Summary Report of Hospital Infection Management Section in 2022 (1)XX Summary of Hospital Infection Work
First, the main work of hospital infection management:
1, according to the requirements of the superior health administrative department, the work plan of hospital infection management and the continuing education and training plan of hospital infection knowledge were formulated for xx years; Review, revise and supplement the quality inspection and scoring standards of hospital infection prevention and control, seriously study and study six standards such as the management standard of disinfection supply center of the Ministry of Health, and further improve and perfect the relevant hospital infection workflow.
2. Strengthen the prevention and control of hospital infection and continuously improve the quality supervision and management, improve the quality supervision and assessment mechanism of hospital infection management, set up a part-time hospital infection quality control team, regularly check and supervise the quality of hospital infection control links such as aseptic technical operation, medical waste management, hand hygiene, disinfection and isolation every month, and insist on evaluating and analyzing the self-inspection, and urge clinical departments to rectify the existing problems in time to ensure the benign operation of the basic work of hospital infection management.
3. Insist on monitoring the environmental microorganisms in key departments, monitor the use process of disinfection and sterilization agents, and monitor the sterilization effect of sterile items, which will play a substantial role in inspection and supervision of clinical disinfection and isolation.
4, completes the hospital infection case monitoring report:
(1) Carry out surveillance of nosocomial infection cases in key areas, and continuously carry out targeted monitoring and direct reporting of nosocomial infection in ICU.
(2) Do a good job in the monitoring report, prevention and control of hospital infection outbreak, conscientiously implement the "Hospital Infection Outbreak Early Warning Report Processing System", strengthen the forward-looking monitoring of hospital infection outbreak, investigate and handle the early warning incident of upper respiratory tract hospital infection in March, and assist the outpatient department to take corresponding control measures, so that the infection outbreak can be controlled in time and not spread.
(3) The prevalence rate of nosocomial infection was investigated and reported directly on the Internet, and the investigation rate reached 97.6%.
5. Do a good job in the prevention and control of nosocomial infection of infectious diseases, and do a good job in the prevention and control of nosocomial infection in pre-inspection triage stations and isolation wards, especially in the prevention and control of hand, foot and mouth disease and influenza A (H 1N 1). The Hospital Infection Department conscientiously implements the relevant spirit of the higher health administrative department, and seriously standardizes and formulates relevant work systems and processes to make them meet the requirements of nosocomial infection prevention and control, and strengthens the training, prevention and control supervision of relevant departments.
6. Further strengthen the continuing education and training of hospital infection knowledge, and carry out hospital-wide training for 4 times throughout the year. Each department conducts intensive training for its employees every month, and distributes more than 1 000 training papers to hospitals. The assessment rate of hospital infection knowledge training reaches 1 000%. In view of the current situation of hospital infection management in our hospital, Yichang Hospital Infection Continuing Education Project Training "Prevention and Control of Hospital Infection in Surgical Incision" was held, and experts in hospital infection management in superior hospitals were invited to give lectures. More than 300 people attended classes in the hospital, and more than 0/00 people attended classes in hospitals inside and outside the city. The effect was good.
7, hand hygiene management: the whole hospital implements hand sanitizer to wash hands, dry towels to achieve a disinfection without secondary pollution, some key departments implement hand dryers.
8. Hospital infection management in key departments: The hospital has strengthened the construction and improvement of the layout of key departments. In recent years, blood purification room, purification ICU, laminar flow operating room, laboratory and gastroscope room have been newly built, and the corresponding facilities and equipment have been standardized to meet the requirements of hospital infection management. A central supply room is under construction.
The nursing department of hospital sensory department jointly implements monthly quality control supervision for key departments such as hospital operating room.
9. Further standardize the classified collection and management of medical waste, as well as the relevant systems and treatment processes of medical waste management.
