Hygiene
Norbert Pfundtner
Ärztl. Direktor, Chefarzt der Klinik für Akutgeriatrie
Brenkhäuser Str. 71
37671 Höxter
Phone: --
A hygiene officer has not been established
Hygiene commission established
Conference frequency: halbjährlich
Contact person
Norbert Pfundtner
Ärztl. Direktor, Chefarzt der Klinik für Akutgeriatrie
Brenkhäuser Str. 71
37671 Höxter
Phone: --
| Hospital hygienists (m/f) | 2 | Ein extern fortgebildeter Hygienebeauftragter Arzt pro Standort. Jede Fachabteilung verfügt über einen intern fortgebildeten hygienebeauftragten Abteilungsarzt (10 fortgebildete Ärzte). |
| Doctors’ hygiene officer | 1 | |
| Hygiene specialists | 2 | Die HFK versorgen alle 4 Standorte vom Standort Höxter aus. Eine weitere HFK in Ausbildung. |
| Hygiene officers in nursing care | 13 | Jeder Pflegebereich verfügt über eine intern fortgebildete hygienebeauftragte Pflegekraft (meist die Teamleitung). |
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 |
Indwelling vein catheter
| 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 |
Antibiotic therapy
| 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 |
Antibiotic prophylaxis
| 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 | Partly |
| 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
| 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 disinfection (ml / patient day)
| Hand disinfectant consumption in all intensive care units | 105,30 ml |
| Hand disinfectant consumption on all general stations | 31,60 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 Auswertungen werden regelmäßig der Hygienekommission vorgelegt.
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| HM03 |
Participation in other regional, national or international networks for the prevention of nosocomial infections Festlegungen im Rahmen des QM-Handbuches nach ISO 9001 im Bereich Hygiene Teilnahme am MRE-Netzwerk Nordwest mit Zertifizierung im Rahmen des internationalen Eurosafety Health-Net |
| HM04 |
Participation in the (voluntary) “Clean Hands Initiative” (CHI) Teilnahme (ohne Zertifikat) |
| HM05 |
Annual inspection of the preparation and sterilisation of medical devices Die Aufbereitung aller Instrumente und OP-Siebe erfolgt in einer nach ISO 13485 TÜV-zertifizierten Zenralsterilisationseinheit (ZSVA) am Standort Brakel. Zusätzlich wird die ZSVA jaährlich durch den Arzt für Krankenhaushygiene und die Hygienefachkräfte begangen. Regelmäßige Begehungen der Aufsichtsbehörden finden statt. Frequency : quartalsweise |
| HM09 |
Training of employees on hygiene-related topics Alle Mitarbeiter mit direkten Patientenkontakt werden jährlich geschult (Pflichtschulung). Frequency : jährlich |