Ask the medical department for a year-end summary

First, political and ideological aspects.

Seriously study and practice Scientific Outlook on Development, combine the study and practice of Scientific Outlook on Development with the current hospital infection management and control work and patient safety, and improve our professional ethics and professional technical level. Give priority to prevention, reduce the occurrence of hospital infection, improve the quality of medical care and ensure the safety of patients.

Second, the hospital infection management work

1. The members of hospital infection management committee and clinical department infection monitoring team were adjusted, and the three-level organization was improved. The hospital office will refine the task and implement it to people. Convene hospital infection committee meetings and department infection controller meetings regularly to study and solve the problems in hospital infection management, so as to continuously improve the hospital infection work and fully meet the standards in the inspection and monitoring of higher authorities.

2. Monitor hospital infection with scientific methods. Strengthen the management of nosocomial infection in key departments. ICU, operating room, supply room, delivery room, pediatrics, dialysis center, stomatology and endoscopy room are all key departments of hospital infection management. In normal work, there are not only daily arrangements, but also special personnel responsible. For example, the focus of ICU control is how to reduce the incidence of hospital infection and implement the hospital infection management system in key departments;

3. Adjust the bacterial monitoring items according to the actual working conditions: air, hands, object surfaces, medical supplies and disinfectants in use.

4. To prepare for the evaluation and inspection, a series of evaluation and inspection work were carried out for reference, according to the evaluation standard of grade hospitals and the inspection standard of "medical quality goes to Wan Li Road" and combined with the actual situation of hospitals.

5. Publish "Hospital Infection Management Newsletter" on schedule, and timely report the new information, new knowledge, new trends and new measures of hospital infection management at home and abroad, as well as the hospital infection situation in our hospital.

6. Quality control inspection of hospital infection management: conduct a comprehensive hospital infection inspection for all clinical and medical departments of the hospital every month, carefully analyze and score the inspection results, make clear rewards and punishments, feed back the results to all departments, assist all departments to solve the problems existing in the inspection, put forward rectification opinions and supervise the rectification.

7. Acceptance of superior inspection: The inspection team of "Building a Civilized City" has been inspected by provincial, municipal and district CDC for many times and has been well received by the expert group.

8. Seriously complete the health emergency work temporarily arranged by the health department.

Three, hospital infection monitoring work

1) From comprehensive monitoring to targeted monitoring, full-time staff monitor the incidence, characteristics and risk factors of hospital infection in key populations, key departments and key links according to the professional characteristics of their respective fields. Complete the target monitoring: nosocomial infection monitoring of ICU patients. Ongoing target monitoring: ventilator-associated pneumonia monitoring, surgical incision infection monitoring, urinary tract and arteriovenous intubation monitoring, and hospital-wide drug-resistant strains monitoring.

2) Check the medical records discharged from clinical departments every quarter, and check 3679 medical records throughout the year. By the end of 10, the incidence of nosocomial infection was 3. 14%, and the rate of missing report was 1.08%. The utilization rate of antibiotics was 365,438 0.88%, the rate of specimen inspection was 23.46%, and the utilization rate of antibiotics in perioperative period was 68.06%.

3) Investigation on the prevalence rate of nosocomial infection 1 1 Investigate the prevalence rate of nosocomial infection. The summary will be completed by the end of this month.

4) Annual sampling number of environmental sanitation and biological monitoring *** 1 122. The qualified rate of air culture is 98.27%, the qualified rate of medical supplies is 80%, the qualified rate of object surface is 73.68%, the qualified rate of medical staff's hands is 88.46%, the qualified rate of hard mirror is 9 1.2 1%, the qualified rate of soft mirror is 100%, and the qualified rate of dialysate is/kloc-0.

5) Epidemic Outbreak of Infection and Monitoring of Special Pathogen Infection There were three epidemic and suspicious outbreaks of infection in the whole year: several patients had fever in endocrinology department and neurology department, and Acinetobacter baumannii infection occurred in rehabilitation department and ICU. Full-time staff can formulate control measures in time according to the epidemic situation of infection and the characteristics of special pathogens, and conduct supervision and guidance to prevent the spread of infection.

6) Ultraviolet intensity monitoring: sampling each batch of newly purchased ultraviolet lamps, and monitoring the intensity of ultraviolet lamps used in clinical departments, medical technology departments and outpatient departments of hospitals. * * * 226 ultraviolet lamps were monitored, and 2 13 lamps were qualified, with a qualified rate of 94.25%. Feedback the results in time and replace them in time.

Fourth, serve the clinical front line.

1. Standardize the methods and steps of surgical hand washing and hand disinfection, and isolate signs, which is beneficial for surgeons, advanced students and interns to wash, disinfect and protect their hands correctly.

2. Solve the difficulties encountered by clinical departments in time, provide technical guidance for the problems existing in clinical departments, and provide new information for clinical reference.

3. Participate in the reconstruction and expansion of the hospital clinic, so as to make its building layout, functional flow and regional division more in line with the isolation requirements and prevent cross-infection in the hospital.

Five, hospital infection management knowledge training

1, 1 Full-time staff attended the national annual conference on hospital infection control and studied for three months. 1, two of them were trained by the provincial hospital infection monitoring center.

2. The hospital doctors, nurses, medical technicians and cleaning staff were trained in the knowledge of hospital infection prevention and control.

3. Train new employees in hospital infection prevention and control and personal protection knowledge. Four. Hospital infection related knowledge training: all medical staff were trained 3 times, new employees were trained 1 time, and cleaning staff were trained 1 time. There were 5 trainings in the whole year, with 600 participants, and the qualified rate was 100%.

4. Design the bulletin board of hospital infection, so as to enhance the popularization of disease prevention knowledge among medical staff, nursing staff and patients.

Scientific research and teaching of intransitive verbs

A total of professional papers 10 have been written this year, of which 5 have been published and 5 are to be published, among which 1 is published in professional core magazines.

Seven. Strengthen the management of medical waste

After several years of exploration, the management of medical waste in our hospital has embarked on the track of standardized management. With the cooperation of the property center, the hospital management office has continuously improved various rules and regulations, strengthened supervision and management, implemented the responsibilities of various personnel, and standardized the management of classification, collection, storage, packaging, transportation and handover of medical wastes in our hospital.

Eight, there are shortcomings

1, lack of coordination with the bacteria room, and the monitoring of drug-resistant bacteria lags behind.

2. Medical staff's hand hygiene compliance needs to be improved.

Nine. 20 1 1 main work contents

1. Revise various systems of hospital infection management, and improve relevant processes (such as SOP for surgical site infection, SOP for prevention and control of nosocomial pneumonia, SOP for hand hygiene, SOP for catheter-related bloodstream infection, and SOP for cleaning and disinfection of ICU environment), so as to standardize and streamline hospital infection management in our hospital and make it more convenient for clinical medical personnel to operate.

1. Carry out targeted monitoring such as ventilator-associated pneumonia monitoring, surgical incision infection monitoring, urinary tract and arteriovenous intubation monitoring.

2. Work closely with the bacteria room and pharmacy department to further improve the prevention and control of hospital infection by monitoring the drug-resistant strains in the hospital.

3, improve the computer hospital infection management system, the implementation of hospital infection online direct reporting, inspection results and microbial detection online viewing, data collection, analysis, improve work efficiency.