1 Measures taken to prevent in-hospital infections
We implement the following items as measures to prevent in-hospital infections:
- Enforcement of routine infection control measures
- Informing and enforcing the measures to prevent the spread of infection in case of outbreak
- Measures for the proper use of antimicrobial drugs
- Establishment of in-hospital infection control manuals
- Staff training on infection control
- Survey of in-hospital infections
- Collaboration with regional medical institutions
2 Organization for infection control
The University of Yamanashi Hospital has established the infection control committee to discuss the items relating to measures and implementation of infection prevention at the hospital. In addition, the infection control office has been established as a small group for discussing the items to be proposed to the infection control committee and to investigate the state of individual infections in the hospital. Furthermore, the infection control team has been formed as a substructure of the infection control committee. The infection control team consists of link doctors, link nurse, co-medical staff, et al., and these team members are responsible for implementing infection control measures.
3 Policies for in-hospital infection control
Infection control policies are set out to ensure the system of infection control management at the University of Yamanashi Hospital in order to promote the prevention of in-hospital infections and to provide advanced medical care.
4 Preparation of infection control manual
An infection control manual is prepared according to “Guidelines for Isolation Precautions in Hospitals” by the CDC in the United States, and the Guidelines for Infection Control in University Hospitals (2nd edition), edited by the Japan Infection Prevention and Control Conference for National and Public University Hospitals. The manual is reviewed every year. In the establishment and revision of the manual, an investigation is conducted based on the latest information available, and such information is introduced as necessary. The manual was revised in October 2013.
5 Preparation of guidelines for the use of antimicrobial drugs (revised 2009)
In-hospital infections, especially those involving drug-resistant microorganisms, are posing a great threat to hospitals and patients. Two important measures must be taken to control in-hospital infections that involve resistant microorganisms. The first measure is to prevent the transmission of resistant pathogens from patients with infections to other patients through medical professionals. For this purpose, the infection control committee of the University of Yamanashi Prefecture has prepared an “infection control manual.” In addition, we are providing guidance for preventive measures for each infection route (including standard preventive measures) and encouraging the enforcement of these measures in each section. However, in addition to the preventive measures on transmission of the pathogens, it is essential to prevent the generation of infections involving resistant microorganisms as the infection source within the hospital to ensure the control of in-hospital infections by resistant microorganisms. Infections involving resistant microorganisms are known to be promoted by the inappropriate use of broad-spectrum antimicrobial agents. For this reason, the proper use of antimicrobial drugs is considered extremely important as the second measure against infections. The guidelines prepared in 2004 had been established by the infection control committee and the infection control team committee at the University of Yamanashi Hospital, with the cooperation of various clinical departments, Department of Pharmacy, and Department of Clinical Laboratory, to promote the proper use of antimicrobial drugs at the hospital. The guidelines include policies on the use of microbial drugs that can be used at the hospital for the treatment of various infections. Since the type of microbial drugs allowed for use at the hospital changes every year, the guidelines were revised in 2009. The list of antiviral drugs, including the treatment drugs for influenza, is attached as an appendix.
6 Hosting of training session for infection control
In regards to the training session for infection control, lecture sessions are held twice a year and activity report meetings are held twice a year. These sessions are held jointly with the safety management committee. In addition, training is held for new employees, returning employees, and mid-career employees.
7 Route of communication in case of discovering patients with infections
A system is established so that when an infection is discovered, this is reported immediately to the infection control committee, allowing the committee to investigate the actions to be taken and to implement measures to prevent the spread of the infection.