DART: The German Strategy for Combating Superbugs

Developments in Hospital Hygiene in Germany

Christoph HuesmannSpecialist Nurse for hygiene and infection prevention

Development of HFK*

Simple further trainingCollaboration with...

Further educationCollaboration with... with distinct areas of responsibility

Independent studies/ professional studies

*Hygiene Fachkraft (hygiene specialists/ hygienists)

Development of roles

1. Disinfection plans

2. Hygiene standards

3. Investigations in surrounding areas

4. Hygiene plans/ instructions

5. Quality management/ recording infection/ basic hygiene and targeted hygiene

Tasks

Preventing infection• Plague, smallpox, cholera

Preventing nosocomial infection• UTI*, BPI**, wound infections, sepsis

Preventing the spread of

multiresistant bacteria• MRSA, ESBL, VRE, EHEC

*Urinary Tract Infection **bactericidal/permeability-increasing protein (contributes to wound defence)

Development of resistance3rd generation Cephalosporin resistant isolates

Key

Grey = Resident Doctors (N)

Red = Dialysis centres (D)

Yellow = Hospitals (K)

DART

Deutsche Antibiotika-

Resistenzstrategie**German Antibiotic Resistance Strategy

DART = Deutsche Antibiotika-Resistenzstrategie

5.1 Main aims of the strategyThe Deutsche Antibiotika-Resistenzstrategie DART

is to contribute significantly to reducing and preventing antibiotic resistance spreading in Germany.

To achieve this aim all affected parties are to take part in realising the national aims and work together closely.


5.2 National aimsThe national goals outline the strategic structure of the national antibiotic-

resistance strategy and establish the focal points of the content. The goals reshape principles on national, regional and local levels to develop, maintain or improve activities and to establish areas of action and milestones. The following strategy contains 10 national goals in total which consist of 4 components:

I. Surveillance systems of antibiotic resistantance and antibiotic use.

II. Prevention and combatitive measures to reduce antibiotic resistance

III. Coorperation and coordinationIV. Research and evaluation


1.3.3.1.3 Hygiene recommendations for preventing and combating Methicillin-resistenten Staphylococcus aureus– strains in hospitals and medical establishments 87

Responsibility: KRINKO*Goal: preventing and combating Methicillin-resistant

Staphylococcus aureus strains in hospitals and medical establishments.

Features: Legal power of KRINKO and its recommendations in § 23 Abs. 2 IfSG

Limitations: The implementation of recommendations in medical establishments and checking the application of them through the Public Health Service (ÖGD) is often inadequate.

Status: April 2011

*Kommision für Krankenhaushygiene und Infektionsprävention (The Commission for Hospital Hygiene and Infection Control)

DART = Deutsche Antibiotika-ResistenzstrategieKrankenhaus- Infektions- Surveillance- System (KISS)*Responsibility:

NRZ** for the surveillance of nosocomial infections at the Institute for Hygiene and Environmental Medicine, Charité – Medical University, Berlin

Aim: To establish a uniform method for monitoring hospital acquired infections (nosocomial infections)

Features: In the model ITS-KISS, resistance data from about 300 ICUs with surveillance of nosocomial infections, entering data online by participants; central evaluation of data, feedback of resistance and infection rates for participants

Limitations: Recording a total of 4 resistant bacteria in the ICU, questions of quality control

*Hospital Infection Surveillance System

**Nationales Referenzzentrum für Surveillance von nosokomialen Infektionen (National Reference Centre for the Surveillance of Nosocomial Infections)

