I. Purpose

Strengthen the management of hospital infection, effectively prevent and control hospital infection, ensure medical safety and improve medical quality.

Second, the scope of application

All clinical and medical departments.

Three. accountability

1. The main responsibilities of the hospital infection control department (full-time staff, the same below):

(1) According to the regulations and standards of national and local health administrative departments on hospital infection management, formulate hospital infection control plans and work plans, organize the formulation of hospital and hospital infection management rules and regulations, and organize the implementation, supervision and evaluation after approval.

(2) Responsible for the training and assessment of hospital infection prevention and control knowledge and skills for all kinds of hospital personnel at all levels.

(3) Responsible for monitoring the incidence of hospital infection, regularly supervise and monitor, timely summarize and analyze the monitoring results of hospital environmental sanitation, disinfection and sterilization, find problems, formulate control measures, and supervise their implementation.

(4) Investigate and analyze the prevalence and outbreak of nosocomial infection in the hospital, put forward control measures and organize their implementation.

(5) Participate in the management of the use of anti-infective drugs by the Pharmaceutical Administration Committee, assist in formulating rules and regulations for rational drug use, and participate in the supervision and implementation.

(6) Review the purchased sterile medical devices and disposable medical care products, and supervise their storage, use and post-treatment.

(7) Timely report the trends of hospital infection control to the competent leader and the hospital infection management committee, and inform the whole hospital.

2. The clinical departments to establish hospital infection management team, composed of director, head nurse and undergraduate part-time monitoring doctors and nurses, work under the leadership of the director. Its main responsibilities are:

(1) is responsible for all the work of undergraduate course room hospital infection management, according to the characteristics of undergraduate course room hospital infection management system, and organize their implementation.

(2) Monitor the nosocomial infection cases and infection links, and take effective measures to reduce the incidence of nosocomial infection in undergraduate department; When finding the epidemic trend of nosocomial infection, report it to the hospital infection management department in time and actively assist in the investigation.

(3) supervise and inspect the use of anti-infective drugs in undergraduate course room.

(4) organize undergraduate course room to prevent and control hospital infection knowledge training.

(5) urge undergraduate course room personnel to implement aseptic operation technology, disinfection and isolation system.

(6) Do a good job in health management of health workers, caterers, escorts and visitors.

3. Medical personnel shall perform the following duties in hospital infection management:

(1) Strictly implement the rules and regulations of hospital infection management, such as aseptic technical operation procedures.

(2) To master the principle of rational use of anti-infective drugs in clinic, so as to achieve rational use.

(3) Master the diagnostic criteria of nosocomial infection.

(4) When hospital infection cases are found, pathogen examination and drug sensitivity test should be sent in time to find out the source and route of infection, control the spread, actively treat the patients, and fill in the report truthfully; When there is an epidemic trend of nosocomial infection, report it to the infection management department in time and assist in the investigation. If a legal infectious disease is found, it shall be reported in accordance with the provisions of the Law on the Prevention and Control of Infectious Diseases.

(5) Participate in the training of hospital infection prevention and control knowledge.

(6) Master the knowledge of self-protection, conduct various technical operations correctly, and prevent sharp objects from stabbing.

Four. working procedure

1. Report and control of nosocomial infection

(1) When there are sporadic cases of hospital infection, the attending physician should report to the hospital infection supervisor of the undergraduate course room in time.

Report to the person in charge of the control team, and fill in the form and report it to the hospital infection management department within 24 hours.

(2) The head of the department monitoring team should organize the attending doctors and nurses to find out the cause of infection in time and take effective control measures under the guidance of the hospital infection control department.

(3) Nosocomial infection diagnosed as beam disease shall be reported and controlled in accordance with the relevant provisions of the Law on the Prevention and Control of Infectious Diseases.

2. Report and control of nosocomial infection epidemic and outbreak

(1) Epidemic Report of Hospital Infection

(1) When there is an epidemic trend of hospital infection, the hospital infection control department should report to the department director and the medical department within 24 hours, and notify the relevant departments.

(2) After investigation, it is confirmed that there is an epidemic situation of hospital infection, and the hospital should report to the local health administrative department within 24 hours.

③ When the local health administrative department determines the prevalence or outbreak of hospital infection, it should report it to the provincial health administrative department step by step within 24 hours; The provincial health administrative department shall report to the health administrative department of the State Council within 24 hours after receiving the report of hospital infection epidemic or outbreak.

