Hygiene

René Keller

Ärztlicher Direktor

Störtebekerstraße 6
23966 Wismar

Phone: 03841 -331338-
Mail: ed.anas@rellek.ener

A hygiene officer has not been established

Hygiene commission established
Conference frequency: halbjährlich

Contact person

René Keller

Ärztlicher Direktor

Störtebekerstraße 6
23966 Wismar

Phone: 03841 -331338-
Mail: ed.anas@rellek.ener

Hospital hygienists (m/f) 1 Pro Fachabteilung gibt es einen hygienebeauftragten Arzt. 8 von 14 haben den Grundkurs zum hygienebeauftragten Arzt erfolgreich absolviert. Durch Mitarbeiter-Fluktuation gehen trotz fortlaufender Fortbildung immer wieder Qualifikationen verloren.
Doctors’ hygiene officer 14
Hygiene specialists 2
Hygiene officers in nursing care 51 Es gibt jeweils einen Beauftragten und ggf. einen Vertreter pro Station/Funktionsabteilung. 31 Beauftragte haben den 40h Hygiene-Grundkurs erfolgreich absolviert. Eine weitere Ausbildung folgt voraussichtlich in 2024.
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 127,45 ml
Hand disinfectant consumption on all general stations 22,35 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
HM01

Publicly available reporting on infection rates

Auf der Homepage gibt es ein "Hygiene-Cockpit" mit der Veröffentlichung der hygienerelevanten Daten

http://www.sana-hanse-klinikum-wismar.de

HM02

Participation in the Hospital Infection Surveillance System (HISS) of the National Reference Centre for Surveillance of Nosocomial Infections

  • HAND-KISS
  • ITS-KISS
  • MRSA-KISS
  • OP-KISS
HM03

Participation in other regional, national or international networks for the prevention of nosocomial infections

Sana Erfassung hygienerelevanter Erreger. CDAD analog CDAD KISS Kriterien

KISS, BQS, Sana interne Erregererfassung

HM04

Participation in the (voluntary) “Clean Hands Initiative” (CHI)

i.R.d. Corona-Pandemie ist die ASH-Veranstaltung ausgefallen. Veranstaltungen wieder ab 2023.

Zertifikat Silber

HM05

Annual inspection of the preparation and sterilisation of medical devices

Wird durch das Landesamt für Gesundheit und Soziales MV jährlich durchgeführt. Zusätzlich erfolgt die Überprüfung in der jährlichen Validierung der Geräte in der AEMP und Endoskopie. Zusätzlich Hygienebegehungen in ZOP und ITS. Die behördliche Hygienebegehung konnte in 2022 wie geplant stattfinden.

Frequency : monatlich

HM09

Training of employees on hygiene-related topics

Jährliche Pflichtschulung zur Händehygiene für jeden Mitarbeiter. Pflichtschulung Hygieneersteinweisung für neue Mitarbeiter wird 6x/ Jahr angeboten (alle 2 Monate). Abteilungsbezogene Schulungen (fachspezifisch). Teamschulungen/- auswertungen nach Hygienehospitationen/-Beobachtungen. Anlassbezogene Schulungen z.B. im Rahmen des Ausbruchmanagements. Jährliche Schulung der Auszubildenden (aufgeteilt nach Lehrjahr)

Frequency : monatlich