Wound infection rate

Risk Category Number of

departments

Number of

operations

Number of

wound

infections

Mean 25% quartile Median 75% Quartile

0 29 7958 9 0.11 0.00 0.00 0.00

1, 2, 3 29 4303 31 0.72 0.00 0.00 1.16

0, 1, 2, 3 29 12261 40 0.33 0.00 0.00 0.60

KISS Hospital Infection Surveillance System

OP-KISS Model

Time period: January 2006 – December 2010

Reference data – Rates of wound infection

Type of operation: knee arthroscopy

Table 1: Wound infection rate by risk category

Wound infection rate

Type of

infection

Number of

departments

Number of

operations

Number of

wound

infections

Mean 25% quartile Median 75% quartile

A1 29 12261 11 0.09 0.00 0.00 0.00

A2, A3 29 12261 29 0.24 0.00 0.00 0.40

Table 2: Wound infection rate by infection type

Translation

In-house wound infection rate

Risk Category Number of

departments

Number of

operations

Number of

wound

infections

Mean 25% quartile Median 75% Quartile

0 29 7958 0 0.00 0.00 0.00 0.00

1, 2, 3 29 4303 12 0.28 0.00 0.00 1.16

0, 1, 2, 3 29 12261 12 0.10 0.00 0.00 0.60

KISS Hospital Infection Surveillance System

OP-KISS Model

Time period: January 2006 – December 2010 (cont.)

Table 3: In-house wound infection rate by risk category

In-house wound infection rate

Type of

infection

Number of

departments

Number of

operations

Number of

wound

infections

Mean 25% quartile Median 75% quartile

A1 29 12261 2 0.02 0.00 0.00 0.00

A2, A3 29 12261 10 0.08 0.00 0.00 0.05

Table 2: In-house wound infection rate by infection type

Notes:

• Risk category (per number) represents: operation length (in minutes)>55, wound classification >2 and ASA score* >2

• Only data from departments with at least 30 recorded operations are entered into the reference data

*American Society of Anaesthesiologists physical status classification system


In animal health, infectious illnesses have a similiar significance as in human medicine.

In addition, infectious illness cause serious economic difficulties in the agricultural livestock industries.

In the field of vetenary medicine, the outbreak and spread of resistant bacteria (both human and animal) is to be reduced as part of the antibiotic resistance strategy.

Through responsible use of antibiotics the health of the user is to be protected without damaging animal health.

Animal feed

“We can therefore assume that most battery hens receive antibiotics for around two-thirds of their lives –although they only live for 32 days“ – Hermann Focke,

author of ‘Tierschutz in Deutschland – Etikettenschwindel?!‘*

*The protection of animals in Germany – false labelling?!

In recent years Lower Saxony has established that antibiotic use in chicken feed has risen. In North Rhine-Westphalia an extensive investigation has been underway since the beginning of the year. It will report what quantities of medication are used by which companies. „It must be pointed out that the use of antibiotics is rising“ – Johannes Remmel (Green MP) quoted from NDR Info.

© dpa-Bildfunk Fotograf: Carmen Jaspersen

50% – 60% laMRSA* ?*livestock-acquired MRSA

Publicity

EHEC in Germany – Is this only the beginning?*

LATESTScientific forum Petersberg with Nina Ruge –

Broadcasted on 31/10/2010 at 1pm and 10.30pm on „Phönix“ (information channel from ARD and

ZDF):Illness due to clinical germs – The

underestimated dangerNina Ruge spoke with:Dr. Alexander Friedrich, Institut für Hygiene, Universitätsklinikum Münster (Institute for Hygiene, University clinic Münster) Dr. Burkhard Kirchhoff, patient lawyerDr. Rudolf Kösterst, President of the Deutsche Krankenhausgesellschaft (the German Association of Hospitals)Prof. Dr. Martin Mielke, leader in the field of applied infection and hospital hygiene, Robert-Koch-Institut Berlin

The revenge of bacteriaNew information on resistant microbes

The programme ARTE reported on the newest strategies and scientific knowledge in the fight

against bacteria on 15/10/2010 at 21.45.

Antibiotic research in the hands of the state? Is Germany and the world armed against

superbugs? Critical comments on the situation in Germany

Anne Will – Programme broadcasted on 29/8/2010 on ZDF: "Killer germs in hospitals

– How dangerous are our clinics?"

The ZDF programme "ML Mona-Lisa" broadcasted a report „Ill due to the hospital" on 29/08/2010 about the fate of one of our clients

3 dead infants in Mainz – Bacteria claims more victims in Germany!

Is the "Superbacterium“ NDM-1 really new? This development was foreseeable Our

summary of NDM-1!

