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St. Marien- und St. Annastiftskrankenhaus

Salzburger Straße 15
67067 Ludwigshafen

Phone: 0621-5501-0
Fax: 0621-5501-2266
Mail: ed.suahneknarkneiram-ts@ofni

https://www.st-marienkrankenhaus.de/

Basic information

Number of beds: 368
Number of specialist departments: 13

Number of inpatient cases: 12.661
Number of partial inpatient cases: 174
Number of outpatient cases: 22.831

Hospital owners: St. Dominikus Krankenhaus und Jugendhilfe gGmbH
Type of provider: freigemeinnützig

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law

Bezeichnung
Teilnahme externe Qualitätssicherung	yes

Quality of participation in the Disease Management Programme (DMP)
No participation

Implementation of the minimum quantity agreement

Treatment area

Knee joint total endoprostheses

Quantity performed	477
Exception?	No exception

Care of premature and mature infants (with an admission weight < 1250g)

Quantity performed	21
Exception?	No exception

Minimum quantities forecast

Knee joint total endoprostheses

Overall result forecast presentation:	yes
Quantity performed reporting year:	477
Quantity forecast year:	515
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Care of premature and mature infants (with an admission weight < 1250g)

Overall result forecast presentation:	yes
Quantity performed reporting year:	21
Quantity forecast year:	24
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Implementation of resolutions of the Federal Joint Committee on quality assurance (G-BA)

No.	Explanation
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
CQ01	Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm

Compliance with staffing requirements

Clarifying chat completed: no
Clarifying chat not completed: no
No participation in clarifying chat: no
Notification of non-fulfilment of nursing care not made: yes

Further training
pursuant to Article 136b, para. 1, sentence 1, no. 1 of the SGB

Number	Group
77	Medical specialists (m/f) , psychological psychotherapists (m/f) and child and adolescent psychotherapists (m/f) who are subject to the obligation to undergo further training*
77	Number of medical specialists (m/f) from no. 1 who have completed a five-year period of further training and are therefore subject to the obligation to provide evidence
77	Number of those persons from no. 2 who have provided proof of further training according to Article 3 of the G-BA regulations

* according to the “Provisions of the Joint Federal Committee for the Further Training of Medical Specialists (m/f), Psychological Psychotherapists (m/f) and Child and Adolescent Psychotherapists (m/f) in Hospitals”

General information

Protection concept against (sexual) violence against children and young people

Advice on prevention and intervention in cases of violence and abuse

According to Section 4 (2) of the Quality Management Guideline, facilities must provide for the prevention of and intervention in cases of violence and abuse as part of their internal quality management. The aim is to prevent, recognise and respond appropriately to abuse and violence, particularly against vulnerable patient groups such as children and adolescents or people in need of help, and also to prevent it within the facility. The respective procedure is aligned with the size of the facility, the range of services and the patients in order to define customised solutions for sensitising the teams as well as other suitable preventative and interventional measures. These may include information materials, contact addresses, training/education, codes of conduct, recommendations for action/intervention plans or comprehensive protection concepts.

Is a protection concept in place? Yes
Measures
- Prevention
  Code of conduct with rules for treating children and young people with respect
  Last review of the measure
  31.10.2023 15:48:20
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Last review of the measure
  31.10.2023 15:48:20
- Review
  Recommendations for dealing with/processing cases that have occurred
  Last review of the measure
  31.10.2023 15:48:20

In den verschiedenen Einrichtungen der gGmbH sind die notwendigen Abläufe in differenzierten Konzepten veröffentlicht. Auch besteht Zugriff auf die verschiedenen gesetzlichen Leitlinien/ Schutzkonzepte.

