Department Hospital Infection Management Work Plan

202 1 year departmental hospital infection management work plan model

Time flies like a blink of an eye. There are new opportunities and challenges ahead. At this moment, we need to start making a work plan. Speaking of writing a work plan, I believe many people are in a state of confusion and internal collapse! The following is a sample of the department hospital infection management work plan I collected for you in 20021year. Welcome to read the collection.

Department Hospital Infection Management Work Plan 1 Combined with the requirements of the superior health administrative department and hospital infection control work, in order to improve the quality of hospital infection management in our department, according to relevant documents and regulations, our department has formulated the corresponding hospital infection control plan 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.

Department hospital infection management work plan II I. Work objectives

1, according to the specifications and technical guidelines issued by the Ministry of Health. Improve and standardize the hospital infection management system in our hospital, and seriously implement it.

2. Hospital infection rate ≤ 10%.

3. The underreporting rate of nosocomial infection is ≤20%.

4. The medical waste disposal rate reaches 100%.

5. The intensity of ultraviolet lamp (old: > > 70uw/cm2；; New: > 90 uw/cm2).

6. The primary healing rate of aseptic incision (≥97%) and the infection rate of aseptic incision (≤0.5%).

7. The qualified rate of disinfection and sterilization reached 100%.

8. The actual investigation rate of nosocomial infection is ≥96%. The prevalence rate of nosocomial infection is ≤8%.

Second, the main tasks and measures

(A) the monitoring of hospital infection

Do a good job in comprehensive monitoring of inpatients, targeted monitoring (surgical site, ICU inpatients), nosocomial infection monitoring of multi-drug resistant bacteria, environmental hygiene monitoring, infectious disease inspection, chronic disease monitoring, annual prevalence survey, etc.

(2) Strengthen quality control inspection and earnestly implement hospital infection monitoring measures.

According to the requirements of hospital infection quality evaluation in Renshou Yunchang Hospital, the quality inspection of hospital infection management was carried out, which provided guidance for hospital cleaning, sterilization and isolation, aseptic technology and medical waste management. Summarize the inspection and monitoring situation and report it to the hospital department every month. Report hospital infection management information to the competent leader, and timely feedback to clinical departments, urge rectification and continuous improvement, and ensure medical safety. Each clinical department conducts self-examination once a month, and records it according to the Self-examination Record of Hospital Sense Monitoring in Departments.

(3) Strengthen the management of nosocomial infection in key departments.

Focus on the inspection of cleaning and disinfection records in supply room, surgical hand brush problems in operating room and aseptic operation in ICU.

Fourth, strengthen hand hygiene management.

According to the Hand Hygiene Standard for Medical Staff, strengthen the hand hygiene training and publicity of medical staff at all levels, and improve their hand hygiene awareness and compliance.

Five, strengthen the training of hospital infection management knowledge.

Go out to study and give lectures in the whole hospital. In the form of learning and self-study in the department, the hospital staff at all levels are trained in hospital infection management knowledge. Pre-job training for new employees.

Six, strengthen the management of occupational protection of medical personnel.

Guide the health and safety occupational protection of medical staff, enhance their awareness of occupational exposure protection, conscientiously implement occupational exposure protection measures, and ensure the occupational safety of employees.

Seven, strengthen the prevention and control of nosocomial infection of infectious diseases.

Seriously guide the prevention and control of nosocomial infection of infectious diseases, strengthen the prevention and control of major emerging infectious diseases, and actively complete the prevention and control tasks assigned by superiors.

Eight, strengthen the hospital disinfection medical equipment and disposable medical supplies audit work.

Regularly check the use level certificate of disposable medical supplies and sterilized medical devices.

Department Hospital Infection Management Work Plan 3 In order to protect the health of inpatients and medical staff, reduce the occurrence of hospital infection and avoid the outbreak of hospital infection, it is necessary to further strengthen hospital infection monitoring this year. The following monitoring plan is specially formulated:

1, monitoring of nosocomial infection incidence

1. 1 During this year, full-time hospital infection staff should continue to go deep into clinical departments and related departments to conduct prospective hospital infection monitoring every month, collect hospital infection case report cards every day, communicate with various departments, verify the diagnosis of hospital infection, and find out the related risk factors that cause infection; Timely discover hospital infection and its clustering, timely analyze the causes of infection, find out the risk factors of hospital infection, and put forward corresponding prevention and control measures to continuously monitor hospital infection events. Minimize the occurrence of hospital infection and avoid the outbreak of hospital infection and suspected hospital infection.

