Hygiene
A hygiene officer has not been established
Hygiene commission established
Conference frequency: halbjährlich
Contact person
| Hospital hygienists (m/f) | 1 | Der Chefarzt des St.-Elisabeth-Krankenhauses ist zugleich der Hygienebeauftragte Arzt für das St.-Elisabeth-Krankenhaus. |
| Doctors’ hygiene officer | 1 | |
| Hygiene specialists | 1 | Ein Team aus fünf Hygienefachkräften betreut die drei Krankenhäuser der SJG St. Paulus GmbH. |
| Hygiene officers in nursing care | 4 |
CVC hygiene default
| A site-specific guideline on antibiotic therapy is available | Yes |
| The standard was authorised by management or the hygiene commission | Yes |
| The standard deals with hygienic hand disinfection | Yes |
| The standard deals with skin disinfection (skin antiseptics) of the catheter puncture site with adequate skin antiseptics | Yes |
| The standard deals with the observance of the exposure time | Yes |
Application of further hygiene measures
| Sterile gloves | Yes |
| Sterile gown | Yes |
| Head hood | Yes |
| Mouth and nose protection | Yes |
| Sterile drape | Yes |
No operations performed
Default wound care dressing change
| Default wound care dressing change is available | Yes |
| The internal standard has been authorised by management or the Drug Commission or the Hygiene Commission | Yes |
| Hygienic hand disinfection (before, if necessary during and after dressing changes) | Yes |
| Dressing changes under aseptic conditions (application of aseptic working techniques, no-touch technique, sterile disposable gloves) | Yes |
| Antiseptic treatment of infected wounds | Yes |
| Checking the further necessity of a sterile wound dressing | Partly |
| Doctor notification and documentation if a postoperative wound infection is suspected | Yes |
Hand disinfection (ml / patient day)
| Hand disinfectant consumption in all intensive care units | non-existant |
| Hand disinfectant consumption on all general stations | 21,00 ml |
| Hand disinfectant consumption is recorded on a ward-specific basis. | Yes |
Dealing with multi-resistant pathogens (MRE) and methicillin-resistant staphylococcus aureus (MRSA)
| The standardized information of patients with a known colonization or infection by the methicillin-resistant staphylococcus aureaus (MRSA) is e.g. through the flyers of the MRSA networks. | yes |
| A site-specific information management with regard to MRSA-populated patients is available (site-specific information management means that there are structured guidelines on how information about settlement or infections with resistant pathogens at the site can be identified at their site employees in order to avoid the spread of pathogens). | yes |
| There is a risk-adapted admission screening based on the current RKI recommendations. | Yes |
| There are regular and structured training courses for employees on how to deal with patients populated by MRSA / MRE / Noro viruses. | Yes |
| No. | Instrument or measure |
|---|---|
| HM02 |
Participation in the Hospital Infection Surveillance System (HISS) of the National Reference Centre for Surveillance of Nosocomial Infections
|
| HM03 |
Participation in other regional, national or international networks for the prevention of nosocomial infections http://www.mre-net.org/netzwerk-kh_stadt.html MRE-Netzwerk Qualitätssiegel liegt vor. |
| HM04 |
Participation in the (voluntary) “Clean Hands Initiative” (CHI) https://www.aktion-sauberehaende.de/teilnehmende-einrichtungen Zertifikat Silber |
| HM05 |
Annual inspection of the preparation and sterilisation of medical devices |
| HM09 |
Training of employees on hygiene-related topics |