院内感染管理制度

院内感染 管理制度 档案管理制度下载食品安全管理制度下载三类维修管理制度下载财务管理制度免费下载安全设施管理制度下载 一、为认真贯彻执行《中华人民共和国传染病和防治法》，《中华人民共和国传染病和防治法 实施细则 工程地质勘察监理实施细则公司办公室6S管理实施细则国家GSP实施细则房屋建筑工程监理实施细则大体积混凝土实施细则 》及《消毒管理办法》的有关规定，医院成立院内感染控制委员会，全面领导院内感染管理工作。 二、建立健全院内感染监控网，以医院住院患者和工作人员为监测对象，统计住院患者感染率。 三、感染管理办公室医护人员定期或不定期深入各科病房及重点科室工作，做空气、物体表面、工作人员手的微生物学监测，督促检查预防院内感染工作。 四、定期或不定期进行院内感染漏报率的调查，督促病房如实登记院内感染病例，杜绝漏报。 五、 分析 定性数据统计分析pdf销售业绩分析模板建筑结构震害分析销售进度分析表京东商城竞争战略分析 评价监测资料，并及时向有关科室和人员反馈信息，采取有效措施，减少各种感染的危险因素，降低感染率，将院内感染率控制在10,以内。 六、经常与检验科细菌室保持联系，了解微生物学的检验结果及抗生素耐药等情况，为采取相应措施提供科学依据。 七、加强院内感染管理的宣传教育，宣传院内感染监测工作的意义和监测知识，提高医护人员的监控水平。 八、拟定全院各科室 计划 项目进度计划表范例计划下载计划下载计划下载课程教学计划下载 并组织具体实施。 九、协调全院各科室的院内感染监控工作，提供业务技术指导和咨询，推广新的消毒方法和制剂。 十、对广大医务人员进行预防院内感染知识的培训和继续教育，做好有关消毒、隔离专业知识的技术指导工作。 南星中心卫生院 yan Zhen and other places. Shan Bao Zhuang Shaozhen ban during the evening, offered to help make teaching preparation, such as take a stool, greeting students, cleaning up the classroom, trainees carry out various cultural activities and organizations. Zhuang Shaozhen in Dai Xiuchang home, ate and lived with juvenile Dai Xiuchang Zhuang Shaozhen, get along with long, Dai Xiuchang was coming under the influence of revolutionary thoughts. Zhuang Shaozhen also loved and trusted the bright teenager, often let him assist services. Zhuang Shaozhen out active at a time, Dai Xiuchang row a boat send him. Zhuang Shaozhen to contact party letters sent out by Dai Xiuchang. Directed by the Zhuang Shaozhen, Dai Xiuchang keep in touch with enter the confidential code clerk of the County Government of the Kuomintang Shen Wenjing. Zhuang Shaozhen in Che Jia BA spent 3 years, Dai Xiuchang help from start to finish. (15) Shao work running underground library in October 1940, in Jiangsu, Zhejiang and special branch of the Communist Party, under the leadership of young founded the "Youth Club" Al read progress books, publishing mimeographed letters of the justice. In November, another nearby rural big "adult literacy" to promote anti-Japanese way. Being a strict party branch members of the publicity of the tomb of Shao deeply shoulder 控制院内感染各项卫生学标准 一、普通手术室、产房、新生儿室、供应室、无菌间、 3烧伤病房、重症监护室，空气中细菌总数不得超过500个/m， 3乙型链球菌不得超过20个/m ，物体表面、医务人员的手 2上不得超过8个/cm。 二、儿科病房、妇产科检查室、注射室、换药室、治疗室、供应室清洁区、急症室、化验室、各类普通病房和房间， 3空气中细菌总数不得超过500个/m，物体表面细菌总数不 22得超过10个/cm，医务人员的手细菌总数不得超过8个/cm。 3门诊大厅空气中细菌总数不得超过4000个/m。 三、产科病房、产房、婴儿室、儿科病房、外科病房,空气、物体表面和医务人员的手，不得检出金黄色葡萄球菌。 四、内科、外科、妇产科和儿科病房物体表面，不得检出绿脓杆菌。 五、婴儿室、儿科病房,物体表面不得检出沙门氏菌和化脓菌。 六、凡灭菌的医疗用品不得检出其他任何种类的微生物，消毒的医疗用品不得检出病原微生物。 七、各种使用的紫外线灯强度，不得低于70微瓦?秒 2/cm。 南星中心卫生院 yan Zhen and other places. Shan Bao Zhuang Shaozhen ban during the evening, offered to help make teaching preparation, such as take a stool, greeting students, cleaning up the classroom, trainees carry out various cultural activities and organizations. Zhuang Shaozhen in Dai Xiuchang home, ate and lived with juvenile Dai Xiuchang Zhuang Shaozhen, get along with long, Dai Xiuchang was coming under the influence of revolutionary thoughts. Zhuang Shaozhen also loved and trusted the bright teenager, often let him assist services. Zhuang Shaozhen out active at a time, Dai Xiuchang row a boat send him. Zhuang Shaozhen to contact