In 2022 1 **, the annual work summary of the director of hospital infection department will soon be over. With the correct leadership and strong support of hospital leaders, and under the guidance of the Hospital Infection Committee, the hospital medical staff actively participated in the hospital infection monitoring. Doctors in various clinical departments conducted a prospective survey of all hospitalized patients and found that hospital infection could be reported in time and accurately. At the same time, the hospital infection department has also strengthened the management of hospital infection case reports and strengthened monitoring and control when there are hospital infection cases. Relying on the nursing department to carry out routine supervision of disinfection and isolation quality, aseptic technical supervision and feedback, the medical department and nursing department cooperate with hospital leaders to do a good job in medical safety management. Hold a meeting of the hospital perception Committee under the auspices of the dean every quarter, and issue a hospital perception newsletter.
Summary of work in 2022 Director of Hospital Infection Department 2 1. This year, our hospital carried out compulsory monitoring on key departments, key links and key areas, and carried out biological and chemical monitoring on disinfection and sterilization effect and disinfectant in use, with strict records and rectification measures.
2. An ultraviolet intensity monitor was purchased to monitor the ultraviolet germicidal lamp in use in the whole hospital.
3. Conduct process monitoring, chemical monitoring and biological monitoring on the sterilized articles in the supply room, and make strict records.
In 2022, the annual work summary of the director of hospital infection department wrote 3 1. Since the beginning of this year, in response to the epidemic situation of avian influenza and hand, foot and mouth combined with influenza A (h 1n 1), the hospital opened a fever clinic in time, purchased protective facilities, disinfection equipment and disinfection drugs, improved the system, fixed special personnel, and made reasonable arrangements according to the prevention and control process.
2. Establish an organization and improve the system. Actively respond to possible epidemics.
3. Organize the propaganda, study, evaluation and drills of infectious diseases knowledge, and correctly prevent and control infectious diseases; According to the spirit of superiors, zero report of infectious diseases was realized.
Summary of work in 2022 Director of Hospital Infection Department 4 With the development of medicine and the change of medical model, hospital infection plays an important role in hospital management. Hospital infection is not only related to the health of both doctors and patients, but also affects the medical quality of hospitals. With the attention and concern of hospital leaders, various measures have been taken from organization and implementation to strict management system, so that hospital infection management is gradually standardized and institutionalized. In order to further improve the management of hospital infection in the future, the hospital infection control work this year is summarized as follows:
First, leaders attach great importance to ensuring the smooth development of hospital infection management.
Hospital leaders attach great importance to hospital infection management, and the dean directly serves as the leader of the hospital infection management leading group to guide the daily work of the hospital infection management office.
(a) pay attention to management according to law, and carry out hospital infection management according to norms. Constantly study laws and regulations, and implement the Law on the Prevention and Control of Infectious Diseases, Technical Specification for Disinfection, Management Specification for Hospital Infection and various policies and regulations. Hospital leaders emphasize practicing medicine according to law and standardizing management. Due to the attention of hospital leaders and the serious and responsible management of the director of hospital infection office, the legal awareness and awareness of controlling hospital infection of employees in our hospital have been continuously strengthened.
(2) In order to effectively control hospital infection and ensure medical quality. Hospital leaders attach importance to the construction of key departments, and in strict accordance with the requirements of hospital infection management, provide infrastructure for key departments such as outpatient department, inpatient department, nursing room, treatment room and laboratory department.
(3) Taking the control of hospital infection as the focus of high-risk departments. Often go to the outpatient department to know the situation, check and supervise the implementation of the disinfection and isolation system. Find problems and weak links in the work, communicate with relevant departments in time, try to solve them and carry out the work in a down-to-earth manner.
Second, enrich the infected organizations in health centers.
According to the standard requirements of the Ministry of Health, we will gradually improve various rules and regulations and equip full-time hospital staff to ensure the standardized and orderly development of hospital infection management. The three-level hospital infection management network established by the hospital has played an effective role in functional monitoring. According to the responsibility, the quality assessment standard of hospital infection management was established, and the quality inspection was carried out every month according to the assessment standard, and the quality inspection results were discussed and assessed. At the same time, aiming at the problems existing in hospital infection management, we should formulate improvement measures to standardize hospital infection management. At the same time, the quality control team of hospital infection management in each department reports the hospital infection, disinfection and isolation monitoring of hospitalized patients to the hospital feeling office every month, and organizes medical staff to discuss the problems existing in hospital infection in each department; Hospital infection monitoring personnel at all levels have fulfilled the corresponding functions of hospital infection management, further improving the level of hospital infection management. In hospital infection management, we should standardize and conscientiously implement various rules and regulations, especially the medical waste management system, hospital infection disinfection and isolation system, disposable sterile medical supplies use management system, hospital infection management inspection system, hospital infection management education and training system and hospital infection management assessment system.
