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The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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Page 1: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

The new German hygiene law – regulations and implementationimplementation

VHIG congress, 18 April, 2012Almelo, Netherlands

Walter Popp

Page 2: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

Folie 2 Titel2 Präsentationstitel19.04.2012 | Autor

Page 3: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

1989

Folie 3 Titel3 Präsentationstitel19.04.2012 | Autor

Page 4: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

Germany

16 federal states.

States have many duties in healthcare, e.g. legislation.

Folie 4 Titel4 Präsentationstitel19.04.2012 | Autor

Page 5: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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

Page 6: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

State hygiene regulations

Berlin (1985)Bremen (1990)Bremen (1990)Nordrhein-Westfalen (1989)Sachsen (1998)

Page 7: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

No state hygiene regulations

Bayern (2010)Hessen (2012)Baden-Württemberg (2010)Rheinland-PfalzRheinland-PfalzSaarland (2007)BrandenburgThüringenSachsen - AnhaltSchleswig-HolsteinHamburgNiedersachsenMecklenburg-VorpommernMecklenburg-Vorpommern

Page 8: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

1992

Folie 8 Titel8 Präsentationstitel19.04.2012 | Autor

Page 9: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

1994

Folie 9 Titel9 Präsentationstitel19.04.2012 | Autor

Page 10: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

1996

First study:German Hospital Federation 6 % NI

NIDEP: 3,5 %

Folie 10 Titel10 Präsentationstitel19.04.2012 | Autor

NIDEP: 3,5 %

Politicians: how nice, no problem

Page 11: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

Folie 11 Titel11 Präsentationstitel19.04.2012 | Autor

Page 12: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

Folie 12 Titel12 Präsentationstitel19.04.2012 | Autor

Page 13: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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

Page 14: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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 %

Folie 14 Titel14 Präsentationstitel19.04.2012 | Autor

Gelsenkirchen: 2.5 %Essen: 2 %

Page 15: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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:

Folie 15 Titel15 Präsentationstitel19.04.2012 | Autor

Court:Handicapped babyCompensation 250,000 €Annuity lifelong 800 € per month

Page 16: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

DGKH 2008

400 hygiene doctors needed

Folie 16 Titel16 Präsentationstitel19.04.2012 | Autor

400 hygiene doctors neededOnly 5 % of hospitals have hygiene doctors

Page 17: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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

Page 18: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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 Titel18 Präsentationstitel19.04.2012 | Autor

Page 19: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

End of 2010

MPs Ackermann und Lindner, FDP (Liberals) – own draft law

Followed by coalition parties (CDU, FDP – Conservatives, Liberals) – draft law

Folie 19 Titel19 Präsentationstitel19.04.2012 | Autor

Liberals) – draft law

Also oppositional parties: SPD, Grüne (Social Democratics, Green party)

Page 20: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

Infection protection changing act

Passing Parliament in June 2011

Passing also States Chamber without problems

Folie 20 Titel20 Präsentationstitel19.04.2012 | Autor

Page 21: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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

Page 22: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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

Page 23: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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

Folie 23 Titel23 Präsentationstitel19.04.2012 | Autor

Hygiene plan in each hospital (old)

Page 24: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

Infection protection act

§ 23 Nosocomial infections

Hospital hygiene regulations in each state until end of March 2012

Folie 24 Titel24 Präsentationstitel19.04.2012 | Autor

Page 25: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

Problem: MRSA decontamination stops when patient is leaving hospital

Reason: no money for practitioners

Folie 25 Titel25 Präsentationstitel19.04.2012 | Autor

Page 26: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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 €

Page 27: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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 €

Page 28: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

Social Act V (SGB V)

§ 137 (old)

Hospitals are under duty to participate in measures of quality assurance

Sozialgesetzbuch V (SGB V)

Folie 28 Titel28 Präsentationstitel19.04.2012 | Autor

§ 137„Die Krankenhäuser sind verpflichtet, sich an Maßnahmen der Qualitätssicherung zu beteiligen.“

Page 29: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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).

Folie 29 Titel29 Präsentationstitel19.04.2012 | Autor

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.

Page 30: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

Federal Joint Committee – G-BA

Develop benchmarking parameters for hospital hygiene

Parameters must overlap sectors

Folie 30 Titel30 Präsentationstitel19.04.2012 | Autor

Page 31: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

Aqua Institute – task from G -BA:

Folie 31 Titel31 Präsentationstitel19.04.2012 | Autor

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?

Page 32: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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

Folie 32 Titel32 Präsentationstitel19.04.2012 | Autor

Link doctors and nursesCan be reached in 2-3 years

Page 33: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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.

Folie 33 Titel33 Präsentationstitel19.04.2012 | Autor

Mentor requirements: Authorization of at least 2 years to qualify doctors for hospital hygiene or microbiology, additionally experiences in hospital hygiene.

Page 34: The new German hygiene law – regulations and ... · The new German hygiene law – regulations and implementation VHIG congress, 18 April, 2012 Almelo, Netherlands Walter Popp

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.

Folie 34 Titel34 Präsentationstitel19.04.2012 | Autor

More hygiene in education needed, especially in medical students.

More hygiene institutes needed at universities.

Development of valide benchmarking parameters.