A, hospital infection management system
(a) the establishment of hospital infection management committee, department hospital infection management team and hospital full-time (part-time) management staff three-level monitoring organization, to carry out hospital infection monitoring.
(two) the hospital infection management committee should hold regular meetings, listen to the work report of full-time hospital infection management personnel, and study and improve the work.
(three) the full-time (part-time) staff of hospital infection management should make plans according to hospital infection monitoring, and conduct sampling investigation and testing on environmental sanitation, microbial pollution, disinfection and sterilization, sewage treatment, etc. The incidence of nosocomial infection was investigated every six months, once a month/kloc-0 times, and the disinfection and isolation technology of medical staff was assessed regularly.
(4) Departments should designate doctors or head nurses to monitor the incidence of hospital infection, find problems, give timely feedback and put forward improvement measures.
(five) to strengthen the publicity and education of hospital infection management, understand the significance of hospital infection monitoring, master the monitoring knowledge, and improve the monitoring level of medical staff.
Second, the hospital infection source management system
(a) hospitals should strictly isolate infectious patients according to the route of transmission, and isolate respiratory tract, digestive tract, contact, insects and blood.
(2) Strictly carry out disinfection routine. When infectious patients leave the isolation area, such as discharge, transfer to other departments, death, etc. Everything will be disinfected at last.
(3) When testing infectious specimens, pollution of the workbench, ground and clothes should be prevented. After inspection, the specimens should be disinfected before treatment, and the inspection list can only be issued after disinfection. Bacteria should be kept by special personnel and registered in special account books.
(four) the infected patients should be treated as soon as possible, and the medical staff should strictly implement the disinfection and isolation system when contacting the infected patients.
(five) the staff in high-risk areas should carry out regular bacterial inspection and take corresponding measures according to the inspection results.
Three. Environmental sanitation management system
(a) smoking is prohibited in the sick room, so that the air is fresh and free of mosquitoes, flies, rats and cockroaches, and it is cleaned regularly, and the sanitary ware room is dedicated.
(two) prohibit spitting, littering dirt and sewage.
(3) Hospital sewage discharge shall conform to the hospital sewage discharge standards stipulated by the state.
(4) Disinfection of all kinds of medical instruments, indoor tables and chairs, operation desks, floors and air shall be carried out in accordance with the relevant requirements of the Technical Operation Specification for Medical Care and the Management Measures for Disinfection, and the concentration, effect and bacterial content of disinfectants in the air shall be monitored regularly.
(5) Medical personnel must wash their hands as required before and after various operations, and medical personnel in areas with high incidence of infection should disinfect their opponents before and after operations. All kinds of injection, puncture and blood collection instruments must be disinfected by one person, and disposable medical and health supplies must be recycled and destroyed in time after use.
(6) * * * Key monitoring departments (disinfection supply room, operating room, treatment room, injection room) should strictly implement disinfection routine, disinfection and sterilization items should be marked with expiration date, and bacteriological monitoring should be carried out on sterilized items and air regularly.
Four, hospital infection prevention system
1. Medical personnel should wear clean clothes, perform strict aseptic operation, and wear masks and hats when entering the room.
2. Sterile items and non-sterile items should be placed separately. The upper layer of the treatment vehicle is a clean area, and the lower layer is a polluted area.
3, washing, atomization, laser, microwave and other treatments to achieve one person and one thing, a disinfection (sterilization), a wipe (disinfectant wipe) (chlorine disinfectant), one person and one washing liquid, quickly exposed to the air, patients will be sorted out in time after treatment.
4. The unsealed sterile solution should be used within 4 hours, and the unsealing time of various solutions should not exceed 24 hours.
5. Once opened, the aseptic items of cattle in the container should be kept for no more than 24 hours.
6. The used disposable goods will be destroyed in time, put into a designated container for centralized soaking, then put into a yellow garbage bag and sent to the designated place.
7, the ground and desktop with chlorine disinfectant wet wash twice a day.
8. Dry the tongs, open the tongs and write down the opening time. The use time shall not exceed 4 hours. Sterilization date, expiration date and unsealing time should be written on the ointment tube. Cotton balls containing salt water should be replaced 24 hours after opening, and ointment tubes containing iodophor should be replaced twice a week.
9, ultraviolet irradiation for half an hour every day, and make records, ultraviolet intensity monitoring once every six months.
Wipe the test tube with 95% alcohol gauze once a week and conduct air culture once a month.
10, once a week, thoroughly clean doors, windows, walls, floors and object surfaces.
1 1. Check whether there are expired items every day. Under normal circumstances, sterilized items shall not exceed one week.
12, non-therapeutic items are not allowed to enter the treatment room.
Verb (abbreviation for verb) antibiotic use system
(a) the hospital regularly investigates and analyzes the use of antibiotics in our hospital, and puts forward improvement measures in view of the existing problems; And formulate management measures for rational use of antibiotics.
(2) Doctors at all levels should strictly control the indications and routes of administration of antibiotics to avoid the increase of drug-resistant strains and the imbalance of normal flora caused by abuse. Combined use of antibiotics should have clear indications, and drug interaction should be considered to prevent adverse reactions. External use of antibiotics should be strictly controlled.
(three) those who have been identified as simple virus infections do not use antibiotics. If the cause of fever is unknown, antibiotics should be used after the diagnosis of the cause. Patients with particularly serious bacterial infection can initially choose antibiotics after blood or body fluids are sent for bacterial culture, and then use antibiotics according to the results of bacterial drug sensitivity test after the results of bacterial culture come out.
