Hygiene

Frank Bessler

Medizinischer Geschäftsführer

Lothar-Gau-Straße 11
58300 Wetter

Phone: 02331 -476-2001
Fax: 02331-476-2003
Mail: ed.vse@frelsseb

A hygiene officer has not been established

Hygiene commission established
Conference frequency: halbjährlich

Contact person

Frank Bessler

Medizinischer Geschäftsführer

Lothar-Gau-Straße 11
58300 Wetter

Phone: 02331 -476-2001
Fax: 02331-476-2003
Mail: ed.vse@frelsseb

Hospital hygienists (m/f) 1 Der hygienebeauftrage Arzt arbeitet in enger Abstimmung mit der Hygienekommission, den Hygienefachkräften und den Hygienebeauftragten in der Pflege im Hygienemanagement.
Doctors’ hygiene officer 1
Hygiene specialists 2 Die Hygienefachkräfte aus dem GB Medizin der Evangelischen Stiftung Volmarstein koordinieren in Absprache mit dem Vorsitzenden der Hygienekommission und den Hygienebeauftragten in der Pflege alle strategischen und operativen Maßnahmen der Hygiene. Die Hygienefachkräfte sind ständige Mitglieder der Hygienekommission.
Hygiene officers in nursing care 11 Die pflegerischen Leitungen sind ausgebildete Hygienebeauftragte. In regelmäßigen Sitzungen mit den Hygienefachkräften wird das strategische und operative Hygienemanagement sichergestellt.
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
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 20,63 ml
Hand disinfectant consumption on all general stations 13,47 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
HM02

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

  • MRSA-KISS
  • OP-KISS
HM03

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

Verstetigung des MRE Siegels.

Die Orthopädische Klinik Volmarstein ist Mitglied im MRSA-Netzwerk NRW und im überregionalen MRE-Netzwerk Nord-West.

HM04

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

Teilnahme (ohne Zertifikat)

HM05

Annual inspection of the preparation and sterilisation of medical devices

Durch unseren externen Partner Fa. Hybeta

Frequency : monatlich

HM09

Training of employees on hygiene-related topics

Regelmäßig wiederkehrende Schulungen aller Mitarbeitenden. Die Schulungen sind interdisziplinär, interprofessionell und risikoadaptiert.

Frequency : monatlich