Hygiene
Andreas Klamann
Chefarzt Klinik für Innere Medizin und Ärztlicher Direktor
Rudolf-Virchow-Str. 2
04552 Borna
Phone:
03433
-21-1701
Fax: 03433-21-1702
Mail:
ed.anas@nnamalk.saerdna
A hygiene officer has not been established
Hygiene commission established
Conference frequency: quartalsweise
Contact person
Andreas Klamann
Chefarzt Klinik für Innere Medizin und Ärztlicher Direktor
Rudolf-Virchow-Str. 2
04552 Borna
Phone:
03433
-21-1701
Fax: 03433-21-1702
Mail:
ed.anas@nnamalk.saerdna
| Hospital hygienists (m/f) | 1 | Dipl.-Med. Roswitha Tauchnitz-Hiemisch ; Fachärztin für Mikrobiologie und Infektionsepidemiologie; Krankenhaushygienikerin |
| Doctors’ hygiene officer | 15 | |
| Hygiene specialists | 3 | Diese Angaben beziehen sich auf die Standorte Borna und Zwenkau. |
| Hygiene officers in nursing care | 65 |
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 | 95,00 ml |
| Hand disinfectant consumption on all general stations | 25,30 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 |
|---|---|
| HM01 |
Publicly available reporting on infection rates Zahl der Keimnachweise pro 100 Patienten zu MRSA, VRE, 3-MRGN, 4- MRGN, CDI Fakten zur Händedesinfektion - Gesamtverbrauch, durchschnittlicher Verbrauch pro Patient täglich Antibiotikaverbrauch in RDD pro 100 Pflegetage Fachbegriffe der Hygiene verständlich erklärt |
| HM02 |
Participation in the Hospital Infection Surveillance System (HISS) of the National Reference Centre for Surveillance of Nosocomial Infections Seit bereits über 20 Jahren ist bekannt, dass die fortlaufende, systematische Erfassung, Analyse und Interpretation relevanter Daten zu nosokomialen Infektionen sowie deren Feedback an das ärztliche und pflegerische Personal die Häufigkeit nosokomialer Infektionen reduzieren kann. Diese Form der internen Qualitätssicherung wird als Surveillance bezeichnet. Eigene Daten zu Infektionshäufigkeiten werden mit denen anderer verglichen.
|
| HM03 |
Participation in other regional, national or international networks for the prevention of nosocomial infections Das MRE-Netzwerk Sachsen koordiniert und bündelt seit 2010 alle Anstrengungen, die darauf zielen, die Ausbreitung multiresistenter Erreger (MRE), insbesondere in Einrichtungen des Gesundheitswesens im Freistaat Sachsen, einzudämmen und zu verhindern. Teilnahme MRE- Netzwerk Sachsen (© Sächsisches Staatsministerium für Soziales und Verbraucherschutz) |
| HM04 |
Participation in the (voluntary) “Clean Hands Initiative” (CHI) monatliche Auswertungen in der Klinik Zertifikat Silber |
| HM05 |
Annual inspection of the preparation and sterilisation of medical devices jährlich Frequency : jährlich |
| HM09 |
Training of employees on hygiene-related topics Pflichtschulungen einmal jährlich für alle Mitarbeiter, Schulungen für neue Mitarbeiter, Situationsbezogene Schulungen fortlaufend, Schulungen im Rahmen der Sitzung der hygienebeaufragten Ärzte und Pflegepersonen Frequency : jährlich |