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Städtisches Klinikum Karlsruhe gGmbH

Moltkestraße 90
76133 Karlsruhe

Phone: 0721-974-0
Fax: 0721-974-1009
Mail: ed.ehurslrak-mukinilk@gnurheufstfeahcseg

http://www.klinikum-karlsruhe.de

Basic information

Number of beds: 1.533
Number of specialist departments: 28

Number of inpatient cases: 51.131
Number of partial inpatient cases: 683
Number of outpatient cases: 191.585
Number of cases of inpatient-equivalent psychiatric treatment (StäB): 72

Hospital owners: Städtisches Klinikum Karlsruhe gGmbH
Type of provider: öffentlich

Academic teaching hospital

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law

Bezeichnung
Teilnahme externe Qualitätssicherung	yes
Bezeichnung
Teilnahme externe Qualitätssicherung	yes
Bezeichnung
Teilnahme externe Qualitätssicherung	yes

External quality assurance according to the DMP

Asthma bronchiale

Implementation of the minimum quantity agreement

Treatment area

Complex interventions on the organ system esophagus for adults

Quantity performed	9
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	30
Exception?	No exception

Stem cell transplant

Quantity performed	57
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	71
Exception?	No exception
Coronapandemie, Einschränkung der elektiven Operationen in 2021

Care of premature and mature infants (with an admission weight < 1250g)

Quantity performed	30
Exception?	No exception

Minimum quantities forecast

Complex interventions on the organ system esophagus for adults

Overall result forecast presentation:	Pending lawsuit
Quantity performed reporting year:	9
Quantity forecast year:	8
Examination by state associations?	Pending lawsuit
Exemption?	yes
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Complex operations on the pancreatic organ system

Overall result forecast presentation:	yes
Quantity performed reporting year:	30
Quantity forecast year:	24
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Stem cell transplant

Overall result forecast presentation:	yes
Quantity performed reporting year:	57
Quantity forecast year:	58
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Knee joint total endoprostheses

Overall result forecast presentation:	yes
Quantity performed reporting year:	71
Quantity forecast year:	102
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Care of premature and mature infants (with an admission weight < 1250g)

Overall result forecast presentation:	yes
Quantity performed reporting year:	30
Quantity forecast year:	35
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Surgical treatment of breast cancer (mamma surgery)

Overall result forecast presentation:	yes
Quantity performed reporting year:	319
Quantity forecast year:	329
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Thoracic surgical treatment of lung cancer in adults

Overall result forecast presentation:	no
Quantity performed reporting year:	6
Quantity forecast year:	5
Examination by state associations?	no
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Implementation of resolutions of the Federal Joint Committee on quality assurance (G-BA)

No.	Explanation
CQ01	Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm
CQ02	Quality assurance measures for the inpatient care of children and adolescents with haemato-oncological diseases
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
CQ30	Quality assurance guideline for interstitial LDR brachytherapy for low-risk localized prostate cancer (effective January 8, 2021).
CQ24	Quality assurance measures for allogeneic stem cell transplantation for multiple myeloma (valid until 30 June 2022)
CQ25	Measures for quality assurance in the performance of minimally invasive heart valve interventions pursuant to Article 136, para. 1, sentence 1, number 2 for hospitals licensed in accordance with Article 108 of the SGB V
CQ27	Guideline on quality assurance measures for inpatient care with bronchoscopic lung volume reduction procedures for severe emphysema (QS Guideline bronchoscopic LVR /QS-RL BLVR)

Compliance with staffing requirements

Clarifying chat completed: no
Clarifying chat not completed: no
No participation in clarifying chat: no
Notification of non-fulfilment of nursing care not made: yes

Further training
pursuant to Article 136b, para. 1, sentence 1, no. 1 of the SGB

Number	Group
438	Medical specialists (m/f) , psychological psychotherapists (m/f) and child and adolescent psychotherapists (m/f) who are subject to the obligation to undergo further training*
246	Number of medical specialists (m/f) from no. 1 who have completed a five-year period of further training and are therefore subject to the obligation to provide evidence
244	Number of those persons from no. 2 who have provided proof of further training according to Article 3 of the G-BA regulations

* according to the “Provisions of the Joint Federal Committee for the Further Training of Medical Specialists (m/f), Psychological Psychotherapists (m/f) and Child and Adolescent Psychotherapists (m/f) in Hospitals”

General information

Protection concept against (sexual) violence against children and young people

Advice on prevention and intervention in cases of violence and abuse

According to Section 4 (2) of the Quality Management Guideline, facilities must provide for the prevention of and intervention in cases of violence and abuse as part of their internal quality management. The aim is to prevent, recognise and respond appropriately to abuse and violence, particularly against vulnerable patient groups such as children and adolescents or people in need of help, and also to prevent it within the facility. The respective procedure is aligned with the size of the facility, the range of services and the patients in order to define customised solutions for sensitising the teams as well as other suitable preventative and interventional measures. These may include information materials, contact addresses, training/education, codes of conduct, recommendations for action/intervention plans or comprehensive protection concepts.