Third, strengthen the training of hospital infection knowledge and improve the awareness of medical staff to control hospital infection.
Combined with the actual situation of our hospital and creating an atmosphere, the Hospital Sense Office organized a series of special lectures and hospital infection training, and used the Internet to keep abreast of the current situation, principles and new progress in control methods of hospital infection at home and abroad, and trained the medical staff in hospital on the prevention and control of hospital infection. Enhance everyone's awareness of preventing and controlling hospital infection; Improve the level of hospital infection prevention and control. In the hospital infection control work throughout the year, due to the great attention of hospital leaders and the active cooperation of various departments, the work was carried out smoothly and achieved good results.
Four, to 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. In order to improve the quality and effect of hospital consciousness work in our hospital, a set of scientific and practical management system has been formulated to standardize the behavior of relevant personnel in the hospital. According to the Measures for the Management of Hospital Infection, the disinfection and isolation management system and comprehensive scoring rules of hospital infection in all departments of our hospital were formulated. According to the hospital infection system, norms and detailed rules of our hospital, we regularly or irregularly inspect, evaluate and score the quality of hospital infection management in various departments, check the implementation of the system and check the operating specifications, and go deep from link to link. The hospital office regularly checks the implementation of the system, gives full play to the binding role of the system, and implements all the work.
Five, the establishment of "hospital infection case reporting system"
In order to conscientiously implement the relevant provisions of the Measures for the Administration of Hospital Infection, and timely grasp the infection status, incidence, diseases, common pathogens and drug resistance in our hospital, according to the requirements of the Diagnostic Criteria for Hospital Infection and the actual situation of our hospital, we formulated the system of hospital infection monitoring and registration report. When medical staff find nosocomial infection cases or infection trends, they must promptly send pathogens for testing to find out the source and route of infection. It is required to fill in the hospital infection case report truthfully and report it to the hospital infection management office in time. The person in charge of hospital infection will monitor, analyze and feedback the related risk factors to help control the spread of the disease. When necessary, the office will organize seminars to eliminate hidden dangers and ensure medical safety. In order to ensure the reliability of hospital infection control, the hospital office will randomly check the incidence rate and missed report rate of hospital infection. Find out what the department is hiding. Once found, except informed criticism, the parties and department heads shall be punished according to regulations. At the same time, medical staff should be alert to the occurrence of hospital infection outbreaks, and the underreporting of hospital infection cases is also an important factor causing hospital infection outbreaks. When the infection is found to have an outbreak trend, it should be reported to the hospital infection management office in time. The hospital infection management office investigates and statistically analyzes the occurrence of hospital infection, and reports to the hospital infection management committee or the person in charge of the hospital.
Six, for all medical staff to prevent infectious diseases standard protection training.
According to the requirements of the Work Plan for the Prevention and Reporting of Infectious Diseases, the Hospital Infection Office provides necessary guidance and study on the health and safety protection work of all departments in our hospital, supervises the preparation of protective equipment in all departments, grasps the knowledge of self-protection, and strictly implements the standard prevention principle when engaging in medical activities in an emergency. Correctly perform various technical operations to prevent sharp instrument stab wounds. Once occupational exposure occurs, local treatment measures should be implemented immediately and reported to the hospital infection management office in time. However, there are still many shortcomings in this work, and further specific training is needed. At the same time, in order to ensure the safety of operators and minimize the risk of occupational exposure, yellow surgical notice is strictly used in infectious surgery, and the use of yellow infectious surgical notice is included in the accusation assessment standard. 、
2022 Work Summary Director of Hospital Infection Department 5 In the second half of this year, under the leadership of the two committees and the dean in charge, the hospital infection department will pay close attention to the implementation of the system, clarify responsibilities, improve execution, continuously improve quality, reduce hospital infection rate, improve medical quality and ensure patient safety.
First, continue to strengthen the construction of hospital infection organization system, and give full play to the role of hospital infection management Committee, hospital infection management department and clinical department hospital infection management team in hospital infection management.
Second, in the actual work of the hospital, constantly standardize and improve the relevant systems and responsibilities, and at the same time pay close attention to the implementation of the system in combination with the assessment office, so as to make the responsibilities clear and the personnel clear. Put forward rectification measures in time for the problems existing in hospital infection management.
Three, the implementation of the Ministry of health "hospital infection monitoring standards", monthly statistics, analysis, feedback of infection cases monitoring.