(four) acute bacterial infection using antibiotics for 3-5 days, but the clinical effect is not obvious, should consider adjusting the dosage and route of administration, or according to the results of bacterial culture and drug sensitivity test to adjust antibiotics.
(five) after the bacterial infection is effectively controlled, antibiotics should be stopped in time.
(6) In general, antibiotics are not used as preventive drugs, but under special circumstances, they can be used as short-term preventive drugs or disposable preventive drugs.
(seven) the use of antibiotics should be based on the principle of effective and sufficient, formulate individualized medication plan, determine the dosage and course of treatment, and master the contraindications, concentration, drip speed, and prevention and rescue of allergic reactions.
(eight) the pharmacy department should establish a registration system for the storage and consumption of various antibiotics, limit the use of expensive and toxic antibiotics, and report the clinical use of antibiotics and existing problems on a regular basis.
Medical information work system
First, the medical statistical system
(1) Medical registration and statistical data are the scientific basis for improving hospital work and strengthening medical quality management. All departments and relevant personnel are responsible for collecting, summarizing, analyzing, counting and reporting on schedule.
(2) The outpatient department should make outpatient registration and hospitalization registration, fill in the hospitalization card and infectious disease report card, summarize the patient flow in all subjects, and report it to the medical department and the medical information statistics room every day.
(3) Each clinical department should fill in the medical record home page, admission registration and patient flow daily report in detail, and register critically ill patients' rescue, new technology and new business development, hospital infection, medical errors and accidents, blood transfusion reactions, etc. in detail, and report them in accordance with regulations.
(four) the medical department should do a good job in quality registration, statistics, and report on time.
(5) The medical information statistics room is responsible for the collection, sorting, analysis and reporting of medical information in the hospital, implementing statistical services and statistical supervision, making health statistics reports and reporting them on time.
(six) all kinds of medical registration and statistical data should be filled in completely, accurately, legibly and properly kept, and the health statistical reports should be kept permanently.
(seven) the time of various statements.
1. Daily: It will be published at 9: 00 the next morning (except for special circumstances such as holidays).
2. Monthly report: submitted before the 6th of next month.
3. Quarterly report: report before the first month of the next quarter 10.
4. Annual report: submitted before June 20th of the following year.
5. Semi-annual report: submitted before July 15.
6. Make an annual statistical summary in the first quarter of next year.
7. The annual report of inpatient disease classification is before the next year 1 15.
Second, the medical record management system
(a) the hospital medical record room is responsible for the collection, sorting and storage of hospital medical records.
(two) according to the disease classification card number, unified centralized management.
(three) shall not read, copy and copy the medical records without authorization.
(four) copying medical records, must have a letter of introduction, approved by the medical department, can be carried out.
(5) Medical records involving medical disputes or accidents shall be properly kept by the Medical Department before being identified. No individual may borrow, copy or duplicate them without the approval of the hospital leaders.
(6) The medical record room shall file the discharged medical records on time, have the right to inquire about the whereabouts of the medical records that have not been returned to the clinical departments, and report the medical record filing and management to the hospital leaders in writing on time.
(seven) hospital medical records should be permanently preserved, and abide by the medical record confidentiality system.
(eight) keep the medical record room clean and tidy, do a good job of fire prevention, moisture prevention and loss prevention, and prohibit smoking indoors.
Third, the book management system
(a) the library should register, classify, catalogue and shelf books according to the China Book Classification, and improve the collection catalogue for the convenience of readers.
(2) Any staff member in our college must apply for a library card and voucher when borrowing books, and return the books when leaving the hospital? Certificate? Procedures: no more than two books can be borrowed at a time, and the borrowing time should not exceed one month. If it is overdue, the library has the right to urge the return. If it is not returned for more than three months, the compensation will be deducted according to the lost books (3-5 times the original book price).
(3) Readers should take good care of books and periodicals, and the borrowed books must be properly kept. Do not scribble, scribble, tear, cut, damage or lose books and periodicals, and offenders will be compensated according to regulations. Where the library books and periodicals with high value are lost or lost, the compensation shall be 5- 10 times.
(four) the library staff should closely cooperate with medical treatment, prevention, teaching, scientific research and other tasks, take the initiative to provide relevant information, regularly introduce the contents of new books and magazines.
(5) The latest magazines, reference books and libraries have only orphans, and they are only allowed to read indoors and are not allowed to go out.
(6) The library should be kept quiet and tidy, and smoking is prohibited. Periodicals that have been put on the shelves should be read back to their original places, and they should not be taken away without the consent of the management personnel.
Fourth, the microcomputer working system
(1) When using computers, the staff must take good care of the computers and other auxiliary equipment in the computer room, and the use of all kinds of equipment should strictly abide by the operating procedures. The application software shall be tested regularly, and the software of other units shall not be used or copied without testing.
(2) Strictly implement the confidentiality system and do a good job in keeping all kinds of information. In use, it shall be handled in accordance with the relevant confidentiality system, and shall not be leaked, lost or leaked.
(2) The computer room should be kept clean and tidy. Smoking, noisy visitors, playing games and other activities unrelated to work are strictly prohibited in the computer room. No one else is allowed to enter the computer room.
(four) the data should be managed by special personnel, such as the need to call and copy, should be approved by the leadership.
(5) Turn off the machine after work, cut off the power supply and close the doors and windows to ensure safety.