All, and standardize the implementation of classified collection and reasonable temporary storage, focusing on rationalizing the packaging of uncontaminated medical waste, prohibiting mixing with infectious medical waste, standardizing the configuration of medical waste containers in collective infusion vehicles and standardizing the use of medical waste containers in the hospital; Infectious and other medical wastes should be burned in time every day, and the incinerator in the hospital is smokeless; There are standardized new sewage treatment facilities, relevant management systems and responsibilities, and special personnel are in charge.
10. Strengthen the management of multi-drug resistant bacteria: the hospital has disinfection and isolation measures for multi-drug resistant bacteria and implements them. The clinical laboratory can report the multi-drug resistant bacteria to the hospital infection department in time, and the hospital infection department will give timely feedback to guide the clinical departments to take disinfection and isolation measures and implement identification management for patients with multi-drug resistant strains.
1 1. Strengthen the management of occupational exposure protection for medical staff: improve the emergency plan, treatment process and registration and reporting system of occupational exposure for medical staff, train medical staff in the hospital on relevant knowledge, and have special prevention funds for occupational exposure for medical staff; Medical staff have occupational protection awareness and corresponding protective equipment (hats, masks, isolation gown, protective clothing, masks, eye masks, rubber shoes, etc. ) available in key positions, the staff can use protective equipment correctly.
12. management of sterile medical devices and disposable medical supplies: the hospital infection management department has supervision and supervision over the procurement, storage and use of sterile medical devices and disposable medical supplies, and has quarterly inspection guidance and analysis reports.
13, conscientiously implement the system of hospital infection evaluation and analysis, do a good job in statistical reporting of relevant information, insist on holding regular hospital infection work meetings, evaluate and report the occurrence, monitoring and evaluation of hospital infection, and the implementation of hospital infection prevention and control measures, monitor drug-resistant strains, analyze the pathogenic inspection rate of hospital infection cases, and publish hospital infection newsletters regularly.
Second, the existing problems:
1, the hospital does not implement centralized cleaning and disinfection supply, and a few departments have their own cleaning, disinfection and soaking bags or daily medical supplies. Cleaning facilities are not standardized, and a small number of medical staff do not master disinfection methods and the use of chemical disinfectants (disinfection supply center is under construction).
2. Medical staff's awareness of hand hygiene needs to be further strengthened (hand-dried disinfectant should be eliminated by hand in transfusion, wound surgical dressing change and key rounds). The hospital buys only 500 bottles of hand sanitizer every year, which is far from meeting the standard requirements of disinfection of clinical opponents, indicating that medical staff have not standardized the implementation of hand hygiene system in actual operation.
According to the requirements of hospital's "safe production" and "quality management", the Summary Report of Hospital Infection Management Department in 2022 improved the quality control and evaluation system of hospital infection, refined the comprehensive target evaluation standard of hospital infection quality, conducted supervision and feedback according to the comprehensive target, comprehensively inspected and combed all links of hospital infection prevention and control, carefully investigated potential safety hazards, and made a good job in key departments, key parts and key links of hospital infection to ensure hospital safety. Hospital infection prevention and control measures for key parts and key links have also been formulated, and the hospital infection department regularly conducts supervision and guidance to prevent hospital infection from erupting in the hospital.
Summary Report of Hospital Infection Management Section in 2022 (Chapter III) Summary of Hospital Infection Work in XX years
Over the past xx years, with the attention and concern of hospital leaders, the hospital infection team in our hospital has done a lot of work to control hospital infection. From organization and implementation to strict management system and necessary clinical monitoring, various measures have been taken to make the hospital infection management in our hospital standardized, institutionalized and scientific step by step, and to control the hospital infection rate at a low level. In order to further improve the management of hospital infection in the future, the hospital infection control work in our hospital this year is summarized as follows:
A, strengthen organizational leadership, to ensure the smooth development of hospital infection management, hospital infection management team led by business dean, medical department, nursing department part-time participation, each department head for team members. Be responsible for infection control in the whole hospital and give guidance to all departments. The hospital infection team pays special attention to its daily work, regularly and irregularly supervises and inspects the hospital infection control work in all subjects, and collects and counts the relevant data of the whole hospital. The implementation of the work at different levels ensures the smooth development of hospital infection management in our hospital.
