抗菌藥物管理工作制度

抗菌藥物管理工作制度

XXXX大學(xué)XXXX醫(yī)院抗菌藥物管理工作制度為了促進(jìn)抗菌藥物的合理使用，有效控制細(xì)菌耐藥，保證醫(yī)療質(zhì)量和醫(yī)療安全，本醫(yī)院按照衛(wèi)生部的相關(guān)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(yīng)用管理責(zé)任制。臨床科室負(fù)責(zé)人是科室抗菌藥物臨床應(yīng)用管理的第一責(zé)任人。科室應(yīng)將抗菌藥物臨床應(yīng)用管理作為醫(yī)療質(zhì)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(yīng)用管理工作制度和監(jiān)督管理機(jī)制。同時，明確抗菌藥物合理應(yīng)用的控制指標(biāo)，醫(yī)院與臨床科室負(fù)責(zé)人簽訂抗菌藥物合理應(yīng)用責(zé)任狀，將抗菌藥物合理應(yīng)用情況作為科室和醫(yī)務(wù)人員績效考核的重要依據(jù)，并作為科室主任綜合目標(biāo)考核以及醫(yī)務(wù)人員晉升、評先評優(yōu)的重要指標(biāo)。（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(jī)制。在醫(yī)務(wù)科的總體協(xié)調(diào)下，醫(yī)院感染管理科負(fù)責(zé)落實(shí)抗菌藥物分級專業(yè)資料管理制度、抗菌藥物臨床應(yīng)用和細(xì)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(dǎo)檢查。藥劑科負(fù)責(zé)抗菌藥物采購供應(yīng)管理、抗菌藥物處方、醫(yī)囑專項點(diǎn)評以及圍手術(shù)期預(yù)防用藥監(jiān)控等專項工作。醫(yī)療質(zhì)量管理科負(fù)責(zé)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(jié)果納入醫(yī)療質(zhì)量公示考評。信息科負(fù)責(zé)完善抗菌藥物分線管理相關(guān)審核程序，協(xié)助抗菌藥物相關(guān)數(shù)據(jù)的統(tǒng)計分析。機(jī)關(guān)和各職能科室通過加強(qiáng)管理、加強(qiáng)監(jiān)督，對全院醫(yī)務(wù)人員抗菌藥物臨床應(yīng)用行為進(jìn)行檢查和干預(yù)，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(yīng)用基本情況調(diào)查。抗菌藥物管理工作組定期對院、科兩級抗菌藥物臨床應(yīng)用情況開展調(diào)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(qiáng)度、I類切口手術(shù)和介入診療抗菌藥物預(yù)防使用率、特殊使用級抗菌藥物使用率、使用強(qiáng)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(yīng)用技術(shù)支撐體系。本醫(yī)院將建立完善抗菌藥物臨床應(yīng)用技術(shù)支撐體系，為醫(yī)務(wù)人員提供必要的技術(shù)支持和培訓(xùn)，以提高抗菌藥物的合理使用率和細(xì)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