(4) If the hospital infection is diagnosed as an infectious disease, it shall be reported in accordance with the relevant provisions of the Law on the Prevention and Control of Infectious Diseases.

(2) When there is an epidemic or outbreak trend of hospital infection, the following control measures should be taken:

(1) Clinical departments must find out the reasons in time, assist in investigation and implement control measures. (2) The hospital infection control department must carry out epidemiological investigation and treatment in time, and the basic steps are as follows:

A. confirmed epidemic or outbreak. Diagnose suspected cases with similar infections and calculate their incidence. If the attack rate is significantly higher than the general incidence rate of hospital infection in this department or ward over the years, it is confirmed that there is an epidemic or outbreak.

B. find the source of infection. Etiological examination of infected patients, contacts, suspected sources of infection, environment, articles, medical personnel and accompanying personnel.

C. find out the factors that cause infection. A detailed epidemiological investigation was carried out on infected patients and surrounding people.

D. formulate and organize the implementation of effective control measures. Including proper treatment of patients, proper disinfection, isolation of patients and even suspension of receiving new patients when necessary.

E. Analyze the investigation data and describe the department, personnel and time distribution of the case; Analyze the causes of epidemic or outbreak, infer the possible source, route or infection factors, and make a comprehensive judgment according to the results of laboratory inspection and the effect of control measures.

F write investigation report, sum up experience and formulate preventive measures.

(3) After receiving the report, the dean in charge should promptly organize relevant departments to assist the hospital infection management department to carry out epidemiological investigation and control, and ensure it from the aspects of manpower, material resources and financial resources.

(4) When nosocomial infection is prevalent or erupts in other hospitals, similar potential risk factors in this area or our hospital should be investigated and corresponding control measures should be taken.

⑤ Hospital infection diagnosed as an infectious disease shall be managed according to the relevant provisions of the Law on the Prevention and Control of Infectious Diseases.

3. Disinfection and isolation

(1) medical personnel must abide by the principle of disinfection and sterilization, and medical supplies entering human tissues or sterile organs must be sterilized; Instruments and appliances that come into contact with skin and mucous membranes must be disinfected. Used medical instruments and articles should be decontaminated and thoroughly cleaned before disinfection or sterilization; In particular, medical instruments and articles used by infected patients should be disinfected and thoroughly cleaned before disinfection or sterilization. All medical devices should be disinfected or sterilized before maintenance.

(2) according to the nature of the goods, choose physical or chemical methods for disinfection and sterilization. Physical sterilization is the first choice for sterilization of heat-resistant and moisture-proof articles; Pressure steam sterilization is preferably used for surgical instruments and articles, various puncture needles, syringes, etc. Dry heat sterilization is the first choice for oil, powder and paste. The thermally unstable articles such as catheters, precision instruments and artificial implants can be sterilized by chemical methods, such as ethylene oxide sterilization, and the endoscope can be sterilized by ethylene oxide sterilization or 2% glutaraldehyde immersion. Physical methods are preferred for disinfection, not chemical methods.

(3) Chemical sterilization or disinfection, high-efficiency, medium-efficiency and low-efficiency disinfectants can be selected according to different situations. When using chemical disinfectants, it is necessary to understand their performance, function, use method and factors affecting sterilization or disinfection effect. Pay attention to the effective concentration during preparation and monitor it regularly. When replacing the sterilizing agent, the container used for soaking sterilized articles must be sterilized.

(4) Formaldehyde gas sterilization should be carried out according to the Technical Specification for Hospital Disinfection. Natural volatile formaldehyde fumigation box can not be used for disinfection and sterilization, nor can it be used for the preservation of sterile items. Formaldehyde is not suitable for air disinfection.

(5) Oxygen humidifying bottle, atomizer, ventilator pipeline, humidifier of premature infant incubator and other equipment. It must be disinfected every day, disinfected at the end of use and kept dry. Humidifying liquid should be sterile water.

(6) Hand skin cleaning and disinfection shall meet the following requirements:

① Hand washing equipment:

A. Wards and medical departments are equipped with running water hand washing facilities, and the switches are pedal, elbow or sensor.

B.soap should be kept clean and dry.

C. you can dry your hands with paper towels and towels. Towels should be kept clean and dry, and disinfected every day.

D. When it is inconvenient to wash your hands, you can use a quick hand disinfectant.

② Finger washing sign:

A before and after contact with patients, especially before and after contact with damaged skin, mucous membrane and invasive operation.

