医院感染工作计划、总结.docx

医院感染工作计划、总结医院感染工作计划、总结 医院感染工作总结我科在院领导和感染管理委员会的领导下，根据医院感染管理规范、消毒技术规范和传染病防治法等有关文件与规定，制定相应的院内感染控制计划，并组织实施，及时监测效果，及时修订措施，使我院院内感染发生率控制在较好的范围内，无院内感染的暴发流行。现将今年主要工作总结如下：一、完善管理体系，发挥体系作用1.为进一步加强医院感染管理工作，明确职责，落实任务，今年8月重新调整充实了医院感染管理委员会、临床科室感染监控小组，完善了三级网络管理体系。在工作中，遇到需要多科室协调和配合时，及时汇报主管领导解决问题。2.11月份在感染管理委员会的倡议下和院领导的支持下，医院感染管理部分加入了我院的医疗护理质量督察中，制订了严厉的奖惩办法。二、医院感染监测方面我科负责全院医院感染发病情况的监测，定期对医院环境卫生学、消毒、灭菌效果进行监督、监测，及时汇总、分析监测结果，发现医院感染存在的危险因素，寻找有效的预防和控制办法。通过监测控制监测，最终减少和控制医院感染的发生，提高医疗护理质量。1、病历监测对院感病例回顾性调查模式(在病案室逐份查阅出院病历，防止漏报)，真实了解我院的医院感染率的基线。并同时采用了前瞻性调查形式，下病区对重点病人整个治疗过程的随访，密切观察院内感染发生情况，既做到对病人的过程管理，同时也是对管床医生的持续培训，此项工作收到预期效果，能及时发现医院感染病例，防止医院感染的暴发流行。感染率监测：发生医院感染242人,感染例次数250例,感染率为1.3%,达到卫生厅规定的8%要求。漏报率的监测：从11月我院将医院感染管理纳入医疗护理质量管理开始，我院的漏报率从50%下降到16%。符合卫生部要求的20%。对全院1751例无菌切口进行感染率调查，发生感染5例，感染率为0.2%。达到了卫生部规定的0.5%的要求2、首次开展现患率调查7月份我科开展了住院病人现患率调查。此次调查有院感科专职人员负责，调查时间为3天，共调查399个在院病人，实查率为98.8%。调查结果显示，院内感染率为2.76%。抗生素使用率为64.4%，送检率为3.8%。3、环境监测方面对全院环境采样366份，合格346份，合格率为94.5%。其中高危科室采样243份，合格233份，合格率为95.8%。普通科室采样133份，合格128份，合格率为96.2%。重点科室手卫生采样144份，合格142份，合格率为98.6%。对于不合格的者，及时查找原因并重新采样。县卫生监督所来我院对层流手术室的空气监测采样9份，合格8份，合格率为88%。透析液采样为180份，合格180份，合格率为100%。对10月份投入使用的层流手术室、产房、ICU的空气采样方法，首次采用中华人民共和国国家标准医院洁净手术部建筑技术规范xxxx20XX中的具体采样要求，采样结果均符合要求。4、消毒灭菌监测1.每月对消毒间预真空高压锅进行效果监测，按全国消毒规范要求，每天做B-D试验，每月做生物监测，保证高压锅消毒灭菌质量。对手术室的快速压力蒸汽消毒锅全国消毒规范要求进行监测以保证灭菌质量。2.每月对全院使用中消毒液的监测：共监测246份，合格246份，合格率为100%。并逐步取消外科病区的戊二醛浸泡消毒，采用压力蒸汽灭菌。3.6月份对使用中的紫外线灯管进行了监测，上半年共监测79根，合格75根，合格率为94.9%。对90%，合格率>80%。 2、进一步完善有关预防和控制医院感染规章制度，并对其落实情况进行检查和指导。二、加强医院感染的监测、监管1、对医院感染及其相关危险因素进行监测、分析和反馈，针对问题提出措施并指导实施。2、对医院的清洁、消毒灭菌与隔离，无菌技术，医疗废物管理等工作提供指导。3、对传染病的医院感染控制工作提供指导。三、提高医院感染控制意识，加强药物人员的自身防护，以防医院感染于未然。 1、加强医务人员的预防意识与相关法律法规知识的培训力度。 2、严格要求医务人员执行无菌技术操作、消毒隔离工作制度、手卫生、手消毒规范，并强制管理。20XX年度感染监测计划为了保护住院患者和医务人员的健康，减少医院感染的发生、避免医院感染暴发事件的出现，在本年度要进一步加强医院感染监测。特制定以下监测计划： 1、 医院感染发病率监测1.1在本年度医院感染专职人员每月要不断深入临床科室及相关部门进行前瞻性医院感染监测，每日收集医院感染病例报告卡和各科沟通、核实医院感染诊断，并查找引起感染的相关危险因素；及时发现医院感染及医院感染的聚集性发生，及时分析感染原因，查找医院感染的危险因素，同时提出相应的预防控制措施，并对医院感染事件进行持续监测。最大限度的减少医院感染发生，避免医院感染暴发及疑似医院感染暴发。 每月第二周重点进行医院感染的漏报调查，调查后对全院及各科的医院感染情况进行汇总，对医院感染的发病率、漏报率和各临床科室的医院感染率、漏报率、漏报、迟报病例及医院感染部位分布进行统计、分析，对感染率高的科室和部位提出相应的预防控制措施，并向全院书面反馈。对医院感染漏报病例的主管医生进行通报批评和适当经济处罚。每季度召开医院感染委员会会议，感染管理科把该季度医院感染管理工作情况和医院感染的发病情况向医院感染委员会汇报，共同讨论、研究，解决医院感染管理工作中存在的问题。1.2在本年度根据医院感染发病情况，计划在5月份进行全院住院患者医院感染现患率调查。由感染管理科主持，各科共同参与，规定统一时间，制定统一表格，按照统一标准进行全院住院患者医院感染现患率调查。了解在同一个时间点全院各科现患率，部位感染率。从而掌握全院及不同科室医院感染基本状况和医院感染高发科室、高发部位，对高发科室和高发部位查找危险因素，制定和采取预防控制措施。1.3本年度对神经外科ICU、NICU、RICU进行医院感染目标性监测，特别加强对呼吸机相关性肺炎、血管内导管所致血行感染、留置导尿管所致尿路感染的监测，感染管理科每周到神经外科ICU、NICU、RICU，评估和了解患者病情和感染情况，对使用呼吸机、留置血管内导管、留置导尿管的患者及插管和拔管时间由神经外科ICU、NICU、RICU值班护士建立ICU日志逐一进行记录，并密切观察感染的症状与体征，及时作出正确诊断，同时查找感染危险因素，积极采取相应的控制措施，进一步降低医院感染率，做好重症患者的感染监测工作。2、手术部位感染监测为了进一步了解手术患者的手术部位感染率；及时发现危险因素，积极进行干预；有效地评价控制效果，降低手术部位感染，进行了手术部位监测：对妇产科所有的择期和急诊手术术后病人的手术部位进行监测。医院感染监控专职人员每天去病房了解、登记被监测手术患者的情况，与手术医生确定换药时间，查看手术切口愈合情况，督促医生对异常切口分泌物送检，及时追查送检结果并要求合理应用抗菌药物；核对每位手术患者的联系方式，对手术患者宣传解释调查目的和方式，电话联系出院后的患者以确定是否发生感染，输入每个手术患者监测数据并进行统计分析，计算手术部位感染率，与医师、科室感控护士共同分析原因以便进行改进，预防并降低手术切口感染。3、进行多重耐药菌监测为了加强多重耐药菌（MDRO）的医院感染管理，有效预防和控制多重耐药菌在医院内的传播，进行多重耐药菌（MDRO）的目标性监测：监测的目标菌为耐甲氧西林金黄色葡萄球菌（MRSA）、耐万古霉素肠球菌（VRE）、产超广谱-内酰胺酶（ESBLs）的细菌、多重耐药的铜绿假单胞菌和多重耐药的鲍曼不动杆菌实施目标性监测。从而督促临床科室对感染患者和可疑感染患者做到有样必采，及时做细菌培养，及时发现、早期诊断多重耐药菌感染患者和定植患者。临床科室、细菌室对确立诊断的多重耐药菌（MDRO）要及时向医务科、医院感染管理科报告。同时细菌室给感染管理科留报告单一份，感染管理科每日到细菌室了解细菌培养阳性结果并记录，并和该患者所在科室负责人联系指导消毒隔离措施实施，同时发放消毒隔离通知，指导相关科室多重耐药菌医院感染的预防控制措施的落实。对由于主观原因预防控制措施落实不到位，发生医院感染的给予相应的经济处罚；感染管理科每季度统计、分析、反馈各科多重耐药菌感染感染状况和各科室预防控制措施落实情况；每季度公布医院常见致病菌的流行和药敏情况；细菌室每季度对耐药菌的变迁和药物敏感性进行分析并反馈。各项监测结果在医疗质量、医疗安全管理会议上通报。20XX医院感染工作计划为加强医院感染管理有效预防和控制医院感染，提高医疗质量，保证医疗安全，并结合我院医院感染管理工作实际，特制订医院感染管理工作计划如下：一、医院感染监测：1、采取前瞻性监测方法，对全院住院病人感染发病率，每月下临床监测住院病人医院感染发生情况，督促临床医生及时报告医院感染病例，防止医院感染暴发或流行。2、每半年采取回顾性监测方法，对出院病人进行漏报率调查。减少医院感染漏报，逐渐使医院感染病历报卡制度规范化。