Commentary on the protection concept

Gemäß § 4 Absatz 2 in Verbindung mit Teil B Abschnitt I § 1 der Qualitätsmanagement-Richtlinie haben sich Einrichtungen, die Kinder und Jugendliche versorgen, gezielt mit der Prävention von und Intervention bei (sexueller) Gewalt und Missbrauch bei Kindern und Jugendlichen zu befassen (Risiko- und Gefährdungsanalyse) und – der Größe und Organisationsform der Einrichtung entsprechend – konkrete Schritte und Maßnahmen abzuleiten (Schutzkonzept). In diesem Abschnitt geben Krankenhäuser, die Kinder und Jugendliche versorgen, an, ob sie gemäß § 4 Absatz 2 in Verbindung mit Teil B Abschnitt I § 1 der Qualitätsmanagement-Richtlinie ein Schutzkonzept gegen (sexuelle) Gewalt bei Kindern und Jugendlichen aufweisen.

Drug therapy safety

Steering committee

Drug commission

Use of standardised forms for drug medical history

Qualitätsmanagementhandbuch

02.11.2022

Electronic support for the admission and anamnesis process (e.g. import of patient master data or medication plans, use of a drug knowledge database, input screen for drugs or anamnesis information)

Process description for an optimal medication process (e.g. drug anamnesis – prescription – patient information – drug delivery – drug application – documentation – therapy monitoring – result evaluation)

Qualitätsmanagementhandbuch

02.11.2022

Possibility of electronic prescription i.e. structured entry of active substances (or name of the preparation), form, dose, dose frequency (e.g. in the HIS, in prescription software)

Provision of one or more electronic drug information systems (e.g. Lauer-Taxe®, ifap klinikCenter®, Gelbe Liste®, Fachinfo-Service®)

Electronic support for the supply of patients with drugs

Vorhandensein von elektronischen Systemen zur Entscheidungsunterstützung (z.B. Meona®, Rpdoc®, AIDKlinik®, ID Medics® bzw. ID Diacos® Pharma)

Electronic documentation of the administration of drugs

Measures to minimise medication errors

Fallbesprechungen
Maßnahmen zur Vermeidung von Arzneimittelverwechslung
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)

Instruments and measures

The instruments and measures to promote drug therapy safety are presented with a focus on the typical procedures of the medication process in inpatient patient care. A special feature of the medication process in the inpatient environment is the transition management during admission and discharge. The instruments and measures listed below address structural elements, e.g. special IT equipment and work materials, as well as process aspects, such as work descriptions for particularly risky process steps or concepts for securing typical risk situations . In addition, proven measures to avoid or learn from medication errors can be specified. The hospital presents here which aspects it has already dealt with and which measures it has specifically implemented. The following aspects can be presented, if necessary using free text fields:
- Admission to hospital, including anamnesis
; Instruments and measures are presented for determining the old medication (drug history), the subsequent clinical assessment and the switch to the medication available in the hospital (house list), as well as for documenting both the patient's original medication and that for hospital treatment adapted medication.
- Medication process in the hospital
In this context, the following sub-processes are assumed as examples: drug history - prescription - patient information - drug delivery - drug use - documentation - therapy monitoring - result assessment. Instruments and measures for safe medication prescription can be presented, e.g. B. in terms of readability, clarity and completeness of the documentation, but also in terms of area of application, effectiveness, benefit-risk ratio, tolerability (including potential contraindications, interactions, etc.) and resource considerations. Information can also be provided to support reliable medication ordering, delivery and use or administration.
- Discharge
In particular, the measures taken by hospitals can be presented to ensure that information on drug therapy is structured and passed on to doctors and physicians providing further treatment, as well as the appropriate provision of patients with drug information, medication plans and medications. Drug prescriptions are made.

AMTS is the totality of measures to ensure an optimal medication process with the aim of reducing medication errors and thus avoidable risks for patients during drug therapy. A prerequisite for the successful implementation of these measures is that AMTS is practised as an integral part of daily routine in an interdisciplinary and multi-professional approach.