*Verotoxin-producing

Escherichia coli

German Social Insurance Code V

Article 3

Change in the Fifth Book of the Social Insurance Code.

The Fifth Book of the Social Insurance Code – National Health Insurance – (Article 1 of the law from 20th December 1988, BGBl. I S. 2477, 2482), has been changed through Article 4 from 22nd June 2011 (BGBl. I S. 1202) as follows:

§ 87 has been amended as follows:

a) The following sentences are added to Paragraph 2a:

“With effect of 1st January 2012 a law is to be made for doctoral payments to be refunded for diagnostics and non-hospital eradication therapy, inclusive of electronic documents, for carriers of Methicillin-resistenten Staphylococcus aureus (MRSA) up to the 31st October 2011. The refund agreement is limited to two years.

German Social Insurance Code V

German Social Insurance Code V / § 137

The Joint Federal Committee decides on:

1. Guidelines for contracted doctoral care and registered hospitals so that they are fundamentally uniform for all patients (...) as well as compulsory measurements of quality assurance for the internal implemention of quality management and

2. Criteria for the necessity and quality of implemented diagnostic and therapeutic payments, in particular expensive medical payments; thereby establishing a minimum level of the quality of structures, processes and results.

Law for preventing and combating infectious diseases in humans

*

*The Federal Ministry of Health

“Church Hygiene“

According to § 33 of the hospital planning law of the state of North Rhine-Westphalia (KHGG NRW)from 11th Dezember 2007 (GV.NRW.S.702 f) i. d. F.from 16th March 2010 (GV.NRW.S.184)

On the basis of § 6 paragraph 2 of this law the decreed hospital hygiene regulations do not apply to Catholic hospitals.

The diocese of Münster is entitled in some circumstances to pass hospital hygiene rules.

“Church Hygiene“

The following applies to the diocese of Münster

§1 In Catholic hospitals in the sense of § 33 KHGG NRW the hospital hygiene regulations are to apply accordingly from 9th December 2009.

§2 It is permitted for hospital bodies to bring out further hygiene standards above the hygiene regulations.

Law for preventing and combating infectious diseases in humans

(Infection protection law - IfSG)

Draft date: 20/07/2000

Status:

Last changed through Article 1 G v. 28.7.2011 I 1622

§ 1 Aim of the law(1) The aim of the law is to:

(1) Prevent contagious diseases (2) Recognise infections earlier and (3) Stop them spreading further.

(2) For this necessary cooperation and collaboration of state, federal and local authorities as well as doctors, vets, hospitals, scientific institutions and other participators they should be equipped and supported by the current medical and epidemiological science and technology.

The seperate responsibilities of bodies and heads of community establishments, food companies, health institutions and of individuals for the prevention of contagious diseases should be clear and should be supported.

IfSG

1) At the Robert Koch Institute a Commission for Hospital Hygiene has been created.The commission makes recommendations for

• Preventing nosocomial infections• as well as operational/organisational• and structural/functional measures

for hygiene in hospitals and other medical institutions.

The recommendations of the commission are further developed with constant consideration of the latest research on the epidemiology of infection.

IfSG

2) At the Robert Koch Institute an Anti-infection, Resistance and Therapy Commision has been created.

The commission produces recommendations with general principles for diagnostics and anti-microbial therapy, particularly for infections with resistant bacteria.

The recommendations of the commission are further developed with constant consideration of the latest research on the epidemiology of infection.

IfSG

(3) The heads of the following establishments are to ensure:

• That the necessary measures according to the status of medical science are met

• To prevent nosocomial infection and

• To prevent the spread of bacteria, particularly those with resistances

IfSG §23

Observing the status of medical science is assumed, provided each of the published recommendations of the Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute and the Anti-infection, Resistance and Therapy Commission at the Robert Koch Institute have been followed.

IfSG §23

(4) The heads of hospitals and of establishments that provide out-patient care are to ensure:

• that the nosocomial infections established by the Robert Koch institute and

• the outbreak of bacteria with special resistances and multi-resistances

• are consistently recorded and evaluated in a special report and

• proper conclusions with regard to necessary prevention measures are made and

• that staff are informed of the necessary prevention measures and they are put into practice.

