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Universitätsklinikum Hamburg-Eppendorf

Martinistraße 52
20246 Hamburg

Phone: 040-7410-0
Fax: 040-7410-54647
Mail: ed.eku@ofni

http://www.uke.de

Basic information

Number of beds: 1.741
Number of specialist departments: 36

Number of inpatient cases: 77.457
Number of partial inpatient cases: 10.627
Number of outpatient cases: 320.569
Number of cases of inpatient-equivalent psychiatric treatment (StäB): 17

Hospital owners: Freie und Hansestadt Hamburg
Type of provider: öffentlich

University Hospital
Academic teaching hospital

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law

Bezeichnung
Teilnahme externe Qualitätssicherung	yes
Bezeichnung
Teilnahme externe Qualitätssicherung	yes

Quality of participation in the Disease Management Programme (DMP)
No participation

Implementation of the minimum quantity agreement

Treatment area

Liver transplantation (including partial liver donation)

Quantity performed	72
Exception?	No exception

Kidney transplant (including living donation)

Quantity performed	85
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	66
Exception?	No exception

Complex interventions on the organ system esophagus for adults

Quantity performed	31
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	120
Exception?	No exception

Quantity performed	278
Exception?	No exception

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

Quantity performed	55
Exception?	No exception

Minimum quantities forecast

Liver transplantation (including partial liver donation)

Overall result forecast presentation:	yes
Quantity performed reporting year:	72
Quantity forecast year:	63
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Kidney transplantation (including living donation)

Overall result forecast presentation:	yes
Quantity performed reporting year:	85
Quantity forecast year:	68
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Knee joint total endoprostheses

Overall result forecast presentation:	yes
Quantity performed reporting year:	66
Quantity forecast year:	53
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Complex interventions on the organ system esophagus for adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	31
Quantity forecast year:	38
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Complex operations on the pancreatic organ system

Overall result forecast presentation:	yes
Quantity performed reporting year:	120
Quantity forecast year:	92
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Overall result forecast presentation:	yes
Quantity performed reporting year:	278
Quantity forecast year:	157
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:	55
Quantity forecast year:	40
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Surgical treatment of breast cancer (mamma surgery)

Overall result forecast presentation:	yes
Quantity performed reporting year:	246
Quantity forecast year:	256
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Thoracic surgical treatment of lung cancer in adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	28
Quantity forecast year:	32
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
CQ03	Quality assurance measures for the implementation of positron emission tomography (PET) in hospitals for the indications non-small-cell lung cancer (NSCLC) and solid pulmonary nodules
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
CQ02	Quality assurance measures for the inpatient care of children and adolescents with haemato-oncological diseases
CQ24	Quality assurance measures for allogeneic stem cell transplantation for multiple myeloma (valid until 30 June 2022)
CQ01	Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm
CQ08	Measures for quality assurance of cardiac surgery care in children and adolescents according to Article 136, para. 1, sentence 1, no. 2 of the SGB V
CQ30	Quality assurance guideline for interstitial LDR brachytherapy for low-risk localized prostate cancer (effective January 8, 2021).
CQ25	Measures for quality assurance in the performance of minimally invasive heart valve interventions pursuant to Article 136, para. 1, sentence 1, number 2 for hospitals licensed in accordance with Article 108 of the SGB V
CQ26	Decision on measures for quality assurance of targeted lung denervation by catheter ablation in chronic obstructive pulmonary disease
CQ27	Guideline on quality assurance measures for inpatient care with bronchoscopic lung volume reduction procedures for severe emphysema (QS Guideline bronchoscopic LVR /QS-RL BLVR)
CQ29

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

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

Number	Group
887	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*
317	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
298	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? No
Measures
- Prevention
  Information gathering on the topic
  Note on the measure
  In Kinderschutzfällen mit Involvierung des Kinderschutzteams und in Fällen, in denen der Sozialdienst involviert wird, wird auf lokale Hilfsangebote hingewiesen oder direkt eine Hilfe vermittelt. Es besteht eine enge Vernetzung zu den Kinderschutzgruppen der Hamburger Kinderkliniken, den Jugendämtern und sozialräumlichen Hilfe- und Versorgungsangeboten. Teilweise sind die auch in den Abläufen der Notaufnahme und der Stationen integriert (z. B. HALT-Projekt).
  Training of employees
  Note on the measure
  Es finden regelmäßige Fortbildungen zum Thema Kinderschutz (inkl. Schweigepflicht, Erkennen von Kindesmisshandlung usw.) statt. Die ärztlichen Mitarbeitenden werden in den regelmäßigen Mittagsfortbildungen von internen und externen Referent:innen geschult. Die Pflegeteams, insbesondere der Notaufnahme werden regelmäßig von Mitgliedern des Kinderschutzteams geschult.
  Education
  Note on the measure
  Team: Fortbildungen s.o., Patienten und Angehörige werden im Verdachtsfall einer möglichen Kindeswohlgefährdung entsprechend sensibilisiert.
  Age-appropriate complaint options
  Note on the measure
  Es gibt Beschwerdemöglichkeiten (extern: Lob-&Beschwerde, intern: CIRS, Hinweisgebersystem). Dieses wird allerdings bisher nicht altersangemessen beworben und ist für jüngere Kinder nicht ohne Hilfe nutzbar.
  Special requirements for the selection of persons
  Note on the measure
  Für alle Beschäftigten im direkten Patientenkontakt mit Kindern wird das erweiterte Führungszeugnis abgefragt. Bei Servicekräften werden im Rahmen aller Einstellungen einfache Führungszeugnisse angefordert.
  Other aspects of prevention
  Note on the measure
  Fälle mit V.a. Kindesmisshandlung und -vernachlässigung werden entsprechend der SOP 2.03.01 per elektronischem Konsil an das Kinderschutzteam (ärztliche, Sozialdienst und Psychologie) gemeldet. Es erfolgt eine interdisziplinäre Abklärung gemeinsam mit relevanten Fachabteilungen (z. B. Rechtsmedizin, Kinderchirurgie, Radiologie...) sowie ggf. eine Vernetzung mit externen Akteuren (z. B. Jugendamt, frühe Hilfen, Polizei).
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Last review of the measure
  01.07.2023 21:03:25
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Vorhanden für Fälle von Außen. Compliance-Beratung und Bewertung erfolgt in Form von rechtlichen/vertraglichen Beratungen, in Ergänzung zu den Leistungen des GB Recht, zu Compliance Sachverhalten und deren Bewertung im Hinblick auf die Einhaltung von Vorgaben, Sachverhaltsaufklärung bei Compliance Meldungen und Bearbeitung und Begleitung von strafrechtlichen Tatbeständen.
  