Four, grasp the distribution of nosocomial infection strains and bacterial drug resistance and regular feedback; Timely find cases of multi-drug resistant bacteria infection and take active and effective measures to prevent and control the outbreak and epidemic of multi-drug resistant bacteria nosocomial infection.
Five, every month to the operating room, delivery room, neonatal ward, disinfection supply room and other key departments and comprehensive departments of the treatment room, dressing room for air, object surface, medical staff hand hygiene monitoring and related guidance, unqualified departments, departments to find out the reasons, related monitoring.
Six, strengthen the awareness of hand hygiene of medical staff, improve the compliance of hand hygiene.
Seven, the disinfection of medical devices and disposable medical devices, appliances related to the proof of a quarterly audit.
Eight, continue to carry out hospital staff awareness knowledge training, improve hospital staff awareness.
Nine, guide and supervise the classified management of medical waste.
Ten, to 20xxxx new recruits and internship training personnel for hospital infection knowledge pre-service training.
6. Summary of work of the director of hospital infection department in 2022 and summary of hospital infection work
In order to further implement the Ministry of Health's "Hospital Infection Management Standard" and "Disinfection Technical Standard", promote the hospital infection management in our hospital, and ensure the medical quality and safety, a series of work has been carried out with the full cooperation of the party and government leaders of the hospital and the staff of the whole hospital. The summary is as follows:
First, strengthen management and improve various rules and regulations:
1. The party and government leaders of our hospital attach great importance to hospital infection management, and the dean in charge directly serves as the director of the hospital infection management committee, and put this work on the agenda, which is included in the comprehensive target management content and annual work plan. The three-level management of hospital infection prevention and control has been effectively achieved, and the management of hospital infection prevention and control has entered standardized management.
2. According to the requirements of hospital classification management and Hospital Infection Management Standard of the Ministry of Health, the Hospital Infection Committee has formulated various rules and regulations for the prevention and control of hospital infection and distributed them to all subjects, and each infection group has carefully organized study and implementation.
3. According to the hospital infection management norms, the Infectious Disease Prevention Law, the disinfection management measures and other relevant provisions of hospital infection management, combined with the actual situation of our hospital, at the beginning of the year, the work plan of xx Hospital Infection Management Committee for Prevention and Control of Hospital Infection was formulated and distributed to the hospital infection management teams in the form of documents. Each hospital infection management team combined with the situation of each department, formulated the work plan of each department management team, and summarized the work for one year. Each department is equipped with quality control management personnel. Therefore, the three-level network of hospital infection management in our hospital can always operate in an orderly and benign manner and play an active role.
4, hospital infection management committee according to the needs of the work held an irregular meeting in time, report the main problems, actively find hidden dangers, formulate and implement improvement measures in time. * * * Held 10 meeting throughout the year, with clear theme, substantial, specific, timely and complete records, which reflected the important role played by the Hospital Infection Management Committee in earnestly performing its functions, achieving its work objectives and strengthening hospital infection management.
5. The hospital infection management team organizes department personnel to learn the knowledge of Hospital Infection Management Standard, Technical Specification for Disinfection, Infectious Disease Prevention Law, etc.
Second, conscientiously perform the functions of the Hospital Infection Management Committee, implement various management norms, actively coordinate and solve major problems in hospital infection management, and propose specific improvement measures:
1. Develop a comprehensive monitoring method for nosocomial infection in our hospital. Full-time hospital infection management personnel insist on daily discharge medical records inspection, do a good job in case registration and infection statistics, conduct hospital infection monitoring and analysis every month, put forward hospital infection priorities at hospital and branch levels in time, and feed them back to the infection management team in time. Issue four bulletins throughout the year, so that hospital infection management has continuity, clear objectives, prominent focus, responsibility implementation and effective prevention.
2. In order to ensure the quality of disinfection work in all departments of our hospital, the Hospital Infection Management Committee has effectively strengthened the management of disinfection work in the whole hospital, and all departments in the whole hospital have established a disinfection management system. All disinfection work carried out is truthfully registered in four special registers: air disinfection, department disinfection, disinfectant replacement and disposable medical supplies disinfection. The records of all subjects are complete, timely and true. Members of the Hospital Infection Management Committee often go deep into the department to check the disinfection management, find out the problems in the disinfection work in time, and put forward improvement measures. Ensure the disinfection quality and reduce the hidden danger of hospital infection.
3. The whole hospital strictly implements various aseptic technical operations, and each subject implements the principle of one person, one needle, one tube, one use and one disinfection. All articles that can be sterilized by high pressure steam should be sterilized by high pressure steam.
