航空总医院sop

航空总医院sop 称:环环环环环环环环环境微生物准操作程 持有部:院感文件号:环 环 环环环 制定者:李敬核者:沈吉云版次: 环 1 制定日期: 2013-08-27 环 核日期:2013-09-20 环行日期:2013-09-20一、目的监监监监 1.感染暴或感染流行,境因素在感染播中有流行病学意。环环环环环环环环环环环环环环环环环环环环环环环环环环 2.环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环潜在的危境状况,明有危的病原体存在或明危的病原体已被清除。3.当某感染控制措施改,估其效果。环环环环环环环环环环环环环环环环环 4.目性的需要。环环环环环环环环 5.环环环环环环环医学据支持。 二、空气培，沉降法,监监监监监监 1.采:?环环环环环环环环环环环环环环环环环环环环环环环环境在系自后与从事医活前采,?、?、?类类境在消毒或环环环环环环环环环环环环环环环环定的通气后与从事医活前采。 2.采高度:距地面垂直高度环环环环环环环环环环环80-150cm。 3.采点定:环环环环环2，1,?、?、?类类境:室内面环?30m,在角环环 环环环环环环环上里、中、外3点,里、外两点位置各距环21m,室内面环>30m～类类、西、南、北、中5点～ 其中类、西、南、北4点均距类1m。9cm直普径 通类类类脂平板打类～?类类境暴露15min～?、?类类 境暴露5min后送类培类。 ;2,,?环环境根据房类的不同类类程度布点～操 作按照GB50333-2002。9cm直普通类类类脂平板在采类点暴露径30min后送类培类。类1 局部百类、周类千类,手类布放区5点;类角布双点,～周类布放区8点;每类内2点,? ? ? ?? ?? ?? ? ?? ?? 类2 局部千类、周类万类～手类布放区3点;类角布点,～周类布放区6点;类类内2点～短类内1点, ? ? ? ?? ? ?? ? 类3 局部万类、周类十万类～手类布放区3点;类角布点,～周类布放区4点;类类内1点～短类内1点, ? ?? ? ? ? ? ? 类4 十万类,布放5点;避类送类口正下方, ? ? ? ? ? 4.采类注意事类, ;1,采类人类做好手类生～佩戴口、帽子等人防类用品。类入类房类;手类室、新生病房罩个清儿 等,采类必类穿类类服;刷手衣、隔衣等,离 ，2,皿盖打序先内后外,手臂和不可越培皿上方,环环环环环环环环环环环环环环环环环环环环环环 行走及放置作要,尽量减少空气流状的影响,皿盖扣放,以防染。环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环，3,采束后,由外向内合上皿盖。环环环环环环环环环环环环环环Oo，4,送不超环环环环环环4小,若品保存于环环环环环环环环0c--4c,送不超环环环环环环24小。环环5.环环环环环室:o，1,培皿在环环环36C培环48小后,行菌落数,新生儿病房、环环环环环环环环环环环环环环环环环无菌包和高危点培出的果必要行菌分离。普通脂培环环环环环环环环环环环环环环环环环环环环环环环基的配制与菌落数方式行环环环环环环WS/T 367-2012环环环环环环环环准,溶血性球菌行GB/T 4789.11-2003,沙菌行环环环环环环GB/T 4789.4-2003环环环环环环环环环假胞菌行GB/T7918.4-1987,金黄色葡萄球菌菌按照环环环环GB/T7918.5-1987。 ，2,果算:环环环环环 环环环平板暴露法按平均皿的菌落数告:每cfu/，皿•暴露,环环环 6.环果判断:参照GB15982-2012《医院消毒生准》环环环环环 三、物体表面监监 1.采:潜在染区、染区消毒后采。清区根据情况确定。环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环2222.采面:被采表面，环环环环环环环环100cm,取全部面,被采表面环环环环环环?100cm,取100cm.3.采方法:用环环环环环5cm×5cm类菌类格板放在被类物表面～用浸有无菌体0.03mol/L酸类类液或磷冲生理类水采类液的棉拭子1支～在类格板类往返各抹内横涂5次～之类类棉拭子～共采并随4类个格板面类～用酒精类手接部分～棉拭子放入类有灯断触将装10ml采类液的类管中送类。类把手等小型物类采用棉拭子直接抹物采类。若采类物表面有消毒类留类～采类液类含中和类。体涂体体残 4.采类注意事类,Oo，1,送不超环环环环环环4小,若品保存于环环环环环环环环0c--4c,送不超环环环环环环24小。