Special instrument-based equipment

Research & teaching

Job

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

MFH Uni. HD Prof. Dr. Hoffmann Uni.klinikum RWTH Aachen Priv.-Doz. Dr. Merz Universität Ulm Priv.-Doz. Dr. Goertz Med.Fak. Ma/ Uni. HD Prof. Dr. Stöve, Priv.-Doz. Dr. Röhm, Prof. Dr. Schreiner Med.Fak. der Uni. HD Prof. Dr. Sertel

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

IVT in Mannheim: Fr. Dr. Dagmar Baus, Schmerzklinik

FL03 - Student training (clinical traineeship / internship year)

Explanation

Als akademisches Lehrkrankenhaus der Medizinischen Fakultät Mannheim der Universität Heidelberg setzen wir uns für die Ausbildung der zukünftigen Ärztegeneration ein. Wir bieten eine Kombination aus interessanten Seminaren und Vorlesungen. PJ-ler, Hospitanten und Famulanten sind sehr willkommen.

FL04 - Project-related cooperation with colleges and universities

Explanation

DGVS-Leitlinie Morbus Crohn mit Universität Jena (Hoffmann) DGVSLeitlinie Helicobacter pylori und gastroduod. Ulkuskrankheit mit der LMU München (Hoffmann) Forschungsprojekt „Guter Start ins Kinderleben“ mit Universität Ulm und Gießen Fachhochschule für Musiktherapie Heidelberg: Geriatrie

FL05 - Participation in multi-centre Phase I/II studies

Explanation

Teilnahme an der DACHS-Studie, Chirurgische Klinik, Dr. N. Nagel Teilnahme an Phase IIb Studie, Medizinische Klinik I, Prof. Dr. med. Jörg Hoffmann

FL06 - Participation in multi-centre phase III/IV studies

Explanation

Teilnahme an mehreren Phase III/VI Studien, Medizinische Klinik I, Prof. Dr. med. Jörg Hoffmann

FL07 - Initiation and management of uni-centric/multi-centric clinical/scientific studies

Explanation

FL08 - Editors of scientific journals/textbooks

Explanation

Chronisch entzündliche Darmerkrankungen: Das CED Handbuch für Klinik und Praxis, und Associate Editor der Zeitschrift BMC Gastroenterology, Medizinische Klinik I, Prof. Dr. med. Jörg Hoffmann.

Training

Training in other healing professions

HB01 - Nurse and health care worker (m/f)

Comment

Ersetzt durch die neue Ausbildung zum Pflegefachmann/zur Pflegefachfrau

HB02 - Health and paediatric nurse (m/f)

Comment

Ersetzt durch die neue Ausbildung zum Pflegefachmann/zur Pflegefachfrau

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Es werden ständig 6-8 PhysiotherapeutInnen kooperierender Schulen im Bereich der Physiotherapie im St. Marienkrankenhaus praktisch ausgebildet.

HB07 - Surgical technical assistant (m/f)

Comment

16 Ausbildungsplätze

HB17 - Auxiliary nurse (m/f)

Comment

25 Ausbildungsplätze

HB19 - Nursing professionals

Comment

Pflegefachfrau/-mann mit Vertiefungen in a) Akutversorgung b) Pädiatrische Versorgung c) Kinder- und Jugendpsychiatrie In jedem Jahr 50 Ausbildungsplätze seit 2020 (Ausbildung St. Marien- und St. Annastiftskrankenhaus)

HB20 - Nursing professional B. Sc.

Comment

Wir bieten den Dualen Studiengang "Angewandte Gesundheits- und Pflegewissenschaften" (mit der Dualen Hochschule Baden-Württemberg in Mannheim)

Hospital staff
Pharmaceutical personnel
- Explanations: Die pharmazeutische Versorgung erfolgt durch Apotheke Stadtklinik Frankenthal (Ltg. Michael Bussemer). Es bestehen digitale Systeme zur Verordnung & Bestellung. Neuentwicklungen werden in der regelmäßig stattfindenden Konferenz der Arzneimittelkommission besprochen. Ab 2023 angestellte Pharmazeutin.
- Nursing staff regulation