Hygiene
Hygiene commission established
Conference frequency: halbjährlich
Contact person
| Hospital hygienists (m/f) | 2 | in jeder bettenführenden Abteilung ist i. d. R. ein Hygienebeauftragter Arzt schriftlich ernannt |
| Doctors’ hygiene officer | 14 | |
| Hygiene specialists | 4 | |
| Hygiene officers in nursing care | 48 | in jeder Station/Funktionsbereich sind i. d. R. 1 oder mehrere Hygienebeauftragte in Pflege- und Funktionsdienst schriftlich ernannt. Regelmäßige Fortbildungskurse nach Curriculum BKG/DGKH finden inhouse statt. |
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 | 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
| 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 | 156,50 ml |
| Hand disinfectant consumption on all general stations | 48,80 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 Umsetzung der NRZ-KISS Module (angemeldet oder hausinterne Umsetzung): Darüber hinaus selbst entwickelte Module MRGN-KISS, VRE-KISS, GE-KISS, DEVICE-KISS (Punkt-Prävalenz-Erhebung), EuroPPS
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| HM03 |
Participation in other regional, national or international networks for the prevention of nosocomial infections Mitgliedschaften: Society for Healthcare Epidemiology of America (SHEA), Healthcare Infection Society (HIS), Dt. Ges. für Hygiene und Mikrobiologie (DGHM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID); Teilnehmer der Aktion Saubere Hände (ASH); MRE-Netzwerk Neumarkt |
| HM04 |
Participation in the (voluntary) “Clean Hands Initiative” (CHI) Goldzertifikat durchgehend seit 2016; Teilnahme seit 2009 Zertifikat Gold |
| HM05 |
Annual inspection of the preparation and sterilisation of medical devices fortlaufende Wartung und Validierung von RDG's und Sterilisatoren. Routinemäßiger Maßnahmen zur Qualitätssicherung durch ZSVA Frequency : jährlich |
| HM09 |
Training of employees on hygiene-related topics ein detailliertes Schulungskonzept und Schulungspräsentationen stehen zur Verfügung, Schulungsveranstaltungen zu Spezialthemen z. B. Händehygiene und MRE; Online-Schulungen im Hauseigenen Intranet Frequency : jährlich |