临床科室医院感染管理质控标准.doc

position-related consumption of civil servants has been swept by finance, consumer, regardless of cost, extravagance and waste in the civil service position-related consumption, abuse, corruption and embezzlement, corruption is important. Then, under the conditions of market economy, how to reform the existing civil duty consumption management, explores a source to prevent and curb the post consumption corruption way, is currently a major issue faced by honest work. Recently, I conducted research on this issue, this problem on some humble opinions. First, the existing public servants duty consumption the main problems seen from the investigation and reasons, in recent years, public servants duty consumption caused by the abuses and not a person of integrity, is one of the major problems in the party in Government, its operation order have a negative effect on the party and Government organs, seriously damaging the image of the party and the Government, undermining the relationship between party and the masses, effect, opening up and economic construction. From I County in recent years of governance situation see, positions consumption in the produced of two not phenomenon rendering four a features: a is positions consumption system lost has due of binding, right is greater than rules, and right is greater than method of phenomenon more highlight; II is in positions consumption in the Camera Obscura operation, using terms, will positions consumption into has personal consumption, will corporate points to into personal points to, makes positions consumption in some aspects has into positions enjoy and self-dealing of means; three is to positions consumption for name, fraud, false impersonator, Trend of negative corruption phenomena such as corruption and misappropriation; four palaces, follow the fashion, rivalries, wasteful, and post consumption became a symbol of showing off their individual capacities. Caused by public servants duty consumption of many two phenomenon in which people reflect the biggest problems are: (a) the official car problems. Mainly in three aspects: one is the larger buses cost expenditure. According to statistics, until November 2003, XX County township Department bus 159 cars, which department owns the bus 145 vehicles, and showed an increasing trend. Financial expenses cost per bus per year to 35,000 yuan, and in fact every cost up to 50,000 yuan. Some units also hiring temporary drivers and expenditure on wages and subsidies. Necessary to keep a car, but also dependants, leading to larger expenses. Second, gongchesiyong