3、消毒灭菌效果监测及环境卫生学监测根据消毒技术规范及医院感染管理办法要求，每月对重点部门的空气、物体表面、工作人员手、消毒剂、灭菌剂、消毒灭菌物品等进行消毒灭菌效果监测。4、根据手术部位医院感染预防与控制技术规范和消毒供应中心感染预防与控制技术规范的要求，严格做好手术室器械的清洗、消毒和保养工作，二、抗菌药物合理使用管理：根据我院“抗菌药物合理使用实施细则及抗菌药物合理管理办法”，对抗菌药物实行分级管理。每季度调查住院病人抗菌药物使用率。三、督促检验科定期公布全院前五位感染细菌谱及其耐药菌，为临床医生合理使用抗菌药物提供依据。四、医院感染管理知识培训：进行全院医务人员分层次进行医院感染知识的培训，主要培训内容为感染预防控制新进展、新方法，医院感染诊断标准、抗菌药物的合理使用知识等。对护理人员主要培训内容为消毒隔离知识、医院内感染的预防控制及医疗垃圾的分类收集。保洁人员的工作要求、消毒灭菌的基本常识、清洁程序、个人防护措施及医护人员手卫生消毒等。五、病区环境卫生学及医疗废物监督管理：定期督查医疗垃圾分类收集及消毒处理情况，监督管理使用后的一次性医疗用品的消毒毁形、回收焚烧处理等工作。六、传染病管理：按照要求搞好法定传染病管理及肠道门诊、发热门诊的管理，防止传染病漏报及流行。尤其要加强对重点传染病的监控与防治力度。杜绝疫情漏报而导致疫情扩散的发生。七、医院改扩建工作：供应室、手术室的改建，应严格区分无菌区、清洁区、污染区;污染物品的清理、消毒和灭菌必须有明确的循环路线，不能逆行;墙面、屋顶要光滑平整，以利清洁消毒。宁县中医院院感科 20XX.1responsibilities, agricultural administrative system coordinated operation.The solution of emancipating the mind, seeking truth from facts, and when all the times, continue to promote rural reform and development.The relevant departments at all levels should further emancipate the mind, deepen the reform of reform, opening up.I go to tell the truth, do practical work, seek practical results, resolutely opposed the formalism and bureaucracy.Leading cadres at all levels should adhere to the right of the people, love the people, and work for the people.The ideological emancipation, adhere to reform and opening up, promote scientific development, promote social harmony.The construction of a faith, dedication dedication, skills, re conduct basic rural grassroots cadres.The comprehensive implementation through Scientific Outlook on Development, uplifting spirit, solid work, forge ahead, pioneering and innovative.I go to the solution to continue emancipating the mind to insist on the implementation of reform and opening, promote scientific development, promote social harmony.The construction of tourism personnel training, introduction, selection, use, management, assessment, evaluation, incentive mechanism and so on.The socialist economic construction, political construction, cultural construction, social construction and Party construction has made new progress.I go Gaga more consciously implement to continue to emancipate the mind persist in reform and opening up, promote scientific development, promote social harmony.In the policy, the Ministry of finance work, put on the work of the whole Party cadres to embody in heavy strategic thinking.- adhere to education, system, supervision, reform, rectification rectification, combination of punishment, to promote rural village construction of punishing and preventing corruption.I go to expand the orderly participation, promote information disclosure, improve business negotiation procedure, strengthen the powers of supervision as the focus, and strengthen the building of grassroots political power.I go to the party construction has become the development of promoting science, led farmers to get rich, close ties with the masses, safeguard the stability of the strong strong core of leadership.The first priority to be more conscious, more firmly grasp the development of the party's affairs, more conscious, more firmly push to promote scientific development.- strengthen the unified leadership of the party committees, government together tube, comprehensive rural work department organization and coordination, relevant departments of agricultural and rural work leadership system and working mechanism.? In the revolution, construction and reform of each historical period, our Party firmly adhere to the basic principle of the Marx doctrine with the concrete practice of China, has always attached great importance to the end, seriously, to solve agriculture, rural and farmers problems.I go to the leadership construction as the focus, improve the party organization as