Hospital infection department work summary

XX years are about to pass, with the correct leadership and strong support of the hospital leadership, under the guidance of the hospitality committee, the hospital's medical staff actively participate in the hospital infection monitoring work, and all clinical department physicians conduct a prospective investigation of hospital infections for all hospitalized patients. It was found that nosocomial infections could be reported in a timely and accurate manner, and the hospital sense department also strengthened the reporting of hospitalized cases. When there were nosocomial infections, monitoring and control were strengthened, and no hospital epidemic occurred. The department relies on the nursing department to conduct quality inspections on disinfection and isolation, aseptic technique supervision and feedback, and cooperate with the medical department and the nursing department to cooperate with the hospital leaders to do medical safety management. A quarterly committee meeting was held under the auspices of the president every quarter, and a hospital briefing was issued.

The hospitality management carried out the following work from January to October:

First, according to the hospital's safety production requirements, refine the hospital's quality management measures

According to the requirements of “safe production” and “quality management” of the hospital, the quality control and evaluation system of nosocomial infections has been improved, the comprehensive target evaluation criteria for hospital infection quality have been refined, supervision feedback has been carried out according to comprehensive targets, and relevant hospitals have been comprehensively inspected and sorted out. All aspects of infection prevention and control, carefully investigate safety hazards, in order to ensure the hospital's sense of safety, and effectively manage the key departments, key parts, key links of the hospital, especially the operating room, disinfection supply room, stomatology, gastroscope room The hospital infection management work of key departments such as the Laboratory, and the prevention and treatment of in-hospital infections at key points and key points, and the supervision and guidance of the hospitality department to prevent the outbreak of the hospital in the hospital.

Second, according to the management requirements of infectious diseases, strengthen the prevention and control of infectious diseases

During the epidemic of hand, foot and mouth disease and influenza A (H1N1), we will further strengthen the management of key places such as pre-examination and triage, pediatric clinics, internal medicine clinics, and fever clinics, and conscientiously implement the control requirements for hand, foot and mouth disease and influenza A h1n1 influenza hospital infection. Intensify the prevention and control of hospital infections, standardize work procedures, especially for medical staff and workers in the hospital, strengthen the training of prevention and treatment of infectious diseases and self-protection of hand-foot-mouth disease, influenza A h1n1 influenza, and strictly implement the hospital. Sense prevention and personal protection measures to prevent cross-infection in the hospital, actively cooperate with relevant departments, and work together to prevent and control the epidemic.

Third, according to the hospital management requirements, do a retrospective investigation of cases

From January to September, a total of XX cases were discharged from the hospital. All the hospitals were retrospectively surveyed. The results showed that the hospital infection rate was 1.04%, and the infection rate was 1.09%. The departments in which nosocomial infection occurred were: the incidence of infection in the second hospital was 2.05%, the incidence of nosocomial infection in the orthopedic department was 1.09%, the incidence of surgical infection was 0.51%, and the incidence of infection in the internal hospital was 0.24%. The prevalence of infection was as follows: the infection rate of lower respiratory tract infection was 0.30%; the infection rate of upper respiratory tract was 0.30%; the infection rate of urinary tract was 0.25%; the infection rate of gastrointestinal tract was 0.25%; the infection rate of hospital incision was 0. %. The incidence of nosocomial infections is: neurological diseases, the case infection rate is 10.28%; endocrine diseases, the case infection rate is 2.30%; circum diseases, the case infection rate is 0.98%, genitourinary diseases, The infection rate was 1.39%, and the musculoskeletal system disease rate was 1.15%. According to the investigation of various risk factors, the infection rate of diabetes was 2.91%, the infection rate of chronic cases was 1.35%, and the infection rate of old age was 1.27%. The first three hospital-related susceptibility factors are chronic disease, advanced age, and diabetes.

