Hygiene
Christoph Raspe
Stv. Ärztlicher Direktor
90744 Fürth
Phone:
0911
-7580-1003
Fax: 0911-7580-1891
Mail:
ed.htreuf-mukinilk@eneigyh
A hygiene officer has not been established
Hygiene commission established
Conference frequency: quartalsweise
Contact person
Christoph Raspé
Stv. Ärztlicher Direktor
90744 Fürth
Phone:
0911
-7580-1281
Fax: 0911-7580-1490
Mail:
ed.htreuf-mukinilk@eneigyh
| Hospital hygienists (m/f) | 2 | In jeder Fachabteilung stehen speziell qualifizierte hygienebeauftragte Ärzte zur Verfügung und überwachen die Einhaltung unserer hohen Hygienestandards. |
| Doctors’ hygiene officer | 16 | |
| Hygiene specialists | 5 | In der Abteilung für Krankenhaushygiene arbeiten Hygienefachkräfte, hygienebeauftragte Ärzte und mikrobiologische Laboratorien eng zusammen. Zusätzlich findet eine Beratung durch einen Facharzt für Krankenhaushygiene statt. |
| Hygiene officers in nursing care | 34 | In jeder Fachabteilung stehen speziell qualifizierte hygienebeauftragte Pflegekräfte zur Verfügung und überwachen die Einhaltung unserer hohen Hygienestandards. |
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 | 236,00 ml |
| Hand disinfectant consumption on all general stations | 58,00 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 Die Daten werden durch entsprechend geschultes Personal gemeinsam mit den Mitarbeitern aus der Hygieneabteilung strukturiert erhoben und ausgewertet. Die Ergebnisse werden den Abteilungen zur Verfügung gestellt und sind Gegenstand der Hygienekommissionssitzung.
|
| HM03 |
Participation in other regional, national or international networks for the prevention of nosocomial infections MRSA Netzwerk |
| HM04 |
Participation in the (voluntary) “Clean Hands Initiative” (CHI) Freiwillige Teilnahme an der "Aktion Saubere Hände" ist am Klinikum selbstverständlich. In jährlich stattfindenden öffentlichen Veranstaltungen werden Mitarbeiter, aber auch Besucher und Patienten zu dem Thema Hygiene sensiblisiert und aufgeklärt. Zertifikat Silber |
| HM05 |
Annual inspection of the preparation and sterilisation of medical devices Strukturierte und valide Aufbereitung und Sterilisation von Medizinprodukten wird in enger Zusammenarbeit mit der Hygieneabteilung und allen kooptierten Abteilungen und Behörden stets nachgehalten und überprüft. |
| HM09 |
Training of employees on hygiene-related topics Besonders geschulte Hygienebeauftragte Mitarbeiter sind in allen relevanten Bereichen vorhanden. Diese tauschen sich mit der Hygieneabteilung des Klinikums aus und arbeiten eng mit dieser zusammen. Basis- und Erhaltungsqualifikationen werden strukturiert angeboten. |