What is the responsibility of the hospital infection management department?

Organizational system of hospital infection management

system

1. Hospital infection management leading organization

(1) Organization Form:

1) Hospitals with more than 300 beds should set up hospital infection management committees.

2) Hospitals with less than 300 beds should set up a hospital infection management team.

(2) Members:

Hospital infection management committee (group) generally has 1 director (group leader), who is concurrently the vice president in charge of business; Deputy director (deputy)

group

Long) 1 ~ 2 people, respectively, by the hospital infection management department director or by the prevention and health care department director, director of the nursing department. commission

The members are medical department, internal and external departments, gynecology and pediatrics department, infectious diseases department, laboratory director, pharmacy department director, head nurse of supply room and hand.

The head nurse of the operating room, the chief of the general affairs department and other relevant personnel are concurrently employed, and the number can be determined according to the scale, nature and tasks of the hospital and the general members.

The number of people in the meeting shall be no less than 10, and the number of people in the group shall be no less than 6.

(3) Tasks and responsibilities:

1) According to the Law of People's Republic of China (PRC) on the Prevention and Control of Infectious Diseases, the Measures for the Administration of Disinfection and the provincial and municipal health administrative departments.

The relevant provisions of the door to prevent hospital infection, hospital infection control planning, health standards and management system.

2) Be responsible for monitoring the incidence of nosocomial infection, find problems in time, put forward countermeasures, evaluate the management effect, and study the rectification.

Further measures.

3) Be responsible for the examination and approval of health standards for new facilities.

4) Be responsible for the business training of hospital infection management related personnel and provide relevant technical consultation.

5) Responsible for reporting the hospital infection incidence monitoring table to the health authorities in accordance with the regulations. When the disease breaks out, immediately

Report to the superior.

2. Hospital infection institutions

(1) Mechanism Settings:

Hospital infection management department is the secondary institution of hospital infection management and the office of hospital infection management Committee. Youzhuan

work

Personnel composition, specifically responsible for the implementation of the hospital infection plan.

Hospitals with less than 200 beds can set up infection management teams in preventive health care departments or nursing departments, which are composed of full-time staff.

(2) Staffing:

1) the hospital infection management department should have a director, deputy director, full-time doctors and nurses, full-time or part-time inspectors, and pass

Corresponding professional training. The director of the department should have middle and senior technical titles; As a doctor of infection management, the requirement is medical school.

A clinician who has graduated from the Department of Public Health or has been specially trained; As an infection management nurse, I need to graduate from a regular nursing school and have a wealth of

Nurses with clinical experience and special training and above.

2) According to the proportion that each person is responsible for 250 beds, it is equipped with hospital infection monitoring nurses.

3) Hospital Infection Management Department is a functional department in administration and a medical department in business, which is dual. This part

Medical staff enjoy all the benefits of medical staff at the same level, such as promotion, nursing age and health allowance.

(3) Tasks and functions:

1) under the leadership of the dean and the hospital infection management committee (group), responsible for drawing up the hospital infection control table.

Plan and organize the implementation.

2) Implement various monitoring systems, and monitor, analyze and report the incidence and disinfection effect every month.

3) Investigate and analyze the epidemic situation of hospital infection in time, report to the hospital infection management committee (group) and put forward suggestions for improvement.

Measures. When the epidemic situation is discovered, it must be reported to the hospital infection management Committee and the health administrative department at the next higher level immediately.

Doors.

4) Coordinate hospital infection monitoring in various departments of the hospital, and provide business technical guidance and consultation.

5) Carry out special research on hospital health management and popularize new disinfection methods and preparations.

6) On-the-job education on hospital infection shall be given to all employees, training of monitoring personnel shall be organized, and various lectures shall be held.

3. Each department hospital infection management team

It is a three-level management organization in hospital infection management organization, which consists of department (deputy) directors, ward monitoring doctors, head nurses and monitoring nurses.

Composition. Under the guidance of hospital infection management department, do a good job in infection management of undergraduate course room.