环环，2,消毒后采一定要采用中和,不同消毒所用中和不同,可参考环环环环环环环环环环环环环环环环环环环环环环环环环环2012版《消毒技范》。环环环环环 5.环环环环环室:Oo，1,把采管充分震后,取不同稀倍数的洗脱液环环环环环环环环环环环环环环环环环环环1.0ml接平皿,将冷至环环环环环环环40c—45co的熔化脂培基环环环环环环环环环皿注每15ml—20ml,36c恒温箱培环48小,算菌落数,环环环环环环环环必要分离治病微生物。环环环环环环环环环 ，2,果算:环环环环环 平均皿菌落数每×采液稀倍数环环环环环环2物体表面菌落数，环环环cfu/cm,=-------------------------------------------------------------2 环环环环采面，cm, 6.环果判断:参照GB15982-2012《医院消毒生准》环环环环环 参考文献 1.中人民共和国生与划生育委会环环环环环环环环环环环环环环环环.WS/T367--2012《医环环环环环环环环环环机构消毒技范》2.中人民共和国国环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环家量督疫局和中国国家准化管理委会.GB15982—2012《医院消毒生准》环环环环环 3.医院感染防与控制准操作程，参考版,环环环环环环环环环环环环环环环环.上海科技出版社.2010 称:手部微生物学准操作程监监监监监监监监 持有部:院感文件号:环 环 环环环 制定者:李敬核者:沈吉云版次: 环 1 制定日期: 2013-08-27 环 核日期:2013-09-20 环行日期:2013-09-20一、目的监监监监 1.环环环环环环环环环环环环环环环环环环环环环环价医人洗手、生手消毒、外科手消毒的效果。 2.环环环环环环环环环环环环环环 疑医院感染暴或流行与手的播有。 二、采监监监 环环环环环环环环环环环环环环环环环环环环手生后,在接触病人或从事医活前采。 三、采方法监监监 1.环环环环环环环环环环环环环环环环环价洗手、生手消毒、外科手消毒的效果采 将浸有无菌0.03mol/L磷酸环环环环环环环环环环环环环环环环环冲液或生理水采液的棉拭子一2,,并随之环环环环采支在双手指曲面从指跟到指端来回涂擦各两次，一只手涂擦面环环30cm棉拭子,用酒精灯断手接触部分,将环环环环环环环环环环环环环环环环棉拭子放入装有10ml采液的管内送。环环环环环环环环若采手上有消毒残环环环环环环环环环环环环环环环环环环环环环留,采液含有中和。 2.环环环环环环环环环环环环环环环疑医院感染暴或流行与手的播有采 根据情况,在接触环环环环环环环环环环环环环环环环环环环同价手患者前或行活前。采步集生效果,但洗脱液改无菌环环环环环环环环环肉增菌液。 四、监监方法 1.环环环菌量 把采管在环环环环环环环环环混匀器上震20s或用力震环80次左右,取不同稀倍数的洗脱液环环环环环环环1.0,接环ooo平皿,将冷至40c—45c的熔化脂培基环环环环环环环环环皿注每15ml—20ml,在36c恒温箱培环48小,环必要行环环环环环环环环环环环环致病性微生物分离。 2.环环环环环菌定o，1,将无菌增菌肉环环环环环环环环培液管置于36c温箱培环48小。环环 ，2,若无菌增菌肉环环环环环环环环环环环环环环环环环环环环环环环环环环环环环培液管,根据情况血平板、中国平板、双S平板、麦康环环环环环环环环环环环环环环环环环环环环环平板或各商用快速平板行菌接。o，3,接后将平板置于环环环环环环环36c温箱培环24-48小,环环环环环环环环环环环环环挑可疑菌落行微生物学定,必要环环环环环环环环环环环环环环环环环环做敏或分子生物学分型。 五、监监监果算 平均皿菌落数每×采液稀倍数环环环环环环2手菌落数，环环环cfu/cm,= -------------------------------------------------------------- 30×2六、类果判定22,外科手消毒类菌类类?数5cfu/cm。类生手消毒后类菌类类?数10cfu/cm 七、注意事类 1.类根据手类生所用方法～类类含相类中和类的无菌洗液。脱o2.类注类度必类控制在温4548—c～度类高可致类菌死亡～类低影类注效果。温响 3.当医与医状况类疑院感染暴类或流行手的类播有类类～类类目的在于考察类类工作中类人类的手类生～ 类然同类在接患者前或类行类类活类前采类～但类人类不一定类行手类生。触医 4.当医与类疑院感染暴类或流行手的类播有类类～目类微生物的类类只能定性不能定量。5.