抗菌藥物管理工作制度

抗菌藥物管理工作制度

XXXX大學XXXX醫(yī)院抗菌藥物管理工作制度為了促進抗菌藥物的合理使用，有效控制細菌耐藥，保證醫(yī)療質量和醫(yī)療安全，本醫(yī)院按照衛(wèi)生部的相關規(guī)定，制定了抗菌藥物管理工作制度。（一）明確抗菌藥物臨床應用管理責任制。臨床科室負責人是科室抗菌藥物臨床應用管理的第一責任人?？剖覒獙⒖咕幬锱R床應用管理作為醫(yī)療質量和科室管理的重要工作之一，并建立、健全抗菌藥物臨床應用管理工作制度和監(jiān)督管理機制。同時，明確抗菌藥物合理應用的控制指標，醫(yī)院與臨床科室負責人簽訂抗菌藥物合理應用責任狀，將抗菌藥物合理應用情況作為科室和醫(yī)務人員績效考核的重要依據，并作為科室主任綜合目標考核以及醫(yī)務人員晉升、評先評優(yōu)的重要指標。（二）發(fā)揮職能科室管理作用，建立抗菌藥物合理使用長效管理機制。在醫(yī)務科的總體協(xié)調下，醫(yī)院感染管理科負責落實抗菌藥物分級專業(yè)資料管理制度、抗菌藥物臨床應用和細菌耐藥動態(tài)管理控制以及住院患者微生物送檢情況的督導檢查。藥劑科負責抗菌藥物采購供應管理、抗菌藥物處方、醫(yī)囑專項點評以及圍手術期預防用藥監(jiān)控等專項工作。醫(yī)療質量管理科負責抽查檢審抗菌藥物使用病歷記錄分析，并將抗菌藥物專項檢查結果納入醫(yī)療質量公示考評。信息科負責完善抗菌藥物分線管理相關審核程序，協(xié)助抗菌藥物相關數(shù)據的統(tǒng)計分析。機關和各職能科室通過加強管理、加強監(jiān)督，對全院醫(yī)務人員抗菌藥物臨床應用行為進行檢查和干預，以控制抗菌藥物的不合理使用。（三）定期開展抗菌藥物臨床應用基本情況調查。抗菌藥物管理工作組定期對院、科兩級抗菌藥物臨床應用情況開展調查，包括抗菌藥物品種、劑型、規(guī)格、使用量、使用金額、使用量和使用金額排名前10位的抗菌藥物品種、住院患者抗菌藥物使用率、使用強度、I類切口手術和介入診療抗菌藥物預防使用率、特殊使用級抗菌藥物使用率、使用強度、門診抗菌藥物處方比例、急診抗菌藥物處方比例等。（四）建立完善抗菌藥物臨床應用技術支撐體系。本醫(yī)院將建立完善抗菌藥物臨床應用技術支撐體系，為醫(yī)務人員提供必要的技術支持和培訓，以提高抗菌藥物的合理使用率和細菌耐藥控制水平。Clinicaldoctorsshouldchooseantibioticsrationallybasedontheresultsofclinicallaboratorytesting.Furthermore,therateofsendingmicrobiologicalsamplesfortreatmentwithrestrictedantibioticsshouldbenolessthan50%,andforspecialantibiotics,itshouldbenolessthan80%.Thelaboratorydepartmentshouldactivelycarryoutbacterialresistancemonitoring,regularlyreleaseinformationonbacterialresistance,establishabacterialresistancewarningmechanism,andtakecorrespondingmeasuresbasedondifferentlevelsofbacterialresistance.Thehospitalshouldregularlypublishclinicalapplicationofantibioticsandbacterialresistancemonitoring,andsuperviseandguideclinicaldepartmentstouseantibioticsrationally.Theusagerateandintensityofantibioticsshouldbecontrolledwithinareasonablerange.Theusagerateofantibioticsforinpatientsshouldnotexceed60%,foroutpatientsshouldnotexceed20%,andforemergencypatientsshouldnotexceed40%.Theintensityofantibioticusageshouldbecontrolledtonomorethan40DDDsperhundredperson-days.Forinpatientswhorequireantibioticprophylaxisforsurgery,thetimeofantibioticadministrationshouldbecontrolledbetween30minutesto2hoursbeforesurgery,andtheselectionanddurationofantibioticuseshouldbereasonable.TheproportionofpatientswhorequireantibioticprophylaxisforI-classsurgicalincisionsshouldnotexceed30%,andforpatientsundergoingfemoralherniarepair(includingpatchrepair),thyroidsurgery,breastdiseasesurgery,arthroscopy,carotidarterymembranepeelingsurgery,skulltumorresectionsurgery,andvascularinterventiondiagnosticsurgery,antibioticsareusuallynotrequiredforprophylaxis(exceptforthosewithindications).ThetimeforantibioticprophylaxisforI-classsurgicalincisionsshouldnotexceed24hours.Thehospitalshouldprovidetrainingandstandardizedmanagementforphysiciansandpharmacistsonclinicalapplicationofantibiotics.Afterpassingthetrainingandexamination,physicianscanbegrantedcorrespondinglevelsofantibioticprescriptionrights,andpharmacistscanbegrantedthequalificationtoadjustantibioticuse.Thehospitalshouldimplementasystemforevaluatingantibioticprescriptions.Relevantprofessionalandtechnicalpersonnelintheinfectionandpharmacydepartmentsshouldconductspecialevaluationsofantibioticprescriptionsandmedicalorders.Usinginformationtechnology,thehospitalshouldconductmonthlyevaluationsof25%ofphysicianswhohaveantibioticprescriptionrights,witheachphysicianbeingevaluatedonnolessthan50prescriptionsandmedicalorders.Clinicaldepartmentssuchasrespiratorymedicineandintensivecareunits,aswellasI-classsurgicalincisionsandinterventionaldiagnosisandtreatmentcases,shouldbethefocusofinspections.Basedontheresultsofevaluations,thehospitalshouldnotifytheentirehospitalofphysicianswhouseantibioticsrationallyorirrationally.Theevaluationresultsshouldbeanimportantbasisfordepartmentalandmedicalstaffperformanceassessments.Physicianswhouseantibioticsexcessivelywithoutjustifiablereasonsmorethanthreetimesshouldbewarnedandhavetheirrightstoprescribespecialandrestrictedantibioticslimited.Iftheycontinuetouseantibioticsexcessivelywithoutjustifiablereasonsaftertheirrightshavebeenlimited,theirantibioticprescriptionrightsshouldbecancelled.Ifpharma