breed unhealthy tendencies. Some people believe that now some bus drivers use one-third, one-third leading private one-third used for official purposes. Some public servants, especially leading officials motoring, cars for private purposes, violating the self-discipline regulations, and even lead to traffic accidents. According to statistics from related departments, since 2004, the correct investigation in our County serves nearly 30 cars for private purposes, only the first half of this year, cars for private purposes or临床科室医院感染管理质控标准(200分） 项目 考核标准及内容分值 扣分标准扣分原因得分组织管理制度落实（15分）1、建立临床科室医院感染管理小组,小组成员包括：科主任、护士长、监控医生（主治或主治医生以上)、监控护士(护师或护师以上）;每个病区必须有1名监控医生和监控护士；小组成员不在岗3个月以上应更换人员,并上报院感科4小组成员不符合要求扣4分2、科室医院感染管理小组人员履行工作职责，做好院感科反馈问题整改，针对本科室专业特点，开展医院感染防控工作。对本科室存在的问题进行讨论、分析及持续改进,并有记录。4反馈问题未整改扣2分至少每季度一次讨论、分析、改进会议,未进行讨论、分析及改进扣2分3、医务人员掌握本科室感染管理制度，能准确回答院感相关问题。4不能准确回答，1人次扣2分4、院感相关资料齐全，包括：院感期刊、院感学习记录、发放的院感资料等2资料缺1项扣2分教育培训（20分）1、全院性培训应按院感科要求安排医务人员参加，并将培训内容传达科室每一位医务人员.5科室未派人参加培训扣当月科室院感质控分，人员未到1人次扣1分、迟到1030分钟，一人扣2分。2、听课人员须签到，禁止多签和代签。5多签或代签 1人次扣1分3、新职工岗前培训不得少于3学时，在职医务人员每年不少于4学时.5未参加培训扣5分4、科室组织培训每季度一次。5科室培训缺1次扣2分,学习记录不真实扣2分医院感染监测（20）1、发现医院感染流行或暴发趋势、新发特殊感染病例应立即上报院感科，5迟报或瞒报扣除当月所有院感质控分.2、出现泛耐药菌感染病例时，立即上报院感科。3未报告1例扣3分3、医院感染病例确诊24小时内上报，项目齐全；接到漏报病例反馈表后，3天内补报。科室医院感染率应8、漏报率15、清洁手术切口感染率1。5%5漏报1份扣 5分，错报1份扣5分,监控指标每上升0。5扣5分。可以倒扣分。4、标本送检：(1）医院感染病例(上呼吸道感染除外）必须进行病原学检测。（2)留置导尿管1周应送尿培养.（3）连续有创机械通气3天应送痰培养.(4）怀疑导管相关血流感染时应做血培养,拔除导管时导管尖端做微生物培养。5未送检1例扣2分5、环境卫生学监测:物体表面、医务人员手、消毒剂等生物监测菌落数符合标准.（物表：10cfu/cm、卫生消毒手:10cfu/、使用中消毒剂:100cfu/ml，无致病微生物生长.）2卫生学监测不符合标准1项扣1分医务人员手卫生（20分)1、科室洗手设施齐全，包括非手触式水龙头、洗手液（皂）、速干手消毒剂、干手用品5手卫生设施不符合要求扣3分2、洗手液首选一次性瓶装产品，使用桶装产品其容器应清洁、消毒,每周1次；选用肥皂应保持清洁干燥.3洗手液（皂）、容器不符合要求扣3分3、洗手方法正确,按“卫生洗手法”标示执行。5洗手方法不正确1人次扣 1分4、外科洗手按标准外科洗手图进行.2不符合要求1人次扣1分5、在诊疗护理活动中，严格执行我院医务人员手卫生管理制度。5未按要求执行手卫生1人次扣 1分诊疗护理操作（20分)1、服装整齐、戴口罩、帽子，头发、口鼻不能外露.2不符合要求1项扣1分2、严格执行无菌技术操作规程，诊疗护理操作时，遵循“由洁到污”的原则。5不符合要求扣2分3、无菌操作时铺无菌盘，并标明铺盘时间,铺好的无菌盘有效期4小时。2未注明铺盘时间扣 1分，过期使用扣2分.4、无菌物品一人一用一灭菌。消毒物品一人一用一消毒.注射一人一针一管；采血一人一针一巾一带.5不符合要求1项扣1分5、换药按无菌操作执行。换下的脏敷料不能直接放置在病床、床头柜或地上。3不符合要求1项扣1分6、治疗车上物品应排放有序,上层为清洁区,下层为污染区；进入病室的治疗车、换药车应配有快速手消毒剂。治疗用物应洁污分置.3不符合要求1项扣3分医疗用品清洁消毒（20分)1、听诊器、血压计袖带、手电筒、病历牌、输液网套、平车、轮椅，各类监护仪器等保持清洁，被病人血液、体液污染时先清洗后用含有效氯500mg/L消毒液浸泡30min或用75乙醇擦拭消毒。4不符合要求1项扣2分2、体温计：腋表使用后用含有效氯250mg/L消毒液浸泡30min，肛表和口表使用后用含有效氯500mg/L消毒液浸泡30min，清水冲净,擦干备用.4不符合要求扣2分3、止血带使用后交消毒供应中心统一处理。4不符合要求扣2分4、吸引瓶、吸引管每日更换，用含有效氯1000mg/L的消毒剂浸泡消毒30分钟，刷洗干净，干燥备用.4不符合要求扣2分5、重复使用的器械、器具、物品，使用后去除污物，放置于专门容器中，由消毒供应中心处理。4未清除污物扣 2分治疗室、换药室、处置室管理(18)分1、室内布局合理,洁、污分区明确，环境清洁,物品放置有序.2不符合要求扣1分2、抽出的药液、开启的静脉输入用无菌液体须注明开启时间，超过2小时后不得使用;启封抽吸的各种溶媒超过24小时不得使用。