Hygiene
A hygiene officer has not been established
Hygiene commission established
Conference frequency: quartalsweise
Contact person
| Doctors’ hygiene officer | 1 | |
| Hygiene specialists | 1 | |
| Hygiene officers in nursing care | 2 |
No CVC (central venous catheter) inserted
Antibiotic therapy
| A site-specific guideline on antibiotic therapy is available | No |
| The standard was authorised by management or the hygiene commission | No |
| The guideline is adapted to the current local/internal resistance situation | No |
Antibiotic prophylaxis
| A site-specific standard for perioperative antibiotic therapy is available | No |
| The standard was authorised by management or the hygiene commission | No |
| 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) | No |
| Indication for antibiotic prophylaxis | {0}Yes|{1}No|{2}Partly |
| Antibiotics to be used (taking into account the expected germ spectrum and the local/regional resistance situation) | {0}Yes|{1}No|{2}Partly |
| Time/duration of antibiotic prophylaxis | {0}Yes|{1}No|{2}Partly |
Default wound care dressing change
| Default wound care dressing change is available | Nein |
| The internal standard has been authorised by management or the Drug Commission or the Hygiene Commission | No |
| Hygienic hand disinfection (before, if necessary during and after dressing changes) | {0}Yes|{1}No|{2}Partly |
| Dressing changes under aseptic conditions (application of aseptic working techniques, no-touch technique, sterile disposable gloves) | {0}Yes|{1}No|{2}Partly |
| Antiseptic treatment of infected wounds | {0}Yes|{1}No|{2}Partly |
| Checking the further necessity of a sterile wound dressing | {0}Yes|{1}No|{2}Partly |
| Doctor notification and documentation if a postoperative wound infection is suspected | {0}Yes|{1}No|{2}Partly |
Hand disinfection (ml / patient day)
| Hand disinfectant consumption in all intensive care units | non-existant |
| Hand disinfectant consumption on all general stations | 70,30 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. | no |
| 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 |
|---|---|
| HM05 |
Annual inspection of the preparation and sterilisation of medical devices |
| HM09 |
Training of employees on hygiene-related topics |