Jan-Peter Linke
Ärztlicher Direktor
Phone:
06721
-907-0
Fax: 06721-907-121
Mail:
ed.suahneiram@eknil.retep-naj
Roland Strasheim
Geschäftsführer
Phone:
06721
-907-120
Fax: 06721-907-121
Mail:
ed.suahneiram@miehsarts.dnalor
A hygiene officer has not been established
Hygiene commission established
Conference frequency: andere Frequenz
Roland Strasheim
Geschäftsführer
Phone:
06721
-907-120
Fax: 06721-907-121
Mail:
ed.suahneiram@miehsarts.dnalor
Hospital hygienists (m/f) | 1 | |
Doctors’ hygiene officer | 4 | |
Hygiene specialists | 2 | |
Hygiene officers in nursing care | 11 |
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 |
Sterile gloves | Yes |
Sterile gown | Yes |
Head hood | Yes |
Mouth and nose protection | Yes |
Sterile drape | Yes |
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 |
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 |
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 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 disinfectant consumption in all intensive care units | 84,75 ml |
Hand disinfectant consumption on all general stations | 44,45 ml |
Hand disinfectant consumption is recorded on a ward-specific basis. | Yes |
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 Zusätzliche Teilnahme am WEA-KISS, ITS-KISS sowie MRE- und Antibiotikaverbrauchs-Surveillance
|
HM03 |
Participation in other regional, national or international networks for the prevention of nosocomial infections MRE Netzwerk Rhein-Nahe |
HM04 |
Participation in the (voluntary) “Clean Hands Initiative” (CHI) Silber Zertifikat für 2021 / 2022 verliehen am 07.10.2021 Gold-Zertifikat für 2022 / 2023 verliehen am 22.09.2022 Zertifikat Gold |
HM05 |
Annual inspection of the preparation and sterilisation of medical devices QM-Handbuch ZSVA, Zusatzqualifikation des Personals, Validierung der Sterilisatoren und Reinigungs-und Desinfektionsautomaten Frequency : jährlich |
HM09 |
Training of employees on hygiene-related topics Jährliche Schulungen zu hygienebezogenen Themen, bei Bedarf auch berufsgruppen- und abteilungsbezogen Frequency : jährlich |