2不符合要求1项扣1分3、使用中的氧气湿化瓶、湿化液（无菌水)、氧气鼻导管必须每日更换；一次性输氧装置按厂家说明使用。供氧管一人一套，每周更换1次;多重耐药菌感染者一人一套，不可混用。3不符合要求1项扣1分4、无菌物品与非无菌物品分开放置。无菌物品按灭菌日期依次放入专柜,在规定有效期内使用.无菌包过期、潮湿、落地、容器未密闭、包装破损等不得使用.2不符合要求1项扣1分5、消毒剂在有效期内使用。使用中的碘酒、酒精每周更换2次。3不符合要求1项扣分无菌物品过期每件扣10分可以倒扣分.6、室内每天开窗通风2次，每次30min。必要时进行空气消毒。2不符合要求1项扣1分7、室内治疗台、无菌物品存放柜、药品柜、治疗车、治疗盘、仪器设备台面等表面使用清洁或消毒布巾擦拭，每日1次.被血液、体液、分泌物污染时,先用吸湿材料去除可见的污染物,然后用含有效氯500mg/L消毒液擦拭。被经血传播的病原体、分支杆菌、细菌芽胞等病原体污染时用含有效氯2000mg/L消毒液擦拭.地面湿式清扫。3不符合要求1项扣1分8、换药操作应按清洁伤口、感染伤口、隔离伤口依次进行。遇炭疽、气性坏疽、破伤风等应就地（诊室或病室)严格隔离,处置后严格进行终末消毒。 2不符合要求1项扣3分病房管理（40分）1、科室最少应设一间隔离病室。5不符合要求扣2分2、感染性疾病患者与非感染性疾病患者分室安置，同种感染性疾病、同种病原体感染患者可安置一室,并挂隔离标识牌。10不符合要求扣5分3、出现多重耐药菌感染病例时,应按多重耐药菌医院感染控制措施进行处置.5不符合要求1项扣2分4、配备防护用品，包括隔离衣、口罩、帽子、手套、护目镜等；医务人员掌握各种职业暴露处理方法及报告流程，正确使用防护用品；在诊疗护理操作时,应对所有病人实行标准预防。5不符合要求1项扣2分5、进行病房保洁时，应遵循“由洁到污的原则进行。3不符合要求1项扣2分6、病室内应定时通风换气，必要时进行空气消毒;地面湿式清扫,每日2次，遇污染时随时清扫和消毒；餐具、便器、痰缸等一人一用一消毒，不得交叉使用。3不符合要求扣2分7、病人被服应保持清洁，每周更换不少于一次，遇污染随时更换；被褥、枕芯、床垫定期清洁、消毒,遇污染随时更换；禁止在病房、走廊清点更换下来的衣物、被服。3违反规定扣1分8、病床湿式清扫,每天一次,一床一套（巾）；床头柜等物体表面每天湿抹一次,一桌一抹布,用后清洗消毒，遇污染及时清洗消毒；病人出院、转科或死亡后，床单元必须进行终末处理.3不符合要求1项扣2分9、抹布、拖巾应分区使用.抹布使用后清洗干净，再用含有效氯250mg/L消毒液浸泡30min，冲净消毒液，干燥备用；拖布使用后清洗干净,再用含有效氯500mg/L消毒液浸泡30min，冲净消毒液，干燥备用.3不符合要求1项扣2分一次性医疗器械和消毒药械使用管理（15分）1、一次性医疗器械和消毒药械相关证照齐全，符合国家要求。1不符合要求1项扣1分2、科室和个人不得私自购买、试用一次性医疗用品.1不符合要求扣1分可以倒扣分.3、一次性使用的医疗器械、器具不得重复使用。5重复使用扣10分，可以倒扣分.4、临床科室使用前应认真检查,如有过期、失效、产品不洁净、外包装破损等不得使用.1不符合要求扣1分.5、消毒器械严格按厂家说明书使用.1不符合要求扣1分.6、消毒剂严格按厂家说明书使用，配制浓度准确；含氯消毒剂每日更换，如出现液体浑浊应立即更换,盛装消毒液的容器外应标识名称、配制日期、浓度、责任人。3不符合要求扣3分7、医疗用品采用浸泡灭菌时，应确保有效浓度，登记灭菌开始时间，如灭菌过程中放入物品应重新计算时间.化学灭菌10小时,做不到时，用品由消毒供应中心低温灭菌.1不符合要求扣1分8、紫外线灯每周清洁、空气消毒机定期清洁、维护，消毒使用有累计时间，有记录。2不符合要求一项扣1分医疗废物管理(12分）1、科室产生的废物按我院医疗废物管理制度进行处置。生活垃圾和医疗废物要严格分开,不能混放.医废处理合格率应达到100。2不符合要求扣2分，可以倒扣分。2、医疗废物分类收集放置，盛放容器符合要求，装放达3/4满时，袋口封扎正确，封口处有标签,标签项目填写齐全。2不符合要求扣2分，可以倒扣分.3、感染性废物、病理性废物放入有警示标志的黄色专用包装袋内,损伤性废物放入锐器盒内，输液器上、下段针头应剪下,按损伤性废物处置。2不符合要求扣2分,可以倒扣分.4、医疗废物应做好交接、详细登记。登记内容：包括产生科室、日期、种类、数量、总数量、交接时间、科室人员及运送人员签名。登记本科室负责保存，保存期至少3年。2登记内容不全1项扣1分不符合要求1项扣1分5、医疗废物运送过程中应加盖密闭，按规定路线运送,运送工具保持清洁。1不符合要求1项扣1分6、处置医疗废物过程中应做好个人防护工作.1不符合要求1项扣1分7、任何科室和个人禁止转让、买卖医疗废物.2不符合要求扣2分可以倒扣分.宜都市认真贯彻省、宜昌市安全生产教育培训工作有关精神，按照继续深入开展“安全生产年”活动要求，扎实推进安全生产宣传教育行动，以全市经济发展为首要，努力拓展培训空间leaders driving a vehicle accident caused by road accidents, 1, 1 people killed and direct economic losses amounting to more than 100,000 yuan. Third, high efficiency and low cost of the bus. Surveys show that, the operating costs of taxis for the 8200/. Is a fundamental priority of the reform, it is a difficult problem that must be solved in the reform process. Clearly, the post consumption averages three years before as a base and fine-tuned on the basis of this single practices must