The main tasks are:

(1) Do a good job in monitoring hospital infection of inpatients in undergraduate course room. The attending physician should handle hospital infection cases within 24 hours.

Report to the hospital infection management department in the form of report card. Once the epidemic situation is discovered, it must be reported to the hospital infection management department immediately.

(2) Do a good job in disinfection, sterilization and isolation of undergraduate course room to prevent exogenous infection.

(3) Observe the principle of rational use of antibacterial drugs and do a good job in microbial monitoring.

(4) Implement various disinfection, isolation and infection control systems.

(5) the implementation of undergraduate course room staff hospital infection in-service education.

Supervision and inspection

The municipal and district health bureaus organize annual inspections, including:

1. Establish relevant documents, training certificates, professional title certificates and other materials of hospital infection management institutions at all levels.

2. The operation of the hospital infection management committee and the daily work of the hospital infection management department, such as meeting minutes, all kinds of

Work records, hospital infection case monitoring, disinfection and isolation monitoring and other information.

3. Hospital infection control system, annual plan, re-education and training work written materials, listen to the work report.

Report and evaluate the effect.

Section 2 Hospital Infection Monitoring and Reporting System

system

1. Clinicians should fill in the Hospital Infection Case Report Card (registration) in time when they find hospital infection among patients under their management.

Table) ",and report to the hospital infection management department or the corresponding functional departments within two days. When leaving the hospital, you should indicate "nosocomial infection" on the first page of the medical record.

Name "column fill in the hospital infection diagnosis.

2. Full-time hospital infection personnel should go to the ward and microbiology room at least once every 2 days to consult, collect and verify infection cases. real

Fill in the Hospital Infection Case Registration Form after hospital infection.

3. Full-time staff of hospital infection should check all the discharged medical records in the medical record room every week, and record the missing cases of hospital infection in time.

Line registration, and feedback to the missing department.

4. Each ward (department) strengthens self-inspection of environmental sanitation, and regularly monitors seven specimens (sterilized items,

Disinfecting articles, disinfectants in use, surfaces of objects, hands of staff, air, ultraviolet lamps). Strengthen special departments

Monitoring of special items (such as monitoring of pressure cooker in supply room, monitoring of dialyzer and dialysate in hemodialysis room, etc.). ).

5. Full-time nurses with hospital infection patrol key wards (departments) every month (such as supply room, hemodialysis room, operating room, delivery room, love room, etc.).

Infant area, surgical ward, intensive care unit, treatment room, etc. ) for microbial monitoring, non-key departments to monitor once every quarter.

6. In order to effectively control hospital infection, full-time hospital infection management personnel should be responsible for the incidence of hospital infection of inpatients in our hospital every month.

Statistical and epidemiological analysis, including the incidence of nosocomial infection in the whole hospital and the nosocomial infection in various wards (departments)

Rate, incidence of infection in various parts, missed diagnosis rate of nosocomial infection cases in the whole hospital and departments, susceptible factors of nosocomial infection,

Statistical analysis of the distribution of pathogenic bacteria in hospital infection, drug sensitivity test results, hospital environmental hygiene monitoring and other items.

7. Full-time staff of hospital infection timely report the results of statistical analysis to each department every month and report to the supervisor in time.

Dean and medical department, nursing department and other relevant departments. , and help the unqualified departments to find out the reasons and put forward control measures.

8. At the monthly medical meeting, the director in charge should report the hospital infection in the whole hospital last month and put forward further suggestions.

Requirements.

9. Three cases of infection caused by the same pathogen occurred in the same ward (department) within one week, and the ward should report it in time within 24 hours.

Report to the hospital infection management department or the corresponding functional department to further identify the pathogen. If the hospital infection is diagnosed.

When an epidemic occurs, the hospital infection management department or the corresponding functional department should report to the hospital management Committee or group within 24 hours.

the same

When reporting to the health administrative department at the next higher level. Hospital infection management committee (group) should immediately hold an emergency meeting to control.

Measures.

10. Full-time staff in hospital infection department and various wards (departments) such as monitoring sterilized articles, sterilized articles and disinfectants in use.