血平板适合于大多类菌和菌生类～中类平板可类类革类氏类性杆菌～数真国双S平板可类类沙类菌 和志类菌～康类平板科类类革类氏类性非类酵菌。麦 参考文献 1.中人民共和国生与划生育委会环环环环环环环环环环环环环环环环.WS/T367--2012《医环环环环环环环环环环机构消毒技范》2.中人民共和国国环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环家量督疫局和中国国家准化管理委会.GB15982—2012《医院消毒生准》环环环环环 3.医院感染防与控制准操作程，参考版,环环环环环环环环环环环环环环环环.上海科技出版社.2010 称:医监监监监监监监监监监监器材采准操作程 持有部:院感文件号:环 环 环环环 制定者:李敬核者:沈吉云版次: 环 1 制定日期: 2013-08-27 环 核日期:2013-09-20 环行日期:2013-09-20一、目的监监监监 环环环环环环环 菌器械菌效果 二、采监监监 环环环环环环环环环环环环环环环在消毒或菌理后,存放有效期内采。 三、菌医环环环环环环环环环环器材方法 1.破坏性方法取:一次性血，液,环环环环环环环环环环环环环环环环环环环环器、注射器和注射等参照《中人民共和国环环环环环环环环环环环环环环环环环环环典》《无菌法》行。 2.不能用破坏性方法取的:在环环环环100环环环环环环环环环环环环环环环环环室行,用浸有无菌生理水2采液的环环环环环环环环环环环环环环环环环环环环环环环环环环环棉拭子在被物体表面涂抹,采取全部表面或不少于100cm,用酒精灯断环环棉拭子的手接触部分同将环环环环环环环环环环环环环环环环环环棉拭子放采管中行无菌。 3.牙科手机:在100环环环环环环环室,将每只手机分置入含20ml—25ml采液的无菌环环环环环环大环管，内径25mm,中,液面高度环环环大于4.0cm于旋混环环环环环环环环环合器上洗震30S以上,取洗脱液环环环环行无菌。 四、消毒医环环环环环环环环器材的方法 1.可整件放入无菌管的:用洗脱液环环环环环环环环环环环环环浸没后震30S以上,取洗脱液1.0ml接平皿,将冷至环环环环环环环ooo40c—45c的熔化脂培基环环环环环环环环环皿注入每15ml—20ml,36c恒温箱培环48小,数菌环环环环环落数，cfu/件,,必要分离环环环环环环环环环环致病性微生物。 2.可用破坏性方法取的:在环环环环100环环环环环环环超工作台称取1g—10g环品,放入装有10ml采液环环的管内行洗脱,取洗脱液环环环环环环环环环环环环1.0ml接平皿,数菌落数，环环环环环环环环环环cfu/g,,必要分离环环环环致病性微生物。 3.不能用破坏性方法取的:在环环环环100环环环环环环环环环环环环环环超工作台,用浸有无菌生理2水采液的环环环环环环环环环环环环环环环环环环环环环环棉拭子在被物体表面涂抹采,被采表面，100cm,取全部表面,被采表面22?100cm,取100cm,然后用酒精灯断手接触部分,将环环环环环环环环环环环环环环环棉拭子放采oo环环环环环环环环环环管中行洗脱,取洗脱液1.0ml接平皿,将冷至环环环环环环环40c—45c的熔化脂培基环环环环环环环环环皿注每o215ml—20ml,36c恒温箱培环48小,数菌落数，环环环环环环环环cfu/cm,,必要分离环环环环环环环环环环致病性微生物。4.消毒后内:取清洗消毒后内,采用无菌注环环环环环环环环环环环环环环环环环环环环射器抽取50ml含相环环环环环环环中和的洗脱液,从活环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环口注入冲洗内管路,并全部收集送。将洗脱液充分混匀,取洗脱液1.0mlooo接平皿,将冷至环环环环环环环40c—45c的熔化脂培基环环环环环环环环环皿注每15ml—20ml,36c恒温箱培环48小环环环环环环环,数菌落数，cfu/件,。将剩余洗脱液在无菌条件下采用环环环膜，0.45um,,环环环环环o将环环环环环环环环环环环环环环环环环环环环环环环环环环环膜接于凝固的脂平板上，注意不要生气泡,,置36c恒温箱培环48小,环环环数菌落数。 当环环环环环环环环环环环环环环膜法不可数:菌落数，cfu/件,=m，cfu/平板,×50 式中:m环两平行平板的平均菌落数 当环环环环环环环环环环环环环膜法可数:菌落数，cfu/件,=m，cfu/平板,+m，cfu/环膜,f 式中:m环两平行平板的平均菌落数,m环环膜上菌落数f 参考文献 1.中人民共和国生与划生育委会环环环环环环环环环环环环环环环环.WS/T367--2012《医环环环环环环环环环环机构消毒技范》2.