In the second week of each month, we will focus on the investigation of missing hospital infection. After the investigation, summarize the nosocomial infection situation in our hospital and various departments, make statistical analysis on the incidence rate, missed report rate, missed report cases and the distribution of nosocomial infection sites in various clinical departments, put forward corresponding prevention and control measures for departments and sites with high infection rate, and give written feedback to our hospital. Informed criticism and corresponding financial penalties were given to the doctors responsible for missing cases of nosocomial infection.

The hospital infection committee meeting is held once every quarter, and the infection management section reports the hospital infection management and the incidence of hospital infection in this quarter to the hospital infection committee for discussion and research, so as to solve the problems existing in the hospital infection management.

1.2 according to the incidence of nosocomial infection this year, it is planned to investigate the prevalence rate of nosocomial infection among inpatients in the whole hospital in may. Hosted by the Infection Management Section, with the participation of * * * of all subjects, the unified time and form were stipulated, and the prevalence rate of nosocomial infection of inpatients in the whole hospital was investigated according to the unified standard. To understand the prevalence rate and site infection rate of all subjects in the hospital at the same time. So as to master the basic situation of hospital infection in the whole hospital and different departments, as well as the high-incidence departments and parts of hospital infection, find out the risk factors of high-incidence departments and parts, and formulate and take preventive and control measures.

1.3 Hospital infections were monitored in neurosurgical icu, nicu and ricu this year, especially ventilator-associated pneumonia, blood infection caused by intravascular catheter and urinary tract infection caused by indwelling catheter. The infection management department goes to neurosurgery icu, nicu and ricu every week to evaluate the patient's condition and infection. Nurses on duty in neurosurgery icu, nicu and ricu record the time of intubation and extubation of patients who use ventilators, indwelling intravascular catheters and catheters one by one, closely observe the symptoms and signs of infection, make a correct diagnosis in time, find out the risk factors of infection, actively take corresponding control measures, further reduce the hospital infection rate and do a good job in infection monitoring of severe patients.

2, surgical site infection monitoring

In order to further understand the surgical site infection rate of surgical patients; Identify risk factors in time and actively intervene; Effectively evaluate the control effect, reduce the infection of the surgical site, and monitor the surgical site: monitor the surgical site of all patients after gynecological elective and emergency operations. Full-time hospital infection monitoring personnel go to the ward every day to know and register the monitored surgical patients, determine the dressing change time with the surgeon, check the healing of the surgical incision, urge the doctor to send the abnormal incision secretion for inspection, trace the inspection results in time and require the rational use of antibacterial drugs; Check the contact information of each surgical patient, publicize and explain the purpose and method of investigation to surgical patients, contact discharged patients by telephone to determine whether there is infection, input the monitoring data of each surgical patient and make statistical analysis, calculate the infection rate of surgical site, analyze the reasons together with doctors and nurses in departments, and improve, prevent and reduce surgical incision infection.

3. Monitor multi-drug resistant bacteria.

In order to strengthen the hospital infection management of multidrug-resistant bacteria and effectively prevent and control the spread of multidrug-resistant bacteria in hospitals, the target bacteria for monitoring are mrsa, vre, esbls-producing bacteria, multidrug-resistant Pseudomonas aeruginosa and multidrug-resistant Acinetobacter baumannii. So as to urge clinical departments to sample infected patients and suspected infected patients, do bacterial culture in time, and find and diagnose patients infected with multi-drug-resistant bacteria and colonized patients in time. Clinical departments and bacteriology departments should report the confirmed diagnosis of mdro to medical department and hospital infection management department in time. At the same time, the bacteria room leaves a list for the infection management department. The infection management department goes to the bacteria room every day to understand the positive results of bacterial culture and record them, contacts the person in charge of the patient's department to guide the implementation of disinfection and isolation measures, and at the same time issues a notice of disinfection and isolation to guide the relevant departments to implement the prevention and control measures of nosocomial infection with multi-drug-resistant bacteria. For those who fail to implement preventive and control measures due to subjective reasons, they shall be given corresponding economic penalties; The Infection Management Section makes statistics, analysis and feedback on the infection situation of multi-drug resistant bacteria in each department and the implementation of prevention and control measures in each department every quarter; Publish the epidemic situation and drug sensitivity of common pathogens in hospitals every quarter; The bacteria room analyzes the changes and drug sensitivity of drug-resistant bacteria every quarter and gives feedback. The monitoring results were reported at the medical quality and medical safety management meeting.