party letters sent out by Dai Xiuchang. Directed by the Zhuang Shaozhen, Dai Xiuchang keep in touch with enter the confidential code clerk of the County Government of the Kuomintang Shen Wenjing. Zhuang Shaozhen in Che Jia BA spent 3 years, Dai Xiuchang help from start to finish. (15) Shao work running underground library in October 1940, in Jiangsu, Zhejiang and special branch of the Communist Party, under the leadership of young founded the "Youth Club" Al read progress books, publishing mimeographed letters of the justice. In November, another nearby rural big "adult literacy" to promote anti-Japanese way. Being a strict party branch members of the publicity of the tomb of Shao deeply shoulder 院内感染监测登记报告 制度 关于办公室下班关闭电源制度矿山事故隐患举报和奖励制度制度下载人事管理制度doc盘点制度下载 一、认真贯彻执行国家卫生部院内感染控制标准及有关规定，建立健全院内感染病例的发现、登记、报告、分析、反馈系统。 二、临床各科医师，要熟悉院内感染分类诊断标准，并不断加强有关院内感染的基础理论学习，不断提高院内感染控制的水平。 三、发现院内感染病例或暴发流行时，应立即按规定程序报告，及时进行隔离治疗，采取相应的防范措施。 四、院领导每周深入科室，督促检查院内感染病例报告执行情况，将院内感染控制在8%以内。 五、感染病例调查表，由各科住院医师填写，兼职医师、护士、专职人员负责核对，共同完成。填写院内感染病例登记表时，应字迹清楚，项目齐全。感染病例报表由兼职医师每周星期一报感染办公室。 六、感染病例的报告应做到不漏报、不错报。 南星中心卫生院 yan Zhen and other places. Shan Bao Zhuang Shaozhen ban during the evening, offered to help make teaching preparation, such as take a stool, greeting students, cleaning up the classroom, trainees carry out various cultural activities and organizations. Zhuang Shaozhen in Dai Xiuchang home, ate and lived with juvenile Dai Xiuchang Zhuang Shaozhen, get along with long, Dai Xiuchang was coming under the influence of revolutionary thoughts. Zhuang Shaozhen also loved and trusted the bright teenager, often let him assist services. Zhuang Shaozhen out active at a time, Dai Xiuchang row a boat send him. Zhuang Shaozhen to contact party letters sent out by Dai Xiuchang. Directed by the Zhuang Shaozhen, Dai Xiuchang keep in touch with enter the confidential code clerk of the County Government of the Kuomintang Shen Wenjing. Zhuang Shaozhen in Che Jia BA spent 3 years, Dai Xiuchang help from start to finish. (15) Shao work running underground library in October 1940, in Jiangsu, Zhejiang and special branch of the Communist Party, under the leadership of young founded the "Youth Club" Al read progress books, publishing mimeographed letters of the justice. In November, another nearby rural big "adult literacy" to promote anti-Japanese way. Being a strict party branch members of the publicity of the tomb of Shao deeply shoulder 院内感染监测制度 一、对高危区如手术室、新生儿室、烧伤病房、产房、婴儿室、供应室无菌间、治疗室、换药室的空气细菌，每月监测一次。 二、对各个科室使用的消毒液，有效成份含量及细菌污染量，每月监测一次。 三、对各个科室使用中的紫外线灯强度，每季度监测一次。 四、对各重点病房及治疗室物体表面和医护人员的手污染细菌，每月监测一次。 五、对供应室、手术室等压力蒸汽灭菌，每锅均用化学指示剂监测，并有记录，每季度用生物指示剂监测一次。 六、对婴儿室、儿科病房的物体表面和医护人员的手沙门氏菌污染状况，每月监测一次。 七、对一些特殊科室如烧伤病房、新生儿室，产房的化脓菌(金葡菌、绿脓杆菌、乙型链球菌)，每月监测一次。 八、对接触血、脓液的器械或物品，每月监测残留血HBsAg。 九、对无菌物品，每季度作一次无菌检验。 十、对院内感染病例调查情况，每月汇总一次。对无菌切口感染情况，每月汇总一次，并进行分析。 十一、对一人一针一管一消毒，空针用过双消毒情况，每月调查一次。 十二、对无菌器械消毒情况，每月调查一次。 