Is a protection concept in place? Yes
Measures
- Prevention
  Information gathering on the topic
  Note on the measure
  -Regelmäßige Teilnahme des Kinderschutzteams an den regionalen Arbeitskreisen zum Thema mit dem Ziel der Informationsgewinnung und regionalen Vernetzung
  -Regelmäßige Kooperationstreffen in der Kinderklinik mit den betreffenden Beratungsstellen Stadt und Land KA
  -Aushänge in Form von Plakaten in den Wartebereichen und auf den Stationen
  -Austeilen/Auslegen von Flyern
  Training of employees
  Note on the measure
  - SOP Leitfaden Kinderschutz
  - Wiederkehrende Vorstellung des Leitfadens Kinderschutz im Rahmen der internen Ärztefortbildung
  - Fallvorstellungen im Rahmen der internen Fortbildung
  - Vermittlung / Information von relevanten Fortbildungen oder E-Learning-Angeboten
  - Anleitung der Mitarbeitenden im konkreten Fall durch das Kinderschutzteam
  - Erfahrene Mitarbeiter*innen coachen neue Kolleg*innen im Rahmen der Notaufnahme/Stationsarbeit
  - Gemeinsame Fallkonferenzen auf Station
  Education
  Note on the measure
  - Immer Einbezug des Kinderschutzteams oder zu Beginn niedrigschwellig des Psychosozialen Teams
  - Immer im Einzelgespräch mit den Jugendlichen, alterspassend mit Kindern konkrete Nachfragen zum Thema (Öffnungsangebote)
  Code of conduct with rules for treating children and young people with respect
  Last review of the measure
  17.06.2021 16:54:54
  Age-appropriate complaint options
  Note on the measure
  - Beachten der in der Kinderschutzleitlinie geforderten Partizipation von Kindern und Jugendlichen (Gespräche suchen und anbieten, Lösungswege gemeinsam finden, aktiv zuhören, Situation erklären (altersgerechte Transparenz), Versprechungen einhalten
  - Vermittlung von Hilfsangeboten
  Special requirements for the selection of persons
  Note on the measure
  - Erweitertes Führungszeugnis erforderlich
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  - SOP / Leitfaden Kinderschutz der Kliniken für KiJu-medizin und –chirurgie (aktuell in Überarbeitung, heißt derzeit noch Leitfaden Gewalt)
  - Etabliertes Kinderschutzteam, inkl. eines Kinderschutzmediziners, weitere Personen werden die Ausbildung 2024 absolvieren (fest geplant)
  - Verbindlichkeit der LL Kinderschutz in der Medizin
  - Regelmäßige Schulungen zur SOP intern
  
  Last review of the measure
  17.06.2021 16:54:54
- Review
  Other information on recognition
  Note on the measure
  - gemäß § 4 Abs. 4 KKG (Beratung und Übermittlung von Informationen durch Berufsgeheimnisträger bei Kindeswohlgefährdung) bitten wir die Jugendämter im Verlauf um Klärung und Rückmeldung zu den gemeldeten Fällen
  - zum Teil Nachbesprechen einzelner Fälle, ggf. auch mit externen Partnern (Labor, Rechtsmedizin, Jugendamt, …)
  - interne Fallkonferenzen

-Regelmäßige Teilnahme des Kinderschutzteams an den regionalen Arbeitskreisen zum Thema mit dem Ziel der Informationsgewinnung und regionalen Vernetzung -Regelmäßige Kooperationstreffen in der Kinderklinik mit den betreffenden Beratungsstellen Stadt und Land KA -Aushänge in Form von Plakaten in den Wartebereichen und auf den Stationen -Austeilen/Auslegen von Flyern

Commentary on the protection concept

Gemäß § 4 Absatz 2 in Verbindung mit Teil B Abschnitt I § 1 der Qualitätsmanagement-Richtlinie haben sich Einrichtungen, die Kinder und Jugendliche versorgen, gezielt mit der Prävention von und Intervention bei (sexueller) Gewalt und Missbrauch bei Kindern und Jugendlichen zu befassen (Risiko- und Gefährdungsanalyse) und – der Größe und Organisationsform der Einrichtung entsprechend – konkrete Schritte und Maßnahmen abzuleiten (Schutzkonzept). In diesem Abschnitt geben Krankenhäuser, die Kinder und Jugendliche versorgen, an, ob sie gemäß § 4 Absatz 2 in Verbindung mit Teil B Abschnitt I § 1 der Qualitätsmanagement-Richtlinie ein Schutzkonzept gegen (sexuelle) Gewalt bei Kindern und Jugendlichen aufweisen.