Fourth, environmental hygiene, disinfection and sterilization effects and hand hygiene monitoring

In order to standardize the disinfection and sterilization work in the hospital and prevent nosocomial infections, the hospital sense department in XX strengthened the sampling and monitoring of the hospital sense, and monitored the disinfection and sterilization effects of various departments of the hospital, and strengthened the operating room, gastroscope room, stomatology department, and supply. Environmental hygiene monitoring in high-risk areas such as rooms and bacteria rooms and monitoring of medical staff's hand hygiene. A total of 358 samples were sampled throughout the year, including 56 air sampling cultures, 41 surface samples, 41 medical samples, 47 disinfectant samples, 12 sterile samples, and sterile samples. The amount of autoclave sterilization was monitored 24 times, and the pass rate was 100%. This year, the Municipal Center for Disease Control and Prevention conducted 23 sampling and monitoring of our hospital, with a pass rate of 100%.

The intensity of UV lamps in various clinical departments, medical technology departments, and outpatient clinics of the hospital was monitored. A total of 29 types of UV lamps were monitored and found to be unqualified and replaced in time to achieve a pass rate of 100%.

Fifth, strengthen the management of the use of antibiotics

In accordance with the "Guidelines for the Clinical Application of Antimicrobial Drugs" and the "Administrative Measures for the Implementation of the Guiding Principles for the Clinical Application of Antimicrobial Drugs in Anhui Province", in order to strengthen the management of the clinical use of antibacterial drugs, our hospital has established clinical application classification and branch management of antibacterial drugs. Institutions, each clinical department combines its own actual situation to formulate specific implementation measures.

The Hospital Infection Management Division actively participates in the management of clinically rational use of antibiotics, develops a clinical application system for antibacterial drugs, strengthens the supervision of the application of antibacterial drugs, and reports the results to the hospital on a monthly basis. The use of antibiotics in the hospital was as follows: XX cases were discharged from January to September, 689 cases of antibiotics, 247 cases of two or more, 142 cases of bacteria, and antibiotic use rate of 34.26%, two or more The utilization rate is 35.85, and the bacterial detection rate is 20.61%. The analysis of bacterial isolation rate and bacterial resistance is published quarterly, which provides reliable help for clinicians to use antibiotics reasonably.

Sixth, strengthen medical waste management

The hospital sense department constantly improved various rules and regulations, clarified the responsibilities of various personnel, implemented the responsibility system, strengthened the management of medical wastes and routine inspections, and found problems in time for rectification and feedback. The training of the workers and workers will be carried out to standardize and manage the classification, collection, storage, packaging, transportation and handover of medical wastes in our hospital, so as to prevent the outbreak of infection due to poor management of medical waste. .

Seven, hospital training and assessment

9 hospital infection knowledge trainings were conducted, including 246 person-times of medical staff and workers in the hospital. The training content is: hospital basic knowledge training, hand, foot and mouth disease disinfection and isolation knowledge training, occupational protection and disinfection and isolation knowledge training for workers and workers, hospitality control and disinfection and isolation knowledge training for type A h1n1 flu, medical staff manual hygiene training , the newly-employed medical staff pre-job training. The five newly-employed medical staff were trained and evaluated, and they were qualified after graduation.

8. Forward-looking investigation and underreporting rate investigation

In the third quarter, a comprehensive cross-sectional survey of the current hospital cases was conducted. The hospital had a total of 64 inpatients and 64 people surveyed, and the survey rate was 100%. The resulting prevalence rate was 0, and no hospitality was reported. In the first half of the year, 363 cases were filed in March for a false negative rate survey, with a false negative rate of zero.

9. Management of disinfectant medicines and disposable medical supplies

In order to strengthen the management of disinfectant medicines and disposable sterile medical supplies, in XX, the hospital has conducted regular inspections and regular inspections on its use. The spot check of disinfectant medicines and disposable sterile medical supplies is once every quarter, and a total of 4 times in the whole year. The method is to sample from clinical departments and to the medical equipment. A total of 45 copies were obtained throughout the year, and the results were complete and all qualified.