2022年20XX年医院院感科年终工作总结 .pdf
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1、 20XX年医院院感科年终工作总结在院领导的大力支持,各职能科室共同协作,科主任护士长以及全体员工的共同努力,院感控制工作取得了一定的成绩,为了更好地做好院感控制工作,防止医院感染暴发流行,现将近来主要工作总结如下:一、完善管理体系,发挥体系作用1、及时调整医院感染管理委员会、临床科室感染管理小组人员,定期召开会议,讨论医院感染管理中存在的问题,提出改进措施,做好下一步的落实工作。2、根据卫生部新的要求和规范,修订和完善了各项制度并监督落实执行情况。二、医院感染监测方面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、检查,及时汇总、分析反馈与改进,发现医院感染存在
2、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,提高医疗质量。1、感染率监测:全院1-12 月份共监测2408 例住院病人,妇产科分娩人数904 例、妇产科手术531 例、儿科手术114 例、新生儿住院人数73 例、全院发生医院感染7 例,无菌切口感染0 例,妇产科上呼吸道感染2例,下呼吸道感染1 例,儿科上呼吸道感染3 例、消化道感染1 例、全院感染发生率0.3%。符合标准。2、1-12 全院无菌切口进行感染率调查,感染率为0%。达到了卫生部规定的1.5%的要求,无菌切口甲级愈合率 99.7%,达到卫生部要求 97%。3、开展现患率调查情况9 月份我科开
3、展了住院病人现患率调查。调查时间为1 天,共调查16 例在院病人,实查率为 100%。调查结果显示,院内感染率为0%,抗生素使用率为75%。4、开展目标性监测1-8 月妇产科会阴侧切口切口感染监测,无切口感染。5、环境卫生监测方面我院环境卫生监测受条件限制未能做文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:
4、CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2
5、HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 Z
6、L6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编
7、码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J
8、2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5
9、 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3到
10、,望领导尽快落实解决6、消毒灭菌监测1.按要求压力蒸汽灭菌高压锅进行效果监测,物理监测和化学监测我们都做得很好,但按卫生部消毒规范要求,每周做生物监测,我们受条件限制未做到。2.各科室对使用中的紫外线灯管进行了强度监测,每6 月一次,合格率为 100%。对70 W/cm2的紫外线灯管通知科室及时更换。三、无医院感染暴发流行四、加强医疗废物管理,规范下收制度促成全院各科室产生的医疗废物确定由专职人员下收工作的最终实施,并完成对下收专职人员进行必要的法律、法规和个人防护方面的培训。使得医疗废物的管理过程更符合实际,减少了污染和医护人员受伤害的机会。做到医疗废物收集、转运、储存、交接符合标准要求。五
11、、重点科室、重点部位医院感染管理1、定期督查重点科室的感染管理,发现问题及时主动与科主任或护士长进行沟文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编
12、码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J
13、2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5
14、 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文
15、档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O1
16、0J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9
17、A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3通,持续质量改进。将重点科室、重点部位医院感染的相关资料下发到相应科室组织科室人员学习,如:为儿科提供新生儿暖箱的拆洗及日常清洗消毒登记表。六、开展培训,提高医务
18、人员院感意识1、专职人员参加全省级医院感染监控中心培训班 2 人次。科室每月进行业务学习和医院感染病例讨论,不断提高业务技术水平和医院感染水平。2、新职工培训对今年新上岗职工进行了医院感染概论、医院感染诊断知识、消毒隔离知识、手卫生、医务人员职业防护、医院感染暴发流行、医疗废物管理知识培训与考核,考核合格率为100%;虽然近阶段我科的工作取得了很大的进展,但是存在以下问题:1、临床感染管理小组没有充分发挥其作用。2、对重点科室院感控制干预工作做得不够,文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 Z
19、L6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编
20、码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J
21、2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5
22、 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文
23、档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O10J2 HB8G9S1L9A5 ZL6J1B8R3S3文档编码:CA8O7G8O1
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