中人民共和国国环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环家量督疫局和中国国家准化管理委会.GB15982—2012《医院消毒生准》环环环环环 称:消毒准操作程监监监监监监监监监 持有部:院感文件号:环 环 环环环 制定者:李敬核者:沈吉云版次: 环 1 制定日期: 2013-08-27 环 核日期:2013-09-20 环行日期:2013-09-20一、目的监监监监 环环环环环环环环消毒液有效度和染菌量 二、范监监监监 环环环环环环环环环环环环环环环环新配制，,的消毒液或使用中的消毒液。 三、方法监监监监 1.环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环度:根据消毒液,相的度条。若戊二环环环环环环环环环环环环环环环环环环环环环环环度科戊二卡,含制和氧乙酸采用G-1型消毒液度。果环环环环环环环按环环环环环环环环环环环环环条明操作并判断果。 2.染菌量:环环环 ，1,用无菌注射器按无菌操作方法吸取1.0ml被消毒液,环环环环环环环加入9ml中和中环环环环环混匀。 醇环环环环消毒------------------------------普通环环环环环环肉中和 酚环环环环消毒------------------------------普通环环环环环环肉中和 含环环环环消毒----------------------------- 0.1%硫代硫酸环环环环中和 含碘消毒环----------------------------- 0.1%硫代硫酸环环环环中和 环环 氧化物消毒--------------------- 0.1%硫代硫酸环环环环中和 环洗必泰消毒-------------------------- 0.3%吐温80和0.3%卵磷脂中和环 环环环环环环季消毒---------------------- 0.3%吐温80和0.3%卵磷脂中和环 环环环消毒-------------------------------0.3%甘氨酸中和环 环环环环环环环环环环环环环环环环环环环含有表面活性的各方消毒可在中和中加入吐温80至3%,也可使用消毒环消毒效果的中和定确定的中和。环环环环环环环环环环环环环环环环环oo2.用无菌吸管吸取一定稀环环环环环环环环环环比例的中和后混匀液1.0ml接平皿,将冷至环环环环环环环40c—45c熔化环o环环环环环环脂培基皿注15ml—20ml每,36c恒温箱培环72小,数菌落数,必要环环环环环环环环环环环分离致病性微生物。 四、果算监监监监 消毒液染菌量，cfu/ml,=平均皿菌落数每×10×稀倍数环环环 参考文献 1.中人民共和国生与划生育委会环环环环环环环环环环环环环环环环.WS/T367--2012《医环环环环环环环环环环机构消毒技范》2.中人民共和国国环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环家量督疫局和中国国家准化管理委会.GB15982—2012《医院消毒生准》环环环环环 称:紫外灯准操作程监监监监监监监监监监 持有部:院感文件号:环 环 环环环 制定者:李敬核者:沈吉云版次: 环 1 制定日期: 2013-08-27 环 核日期:2013-09-20 环行日期:2013-09-20一、目的监监监监 环环环环环环环环环环紫外灯的消毒参数。 二、范监监监监 环环环使用中的紫外灯。 三、方法监监监监 1.指示卡法:环环环环环环启紫外灯5min后,将指示卡置于紫外灯环环环环环环环下垂直距离1米环环环环,有案一面朝上,照射1min,环环环环环环环环环环环环环环环环环环环环察指示卡色色,将其与准色比。 2.染菌量:将定环环环环环环环环环波253.7nm的紫外照环环环环环环环环环环环环环环环环环环环探置于被紫外灯下垂直距离1m的中央环环环环环环环环,启紫外灯5min后,打环环环环环环环环源,器示000或001环环环环环正常,打探盖,待器示环环环环环环环环环环环环环环环环环环环环环环环环环环环定后数,所示数据即紫外灯的射照度环环环环环环环环环环环环环环环环环环环环环,量完,盖上探盖源,数。 四、注意事监监监监监监 1.紫外照环环环环环环环环环环环环环环环环环环环环环环年由量部一次,在有效期内每使用。 2.紫外环环环环环环环环环环环环环环环环环环环环环环环环环环环环指示卡国家生行政部批准,并在有效期内使用。 参考文献 1.中人民共和国生与划生育委会环环环环环环环环环环环环环环环环.WS/T367--2012《医环环环环环环环环环环机构消毒技范》2.