Second, further improve the management system and implement it.
Hospital infection management system is the basis and important guarantee for doing a good job in hospital infection, so it is very important to formulate a scientific and practical management system. At the beginning of the year, according to the specific situation of our hospital, SOP was formulated to revise the hospital work; Strengthen system construction and study, regularly train and assess all medical staff, and conscientiously implement them to improve prevention awareness and reduce the incidence of hospital infection; The hospital infection group regularly checks the implementation of the system, gives full play to the binding role of the system, and puts all the work in place.
Third, continue to pay special attention to disinfection and isolation and infection monitoring in clinical departments.
1, according to SOP and Law on the Prevention and Control of Infectious Diseases, etc. The hospital infection group strengthened disinfection and isolation and infection monitoring in all clinical departments. Check once a month, and handle the problems in time, which greatly reduces the possibility of hospital infection. Disinfectants are replaced and replaced throughout the year.
In the soaking inspection of 1 machinery, except for occasional omissions or incomplete records of individual departments, the time for equipment soaking, disinfectant preparation and replacement all met the requirements.
2. Monitor hand surface, object surface, air, disinfectant, ultraviolet intensity, autoclaved packaging, etc. The qualified rate of nurses in clinical departments reached 100%.
3. The staff of the hospital infection group regularly go to relevant departments to find out whether there is nosocomial infection, whether there is omission or misstatement. All departments should register the hospital infection cases found in time and report to the hospital infection team. According to statistics, the culture rate of functional microorganisms in this hospital is 100%, and the incidence of nosocomial infection in the whole year is 8%, which is 1. 1% lower than last year.
Four, the management of disposable supplies, to ensure the medical safety of patients, to prevent social pollution.
In this year's disposable supplies procurement, the leaders of the hospital strengthened the management work in this area and carried out strict verification and inspection on the quality. Hospital infection department and warehouse keeper are responsible for checking and registering the purchased disposable articles, ensuring the purchase of disposable articles and sterilized medical devices, and preventing unqualified products from entering our hospital. This year, all disposable supplies purchased by our hospital were unqualified. The hospital infection team shall inspect the disposable sterile medical supplies stored in warehouses and departments once every quarter, and the nursing staff shall strictly inspect them before using them to prevent the expired disposable supplies from being used by patients. Due to strict control, no patients used unqualified disposable sterile medical supplies. For used disposable products, all departments have always insisted on destruction, disinfection and recording. Therefore, the disinfection rate of disposable empty needles, infusion sets and urine bags in our hospital reached 100%. Disposable sterile medical supplies after destruction and disinfection shall be recovered by the Municipal Health Bureau.
Five, strengthen the training of hospital infection knowledge, improve the awareness of hospital staff to control hospital infection.
Combined with the actual situation of our hospital, the hospital infection group organized a special lecture on preventing hospital infection, such as the diagnostic criteria of hospital infection, the use of antibiotics, the regulations on handling medical accidents, disinfection, safety knowledge training, blood transfusion-related laws and regulations, and blood transfusion knowledge learning. To provide a good understanding for the medical staff in our hospital.
2. Carry out training on the knowledge of hospital infection prevention and control, and enhance everyone's awareness of hospital infection prevention and control. Improve the level of prevention and control of nosocomial infection in our hospital.
In the hospital infection control work throughout the year, due to the great attention of hospital leaders, the guidance of superior experts, the organization and guidance of hospital infection group and the active cooperation of various departments, the work was carried out smoothly and achieved good results. However, due to the late start of nosocomial infection control in our hospital, there are still some shortcomings in the diagnosis, reporting and statistics of nosocomial infection cases, which need to be improved and perfected in the future. We believe that in the new year, as long as we constantly sum up experience and learn with an open mind, we will certainly do a better job in hospital infection control.
