Overall result forecast presentation:	yes
Quantity performed reporting year:	6
Quantity forecast year:	0
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Care of premature and mature infants (with an admission weight < 1250g)

Overall result forecast presentation:	yes
Quantity performed reporting year:	60
Quantity forecast year:	58
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Implementation of resolutions of the Federal Joint Committee on quality assurance (G-BA)

No.	Explanation
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1

Compliance with staffing requirements

Clarifying chat completed: no
Clarifying chat not completed: no
No participation in clarifying chat: no
Notification of non-fulfilment of nursing care not made: yes

Management of quality assurance for proximal femoral fracturet (QSFFx)

Full record of compliance maintained

Number of days shown	366
Days of non-performance	0
Number of minimum requirements not met	0

General minimum requirements

Minimum requirement	Days of non-performance
Trauma room	0
Availability	0
Computed tomography (CT)	0
Intensive care beds	0
Department of Surgery	0
Forwarding by air	0
Department of Internal Medicine	0
Intensive care beds with ventilator facilities	0
Emergency care training courses	0
Treatment prioritisation system (triage)	0
Responsibility for emergency care	0

Specific minimum requirements

Minimum requirement	Days of non-performance
Doctor on duty	0
Supervision by a medical specialist	0
Geriatric expertise	0
Operating room equipment	0
Post-operative physiotherapy	0
Independent organisational unit	0

Minimum requirements for process quality

Minimum requirement	Days of non-performance
SOP: Surgical procedures	0
SOP: Perioperative Planning	0
SOP: Capacity to consent	0
Standard Operating Procedure for the Management of Anticoagulants	0
SOP: Ortho-geriatric Care	0
SOP: Physiotherapy Measures	0
SOP: Patient-centred blood management	0

Further training
pursuant to Article 136b, para. 1, sentence 1, no. 1 of the SGB

Number	Group
134	Medical specialists (m/f) , psychological psychotherapists (m/f) and child and adolescent psychotherapists (m/f) who are subject to the obligation to undergo further training*
74	Number of medical specialists (m/f) from no. 1 who have completed a five-year period of further training and are therefore subject to the obligation to provide evidence
58	Number of those persons from no. 2 who have provided proof of further training according to Article 3 of the G-BA regulations

* according to the “Provisions of the Joint Federal Committee for the Further Training of Medical Specialists (m/f), Psychological Psychotherapists (m/f) and Child and Adolescent Psychotherapists (m/f) in Hospitals”

General information

Protection concept against (sexual) violence against children and young people

Advice on prevention and intervention in cases of violence and abuse

According to Section 4 (2) of the Quality Management Guideline, facilities must provide for the prevention of and intervention in cases of violence and abuse as part of their internal quality management. The aim is to prevent, recognise and respond appropriately to abuse and violence, particularly against vulnerable patient groups such as children and adolescents or people in need of help, and also to prevent it within the facility. The respective procedure is aligned with the size of the facility, the range of services and the patients in order to define customised solutions for sensitising the teams as well as other suitable preventative and interventional measures. These may include information materials, contact addresses, training/education, codes of conduct, recommendations for action/intervention plans or comprehensive protection concepts.

Is a protection concept in place? Yes
Measures
- Prevention
  
  Training of employees
  
  Education

Commentary on the protection concept

Gemäß Teil A § 4 Absatz 2 in Verbindung mit Teil B Abschnitt I § 1 der Qualitätsmanagement-Richtlinie haben sich Einrichtungen, die Kinder und Jugendliche versorgen, gezielt mit der Prävention von und Intervention bei (sexueller) Gewalt und Missbrauch bei Kindern und Jugendlichen zu befassen (Risiko- und Gefährdungsanalyse) und – der Größe und Organisationsform der Einrichtung entsprechend – konkrete Schritte und Maßnahmen abzuleiten (Schutzkonzept). In diesem Abschnitt geben Krankenhäuser, die Kinder und Jugendliche versorgen, an, ob sie gemäß Teil A § 4 Absatz 2 in Verbindung mit Teil B Abschnitt I § 1 der Qualitätsmanagement-Richtlinie ein Schutzkonzept gegen (sexuelle) Gewalt bei Kindern und Jugendlichen aufweisen.

Drug therapy safety

Steering committee

Drug commission

Process description for an optimal medication process (e.g. drug anamnesis – prescription – patient information – drug delivery – drug application – documentation – therapy monitoring – result evaluation)

VA "Umgang mit Medikamenten, Infusionen und BtM"

15.12.2024

Provision of one or more electronic drug information systems (e.g. Lauer-Taxe®, ifap klinikCenter®, Gelbe Liste®, Fachinfo-Service®)

Measures to ensure seamless drug therapy after discharge

Aushändigung von arzneimittelbezogenen Informationen für die Weiterbehandlung und Anschlussversorgung der Patientin oder des Patienten im Rahmen eines (ggf. vorläufigen) Entlassbriefs
Aushändigung von Patienteninformationen zur Umsetzung von Therapieempfehlungen
bei Bedarf Arzneimittel-Mitgabe oder Ausstellung von Entlassrezepten

