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The new German hygiene law – regulations and implementationimplementation
VHIG congress, 18 April, 2012Almelo, Netherlands
Walter Popp
Folie 2 Titel2 Präsentationstitel19.04.2012 | Autor
1989
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Germany
16 federal states.
States have many duties in healthcare, e.g. legislation.
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Conference of state health ministers 1991 demands:
� Hospital hygienists (doctors)� Hygiene nurses� Link nurses and doctors� Hygiene commission� Documentation of nosocomial infections
Folie 5 Titel5 Präsentationstitel19.04.2012 | Autor
� Documentation of nosocomial infections
State hygiene regulations
Berlin (1985)Bremen (1990)Bremen (1990)Nordrhein-Westfalen (1989)Sachsen (1998)
No state hygiene regulations
Bayern (2010)Hessen (2012)Baden-Württemberg (2010)Rheinland-PfalzRheinland-PfalzSaarland (2007)BrandenburgThüringenSachsen - AnhaltSchleswig-HolsteinHamburgNiedersachsenMecklenburg-VorpommernMecklenburg-Vorpommern
1992
Folie 8 Titel8 Präsentationstitel19.04.2012 | Autor
1994
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1996
First study:German Hospital Federation 6 % NI
NIDEP: 3,5 %
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NIDEP: 3,5 %
Politicians: how nice, no problem
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Folie 12 Titel12 Präsentationstitel19.04.2012 | Autor
Nosocomial infections per year in Germany
KISS SepNet, DGP
Sepsis 28.000 50.000Sepsis 28.000 50.000
Pneumonia 80.000 200.000
Urinary tract infections 155.000
SIS 225.000
Others 70.000
Folie 13 Titel13 Präsentationstitel19.04.2012 | Autor
Sum 558.000 700.000
MRSA prevalence in hospitals
KISS (2010): 0.75 %
MRE networks: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 %
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Gelsenkirchen: 2.5 %Essen: 2 %
Outbreak in Giessen 1997
Neonatology of University Clinics Giessen
1996 – 19991996 – 199936 neonates infected by Klebsiella oxytoca4 died24 have physical and mental illnessBacteria was found in surface disinfectant
Court:
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Court:Handicapped babyCompensation 250,000 €Annuity lifelong 800 € per month
DGKH 2008
400 hygiene doctors needed
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400 hygiene doctors neededOnly 5 % of hospitals have hygiene doctors
2009Left party (post communists)Left party (post communists)
Draft law about hospital hygiene
Hearing in Health Select Committee of German Parliament
Law did not pass Parliament
Folie 17 Titel17 Präsentationstitel19.04.2012 | Autor
But start of interest of political parties
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 %
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End of 2010
MPs Ackermann und Lindner, FDP (Liberals) – own draft law
Followed by coalition parties (CDU, FDP – Conservatives, Liberals) – draft law
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Liberals) – draft law
Also oppositional parties: SPD, Grüne (Social Democratics, Green party)
Infection protection changing act
Passing Parliament in June 2011
Passing also States Chamber without problems
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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 Titel21 Präsentationstitel19.04.2012 | Autor
Infection protection act
§ 23 Nosocomial infections
Commission for antiinfectiva, resistence and therapy (ART) at Robert Koch InstituteNew!New!
Develops recommendations for diagnostics and therapy, based on epidemiologic evaluations
Ongoing update mandatory
Folie 22 Titel22 Präsentationstitel19.04.2012 | 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 implementedNew!
Example:Recommendation re staff structure from 2009If not –> lack of organisation –> legal consequences
Statistics about nosocomial infections and multiresistant bacteriaAlso conclusions, consequences and training of staff about new regulations
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Hygiene plan in each hospital (old)
Infection protection act
§ 23 Nosocomial infections
Hospital hygiene regulations in each state until end of March 2012
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Problem: MRSA decontamination stops when patient is leaving hospital
Reason: no money for practitioners
Folie 25 Titel25 Präsentationstitel19.04.2012 | 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 255, for each 10 8.93 €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 €
Folie 26 Titel26 Präsentationstitel19.04.2012 | Autor
swab in a case
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.
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 255, for each 10 8.93 €
Patients
Risk groups: Inpatient in last 6 months AND risk factors
(that means not all KRINKO risk groups)
Also contact persons
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 €
Folie 27 Titel27 Präsentationstitel19.04.2012 | Autor
Prescription of antiseptic solutions (throat, skin) not clear.
swab in a case
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)
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§ 137„Die Krankenhäuser sind verpflichtet, sich an Maßnahmen der Qualitätssicherung zu beteiligen.“
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 andRepresents organisations of physicians, hospitals, sickness funds andpatients.Evidence-based coverage decisions regarding innovations foroutpatient and hospital care (which therapy, drugs…sickness funds have to pay for)
Quality directives according to Federal Joint Commi ttee(G-BA)
Quality reports of all hospitals every 2 years (mainly structure,most important DRGs).
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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: 20Bone marrow transplantation: 25
Neonatology regulations.
Federal Joint Committee – G-BA
Develop benchmarking parameters for hospital hygiene
Parameters must overlap sectors
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Aqua Institute – task from G -BA:
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SISIndicator operations must be done inpatient and outpatient-> no heart operation, no HPRO
Central venous catheter associated infectionsCentral venous catheters are not used by practitionersPorts?
Staff according to KRINKO 2009
Hygiene doctors: fulltime over 400 beds200-300 hygiene doctors in Germany30 (?) with authorization of Medical Councils to 30 (?) with authorization of Medical Councils to
qualify new hygiene doctors (5 years)
Hygiene nurses: around 100 % more neededCan be reached in 4-5 years
Link doctors and nurses
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Link doctors and nursesCan be reached in 2-3 years
Discussion about structured training of hospital hy gienists (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).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.
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Mentor requirements: Authorization of at least 2 years to qualify doctors for hospital hygiene or microbiology, additionally experiences in hospital hygiene.
Conclusion
Big step after 20 years of stagnation.
More staff:Hygiene nurses doubled.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.
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More hygiene in education needed, especially in medical students.
More hygiene institutes needed at universities.
Development of valide benchmarking parameters.