南星中心卫生院 yan Zhen and other places. Shan Bao Zhuang Shaozhen ban during the evening, offered to help make teaching preparation, such as take a stool, greeting students, cleaning up the classroom, trainees carry out various cultural activities and organizations. Zhuang Shaozhen in Dai Xiuchang home, ate and lived with juvenile Dai Xiuchang Zhuang Shaozhen, get along with long, Dai Xiuchang was coming under the influence of revolutionary thoughts. Zhuang Shaozhen also loved and trusted the bright teenager, often let him assist services. Zhuang Shaozhen out active at a time, Dai Xiuchang row a boat send him. Zhuang Shaozhen to contact party letters sent out by Dai Xiuchang. Directed by the Zhuang Shaozhen, Dai Xiuchang keep in touch with enter the confidential code clerk of the County Government of the Kuomintang Shen Wenjing. Zhuang Shaozhen in Che Jia BA spent 3 years, Dai Xiuchang help from start to finish. (15) Shao work running underground library in October 1940, in Jiangsu, Zhejiang and special branch of the Communist Party, under the leadership of young founded the "Youth Club" Al read progress books, publishing mimeographed letters of the justice. In November, another nearby rural big "adult literacy" to promote anti-Japanese way. Being a strict party branch members of the publicity of the tomb of Shao deeply shoulder 抗菌药物合理使用监测制度 抗菌药物广泛使用，破坏了人体内正常存在的微生物群与宿主(人体)的生态平衡，导致正常微生物群在定量、定位方面的生物学行为改变，由原不致病的或在特定条件才致病的机会病原体成为致病的病原体，引发内源性感染。为规范抗菌药物的使用管理，特制定本监测制度，请各临床医师遵照执行。 一、抗菌药物使用率监测 高抗生素使用率是抗生素不合理使用的标志之一。世界卫生组织(WHO)倡导的抗生素使用率为20,,30,，本院要求抗生素使用率控制在20%,30%以内。 二、抗菌药物使用合理性的监测 针对医院的抗生素使用率，从适应症、剂量、疗程、预防用药等方面分析，揭示不合理使用的原因及程度，可作为教育医务人员的资料。 三、外科系统科室预防用药监测 对临床抗生素使用监测，还需从治疗用药、预防用药两大部分监测分析。目前抗生素预防应用中存在不少问题，尤其在外科，术后预防用药几乎占100,，对药物的选择、剂量、疗程、联合用药指征的监测分析，发现不少弊端。不少临床医生试图用抗生素来弥补手术操作中的缺陷。术后盲目、长期给药只会起到破坏宿主与正常菌群的生态平衡的作用，增加内源性感染的机会。因此，应对之进行严格监测，尽量避免使用抗菌药物。四、根据医院感染病原菌、药敏谱监测临床用药的合理性 (一).社会感染与医院内感染的患者，各部位常见病原菌、药敏谱不一，即使同类细菌，其药敏谱也完全不一样，用药前必须做到心中有数，应急情况下凭临床经验用药无可yan Zhen and other places. Shan Bao Zhuang Shaozhen ban during the evening, offered to help make teaching preparation, such as take a stool, greeting students, cleaning up the classroom, trainees carry out various cultural activities and organizations. Zhuang Shaozhen in Dai Xiuchang home, ate and lived with juvenile Dai Xiuchang Zhuang Shaozhen, get along with long, Dai Xiuchang was coming under the influence of revolutionary thoughts. Zhuang Shaozhen also loved and trusted the bright teenager, often let him assist services. Zhuang Shaozhen out active at a time, Dai Xiuchang row a boat send him. Zhuang Shaozhen to contact party letters sent out by Dai Xiuchang. Directed by the Zhuang Shaozhen, Dai Xiuchang keep in touch with enter the confidential code clerk of the County Government of the Kuomintang Shen Wenjing. Zhuang Shaozhen in Che Jia BA spent 3 years, Dai Xiuchang help from start to finish. (15) Shao work running underground library in October 1940, in Jiangsu, Zhejiang and special branch of the Communist Party, under the leadership of young founded the "Youth Club" Al read progress books, publishing mimeographed letters of the justice. In November, another nearby rural big "adult literacy" to promote anti-Japanese way. Being a strict party branch members of the publicity of the tomb of Shao deeply shoulder 非议，但当细菌培养出来后，应该及时修正用药方案。 (二).院内各病区所收治的病种不一，病情轻重程度不一，用药习惯不一，既往用药史不一，因此医院内甚至病区内医院感染菌种、株、耐药谱也不完全一致，对此也应进行监测。 (三).