4, adhere to the preventive terminal disinfection in all subjects. The disinfection management of key areas such as operating room, delivery room, ICU ward, supply room and blood bank was strengthened, and the disinfection and isolation work of fever clinic, intestinal clinic and isolation ward was strengthened, effectively curbing the spread of cross-infection in the hospital.
5. Strictly implement the "three unifications" of blood transfusion.
6, strengthen the management of disposable medical supplies, require five certificates to be complete, and standardize management from inspection documents, procurement, storage, distribution, use and recycling. , and immediately after use by the supply room to recover, verify the distribution, do a good job in all kinds of registration. To ensure the safe use of disposable medical supplies used in our hospital.
7. The management of medical waste has been strengthened: (1), and various rules and regulations for the collection, recovery and management of medical waste have been formulated. The medical wastes of each department are collected by each department in a unified way, and special personnel are arranged to go to the next department for recycling every day, and the registration work is done well, and incineration treatment is carried out in time. (2) Strengthen the management of recycling disposable blood transfusion bags, fill in the recycling form after each department uses it, and submit it to the next department for collection, which shall be signed by both parties. The preventive medicine department shall check it once a month to prevent the outflow of blood bags. (3) Pay attention to the discharge and treatment of hospital sewage, designate a person to be responsible for the disinfection and treatment of hospital sewage, and the environmental protection department will monitor the discharge up to standard. The management of all kinds of medical wastes has been done well, and the hidden danger of hospital infection caused by this poor work has been controlled to the maximum extent.
8. Strengthen the clean and hygienic management of the whole hospital: According to the concept and management standards of modern hospital sanitary environment, the Hospital Infection Management Committee has formulated the standards, requirements and reward and punishment system for clean and hygienic management in cooperation with other relevant departments. Hospital infection management office will send people to participate in regular and irregular hospital cleaning and hygiene inspection every month. Assess and score the inspection, which is linked to the salary of the cleaning staff. Pay attention to the work of eliminating the "four pests" in the hospital, prepare disinfectants all the year round, especially in the breeding season, and persevere. Do daily garbage, daily garbage, medical garbage as much as possible, and treat the secretions, excreta, special hospital waste, abandoned blood, blood-contaminated items, ward sewage and so on infected patients harmlessly. The ward insisted on bed wetting and sweeping. Sterile area, clean area, polluted area and toilet sanitary ware should be used separately, and cleaned and disinfected after use. Minimize the hidden danger of hospital infection caused by such work defects.
9. In order to ensure medical safety, continuously improve medical quality and reduce medical disputes caused by hospital infection, the Hospital Infection Management Committee actively cooperates with various departments to find out the hidden dangers of hospital infection. For example, the disposal of discarded items in individual departments is not standardized; Some medical staff have insufficient knowledge of hospital infection management, weak awareness of two-way protection and unreasonable use of antibiotics. Through careful search, timely improvement and preventive measures are put forward, which plays a powerful role in eliminating the hidden dangers of hospital infection and effectively controlling the occurrence of hospital infection.
Third, strengthen the management of infectious diseases:
1, strengthen the prevention and control of infectious atypical pneumonia and human infection with highly pathogenic avian influenza;
(1), the health education and legal publicity of SARS and human infection with highly pathogenic avian influenza were strengthened, the environment was purified, people's awareness of prevention and control was improved, and the transmission route was cut off.
(2), department staff actively participate in the province, city and county held training courses on the prevention and treatment of infectious atypical pneumonia and human infection with highly pathogenic avian influenza, earnestly study and train the hospital staff in stages.
(3), according to the requirements of SARS and human infection with highly pathogenic avian influenza prevention and control, continue to set up a fever clinic:
The management system of fever clinic, the responsibility system of first consultation, workflow, the staff's own protection system, and the escort procedure of SARS patients in hospital were formulated. The disinfection and isolation work of fever clinic has been strengthened, and various disinfection drugs and protective articles have been prepared, and they are often supervised, inspected and guided by departments.
2. Each department organizes medical personnel to learn the new Law on the Prevention and Control of Infectious Diseases. Hospital Infection Management Committee attaches great importance to the management of hospital infectious diseases. In addition to frequent visits to infectious diseases departments, fever clinics and diarrhea clinics for disinfection and isolation, we also actively urge relevant departments to seriously report the epidemic situation of infectious diseases and make timely and accurate online direct reports.
3, conscientiously do a good job of centralized management of pulmonary tuberculosis patients, fill in the referral list of pulmonary tuberculosis patients up to 100%.
