The new German hygiene law regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp
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1989 Folie 3 3 19.04.2012 Autor
Germany 16 federal states. States have many duties in healthcare, e.g. legislation. Folie 4 4 19.04.2012 Autor
Conference of state health ministers 1991 demands: Hospital hygienists (doctors) Hygiene nurses Link nurses and doctors Hygiene commission Documentation of nosocomial infections Folie 5 5 19.04.2012 Autor
State hygiene regulations Berlin (1985) Bremen (1990) Nordrhein-Westfalen (1989) Sachsen (1998)
No state hygiene regulations Bayern (2010) Hessen (2012) Baden-Württemberg (2010) Rheinland-Pfalz Saarland (2007) Brandenburg Thüringen Sachsen - Anhalt Schleswig-Holstein Hamburg Niedersachsen Mecklenburg-Vorpommern
1992 Folie 8 8 19.04.2012 Autor
1994 Folie 9 9 19.04.2012 Autor
1996 First study: German Hospital Federation 6 % NI NIDEP: 3,5 % Politicians: how nice, no problem Folie 10 10 19.04.2012 Autor
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Nosocomial infections per year in Germany KISS SepNet, DGP Sepsis 28.000 50.000 Pneumonia 80.000 200.000 Urinary tract infections 155.000 SIS 225.000 Others 70.000 Sum 558.000 700.000 Folie 13 13 19.04.2012 Autor
MRSA prevalence in hospitals KISS (2010): 0.75 % MRE networks: Saarland: 2.2 % Siegen-Wittgenstein: 1.4 % Sachsen-Anhalt: 1.1 % Kreis Höxter: 3.4 % Netzwerk Euregio MRSA-net, Münster: 1.6 % Gelsenkirchen: 2.5 % Essen: 2 % Folie 14 14 19.04.2012 Autor
Outbreak in Giessen 1997 Neonatology of University Clinics Giessen 1996 1999 36 neonates infected by Klebsiella oxytoca 4 died 24 have physical and mental illness Bacteria was found in surface disinfectant Court: Handicapped baby Compensation 250,000 Annuity lifelong 800 per month Folie 15 15 19.04.2012 Autor
DGKH 2008 400 hygiene doctors needed Only 5 % of hospitals have hygiene doctors Folie 16 16 19.04.2012 Autor
2009 Left party (post communists) Draft law about hospital hygiene Hearing in Health Select Committee of German Parliament Law did not pass Parliament But start of interest of political parties Folie 17 17 19.04.2012 Autor
DGKH: Survey by Infratest in 2010 Each hospital should have a hygiene doctor and hygiene nurses: 68 % The big number of nosocomial infections is a scandal: 56 % Hygiene in hospitals must urgently be improved: 49 % Politics has to care for the issue: 48 % I would accept higher costs if hospital hygiene would be improved: 35 % Folie 18 18 19.04.2012 Autor
End of 2010 MPs Ackermann und Lindner, FDP (Liberals) own draft law Followed by coalition parties (CDU, FDP Conservatives, Liberals) draft law Also oppositional parties: SPD, Grüne (Social Democratics, Green party) Folie 19 19 19.04.2012 Autor
Infection protection changing act Passing Parliament in June 2011 Passing also States Chamber without problems Folie 20 20 19.04.2012 Autor
Infection protection act 23 Nosocomial infections Commission for hospital hygiene and infection prevention (KRINKO) at Robert Koch Institute (RKI) Develops recommendations to prevent nosocomial infections Ongoing update mandatory Folie 21 21 19.04.2012 Autor
Infection protection act 23 Nosocomial infections Commission for antiinfectiva, resistence and therapy (ART) at Robert Koch Institute New! Develops recommendations for diagnostics and therapy, based on epidemiologic evaluations Ongoing update mandatory Folie 22 22 19.04.2012 Autor
Infection protection act 23 Nosocomial infections Heads of hospitals are in charge of hospital hygiene working according to scientific knowledge Recommendations of KRINKO and ART have to be implemented New! Example: Recommendation re staff structure from 2009 If not > lack of organisation > legal consequences Statistics about nosocomial infections and multiresistant bacteria Also conclusions, consequences and training of staff about new regulations Hygiene plan in each hospital (old) Folie 23 23 19.04.2012 Autor
Infection protection act 23 Nosocomial infections Hospital hygiene regulations in each state until end of March 2012 Folie 24 24 19.04.2012 Autor
Problem: MRSA decontamination stops when patient is leaving hospital Reason: no money for practitioners Folie 25 25 19.04.2012 Autor