IfSG §23

In addition the heads are to guarantee that the (...)

• data on the type and extent of antibiotic use is consistently recorded in a summarised form

• which is evaluated with consideration of the local resistance situation and

• proper conclusions with regard to the use of antibiotics are made and

• that staff are informed of the necessary adjustments to antibiotics and they are put into practice.

• The records referred to in points 1 and 2 are to be stored for 10 years after they are made.

IfSG §23

(5) The heads of the following institutions have to guarentee that internal procedures for infection hygiene are established in hygiene plans: ...

IfSG §23

(8) The state governments have until the 31st March 2012 to arrange the necessary measures to prevent, recognise, record and combat nosocomial infections and pathogens with resistances; through legal regulation for hospitals, establishments for out-patient operations, care or rehabilitation establishments in which comparable medical care for hospitals takes place, as well as for dialysis clinics and day clinics. In addition specific regulation is to be to followed regarding:

1. Minimum requirements for the structure, equipping and running of the establishment2. Ordering, tasks and the make up of a hygiene commission,

IfSG §23

3. Equipping staff with hygiene specialists and hospital hygienists and

Appointing hygiene representatives (doctors).

Transitional provisions for qualifying a sufficient number of suitable staff members by 31st December 2016,

4. Tasks and requirements for further training in the implementation of necessary hygiene specialists, hospital hygienists and doctors who specialise in hygiene,

5. Qualifying and training staff with regard to infection prevention,

IfSG §23

Staff and organisational requirements for the prevention of nosocomial infections

Recommendations from the Commission for Hospital Hygiene and infection prevention

Measures for infection prevention are a considerable component of quality management.

Agencies as well as the hospital management or other medical institutions are responsible (§§ 35a, 37 SGB V).

Tab 3. Qualifications and tasks for hygiene representatives (doctors)

Requirements Specialist qualification in a clinical area of responsibility

Specialist doctor with authority to issue instructions

Tasks Operational/organisational

-Mediating decisions from the Hygiene Commission and their area

-Acting as a link between the treatment and hygiene teams

-Member of the Hygiene Commission

-Working together in special workgroups on questions of hospital hygiene and infection prevention (discussing working on standards)

Departmental/area support by specialist staff

-Analysing area-specific infection risks

-Implementing area-specific hygiene plans

-Training staff in hospital hygiene and infection prevention

-Carrying out infection surveillance in area of responsibility (reaching a consensus about the collected results)

Optimising antibiotic use

In his/her medical area of responsibility the hygiene representative contributes to optimising antibiotic use in cooperation with clinical/medical microbiology on the basis of patient-specific aspects, surveillance and resistance data

Outbreak management

-Quickly recognising outbreaks of infection (based on suspicions) and communicating this to the medical heads, hygiene specialist staff and, if necessary, the Department of Health.

-Responsible for clarifying complications from infections

-Introducing protective measures in close cooperation with other colleagues who deal with hygiene

-Collaborating with outbreak management (member of the outbreak team)

Tab 4. Qualifications and tasks of hygiene specialists

Requirements Qualified nurse with at least 3 years’ experience

Further training in hygiene


-Establishing hygiene, cleanliness and disinfection plans on the basis of guidelines

-Consultation tasks in creating medical goods/material

-Consulting patients and relatives

-Taking part preparing for management inspections in coordination with hygiene representatives

-Applying (?) measures for internal and external quality assurance in hospital hygiene

-Taking part in hygiene-relevant working circles, projects and quality groups

-Organising hygiene-relevant operational processes

Structural/functional

-On-location supervision of structural measures

-Planning procedural organisation

-Training staff in hospital hygiene and infection prevention

Departmental

-Implementing hygiene guidelines in care standards and relevant discussions with staff

-Control of translating recommended hygiene measures

-Supervising translating recommendations in the areas of care and waste disposal

-Helping on-location with applying infection prevention measures

-Training staff in the context of one-to-one discussions and lectures

Hygiene-microbiological investigations

-Sampling quality-assured hygiene-microbiological area investigations

Surveillance

-Recording and documenting nosocomial infections in collaboration with hygiene representatives/ hospital hygienists