Key points of hospital infection management in xx years:
1, strengthen the study and training of medical staff. Such as hospital infection diagnosis standards, disinfection technical specifications, rational use of antibiotics in hand hygiene, occupational protection of HIV, etc.
2, clinical departments should organize learning to master the hospital infection diagnosis, inspection, recording and reporting procedures, etc. , improve the accuracy of hospital infection case reports and reduce missed reports;
3. Strengthen microbial culture and drug sensitivity test;
4. Strengthen the monitoring of ultraviolet intensity;
5, medical waste management should be carried out according to the requirements of hospital medical waste management system;
6, the hospital management team should be regular activities, completes the relevant accounting records, and according to the existing problems for rectification.
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65438+10/October 7th
Summary Report of Hospital Infection Management Section in 2022 (Chapter 4) There are two kinds of infections. Medical infection refers to the local tissue and systemic inflammatory reaction caused by pathogens such as bacteria, viruses, fungi and parasites invading the human body. Psychological infection is to make others have the same emotions and behaviors in some way. Essentially, it is the transmission and communication of emotions, which plays a great role in the interaction.
First, the main work carried out by hospitals and hospital sensory departments
1. Seriously study the Detailed Rules for the Implementation of Management Review of Medical Institutions in xx Province, make preparations for the "Second Excellent Review", formulate annual work plan, annual training plan and hospital infection workflow according to the requirements of the detailed rules, sort out and supplement various rules, regulations and quality standards of hospital infection prevention and control management, and further improve the hospital infection management system.
2. Strengthen the supervision of hospital infection prevention and control in clinical departments, communicate in time when problems are found, give timely guidance, and make timely improvements, especially in view of the phenomenon that the medical staff in our hospital repeatedly have unclear classification of medical wastes and a few clinicians' aseptic operations are not in place, thoroughly clean up the dead corner of hospital infection prevention and control, and truly realize the standardization and unification of hospital infection management, which fully reflects the strength of hospital infection management.
3. Strengthen and improve the monitoring of environmental microorganisms and bacteria, combine monitoring with clinical work, and initiate environmental dynamic bacteria monitoring, which will play a substantial role in the inspection and supervision of clinical disinfection and isolation, especially take the initiative to conduct random sampling monitoring of neonatal wards, maternal and child wards, neonatal incubators, etc. And play a good role in monitoring and prompting the environmental quality of disinfection and isolation work in key areas.
4. Carry out monitoring of nosocomial infection cases in key areas and start targeted monitoring of nosocomial infection in icu.
5. Do a good job in hospital infection outbreak monitoring report and prevention and control. In 20xx, the Department of Nosocomial Infection formulated the Early Warning Report System of Clinical Nosocomial Infection Outbreaks to strengthen the prospective monitoring of Nosocomial Infection Outbreaks and implement this system. This year 10, the second department of surgery in our hospital hit the nail on the head, and seriously standardized and formulated relevant work systems and processes to meet the requirements of hospital infection prevention and control. In the first half of the year, there was no nosocomial infection of infectious diseases in our hospital, and we plan to meet the superior inspection.
7. Further strengthen the continuing education and training of hospital infection knowledge. In the first half of the year, the hospital sensory department has completed off-campus training and some in-hospital training.
8. Strengthen the supervision and assessment of the implementation of hospital infection prevention and control measures in clinical departments.
Adhere to the working concept of continuous improvement, find problems, study in time, communicate in time, improve in time, incorporate persistent problems into the quality control assessment score at the hospital level, and honor rewards and punishments; Do check and guide at any time, regularly assess and evaluate, regularly report the assessment to each department, and report relevant information to the higher authorities, hospital leaders and hospital quality control departments on time and in accordance with regulations.
