Hygiene

Kathrin Engels

ärztliche Direktorin

Lindenstraße 29
48268 Greven

Phone: 02571 -502-12201
Fax: 02571-502-12099
Mail: ed.neverg-hjm@ofni

A hygiene officer has not been established

Hygiene commission established
Conference frequency: quartalsweise

Contact person

Kathrin Engels

ärztliche Direktorin

Lindenstraße 29
48268 Greven

Phone: 02571 -502-12201
Fax: 02571-502-12099
Mail: ed.neverg-hjm@ofni

Hospital hygienists (m/f) 1 Das Maria-Josef-Hospital in Greven kooperiert hierzu mit dem mikrobiologischen Kompetenzzentrums am St. Franziskus-Hospital. https://www.sfh-muenster.de/unsere-kompetenzen/mikrobiologie-und-hygiene-1/
Doctors’ hygiene officer 5
Hygiene specialists 2 Ansprechpartner sind Frau Meinert und Frau Wegmann
Hygiene officers in nursing care 11 Benennung für jede Station u. Funktionsabteilung.
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 Partly
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 111,30 ml
Hand disinfectant consumption on all general stations 35,30 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
HM02

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

In der Auswahlliste der KISS-Module in "Hygienebezogenes Risikomanagement", ist bei den Angaben ein Fehler aufgetreten. Das Modul ITS-KISS fehlt, dafür wird DAS-KISS angeboten. Das Maria-Josef-Krankenhaus nutzt ein „ITS-KISS“ und informiert darüber über diese Kommentarfunktion.

  • CDAD-KISS
  • HAND-KISS
  • MRSA-KISS
  • OP-KISS
HM03

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

Eurhealth-1health

HM04

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

Teilnahme (ohne Zertifikat)

HM05

Annual inspection of the preparation and sterilisation of medical devices

Die Überprüfung von Aufbereitung und Sterilisation von Medizinprodukten erfolgt in unserer Zentralsterilisation in Medical Order Instruments in Ahlen.

HM09

Training of employees on hygiene-related topics