Folie 26 26 19.04.2012 Autor Number Points Round-about in (estimated point price 0.035 ) 86770: Clarifying MRSA status of a risk patient until 6 months after leaving hospital 100, once in a case 3.50 86772: Therapy and management of a risk patient with MRSA or of a contact person with MRSA 375, once in a case or decontamination cycle 13.13 86774: Education and advicing a risk patient with MRSA or of a proven contact person 255, for each 10 minutes, maximum twice in a decontamination cylce 8.93 86776: Diagonistic of a contact person after failed decontamination of a person with MRSA 90, once in a case 3.15 86778: participation in a MRSA case or network conference 130, once in a case 4.55 86780: confirmation of MRSA by swab 55, maximum twice in a case 1.93 86781: Exclusion of MRSA by swab 55, maximum twice in a case 1.93 86782: MRSA confirmation by chromogenic agar 5.20 86784: identification of Koagulase and/or Clumpingfactor 2.55
Doctors Must have a specialisation in infectiology or 3-hours-course or online course, Must be members in a MRSA network. Patients Risk groups: Inpatient in last 6 months AND risk factors (that means not all KRINKO risk groups) Also contact persons Prescription of antiseptic solutions (throat, skin) not clear. Folie 27 27 19.04.2012 Autor Number Points Round-about in (estimated point price 0.035 ) 86770: Clarifying MRSA status of a risk patient until 6 months after leaving hospital 100, once in a case 3.50 86772: Therapy and management of a risk patient with MRSA or of a contact person with MRSA 375, once in a case or decontamination cycle 13.13 86774: Education and advicing a risk patient with MRSA or of a proven contact person 255, for each 10 minutes, maximum twice in a decontamination cylce 8.93 86776: Diagonistic of a contact person after failed decontamination of a person with MRSA 90, once in a case 3.15 86778: participation in a MRSA case or network conference 130, once in a case 4.55 86780: confirmation of MRSA by swab 55, maximum twice in a case 1.93 86781: Exclusion of MRSA by swab 55, maximum twice in a case 1.93 86782: MRSA confirmation by chromogenic agar 5.20 86784: identification of Koagulase and/or Clumpingfactor 2.55
Social Act V (SGB V) 137 (old) Hospitals are under duty to participate in measures of quality assurance Sozialgesetzbuch V (SGB V) 137 Die Krankenhäuser sind verpflichtet, sich an Maßnahmen der Qualitätssicherung zu beteiligen. Folie 28 28 19.04.2012 Autor
Federal Joint Committee (G-BA) Established in 2004. Main decision making body in German health care. Issues legally binding directives. Represents organisations of physicians, hospitals, sickness funds and patients. Evidence-based coverage decisions regarding innovations for outpatient and hospital care (which therapy, drugs sickness funds have to pay for) Quality directives according to Federal Joint Committee (G-BA) Quality reports of all hospitals every 2 years (mainly structure, most important DRGs). External quality report every year, e.g. structure data, some mortality and infection data on federal mean level. Minimum rates for treatment, e.g. Liver transplantation: 20 Bone marrow transplantation: 25 Neonatology regulations. Folie 29 29 19.04.2012 Autor
Federal Joint Committee G-BA Develop benchmarking parameters for hospital hygiene Parameters must overlap sectors Folie 30 30 19.04.2012 Autor
Aqua Institute task from G-BA: SIS Indicator operations must be done inpatient and outpatient -> no heart operation, no HPRO Central venous catheter associated infections Central venous catheters are not used by practitioners Ports? Folie 31 31 19.04.2012 Autor
Staff according to KRINKO 2009 Hygiene doctors: fulltime over 400 beds 200-300 hygiene doctors in Germany 30 (?) with authorization of Medical Councils to qualify new hygiene doctors (5 years) Hygiene nurses: around 100 % more needed Can be reached in 4-5 years Link doctors and nurses Can be reached in 2-3 years Folie 32 32 19.04.2012 Autor
Discussion about structured training of hospital hygienists (interim solution) Requirement: Specialisation in clinical medicine (internal medicine, surgery ). Start: Modul I of curriculum ( link doctor ). Search for a mentor and make treaty with him/her. Course: Additional 5 courses (200 h). From the beginning fulltime hospital hygienist in his/her hospital ( Trainee ) Help from mentor. Meeting with mentor at least once a month. Duration: 2 years. Graduation: Examination at Medical Council. Mentor requirements: Authorization of at least 2 years to qualify doctors for hospital hygiene or microbiology, additionally experiences in hospital hygiene. Folie 33 33 19.04.2012 Autor
Big step after 20 years of stagnation. Conclusion More staff: Hygiene nurses doubled. Fulltime hygiene doctors in big hospitals. Link doctors and nurses. Importance of hospital hygiene will grow. Pressure from justice will grow. Heads of hospitals are in charge. More hygiene in education needed, especially in medical students. More hygiene institutes needed at universities. Development of valide benchmarking parameters. Folie 34 34 19.04.2012 Autor