Hygiene
A hygiene officer has not been established
Hygiene commission established
Conference frequency: halbjährlich
Contact person
Peter Lierz
Ärztlicher Direktor
59494 Soest
Phone:
02921
-391-2450
Fax: 02921-391-2549
Mail:
ed.dnubrevlatipsoh@zreil.p
| Hospital hygienists (m/f) | 1 | Hygienebeauftragte Ärzte aus folgenden Fachrichtungen sind benannt: Anästhesie/Intensivmedizin, Thoraxchirurgie, Innere Medizin/Pulmologie, Zentrale Notaufnahme (ab 11/24). |
| Doctors’ hygiene officer | 4 | |
| Hygiene specialists | 3 | Eine Mitarbeiterin besitzt die abgeschlossene Weiterbildung. Eine weitere hat die Weiterbildung in 09/24 abgeschlossen und eine befindet sich in Weiterbildung. |
| Hygiene officers in nursing care | 20 | Im Rahmen von Weiterbildungsentwicklungen konnte das Marienkrankenhaus Soest/ CKSM Hygienebeauftragte für die Pflege und Funktionsbereiche weiterbilden und in den verschiedenen Bereichen einsetzen. Auf jeder Station / in jedem Funktionsbereich ist mindestens eine hygienebeauftragte Pflegekraft benannt. |
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 | 171,00 ml |
| Hand disinfectant consumption on all general stations | 26,30 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. | 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 Weitere Erfassung: ITS-MRE KISS
|
| HM03 |
Participation in other regional, national or international networks for the prevention of nosocomial infections In 2024 haben 3 Treffen stattgefunden. MRE Netzwerk Kreis Soest/ Regionalkonferenz |
| HM04 |
Participation in the (voluntary) “Clean Hands Initiative” (CHI) Teilnahme (ohne Zertifikat) |
| HM05 |
Annual inspection of the preparation and sterilisation of medical devices Überprüfung der Validierungsberichte durch die Hygienefachkräfte und Durchführung einer standardisierten Hygienevisite |
| HM09 |
Training of employees on hygiene-related topics Im Rahmen der jährlichen Pflichtfortbildung für jeden Mitarbeiter 1 x pro Jahr per thinkific.com TV-Hygiene Schulung, nach Vorgabe der HygMedVO und des IfSG sowie bedarfsadaptiert mit wechselnden hygienerelevanten Themen durch die Hygienefachkräfte und den Krankenhaushygieniker |