Hygiene
Christian A. Jantos
Chefarzt des Instituts für Laboratoriumsmedizin, Mikrobiologie und Hygiene
Phone:
0521
-772-79201
Fax: 0521-772-79202
Mail:
ed.bkve@sotnaj.naitsirhc
A hygiene officer has not been established
Hygiene commission established
Conference frequency: andere Frequenz
Contact person
Christian A. Jantos
Chefarzt des Instituts für Laboratoriumsmedizin, Mikrobiologie und Hygiene
Phone:
0521
-772-79201
Fax: 0521-772-79202
Mail:
ed.bkve@sotnaj.naitsirhc
| Hospital hygienists (m/f) | 2 | Das EvKB mit den Standorten Bethel und Johannesstift und das Krankenhaus Mara werden durch zwei gemeinsame Krankenhaushygienikerin (Fachärztin für Medizinische Mikrobiologie) betreut. |
| Doctors’ hygiene officer | 14 | |
| Hygiene specialists | 3 | |
| Hygiene officers in nursing care | 64 | Die Qualifikation zur Hygienebeauftragten Pflegekraft finden in einem hauseigenen Kurs statt. Dieser umfasst 40 Unterrichtsstunden und wird in zwei Blockveranstaltungen durchgeführt. Es werden krankenhausspezifische Themen unter aktuellen Aspekten praxisbezogen dargestellt. Die Qualifikationsmaßnahmen schließen mit einem schriftlichen Lernerfolgsnachweis in Form einer Klausur an einem separaten Prüfungstag ab. Die Schulungen werden von der hauseigenen Krankenhaushygiene durchgeführt. |
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 | 176,00 ml |
| Hand disinfectant consumption on all general stations | 45,00 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 |
|---|---|
| HM01 |
Publicly available reporting on infection rates Über die Abteilung Krankenhaushygiene jederzeit möglich. http://www.evkb.de/kliniken-zentren/diagnostik/laboratoriumsmedizin-mikrobiologie-und-hygiene |
| HM02 |
Participation in the Hospital Infection Surveillance System (HISS) of the National Reference Centre for Surveillance of Nosocomial Infections Das EvKB und das Krankenhaus Mara nehmen jeweils hausweit am MRSA-KISS, CDAD-KISS und HAND-KISS teil; die Neonatologie in Gilead beteiligt sich an NEO-KISS; am Johannesstift beteiligt sich die Onkologie am Stations-KISS.
|
| HM03 |
Participation in other regional, national or international networks for the prevention of nosocomial infections Das EvKB und das Krankenhaus Mara gehören dem MRE-Netzwerk OWL an. 2012 wurde das MRE-Siegel erstmals erhalten und 2015 bestätigt. MRE-Netzwerk OWL, ARS-RKI |
| HM04 |
Participation in the (voluntary) “Clean Hands Initiative” (CHI) Das EvKB und das Krankenhaus Mara (seit 2009) beteiligen sich seit 2010 an der ASH. Zertifikat Gold |
| HM05 |
Annual inspection of the preparation and sterilisation of medical devices Über die Bezirksregierung alle 2 Jahre und regelhaftes TÜV-Audit |
| HM09 |
Training of employees on hygiene-related topics Schulungen zu hygienebezogenen Themen gehören zum Pflichtschulungsrepertoire für Mitarbeitende. Für weitere Präsenzschulungen stehen ganzjährig verschiedene Schulungsmodule zur Verfügung. Die Schulungen werden von der hauseigenen Krankenhaushygiene durchgeführt. Seit 2019 Online. |