B before and after aseptic technique operation, entering and leaving isolation ward, ICU, maternal and infant room, and infection.

In key departments such as STD wards, wear masks and isolation gown before and after.

After contact with blood, body fluids and contaminated items.

D. after taking off the gloves.

③ Hand washing method:

Scrub palms, fingers, backs of hands, knuckles, fingertips, thumbs and wrists carefully with detergent 10 ~ 15 seconds, and then rinse with running water.

④ Indications for hand disinfection:

A. Before and after entering and leaving the isolation ward and putting on and taking off isolation gown.

After contact with blood, body fluids and contaminated items.

C. after exposure to special infectious pathogens.

(5) hand disinfection method:

A. rub your hands with a quick hand disinfectant.

B.soak your hands with disinfectant.

⑥ Wash your hands with detergent to clean the dirt under your nails. Wash and dry your hands, then brush your hands or soak them with hand disinfectant. The time for brushing or soaking hands must meet the requirements. See Technical Specification for Hospital Disinfection for specific methods.

(7) The cleaning and disinfection of the ground shall meet the following requirements:

(1) The floor should be wet washed and kept clean; When there is blood, feces, body fluids and other pollution, it should be wiped immediately with chlorine-containing disinfectant (1000ppm).

② The mopping tools should be disinfected, cleaned and dried after use.

4. Management of sterilized medical equipment

(1) Hospital Infection Management Committee is responsible for the supervision and management of disinfection and sterilization instruments used in the whole hospital.

(2) The Infection Control Division is responsible for purchasing floor disinfection and sterilization instruments in accordance with relevant state regulations.

Supervise, inspect and guide the storage, storage and use, and report the existing problems to the hospital infection management Committee in time.

(3) The pharmacy department should purchase disinfection and sterilization equipment according to the clinical needs and the approval opinions of the hospital infection management committee, check the necessary documents in accordance with the relevant provisions of the state, supervise the quality of purchased products, and register according to the relevant requirements.

(4) The user department should accurately grasp the scope of use, methods and precautions of disinfection and sterilization instruments; Master the concentration of disinfectant, preparation method, replacement time and factors affecting disinfection and sterilization effect. , and report the problem to the hospital infection control department in time to solve the problem.

5. Application and management of anti-infective drugs

(1) The management of anti-infective drugs shall meet the following requirements:

① The hospital has a sound anti-infective drug application management system.

② Make statistics on the utilization rate of anti-infective drugs in hospitals, and strive to control it below 50%.

③ The clinical laboratory and pharmacy departments publish the main pathogenic bacteria and their drug sensitivity test results every six months, providing information on anti-infective drugs to clinical medical staff and providing basis for rational use of anti-infective drugs.

④ Clinicians should improve the submission rate of relevant specimens before drug use, strictly grasp the indications, and rationally select drugs according to the results of bacterial culture and drug sensitivity test; Nurses should accurately carry out doctor's orders, observe patients' reaction after taking drugs, and cooperate with doctors to keep and submit various specimens according to the pharmacological effects, preparation contraindications and preparation requirements of various anti-infective drugs.

⑤ Hospitals should monitor the clinical application of anti-infective drugs, including blood drug concentration monitoring and drug-resistant bacteria (such as [MRSA], [VRSA] and [VRE]), so as to control the irrational use of anti-infective drugs and the emergence of drug-resistant strains.

(2) the principle of rational use of anti-infective drugs:

① Strictly grasp the indications and contraindications of the use of anti-infective drugs, closely observe the efficacy and adverse reactions of drugs, and rationally use anti-infective drugs.

② Strictly grasp the indications of combined use of anti-infective drugs and preventive use.

(3) Make individualized administration plan, and pay attention to dosage, course of treatment, reasonable administration method, interval and route.

④ Close observation of patients with dysbacteriosis and timely adjustment of the application of anti-infective drugs.

⑤ Pay attention to pharmacoeconomics and reduce the cost of anti-infective drugs for patients.

(3) Suggestions on rational use of anti-infective drugs:

① Antibacterials are generally not used for the confirmed virus infection.

② If the cause of fever is unknown and there are no signs of suspicious bacterial infection, anti-infective drugs should not be used. For those who are seriously ill or cannot be excluded from bacterial infection, anti-infective drugs can be selected as appropriate.

③ Correctly grasp the indications and course of preventive use of anti-infective drugs during perioperative period.

④ Before using anti-infective drugs, collect clinical specimens timely and correctly.

⑤ Strictly control the local application of anti-infective drugs on skin and mucosa.

