Kaiserin-Auguste-Victoria Krankenhaus GmbH

Hygiene

Klinikdirektor/Pflegedienstleitung

Michael Werner

Stegwiese 27
35630 Ehringshausen

Phone: 06443-828-180
Fax: 06443-828-172
Mail: ed.suahneknark-vak@renrew.leahcim

A hygiene officer has not been established

Hygiene commission established
Conference frequency: halbjährlich

Contact person

Klinikdirektor/Pflegedienstleitung

Michael Werner

Stegwiese 27
35630 Ehringshausen

Phone: 06443-828-180
Fax: 06443-828-172
Mail: ed.suahneknark-vak@renrew.leahcim

Hospital hygienists (m/f) 2 nach Absprache mit dem Krankenhaushygieniker und dem Gesundheitsamt reicht aufgrund fehlender hygienischer Risikobereiche 1 hygienebeauftragter Arzt für die Klinik aus
Doctors’ hygiene officer 1
Hygiene specialists 1
Hygiene officers in nursing care 3
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 non-existant
Hand disinfectant consumption on all general stations 30,00 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

  • HAND-KISS
HM03

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

MRE Netzwerk Mittelhessen

HM05

Annual inspection of the preparation and sterilisation of medical devices

jährliche Revalidierung, Routineüberprüfungen gemäß dem Hygienehandbuch der ZSVA durch die Mitarbeiter der ZSVA, hygienische Begehungen der ZSVA durch den Krankenhaushygieniker und die Hygienefachkraft, jährliche Überprüfung der Aufbereitung von Medizinprodukten und Validierung der RDG_E in der Endoskopie

Frequency : jährlich

HM09

Training of employees on hygiene-related topics

Mehrmals jährlich

Frequency : quartalsweise