Instruments and measures

The instruments and measures to promote drug therapy safety are presented with a focus on the typical procedures of the medication process in inpatient patient care. A special feature of the medication process in the inpatient environment is the transition management during admission and discharge. The instruments and measures listed below address structural elements, e.g. special IT equipment and work materials, as well as process aspects, such as work descriptions for particularly risky process steps or concepts for securing typical risk situations . In addition, proven measures to avoid or learn from medication errors can be specified. The hospital presents here which aspects it has already dealt with and which measures it has specifically implemented. The following aspects can be presented, if necessary using free text fields:
- Admission to hospital, including anamnesis
; Instruments and measures are presented for determining the old medication (drug history), the subsequent clinical assessment and the switch to the medication available in the hospital (house list), as well as for documenting both the patient's original medication and that for hospital treatment adapted medication.
- Medication process in the hospital
In this context, the following sub-processes are assumed as examples: drug history - prescription - patient information - drug delivery - drug use - documentation - therapy monitoring - result assessment. Instruments and measures for safe medication prescription can be presented, e.g. B. in terms of readability, clarity and completeness of the documentation, but also in terms of area of application, effectiveness, benefit-risk ratio, tolerability (including potential contraindications, interactions, etc.) and resource considerations. Information can also be provided to support reliable medication ordering, delivery and use or administration.
- Discharge
In particular, the measures taken by hospitals can be presented to ensure that information on drug therapy is structured and passed on to doctors and physicians providing further treatment, as well as the appropriate provision of patients with drug information, medication plans and medications. Drug prescriptions are made.

AMTS is the totality of measures to ensure an optimal medication process with the aim of reducing medication errors and thus avoidable risks for patients during drug therapy. A prerequisite for the successful implementation of these measures is that AMTS is practised as an integral part of daily routine in an interdisciplinary and multi-professional approach.

Special instrument-based equipment

Research & teaching

Job

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

Prof. Nacimiento i. R. seiner APL-Professur an der RWTH Aachen und Prof. K. Moussazadeh i. R. seiner Honorarprof. an der Fliedner FHS Düsseldorf; Dr. Schröer: FFH

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Akad.Lehrkrankh. Uni DU-E; Lehrbeauftt.: Prof.Nacimiento, Prof.Schmidt, (RuhrUni BO); Dr.Bentgens; Dr.Schröer: 1-Tages Praktika für Stud. der UDE (Geriatrie) MHH: Uni. Düsseldorf: Prof.Rosenbaum; RuhrUni BO-Wahl-Kurs Mikrochir.-Prof. Scholz;

FL07 - Initiation and management of uni-centric/multi-centric clinical/scientific studies

Explanation

FL08 - Editors of scientific journals/textbooks

Explanation

Herausgeber bzw. Autor wissenschaftl. Artikel in Fachb. u.–zeitschriften (Rosenbaum/Feldkamp/Rech/Ackermann); Lehrb.„Rückenmarkerkrankungen“ Kohlh.-Verlag (Prof.Dr.Nacimiento),Editorial Board Head and Neck Surgery (Prof.Dr.Scholz)

FL06 - Participation in multi-centre phase III/IV studies

Explanation

TIGER-Studie

FL09 - Doctoral supervision

Explanation

Neurochirurgisch: Regelmäßig für die Ruhr-Universität Bochum und weitere Fachabteilungen auf Anfrage

FL04 - Project-related cooperation with colleges and universities

Explanation

Prof.Scholz-Koop. mit Lehrst. für Informatik FH Köln/Gummersb. Prof.Konen,Koop. Uni Alexandria;Koop. Fraunhofer Inst. Duisb;Proj.ltg ESPED(Dr. Brevis);Koop. mit Neurorad. MHH. Koop. bundesweit/Internat. i.R. endovask. Therapie von Säuglingen u. Kindern.

FL05 - Participation in multi-centre Phase I/II studies

Explanation

Neuroonkologisch: Glovaxx-Studie

FL03 - Student training (clinical traineeship / internship year)

Explanation

Durch die Chefärzte der Kliniken bestehen Weiterbildungsbefugnisse der Ärztekammer Nordrhein für fast alle Fachbereiche des Klinikum Duisburg;

Training

Training in other healing professions

HB17 - Auxiliary nurse (m/f)

Comment

HB15 - Anaesthesia technical assistant (m/f)

Comment

Praktischer Teil

HB19 - Nursing professionals

Comment

Vollzeitausbildg. (3 J.) + neu Teilzeitausbildg. Diese dauert 4 J. Unterricht in der Pflegeschule von 8.00 bis 13.00; 2 Modelle zur Arbeitszeitgestaltung - M 1: ungekürzte Dienste + mehr freie Tage; M 2: gekürzte Dienste + mehr freie Zeit am Tag. Vergütung entspricht 75% der norm. Vergtg. über 4 J.

HB01 - Nurse and health care worker (m/f)

Comment

Ausbildung: 2 x jährlich, seit 2024 auch in Teilzeit/Durch die Kooperation mit der TVA können exam. Gesundheits-u. Kinder/Krankenpfleger/Innen mit Berufserfahrung eine 2 jährige berufsbegleitende Weiterbildung in der Erwachsenen- und/oder Pädiatrischen Intensiv-und Anästhesiepflege absolvieren.

HB02 - Health and paediatric nurse (m/f)

Comment

Das KDU bildet 2 x jährlich Gesundheits- und KinderkrankenpflegerInnen aus. Da das KDU über eine Kinderklinik sowie auch über eine Kinder- und Jugendpsychiatrie verfügt, können diese gesetzlich vorgeschriebenen praktischen Einsätze vor Ort stattfinden.

HB07 - Surgical technical assistant (m/f)