be improved. Improvements to adhere to three principles: first, under the existing policy provisions approved for public servants duty consumption standards, calibration, is not contrary to policy. Second, according to the local financial situation and peoples sustainability, public servants duty consumption standards approved, both financial reach, and people passing through. Third, according to the operational needs of civil servants responsible for authorized public servants duty consumption standards, both high and low positions, but also the nature of the work and the workload. In reform of method Shang, approved civil servants positions consumption standard to big unified, and small dispersed suitable, that most positions consumption project should according to policy provides proposed unified standard, consider to ranks, and units and the work task of differences sex, unified of standard should has elastic of and dynamic of, makes regions, and units in implementation unified standard Shi has must of flexible disposal right; but since set of standard must after financial, and audit, sector audit approved Hou to implementation. (C) reform package. Public servants duty consumption elasticity of consumption to limit consumption, turning mess into kitchen after dinner, follow the civil servant with a how to use personal title subsidies, or how to manage a personal duty consumption use of subsidies. Therefore, we must establish and perfect with public servants duty consumption monetization reform support of the series of governance systems such as the civil service examination of responsibility, system, low fault investigation system, the report said. While other measures to keep up. Discipline inspection and supervision organs, financial, auditing departments should strengthen supervision and inspection of public servants duty consumption monetization reform progress, to strengthen the reform of public servants duty consumption monetization system, measures to develop and monitor the implementation of inspection, not consumption as required, even shifting consumer behavior to stop, serious cases to deal with. Three ideas, public servants duty consumption monetization reform of politics, the economy and the deepening of the reform, public servants duty consumption as somewhere between a reform also demonstrated its importance and urgency. First of all, civil servants especially party and Government leaders and public servants duty consumption there are big drawbacks. NPC deputies and CPPCC members and the broad masses are concerned about. Secondly, the