new and rebuilt projects of hospitals and put forward reasonable suggestions on hospital infection control in a timely manner.

(11) to be responsible for the consultation and guidance of hospital infection management;

VI. Feedback from supervision and inspection:

Inspection is standardized, institutionalized, comprehensive and focused. Establish inspection standards, and conduct a comprehensive inspection of each department every quarter, without missing any department or item. Repeatedly check the problems found and continuously check the work assigned by the new requirements. Summarize and analyze the hospital infection management and monitoring results, and give feedback to the competent dean and related departments through quality control meetings and online.

Work Plan of Infection Management 3

Medical quality is an important guarantee for the survival and development of hospitals, and hospital infection management is an important part of medical quality management. Prevention and control of hospital infection is an important work in hospital management. Now the work plan of hospital infection management for 211x years is formulated as follows:

1. Revise the items of quality inspection of hospital infection control in the manual of hospital infection work, and conduct quality inspection of hospital infection in all relevant departments every month. Contents include:

1. Implementation of aseptic technology;

2. Implementation of disinfection and isolation;

3. Disposal of medical wastes;

4. Ward management;

5, the implementation of the department hospital sense knowledge training;

6. Registration of antibiotic use;

7. Reporting and handling of nosocomial infection cases;

8. Hand hygiene. And the results of the inspection shall be recorded, analyzed and evaluated, and corrective measures shall be put forward for the existing problems and feedback shall be given regularly.

second, the head nurse and the department director are required to check the quality of hospital sensation once a month, and record the results of the inspection in the hospital sensation manual. If problems are found, they will be rectified in time.

3. Each department shall formulate a training plan for hospital sensation, and require each department to organize the department personnel to study and evaluate it every month in comparison with the content of the training plan for hospital sensation. Everyone is required to master the responsibilities, occupational safety awareness, disinfection and isolation system in the hospital sense work, and make records.

4. Monitor the implementation of various infection management systems, hospital infection management norms and work systems in each department every month and feed back to the department regularly, so that the hospital infection management control rate is > 95%.

5. Periodically collect hospital infection cases from the lower departments, analyze the diagnosis basis, infection site and causes, find out the susceptible population and factors, count the number of infection cases in various departments, calculate the infection rate, check the discharge medical records for missing infection cases, put forward rectification measures and report them to the hospital and departments regularly.

VI. Earnestly implement the antibiotic drug management system, make statistics on the use of antibiotics, analyze and summarize whether antibiotics are reasonable, and try to monitor drug-resistant strains.

VII. Monitor the disinfection and sterilization effect and environmental hygiene in general departments once a month, including: sterile bags, hands, air, disinfectant and substance table, etc. Monitor the disinfection effect and environmental hygiene of sterile bags, hands, air, disinfectant and substance table in maternity wards, supply rooms and operating rooms once a week, analyze and evaluate the monitoring results every time, find out the reasons, put forward corrective measures and give feedback.

VIII. Strengthen the management of medical wastes, and carry out strict collection, classification, packaging, handover, registration, storage and transshipment according to the medical waste management system. It is forbidden to mix domestic waste and medical waste.

IX. Carry out the training of hospital awareness knowledge for employees in the whole hospital, including new employees, interns and cleaning staff, and assess the training knowledge.

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