If found unqualified, should find the reason within 24 hours, and timely report to the hospital infection management committee (or group).

manufacture

Determine the corrective measures.

Supervision and inspection

1. The hospital infection management team in each ward (department) should do a good job in the daily monitoring of hospital infection in this department.

2. The functional department of infection management is responsible for the statistics of the omission rate, which should be less than 20%.

3. Set up a disinfection and isolation team, and check the quality of cleaning, disinfection and sterilization for all clinical departments of the hospital irregularly every month.

4. When an outbreak of hospital infection is found, the hospital must report it step by step according to regulations, and those who fail to report it will be held accountable by relevant personnel at all levels.

Responsibility.

Section 3 Disposable Medical Supplies Management System

system

1. The hospital infection management department or relevant management departments should purchase, store, distribute and use disposable medical supplies of their own units.

Ensure the quality and safety of products.

2 disposable medical consumables used by medical and health units must have a certificate issued by the health administrative department at or above the provincial level.

License and production license products. The package shall indicate the approval number, factory name, batch number, disinfection method and disinfection method.

The date and expiration date of the poison, with detailed instructions for use, introducing the storage conditions and precautions for use of the product.

3. Every time the equipment department purchases disposable medical supplies, it must carry out quality acceptance to ensure the salesman's certificate, order contract and delivery.

The goods location and payment remittance account number are consistent with the production enterprise, and the inspection certificate, disinfection date and factory date of each batch of products are checked.

Factory date and validity period, make detailed registration and save.

4. The storage environment of disposable medical supplies should be kept clean and dry to prevent re-pollution. One person in charge of disinfection supply room

Distribution of secondary medical supplies and detailed registration. Each department should set up a counter for safekeeping according to the purpose after receiving it.

5. Before using disposable medical supplies, clinical departments should do a good job of inspection, and all products with damaged packaging or expired products.

The law shall not be used. If you have doubts about the product quality, you should stop using it and report it to the Equipment Department and the Hospital Infection Management Department for monitoring.

Its disinfection effect.

6 disposable medical supplies must be disinfected, destroyed or burned in time for harmless treatment after use. Be seriously affected

Pollution should be stored separately from domestic garbage, sealed and directly burned.

Supervision and inspection

1. The hospital infection management department or the relevant administrative department shall "hygiene permit" the disposable medical supplies purchased by the equipment department every quarter.

Certificate and production license, the provincial hygiene license rate must reach 100%, and there are no unqualified products.

2. The hospital infection management department or relevant management departments should check the disposable medical supplies after use every quarter, and whether it is done.

Disinfect, destroy or burn in time.

3. Those who fail to purchase and use unqualified disposable medical consumables according to the system requirements shall be dealt with according to relevant regulations, resulting in the accountability of infected persons.

Ren.

4. Every time the hospital infection department and the health and epidemic prevention department check unqualified items, they should trace the purchase channels and investigate the purchase personnel.

And the responsibility of the supervisor.

The fourth quarter disinfectant management system

system

1. Hospital Infection Management Committee is responsible for the examination and approval of disinfectant varieties and the determination of suppliers. Buy disinfectant or change disinfectant.

Venom producers must obtain the consent of the Hospital Infection Management Committee before implementation.

2. The supplier shall have a Production License and a Hygiene License issued by the pharmaceutical department and the health administrative department at or above the provincial level.

Certificate ".

3. Every time the pharmacy department purchases disinfectants, it must carry out quality acceptance, and check the inspection certificate and approval of each batch of disinfectants.

Document number, production batch number, concentration, expiration date and instructions for use, etc. , and make detailed registration.

4. All kinds of disinfectants prepared in the hospital preparation room must be marked with the approval number, production batch number, effective concentration and validity period, and

Only after passing the inspection by the quality inspection department can it be put into clinical use. All kinds of disinfectants stored must reach their corresponding effective concentrations.

, the monitoring results should meet the national standards. Other departments shall not prepare and dilute disinfectants without authorization.

5. After receiving the disinfectant, the department should store it in a clean and dark place, and seal it immediately after each opening to avoid volatilization and pollution.

