3.3.02 Control tasks in hygiene

1 Purpose and objective

The effectiveness of measures to maintain appropriate hospital hygiene and prevent hospital-acquired infections must be checked regularly. The inspection can be carried out by the hospital hygiene department. If there is no separate function for this, the management can delegate the tasks to the QM group. The checks are carried out according to an explicit procedure.

2 Application

All clinics, institutes, departmentsEdit

3 Description

3.1 Control of documents

The QMK updates and manages the regulations on hygiene-relevant work processes, the hygiene plan, the disinfection and sterilisation procedures, hospital cleaning and the hygienic-microbiological tests.

3.2 Regular system audits

The QMK draws up audit lists for inspections:

• the surgery department
• the nursing department
• Supply and disposal facilities
  (food, medicines, laundry, sterile goods)
• the technology

The audits should be announced. If the quality situation is known, audits do not have to be carried out more frequently than once a year.

The auditor must always be a person who is independent of the audited area. The auditor may be accompanied by the area's hygiene nurse.

The follow-up of corrective actions must be coordinated with the auditor.

3.3 Process checks

Hygienic-microbiological tests are carried out regularly in accordance with Annex 5.6 of the guideline on

• the sterilisation devices
• the disinfection devices
• the supply and disposal systems
• by the water
• Food
• Ventilation systems
• Environmental examinations in risk areas.

The QMK collects the results of the hygiene and microbiological tests, evaluates them and reports regularly to the hospital hygienist.

3.4 Infection statistics

Following consultation with the hospital hygienist and the hygiene specialists, the QMK draws up an infection monitoring programme in which infection statistics are kept. Urinary tract infections, wound infections, respiratory tract infections and septicaemia are to be recorded. The evaluation must take into account epidemiological aspects and the identification of the source and route of infection. Monitoring must be carried out continuously and a report - even in the case of suspected cases - must be submitted immediately to the management so that decisions can be made on therapeutic and organisational measures and preventive measures can be initiated.

The hospital infections are recorded according to frequency, type of illness, type of pathogen, resistance spectra, localisation to certain areas and persons. The patient histories are then analysed.

3.5 Training measures

The QMK updates and monitors the further training measures for hospital staff in accordance with the specifications of the hospital management and the hospital hygienist.

4 Risks and opportunities

5 Documentation

Checklists

Audit report

Data records of the infection statistics

6 Resources

6.1 Time requirement

Depending on the size of the hospital

7 Responsibilities

Where possible, these tasks of the QMK group are performed by a hygiene specialist.

8 Notes and comments

9 Applicable documents

9.1 Literature, regulations

"Guideline for the detection, prevention and control of hospital infections with annexes of 9 January 1976 in the last updated version of the Robert Koch Institute - Federal Institute for Infectious Diseases and Non-Communicable Diseases - 2024

9.2 Terms

to the text of the VA

10 plants

1. Hygiene inspection checklist
2. Microbiological control tests
3. Hygiene inspections Section 5.6