4. Check the outpatient log of the outpatient doctor regularly every month to prevent the omission of infectious diseases. 352 cases of infectious diseases were diagnosed and treated in hospital throughout the year, and 352 cases were reported. The report rate, timely report rate and accurate report rate are 100%. In view of the epidemic season of various infectious diseases, we should take corresponding effective preventive measures in time to effectively put an end to the epidemic of infectious diseases in our hospital.
Fourth, vigorously popularize the knowledge of hospital infection, and strengthen the skills upgrading and training of hospital staff's professional knowledge such as hospital infection norms.
1. Continue to organize the staff of the whole hospital to learn the Regulations on the Prevention of Hospital Infection in Sichuan Province, the Law on the Prevention and Control of Infectious Diseases and its implementation methods, the Regulations on the Management of Hospital Infection, the Measures for the Management of Disinfection and other laws and regulations and the relevant systems of our hospital.
2, the department sent personnel to participate in public health emergencies, infectious disease management, disinfection technical specifications, hospital infection management training organized by the Municipal Center for Disease Control and Prevention 4 times.
3, the organization of infectious disease prevention and control professional group personnel to learn SARS and human infection with highly pathogenic avian influenza prevention and control knowledge training 2 times.
4. Organize canteen staff to seriously study the food hygiene law to prevent the epidemic of diseases caused by unclean diet.
5, organize the floor cleaning staff to learn simple hospital infection prevention knowledge, disinfection and isolation knowledge and hygiene knowledge. Give them the guidance of disinfection and isolation methods, so that the cleaners in the whole hospital can master the health standards and requirements under the specific environment of the hospital, perform their duties seriously, and effectively prevent hospital infection from the perspective of cleanliness and hygiene.
Five, conscientiously implement the "hospital infection management norms", do a good job of monitoring, to provide a scientific basis for hospital infection control.
1. The staff of hospital infection management office insisted on long-term continuous and systematic monitoring and registration of hospital infection in our hospital. In the whole year, 72 19 medical records were examined, among which 60 10 medical records were discharged 48 hours after admission, and 73 cases had hospital infection, the hospital infection rate was 1.2%, mainly respiratory tract infection, followed by skin, gastrointestinal tract, urinary tract, postoperative wound and oral infection; It conforms to the general law of hospital infection in China. The investigation of missing report was carried out, and 5 cases were missed in the whole year, with a missing report rate of 6.8%. Sterile incision operation 1 13 1 case was performed throughout the year, and the first-class healing rate of aseptic incision was11case, and the first-class healing rate of aseptic incision was 100%. Through monitoring, we can know the incidence, multi-site, multi-department, high-risk factors and influencing factors of nosocomial infection in our hospital in time, and put forward targeted opinions or improvement measures to feed back to the infection management team, which effectively promoted the infection management in our hospital.
2. The hospital infection management office cooperates with the clinical laboratory to monitor the disinfection quality of the whole hospital. Throughout the year, disinfectants, aseptic materials, bill of materials, hands of medical staff and air in key departments of the hospital were sampled and monitored 1 time, and * * * monitoring1time. Of 500 samples, 494 were qualified, with a qualified rate of 98.8%. In the process of monitoring, we should focus on common disinfectants and weak links that are easily overlooked, report the problems found in the monitoring to the leaders of the hospital infection Committee in time and contact relevant departments, and put forward rectification measures to ensure the disinfection quality.
3. The county epidemic prevention station carried out disinfection monitoring in our hospital twice a year, and a total of 77 samples were taken, 77 of which were qualified, and the qualified rate was 100%.
4. Carefully monitor the quality of disinfection and sterilization in the supply room. The standard package is placed for the sterilization effect of each pot of the autoclave, and the process monitoring, pot record and monthly biological monitoring are all qualified. The hospital infection management office monitors the disinfection situation in the supply room 1 time every month, so as to know in time whether the sterilized items in the supply room, the washing process, the size of the sterilized package, the number put into the pot, and the operating procedures are standardized and meet the requirements. Timely feedback to the supply room to correct the disinfection defects in clinical medical treatment. This year, the qualified rate of sterilization of sterile articles was 100%.
Six, the existing problems:
1, hospital infection management has not been paid enough attention by some medical staff, some doctors can't make a correct diagnosis of hospital infection, and some doctors still abuse antibiotics in clinic. It is necessary to strengthen the study of medical staff, strengthen inspection and supervision, and make rational use of antibiotics not only in words, but also in action.
2, undergraduate comrades in the next department inspection work, the supervision of the existing problems is not enough, in the future, we should often go deep into the department, work hard, and effectively serve the clinic and patients.
3. Strengthen the training and study of full-time hospital infection staff and medical staff on hospital infection management.