根据所检出的相应的病原菌及药敏谱，应监测临床各科用药方案的正确性、合理性。 南星中心卫生院 yan Zhen and other places. Shan Bao Zhuang Shaozhen ban during the evening, offered to help make teaching preparation, such as take a stool, greeting students, cleaning up the classroom, trainees carry out various cultural activities and organizations. Zhuang Shaozhen in Dai Xiuchang home, ate and lived with juvenile Dai Xiuchang Zhuang Shaozhen, get along with long, Dai Xiuchang was coming under the influence of revolutionary thoughts. Zhuang Shaozhen also loved and trusted the bright teenager, often let him assist services. Zhuang Shaozhen out active at a time, Dai Xiuchang row a boat send him. Zhuang Shaozhen to contact party letters sent out by Dai Xiuchang. Directed by the Zhuang Shaozhen, Dai Xiuchang keep in touch with enter the confidential code clerk of the County Government of the Kuomintang Shen Wenjing. Zhuang Shaozhen in Che Jia BA spent 3 years, Dai Xiuchang help from start to finish. (15) Shao work running underground library in October 1940, in Jiangsu, Zhejiang and special branch of the Communist Party, under the leadership of young founded the "Youth Club" Al read progress books, publishing mimeographed letters of the justice. In November, another nearby rural big "adult literacy" to promote anti-Japanese way. Being a strict party branch members of the publicity of the tomb of Shao deeply shoulder 院内各类人员感染控制教育措施 一、参加有关省市级卫生部门组织的有关院内感染的学习班，参加人员必须有院领导及专职人员参加。 二、全院性培训 (一).护士长和医疗股长担任感染监控员，由他们每年对全院职工进行1,2次的业务指导及培训。 (二).对全院医务人员进行有关院内感染和消毒隔离工作的培训，每年1,2次。 (三).对实习护士来院实习，要进行医院内感染方面的有关知识培训。培训内容:医院感染的概念，医院内感染的控制及预防，医院内感染的常见疾病及预防，消毒、隔离、灭菌等。 (四).每年年底组织座谈会一次，请有关人员参加，由感染办公室提出院内感染中存在的问题。 三、对临床医生的培训 (一).怎样填报院内感染病历调查表，减少漏报率的发生。 (二).重点学习使用抗生素，应聘请有经验的专家、教授讲课。 (三).指导医师掌握医院内感染的诊断标准。 四、对护士重点培训隔离、消毒方面的有关问题。 五、对卫生员培训有关病房卫生清扫、隔离消毒的基本知识、各种消毒液的使用浓度及配制方法。 南星中心卫生院 yan Zhen and other places. Shan Bao Zhuang Shaozhen ban during the evening, offered to help make teaching preparation, such as take a stool, greeting students, cleaning up the classroom, trainees carry out various cultural activities and organizations. Zhuang Shaozhen in Dai Xiuchang home, ate and lived with juvenile Dai Xiuchang Zhuang Shaozhen, get along with long, Dai Xiuchang was coming under the influence of revolutionary thoughts. Zhuang Shaozhen also loved and trusted the bright teenager, often let him assist services. Zhuang Shaozhen out active at a time, Dai Xiuchang row a boat send him. Zhuang Shaozhen to contact party letters sent out by Dai Xiuchang. Directed by the Zhuang Shaozhen, Dai Xiuchang keep in touch with enter the confidential code clerk of the County Government of the Kuomintang Shen Wenjing. Zhuang Shaozhen in Che Jia BA spent 3 years, Dai Xiuchang help from start to finish. (15) Shao work running underground library in October 1940, in Jiangsu, Zhejiang and special branch of the Communist Party, under the leadership of young founded the "Youth Club" Al read progress books, publishing mimeographed letters of the justice. In November, another nearby rural big "adult literacy" to promote anti-Japanese way. Being a strict party branch members of the publicity of the tomb of Shao deeply shoulder