中人民共和国国环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环家量督疫局和中国国家准化管理委会.GB15982—2012《医院消毒生准》环环环环环 3.四牌环环ZY-010型射环环环环环环环环环照度明。 称:外来器械清洗消毒菌准操作范监监监监监监监监 持有部:院感文件号:环 环 环环环 制定者:李敬核者:沈吉云版次: 环 1 制定日期: 2013-10-11 环 核日期:2013-10-11 环行日期:2013-10-12一、接收器械 环环环环环环环环期手器械于手前24小送至环环环环环环环环环环环环环环环环环环供室,急手常用器械菌包在手室保存,环环环环环环环环环环环环环环环器械送至手室。 二、清点监监收 1.供环环环环环环环环环环环环环环环环环环环环环环环环环环环环室或手室和供商共同清点核器械信息,无后去字。 2.核环环环环环环环环环环环环环环环环环环环环环环环信息包括:患者姓名、科室、病号、手名称、器械品牌、名称、环环环环环环环环环环格、是否植入物。 三、清洗和消毒 1.供商提供环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环清洗消毒流程和注意事,指人外来器械行清洗和消毒。2. 清洗和消毒环环环环环环环环环环遵循国家行准。 3.环环环环环环环环环环环环环环环环环环环环环环注意分清洗、消毒,科拆卸的器械必拆卸,裸露的植入物必装环环环环环环环环环环环环环环环环环环环环环入用清洗筐，架,内,耐水洗的器械科采用机械清洗,不耐水的环环环环环环环环环环环环环环环环环环环环环力工具可采用手工清洗,器械盒清洗消毒。 四、和包装监监监监监 1. 按照《航空医院外环环环环环环环环环环环环环环环环环环环环来器械通行》上的清行整理。 2.环环器械清洗效果和器械功能。 3.根据器械材环环环环环环环环环环环环环环环环和菌方式合适的包装材料。 4.环环环环环环环环环环环环环环环菌包的体和量遵循国家行准。 5.在菌包内环环环环环环环环环环环最菌放置5环环环环环环环环环环环环化学指示卡,硬容器将包内化学指示卡放在两角。包外环环环环环环环环环环环环环环粘化学指示胶。 6.如环环环环环环环环环环环环环环环环环环环环环环环环环期手在化学指示胶上除常信息外,另外注明患者姓名、病号、环环环环环环环环器械品牌。 五、菌监监 1.供商提供器械环环环环环环环环环环环环环环环环环环环环的菌方式和菌循参数。 2.根据器械材环环环环环环环环行分菌。 3.环环环环环环环环环环环环环环环环环行物理、化学和生物以菌效果,避免湿包。 4.环环环环环环环环环环环于超大和超重包裹延菌循参数。 5.环环环环环环环环环环环环环运用工具密运送。 六、放与监监监监监使用 1.环环环环环环环环环环环环环环环环环环环环环环环环环环环环环放和使用前确无菌包菌合格,无潮湿、无染、无松散、包装密封完好。2.供环环环环环环环环环环环环环环环环环环环环环环环环室确物理、快速生物合格后放,手室确5环环化学指示卡合格后使用,急环菌包5环化学指示卡合格可以提前使用,48小,普通生物确,环环环环环环环环环环环环环如不 合格,及通环环环环环环环环环环环环环环环环环环环知床科室主管医生切口行。 七、回收 1.手束后,环环环环环环环环环环环环环环环环环环环环环环环环环环急手器械在手室行理后于供商行交接,期手环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环器械和常器械返回供室,期手器械于供商行交接。2. 《航空医院外环环环环环环环环环环环环环环环环环环环环环环环来器械通行》第一留在手室或供室,第二环环环环环环环环环环环环环留在医学装部,表格保存3年。 八、追溯 1.所有环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环环工作人真填写《航空医院外来器械通行》,以便追溯和。参考文献 1.中人民共和国生行准环环环环环环环环环环环环.WS310.1-2009 医院消毒供环环环环中心第1部分:管理环环范2.中人民共和国生行准环环环环环环环环环环环环.WS310.2-2009 医院消毒供环环环环中心第2部分:清消毒环环环 及菌技操作范环环环环环环环环 3.中人民共和国生行准环环环环环环环环环环环环.WS310.3-2009 医院消毒供环环环环中心第3部分:清洗消毒环 环环环环环菌效果准 4.《医院感染防与控制准操作程》环环环环环环环环环环环环