9. Further strengthen the management of classified collection and treatment of medical wastes. After use, the recovery rate in disposable goods is 65,438+000%, and the incineration rate of waste medical waste is 65,438+000%. The key supervision is the classification and packaging of domestic waste and medical waste, the treatment of medical sharps and infectious waste.
10, conscientiously implement the system of hospital infection evaluation and analysis, do a good job in statistical reporting of relevant information, hold regular hospital infection work meetings, evaluate and analyze the occurrence, monitoring and evaluation of hospital infection and the implementation of hospital infection prevention and control measures, monitor drug-resistant strains, analyze the pathogenic inspection rate of hospital infection cases, and publish hospital infection newsletters on a regular basis.
Two, the main problems existing in the hospital work and the focus of next year's work
1, the target monitoring work is not perfect.
2. The facilities for classified collection and treatment of medical wastes in the whole hospital need to be improved (trash cans and garbage bags).
3, hand washing facilities need to be improved (faucet, hand sanitizer, etc.). ).
Summary Report of Hospital Infection Management Department in 2022 (Chapter 5) 20xx, with the strong support of the correct leadership of the hospital, the Hospital Infection Management Department actively worked to further improve and implement the hospital infection organization network, strictly manage the system, and carry out the necessary monitoring and inspection work. All departments of the hospital cooperate vigorously. Nursing department pays special attention to disinfection and isolation technology operation, aseptic technology operation and inspection and assessment of various departments. All clinical departments carefully fill in and report hospital-acquired cases in time, and the hospital-acquired cases are monitored and analyzed by the hospital-acquired departments to guide clinical departments to control hospital infection. Through the above work, 5 cases of nosocomial infection occurred in our hospital in 20xx, and the nosocomial infection rate was 0.9%. There was no outbreak of nosocomial infection in our hospital, and the nosocomial infection was effectively controlled at a low level.
First, improve the organization, formulate and improve the hospital infection management rules and regulations.
In March this year, the hospital adjusted the hospital sensory Committee and improved the two-level quality control management system of hospital sensory. According to the relevant laws, regulations, norms and rules, such as Management Measures for Hospital Infection, Technical Specifications for Disinfection, People's Republic of China (PRC) Law on Prevention and Control of Infectious Diseases, Management Measures for Disinfection, Management Measures for Medical Wastes in Medical Institutions, Technical Specifications for Endoscopic Cleaning and Disinfection, Management Specifications for Infectious Disease Information Report, etc., combined with the actual situation of our hospital, the system and regulations for hospital infection management and infectious disease management were revised.
The second is to strengthen the quality control of hospital infection in view of its weak links.
We further improved the quality control and evaluation system of hospital infection, formulated the comprehensive target evaluation standard of hospital infection quality, conducted supervision and feedback according to the comprehensive target, comprehensively checked and sorted out all links of hospital infection prevention and control, and carefully investigated potential safety hazards. In order to ensure the safety of hospital feeling, we should do a good job in the management of key departments and key links, especially the hospital infection management in key departments such as operating room, delivery room, laboratory, treatment room and emergency department, so as to prevent the outbreak and epidemic of hospital infection.
Three, in accordance with the requirements of infectious disease management, strengthen the prevention and control of infectious diseases.
Further strengthen the management of key places such as internal medicine clinics and hot (emergency) clinics, conscientiously implement the requirements for hospital infection control of infectious diseases, increase the intensity of hospital infection prevention and control, standardize working procedures, especially for medical staff in hospitals, strengthen the prevention and control of infectious diseases and self-protection training, strictly implement hospital infection prevention and control and personal protection measures, prevent cross-infection in hospitals, and actively cooperate with relevant departments to do a good job in epidemic prevention and control.
Four, according to the requirements of hospital management, do a good job of retrospective investigation of cases.
In 20xx, 5,456 people were discharged, including 2,205 in surgery, 2,596 in internal medicine and 655 in obstetrics and gynecology, including 3 cases of surgical infection, with an infection rate of 0. 14%. Hospital infection in internal medicine 1 case, with an infection rate of 0.038%. Obstetrics and gynecology hospital infection 1 case, the infection rate was 0. 15%. The incidence of nosocomial infection in traditional Chinese medicine, otolaryngology and anorectal department was 0%.