⑥ Emphasize comprehensive treatment to improve immunity, and don't rely too much on anti-infective drugs.

6. Management of disposable sterile medical supplies. (See Management System for Storage Monitoring of Disposable Articles and Articles)

7. Hospital infection monitoring

(1) Surveillance of nosocomial infection cases

① The hospital must monitor the patients' nosocomial infection, and master the incidence, multi-site, multi-department, high-risk factors, pathogen characteristics and drug resistance of nosocomial infection in our hospital, so as to provide scientific basis for nosocomial infection control.

② Hospitals should adopt prospective monitoring methods to conduct comprehensive monitoring.

(3) The hospital infection control department shall summarize and analyze the monitoring data every month, report to the dean and the hospital infection management committee in writing every quarter, and give feedback to the hospital medical staff. The monitoring data shall be properly kept. Timely report and feedback on special circumstances.

④ The hospital should evaluate the monitoring data every year, and carry out the investigation of missing hospital infection. The sample size of the survey should not be less than 10% of the number of patients monitored each year, and the rate of missing reports should be less than 20%.

⑤ 100 ~ 500 beds, the incidence of nosocomial infection should be less than 8%; The infection rate of type ⅰ incision should be less than 0.5%.

(2) Monitoring of disinfection and sterilization effect

(1) Hospitals must regularly monitor the disinfection and sterilization effect. The qualified rate of sterilization must reach 100%, and unqualified items shall not enter the clinical use department. See Technical Specification for Hospital Disinfection for monitoring methods.

② Biological and chemical monitoring should be carried out on disinfectants and disinfectants in use.

Biological monitoring: once a quarter, the disinfectant must contain bacteria < 100 cfu/ml, and no pathogenic microorganisms can be detected; The sterilizer shall be monitored once a month, and no microorganisms shall be detected.

Chemical monitoring: it should be monitored regularly according to the performance of disinfection and sterilization agents. For example, chlorine-containing disinfectants should be monitored daily and glutaraldehyde should be monitored at least once a week. At the same time, the disinfection and sterilization effect of disinfection and sterilization items should be monitored, and pathogenic microorganisms should not be detected in disinfection items and microorganisms should not be detected in sterilization items.

③ Pressure steam sterilization: process monitoring, chemical monitoring and biological monitoring must be carried out.

Process monitoring shall be carried out for each tank and recorded in detail; Chemical monitoring is carried out in each bag, and chemical monitoring in the central part of the surgical bag is still needed; Conduct biological monitoring every month. The new sterilizer must be monitored before use, and it can only be used if it is qualified. New packaging containers, placement methods, exhaust methods and special sterilization processes must also undergo biological monitoring before they can be used.

④ Ultraviolet disinfection: Daily monitoring, ultraviolet lamp irradiation intensity monitoring and biological monitoring should be carried out.

Daily monitoring includes the use time, cumulative exposure time and user's signature of the lamp; The irradiation intensity of new and in-use ultraviolet lamps should be monitored. The irradiation intensity of new lamps should not be less than 100μW/cm2, and that of in-use lamps should not be less than 70μW/cm2. Radiation intensity should be monitored every six months.

Biological monitoring should be carried out when necessary. Natural bacteria in sterilized articles or air should be reduced by more than 90.00%, and the killing rate of artificially infected bacteria should reach 99.90%.

⑤ Various disinfected endoscopes (such as gastroscope, enteroscope, laryngoscope, bronchoscope, etc.). ) and other disinfection items for quarterly monitoring, shall not detect pathogenic microorganisms.

⑥ All kinds of sterilization endoscopes (such as laparoscopy), biopsy forceps and sterilized articles must be monitored every month, and no microorganisms can be detected.

⑦ Medical articles that enter sterile tissues and organs of human body or come into contact with damaged skin and mucous membrane, as well as medical articles that come into contact with skin and mucous membrane, shall conform to the Hygienic Standard for Disinfection in Hospitals (GB 15982- 1995). See Hygienic Standard for Hospital Disinfection (GB 15982- 1995) for the monitoring method.

(3) Environmental health monitoring

(1) environmental health monitoring includes air, object surface and medical staff hand monitoring.

② The hospital should monitor the environmental sanitation of key departments such as operating room, intensive care unit, delivery room, sterile area of supply room, treatment room and dressing room every month. When there is an epidemic situation of hospital infection and it is suspected that it is related to hospital environmental hygiene factors, it should be monitored in time.