Department hospital infection management work plan 4- 1. Improve the hospital infection management organization in our hospital, and improve and strictly implement various systems of hospital infection management.

Hospital infection management implements three-level management. Hospital infection management committee is set up in the hospital, with hospital infection management section, and hospital infection control group is set up in all clinical medical departments, with the director or deputy director as the team leader, and each is equipped with a monitoring doctor and a monitoring nurse, who perform their respective duties.

1. Adjust the hospital infection monitoring organization at any time according to the personnel changes, so as to better perform their respective duties and better manage the infection in our hospital.

2. Implement disinfection technical specifications, cooperate with the quality inspection and acceptance of various departments, and do a good job in hospital infection monitoring.

3. Further develop the function of the infection management team, carefully and systematically monitor all indicators, report the monitoring data on time, summarize and analyze the monitoring data every month, and handle the problems in time when found.

The second is to further strengthen monitoring.

On the basis of the leadership of the president, the assistance of the clinical laboratory and the existing conditions of the hospital, we will continue to do a good job in various monitoring work in accordance with the requirements of the "Regulations on Hospital Infection Management".

1, strengthen the monitoring of nosocomial infection cases.

⑴ Using prospective investigation method to control the quality of inpatients. By summarizing and analyzing the data reported by each monitoring group, the infection rate is calculated, the frequent parts and high-risk factors of hospital infection are found, and active preventive measures are taken to reduce the hospital infection rate and improve the medical quality. The nosocomial infection rate should be controlled below 8%, and the infection rate of the first type of operation incision should be controlled below 65438 0.5%.

⑵ Check the discharged medical records every month, conduct a retrospective investigation on the reports and omissions of hospital infection, and calculate the omission rate, which must be controlled below 20%.

⑶ Summarize and analyze the data every month, put forward improvement measures, and feed back the results to all departments in time to guide clinical infection control.

2. Strengthen the monitoring of disinfection and sterilization effect, and the sterilization qualified rate reaches 100%. Find the problem, find the reason in time, and improve in parallel.

3. Environmental health monitoring.

(1) Monthly air monitoring in key departments. When the monitoring is unqualified, find out the reason, analyze and improve until it reaches the standard. The bacteriology of medical staff's articles and hands is expected to be done by the laboratory this year. )

⑵ The Hospital Sense Office conducts spot checks on key departments every quarter, and checks the operating room, supply room, delivery room, endoscopy room, stomatology department and other departments every month. Find problems and give timely feedback.

(3) Actively cooperate with the disease prevention and control department of Yangquan City to monitor the key departments of our hospital, analyze and give feedback in time when problems are found, and put forward improvement measures.

Three, all departments continue to strictly implement the disinfection and isolation system, aseptic technology operating rules, antibacterial drug management system, medical waste treatment system and other rules and regulations, to reduce the occurrence of iatrogenic infection and medical personnel infection.

4. On-the-job education to enhance the awareness of hospital staff to prevent and control hospital infection. Establish the concept of "zero tolerance" for hospital infection.

1. Each department organizes to learn the new Management Measures for Hospital Infection, Technical Specification for Disinfection, Guiding Principles for Clinical Application of Antibiotics, and new regulations and documents issued by the Ministry of Health, so as to establish standard prevention awareness and standardize their own behaviors.

2, to participate in the hospital knowledge training lectures and assessment. Twice a year, twice a year.

3, organize new employees to learn the knowledge and system of hospital infection.

4. Conduct a prevalence survey every year from June 65438 to/kloc-0 to October 65438.

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