Five, pay special attention to environmental sanitation, disinfection and sterilization effect and hand hygiene monitoring.
In order to standardize the disinfection and sterilization work in the hospital and prevent nosocomial infection, the hospital infection department strengthened the sampling and monitoring of nosocomial infection, entrusted the county CDC to monitor the disinfection and sterilization effect of key departments in the hospital, and strengthened the environmental sanitation monitoring of high-risk areas such as operating room, delivery room and nursing department and the hand hygiene monitoring of medical staff. The air in clinical departments, medical technology departments and outpatient departments of the hospital was monitored, and the qualified rate reached 100%.
Intransitive verbs strengthen the management of medical waste.
Hospital infection department constantly improves various rules and regulations, clarifies the responsibilities of medical waste management personnel, implements the responsibility system, strengthens medical waste management and daily supervision, and corrects and gives feedback in time when problems are found. The classification, collection, storage, packaging, transportation and handover of medical waste in our hospital should be standardized to prevent the outbreak of hospital infection caused by poor management of medical waste. Redesign the medical waste recycling registration form to facilitate recycling and filing. Relocation and reconstruction of temporary storage point of medical waste in our hospital. Yes, the management process of medical waste is more realistic, which reduces the chances of pollution and injury to medical staff.
Seven, strengthen the cultivation and assessment of hospital consciousness.
Four times of hospital infection knowledge training were conducted, including medical staff in the whole hospital, *** 1 18 person-times. The training contents include: ① basic knowledge training of hospital infection; ② Guiding principles of clinical application of antibacterial drugs; Interpretation of "Technical Guidelines for Prevention and Control of Multi-drug Resistant Bacteria Nosocomial Infection (Trial)"; ③ Medical waste treatment; ④ Diagnostic criteria of nosocomial infection cases and hand hygiene standards for prevention; Interpretation of "Secondary Hospital"
Through training, hospital medical staff and staff attach importance to hospital infection. The consciousness of aseptic operation of medical staff has been enhanced, and everyone is striving to achieve the concept of aseptic operation with bacteria.
Eight, medical equipment disinfection and disposable sterile medical supplies management
In order to strengthen the management of sterilized medical devices and disposable sterile medical supplies, the hospital infection department conducts daily supervision and regular spot checks on their use. Conduct a spot check on sterile medical devices and disposable sterile medical supplies every quarter. The method is to take samples from clinical departments and ask for certificates from the material library. Results All the certificates were complete and qualified.
Nine, actively participate in hospital architectural design
When building a new ward building, it is suggested to use an induction faucet, and the key departments should be equipped with dry toilet paper, which has been approved by the hospital leaders and put into use. This measure has greatly improved the hand hygiene compliance of medical staff in our hospital. It is suggested that all air disinfection in treatment rooms and dressing rooms should use the suspended ultraviolet sterilizer dynamic ozone air disinfection machine, and the suspended ultraviolet disinfection is not in place, which will be further improved and implemented in all departments.
X. Although our department has done a lot of work, there are still many problems:
1. The quality of nosocomial infection needs to be further strengthened.
2. The clinical infection management team did not give full play to its role.
3. Infection monitoring results should be regularly fed back to clinical departments.
4. Some doctors in clinical departments still don't pay enough attention to hospital infection, and the diagnosis and condition analysis of patients with hospital infection are insufficient, so the hospital infection registration form can't be submitted in time.
5. The aseptic concept and hand hygiene knowledge of medical staff in clinical departments still need to be strengthened.
The new year is coming, and our department will continue to carry out all kinds of work and constantly improve and perfect according to the problems of this year. Constantly sum up experience, learn with an open mind, and strive to pass the "Second Hospital" smoothly.