Andrzej Ploch
Ärztlicher Direktor
Ernst-Moritz-Arndt-Straße 17
58840 Plettenberg
Phone:
02391
-63-7315
Fax: 02391-63-232
Mail:
ed.xarpdar@hcolpa
A hygiene officer has not been established
Hygiene commission established
Conference frequency: quartalsweise
Andrzej Ploch
Ärztlicher Direktor
Ernst-Moritz-Arndt-Straße 17
58840 Plettenberg
Phone:
02391
-63-7315
Fax: 02391-63-232
Mail:
ed.xarpdar@hcolpa
Hospital hygienists (m/f) | 1 | Als Hygienebeauftragte Ärzte sind zwei Fachärzte aus unterschiedlichen Fachgebieten tätig. Sie wurden fachlich geschult und nehmen an den regelmäßigen Sitzungen der Hygienekommission teil. |
Doctors’ hygiene officer | 2 | |
Hygiene specialists | 1 | im Rahmen eines Kooperationsvertrages erfolgt die Gestellung durch das Hygieneinstitut Gelsenkirchen (Zentrum für Hygiene) Neben den ständigen wöchentlichen Präsenztagen besteht die jederzeitige Unterstützung durch die Fachkraft |
Hygiene officers in nursing care | 4 | Die eingesetzten Mitarbeiterinnen wurden nach fachlicher Unterweisung in ihrem Einsatzgebiet tätig. Sie nehmen an den Sitzungen der Hygienekommission regelmäßig teil und sind im ständigen Kontakt zur Hygienefachkraft. Die regelmäßigen Fortbildungen werden von ihnen, soweit es die Pandemielage zulässt, eingehalten. |
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 |
Sterile gloves | Yes |
Sterile gown | Yes |
Head hood | Yes |
Mouth and nose protection | Yes |
Sterile drape | Yes |
A site-specific standard for checking the duration of catherisation of central indwelling venous catheters is available | Yes |
The standard was authorised by management or the hygiene commission | Yes |
A site-specific guideline on antibiotic therapy is available | Yes |
The standard was authorised by management or the hygiene commission | Yes |
The guideline is adapted to the current local/internal resistance situation | Yes |
A site-specific standard for perioperative antibiotic therapy is available | Yes |
The standard was authorised by management or the hygiene commission | Yes |
The standardised antibiotic therapy is checked in a structured way for each patient operated on using a checklist (e.g. using the “WHO Surgical Checklist” or using our own/adapted checklists) | Yes |
Indication for antibiotic prophylaxis | Yes |
Antibiotics to be used (taking into account the expected germ spectrum and the local/regional resistance situation) | Yes |
Time/duration of antibiotic prophylaxis | Yes |
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 | Yes |
Doctor notification and documentation if a postoperative wound infection is suspected | Yes |
Hand disinfectant consumption in all intensive care units | not collected |
Hand disinfectant consumption on all general stations | not collected |
Hand disinfectant consumption is recorded on a ward-specific basis. | No |
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
|
HM04 |
Participation in the (voluntary) “Clean Hands Initiative” (CHI) Innerhalb des Hauses wird durch die Hygienefachkraft mit der UV Box 2 mal im Jahr eine Schulung durchgeführt. Weiterhin finden mindestens 8 Hygieneschulungen pro Jahr statt. Teilnahme (ohne Zertifikat) |
HM05 |
Annual inspection of the preparation and sterilisation of medical devices |
HM09 |
Training of employees on hygiene-related topics Pflichtschulung |