  Last review of the measure
  01.07.2023 21:03:25
  Other information on recognition
  Note on the measure
  Vorstandsbeschluss von 5/2024: Schaffung einer Stelle (1 VK) "Schutzbeauftragte:r für Kinder und andere vulnerable Gruppen".

Vorhanden für Fälle von Außen. Compliance-Beratung und Bewertung erfolgt in Form von rechtlichen/vertraglichen Beratungen, in Ergänzung zu den Leistungen des GB Recht, zu Compliance Sachverhalten und deren Bewertung im Hinblick auf die Einhaltung von Vorgaben, Sachverhaltsaufklärung bei Compliance Meldungen und Bearbeitung und Begleitung von strafrechtlichen Tatbeständen.

Commentary on the protection concept

Gemäß § 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 § 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

Training of employees on AMTS related topics

Availability of appropriate, topic-specific informational materials for patients on AMTS e.g. for chronic diseases, for high-risk drugs, for children

Use of standardised forms for drug medical history

Verschiedene Dokumente im QM-Handbuch (QMH) des UKE. Stand: 04.10.2023

31.10.2021

Electronic support for the admission and anamnesis process (e.g. import of patient master data or medication plans, use of a drug knowledge database, input screen for drugs or anamnesis information)

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

SOP: 6.4.2 Verkehr mit Arzneimitteln

19.06.2020

SOP on good prescription practices

SOP: 6.4.2 Verkehr mit Arzneimitteln

19.06.2020

Possibility of electronic prescription i.e. structured entry of active substances (or name of the preparation), form, dose, dose frequency (e.g. in the HIS, in prescription software)

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

Concepts for ensuring the error-free preparation of medications

Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
Zubereitung durch pharmazeutisches Personal
Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen

Electronic support for the supply of patients with drugs

Vorhandensein von elektronischen Systemen zur Entscheidungsunterstützung (z.B. Meona®, Rpdoc®, AIDKlinik®, ID Medics® bzw. ID Diacos® Pharma)
Versorgung der Patientinnen und Patienten mit patientenindividuell abgepackten Arzneimitteln durch die Krankenhausapotheke (z.B. Unit-Dose-System)

Electronic documentation of the administration of drugs

Measures to minimise medication errors

Fallbesprechungen
Maßnahmen zur Vermeidung von Arzneimittelverwechslung
Spezielle AMTS-Visiten (z. B. pharmazeutische Visiten, antibiotic stewardship, Ernährung)
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)

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
Aushändigung des Medikationsplans
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

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

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

Explanation

FL04 - Project-related cooperation with colleges and universities

Explanation

FL03 - Student training (clinical traineeship / internship year)

Explanation

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

Explanation

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

Explanation

FL09 - Doctoral supervision

Explanation

FL08 - Editors of scientific journals/textbooks

Explanation

Training

Training in other healing professions

HB02 - Health and paediatric nurse (m/f)

Comment

HB01 u. HB02 insgesamt: 349 Ausbildungsplätze

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

Comment

HB01 u. HB02 insgesamt: 349 Ausbildungsplätze

HB07 - Surgical technical assistant (m/f)

Comment

27 Ausbildungsplätze

HB03 - Physical therapist / physiotherapist (m/f)

Comment

68 Ausbildungsplätze

HB16 - Dietician (m/f)

Comment

43 Ausbildungsplätze

HB14 - Orthoptist (m/f)

Comment

6 Ausbildungsplätze

HB15 - Anaesthesia technical assistant (m/f)

Comment

32 Ausbildungsplätze

HB05 - Medical technical radiology assistant (MTRA) (m/f)

Comment

10 Schüler:innen/Jahr

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 30
- Additional staff: 52
- Explanations: Von den 30 Apotheker:innen sind 21 als Klinische Pharmazeuten/Stationsapotheker tätig: Auf Normalstationen Mo-Fr tägliche Kurvenvisiten mit Besuch auf Station, Sa Kurvenvisite virtuell bei allen Stationen/Patient:innen. Auf Int.- u. onkologischen Stationen Mo-Fr zusätzlich Visitenbegleitung am Bett.
- Nursing staff regulation