Drug therapy safety

Steering committee

Drug commission

Training of employees on AMTS related topics

Availability of appropriate, topic-specific informational materials for patients on AMTS e.g. for chronic diseases, for high-risk drugs, for children

Electronic support for the admission and anamnesis process (e.g. import of patient master data or medication plans, use of a drug knowledge database, input screen for drugs or anamnesis information)

Process description for an optimal medication process (e.g. drug anamnesis – prescription – patient information – drug delivery – drug application – documentation – therapy monitoring – result evaluation)

Zentrales elektronisches Qualitäts- u. Organisationshandbuch und zusätzlich Datenbank zum Risikomeldesystem.

15.09.2021

SOP on good prescription practices

Zentrales elektronisches Qualitäts- u. Organisationshandbuch und zusätzlich Datenbank zum Risikomeldesystem.

15.09.2021

Possibility of electronic prescription i.e. structured entry of active substances (or name of the preparation), form, dose, dose frequency (e.g. in the HIS, in prescription software)

Provision of one or more electronic drug information systems (e.g. Lauer-Taxe®, ifap klinikCenter®, Gelbe Liste®, Fachinfo-Service®)

Concepts for ensuring the error-free preparation of medications

Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
Zubereitung durch pharmazeutisches Personal
Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
Plausibilitätsprüfung durch Apotheker vor Zubereitung
Herstellung nach Vier-Augen-Prinzip
Verwendung von Herstellungsanweisungen
Herstellungsprotokolle inkl. Inprozesskontrollen
Freigabe der Zubereitung durch den Apotheker vor der Abgabe

Electronic support for the supply of patients with drugs

Vorhandensein von elektronischen Systemen zur Entscheidungsunterstützung (z.B. Meona®, Rpdoc®, AIDKlinik®, ID Medics® bzw. ID Diacos® Pharma)

Electronic documentation of the administration of drugs

Measures to minimise medication errors

Maßnahmen zur Vermeidung von Arzneimittelverwechslung
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)

Measures to ensure seamless drug therapy after discharge

Aushändigung des Medikationsplans
bei Bedarf Arzneimittel-Mitgabe oder Ausstellung von Entlassrezepten

Instruments and measures

The instruments and measures to promote drug therapy safety are presented with a focus on the typical procedures of the medication process in inpatient patient care. A special feature of the medication process in the inpatient environment is the transition management during admission and discharge. The instruments and measures listed below address structural elements, e.g. special IT equipment and work materials, as well as process aspects, such as work descriptions for particularly risky process steps or concepts for securing typical risk situations . In addition, proven measures to avoid or learn from medication errors can be specified. The hospital presents here which aspects it has already dealt with and which measures it has specifically implemented. The following aspects can be presented, if necessary using free text fields:
- Admission to hospital, including anamnesis
; Instruments and measures are presented for determining the old medication (drug history), the subsequent clinical assessment and the switch to the medication available in the hospital (house list), as well as for documenting both the patient's original medication and that for hospital treatment adapted medication.
- Medication process in the hospital
In this context, the following sub-processes are assumed as examples: drug history - prescription - patient information - drug delivery - drug use - documentation - therapy monitoring - result assessment. Instruments and measures for safe medication prescription can be presented, e.g. B. in terms of readability, clarity and completeness of the documentation, but also in terms of area of application, effectiveness, benefit-risk ratio, tolerability (including potential contraindications, interactions, etc.) and resource considerations. Information can also be provided to support reliable medication ordering, delivery and use or administration.
- Discharge
In particular, the measures taken by hospitals can be presented to ensure that information on drug therapy is structured and passed on to doctors and physicians providing further treatment, as well as the appropriate provision of patients with drug information, medication plans and medications. Drug prescriptions are made.

AMTS is the totality of measures to ensure an optimal medication process with the aim of reducing medication errors and thus avoidable risks for patients during drug therapy. A prerequisite for the successful implementation of these measures is that AMTS is practised as an integral part of daily routine in an interdisciplinary and multi-professional approach.