the guarantee, level three, LIAN activities as the carrier, the construction of Party organization has become to promote scientific development, led farmers to get rich in close contact with the masses, strong leadership to maintain stability in rural areas.The majority of Party members, cadres should adhere to the right to use, for the people, love the people, and work for the people, concerned about the sufferings of the masses, listen to their whirring sound, on the wisdom of the masses, to tell the truth, do practical work, seek practical results, resolutely opposed the formalism, bureaucracy, efforts to create tangible in the performance.According to the construction of democracy and the rule of law, fair justice, honesty and friendship, full of life vitality, stability and order, and harmony between man and nature of the socialist harmonious society will be required to correctly handle the contradictions among the people under the new situation, solve the serious concern, the people most directly, the most realistic interests.That I worry we must be prepared, enhanced sense of urgency, and always maintain the Marxism of Marx, the meaning of socialist China characteristics, faith in the great rejuvenation of the Chinese nation Xing; must quit arrogance and rashness, hard work, keep in mind the socialist primary stage of the basic national conditions, for the party and the people's cause of unremitting efforts sure; to study hard, work hard, do not continue to create a stand the practice, people and history of test results; and must strengthen the unity of the overall situation, and consciously maintaining the unity of the whole party, the party to maintain close ties with the masses, Gong Gong solid people of all nationalities unity.The need to consolidate and strengthen the fundamental position of agriculture industry, has always been to solve the problem of population Shishijiyi priority rule in Ampang must safeguard the rights and interests of farmers; and has always been to realize, safeguard and develop the fundamental interests of the majority of farmers in rural areas as well all the work of the starting point and end point; we must continue to emancipate and the development of rural social productivity, has always been to reform and innovation as the fundamental driving force for rural development; must urban and rural economic and social development, it has always been the focus on building a new type of city workers and peasants, the relationship between urban and rural areas as a major strategy to accelerate the modernization of the rural work; we must adhere to the party tube, beginning Finally to strengthen and improve the party's leadership of the rural work as a political guarantee for promoting the development of rural reform.Economy classThe change in speed, change the kitchen, lavatories, changing circle.The rural land ownership, registration, certification work.The promotion of agricultural production, farmers income, rural prosperity and prosperity.The development of conservation agriculture industry, circular agriculture, ecological agriculture.The cultivation of culture, understand technology, new farmers will operate.The health and improve the rural collective funds, assets and resources management system.The establishment of set management, financing, construction in one of the main business.The industrialization, urbanization, marketization and internationalization step to speed up the pace.The firm confidence, calm observation, multi pronged approach, the effective effect on.The stability of the sown area of product, optimize breed structure, improve the production yield level.The force of China's economic strength, comprehensive