Dyeing affects the disinfection effect. Containers containing disinfectants must be disinfected before use. There must be two people before using disinfectant.

Check the above concentration, expiration date, factory date and recall date, and have a signature record.

6. Clinical medical personnel should understand the performance, function, effective concentration, action time, use method and influence of various disinfectants.

Factors, and in strict accordance with the requirements of disinfection and sterilization items to choose the appropriate disinfectant and disinfection methods, shall not be disposed of without authorization.

Change. If there is any quality problem, stop using it and report it to the hospital infection management department and preparation room in time.

7. The hospital infection management department is responsible for supervising the purchase and preparation of disinfectants and guiding the clinical use of various disinfectants. It should be supervised once a month.

To measure the disinfection effect of disinfectant in use. Clinically, disinfectants that do not meet the hygienic standards for disinfection in hospitals must be stopped immediately.

Stop using.

Supervision and inspection

1. The hospital infection management department or relevant management departments shall inspect the disinfectants purchased by the pharmacy department every quarter, and hold the provincial hygiene license rate.

It must reach 100%, and the prepared disinfectant must undergo quality inspection, indicating the approval number, production batch number, concentration and expiration date.

Qualified products.

2. The hospital infection management department or relevant administrative departments shall check the disinfectants in use every month to see if they conform to the hospital disinfection standards.

Hygienic standard ",whether to use unqualified disinfectant.

3. The municipal and district health and epidemic prevention departments are responsible for regularly testing special disinfectants and feeding back the results to relevant hospitals.

4. Those who do not purchase, prepare and use disinfectants according to the above system are dereliction of duty, and they will be handled according to relevant regulations, resulting in nosocomial infection.

Deal with it seriously according to the situation.

Section 5 Hospital Sewage and Waste Management System

system

1. The hospital should have sewage treatment facilities and be managed by special personnel.

2. Hospital sewage discharge must meet the standards.

3. Inorganic waste should be concentrated at fixed points and transported abroad regularly.

Organic waste should be incinerated. Incinerator should be managed by a special person with working records.

5. The waste gas discharged by the incinerator shall meet the national environmental protection standards.

Supervision and inspection

1. On-site inspection of sewage treatment facilities, whether there is personnel management, daily disinfection records, daily residual chlorine and quarterly disinfection.

Whether the effect reaches the standard.

2. On-site inspection of organic waste collection and incineration process.

3. The incinerator should be managed by a special person, with good equipment operation and complete work records. The waste gas discharged by the incinerator shall meet the national standards.

Environmental standards.

Section 6 Hospital Infection On-the-job Education and Training System

system

1. It is necessary to strengthen the on-the-job education of professionals in hospital infection department and improve the professional quality of full-time staff in hospital infection department.

Organize business study once a year, hold a special lecture every quarter, and go out to study once a year.

2. Training of hospital infection monitoring personnel. pass by

Each clinical department selects doctors and nurses with practical work experience and prestige as hospital infection monitors, and the hospital infection department

Conduct regular business training for them.

3. Re-educate all employees about hospital infection,

Every year, the hospital medical staff are educated about hospital infection knowledge, and the awareness of hospital infection prevention is strengthened. You can use training methods.

Learn hospital infection management documents, books or handouts, watch hospital infection control teaching videos, and invite experts to give special lectures.

, held academic reports, hospital infection knowledge test, etc.

4. Anyone who is the chief resident in the clinical department or will soon be promoted to the attending physician shall go to the hospital infection department for a short-term study for one week.

5. The medical staff newly assigned to the hospital should be trained in the knowledge of hospital infection in the pre-job education course, and may not take up their posts without training.

6. Carry out various professional training courses to train other personnel. For example, doctors' antibiotic classes and nurses are eliminated.

Poison disinfection class, administrator hospital infection management class, cleaner cleaning training class, etc.

Supervision and inspection

The hospital regularly checks the on-the-job education records of infectious disease professionals and other personnel in the hospital item by item every year.

The above information is for reference only!