national strength and international status significantly improved.The transformation of the development concept of pronouncing, innovating the mode of development, improve the development quality.The building of regional, national character, strong participation tourism brand.The last of China's overall has entered the industry promoting agriculture development stage, to the city with the township.The agriculture, rural areas, farmers, relationship between the party and the country's development of the whole country.The health and improve the agricultural subsidy system, expand the range, improve the standard and perfect way.The law to protect farmers contracted land soil possession, use, income and other rights.- promote economic development, improve people's lives is always the central task of the China.- ensure that this base farmland is not reduced, the use does not change, the quality is improved.The construction of full coverage, comprehensive, social service system. The Czech high poopThe establishment of government support, multi party participation, rural credit loan guarantee mechanism of market operation.The formation of East and interaction, complementary advantages, mutual promotion and promote common development of the new pattern.I go to uphold and improve the "governor rice bag", in charge of the system, "food basket" the mayor is responsible for the system.The promoting agricultural technology integration, labor process machine, production and management of information technology.The increase of the old revolutionary base areas, minority areas, areas, poor areas development support.The whole city urban and rural social management, promote the reform of the household registration system and relax the small city settled conditions.That the majority of farmers with education, employment, medical care, medical, and housing.The development to help the old, disabled, save the orphans alone, poor relief, as the focus of social welfare and charity.The guides farmers orderly employment, encourage farmers to encourage employment, entrepreneurship support agricultural migrant workers.I go to carry out thorough and wide coverage, basic, multi-level, sustainable principle, accelerate the establishment of rural social security system.There must be in accordance with high yield, high-quality, efficient, ecological, safety requirements, accelerate the transformation of agricultural development mode change.The rapid construction of stable supply, reserves sufficient, effective adjustment, efficient operation of the food safety guarantee system.The real effective implementation of agricultural production, acquisition, processing, storage and transportation, quality safety supervision and responsibility of each link of sales.Allow the farmers to subcontract, lease, exchange, transfer, share cooperation and other forms of flow circulation of land contract and management rights.? To clear objectives, to develop planning, increase investment, focus on the overall strength of the relationship between the Department of the overall situation, the impact of long-term major events.The construction of production development, well-off life wide, rural civilization, clean village, new socialist countryside village and democratic management.According to the step by step, is about to land, intensive development, reasonable arrangement of distribution principle, promote the urbanization healthy development.There must have a clear goal, and planning, increase investment, focus in the power of good relations overall, long-term effects of long event.I go to market demand, technological innovation as a means, quality and efficiency as the goal, to build a modern ag