-Cooperating with recording and evaluating bacteria with special characteristics (e.g. resistant/ multi-resistant)

-Taking part in establishing infection statistics

-Knowledge about possible infection routes

Outbreak management

-Helping with clarifying transmission chains in the context of outbreak management

-Collaborating with establishing final reports

-Collaborating with putting measures for the practical prevention of outbreaks into place

Tab 3. Qualifications and tasks for hygiene representatives in careRequirements Qualified nurse, with several years’ experience


-Communication partner as well as the connection to members of the hygiene teams

-Regularly taking part in hygiene training/ further education

- “Propagator” of hygiene-relevant topics in wards or area of work

-Taking part in workgroups/quality groups

Departmental/area support by specialist staff

-Collaborating to deal with area-specific infection risks

-Collaborating to establish area-specific hygiene plans and standards

-Small group lessons about correct hygiene practices for critical care measures

-Task-related transfer of correct hygiene practices in own area of responsibility

Outbreak management

-Early warning of clusters/outbreaks and information about transmission to the hygiene specialists

-Collaborating to organise coping with epidemic recurrent hospital infections

(cont.) In addition specific regulation is to be to followed regarding:

6. Stuctures and methods to recognise nosocomial infections and resistant bacteria and recording obligatory documentation requirements for doctors and nurses,

7. Inspecting 4 named people on file who fulfill each of their tasks in each institution including their patient files,

8.Information from staff about measures which are necessary for preventing and combating nosocomial infections and pathogens with resistances,

9. The clinical-microbiological and clinical-pharmaceutical consultation of doctors,

10. Information from relevant establishments and resident doctors about measures which are necessary for the prevention and combating of nosocomial infections and pathogens, such as rescheduling, referring or discharging patients.

IfSG §23

Pharmaceutical Inventory

The St. Franzikus-Hospital in Münster is the first hospital to establish a medicine discussion for in-patients. A hospital pharmacist records directly in the inventory all medication which the patient takes systematically, whether the medication has been wrongly received or whether the specific patient dose is correct.

IfSG

An infringement committed, which:

does not ensure that infections and pathogen outbreaks are recorded and prevention measures are implemented or explained, breaches § 23 Paragraph 4 Clause1,

does not ensure that data is recorded or adjustments are not implemented or explained, breaches § 23 Paragraph 4 Clause 2,

does not have records or has not kept records for the minimum of ten years, breaches § 23 Paragraph 4 Clause 3,

does not grant an inspection, breaches § 23 Paragraph 4 Clause 4,does not ensure that the named procedures are implemented,

breaches § 23 Paragraph 5 Clause 1 and is also connected with the regulation of § 23 Paragraph 5 Clause 2,

Strategies

8. O

snab

rück

er H

ygie

neta

g 20

10The task of the hygiene specialist (of the hygiene manager) is to investigate into the dangers of infection and from that

produce/ release, implement and examine procedural rules which have direct or indirect effects on infection.

Implementing “hygiene-musts”

Job-orientated tasks

Personal hygiene

Cleaning and disinfection

Room requirements/

projects

Purchasing requirements

Care and waste disposal

Establishing procedural rules

Implementing procedural rules

Creating requirements

Training staff

Advisory services

Practical instructions

Lectures/ lessons

Releasing procedural instructions

made by third parties

Inspections of areas

Observing work

Employee questionnaires

Structural/ functional

Area investigations

Statistics

e.g. infection statistics

e.g. resistance statistics

e.g. Hand-KISS

Adjustments to the status of science and

technology

Measures that act as checks

Records

Infection statistics• Wound infections• Outbreaks of noro viruses

Resistence statistics• § 23 IfSG• ESBL, MRSA, VRE

MRSA screening

Hand-KISS

Recordin

g + Assessm

ent

+ Consequences

Number of hand disinfections per day of care – average per quarter

Ward No.

Safety in hospital

Not just transparent but also comprehensible/ measurable

BenchmarksBenchmark/ benchmarking A benchmark or benchmarking ist a comparable analysis mit an established reference value

"If you can´t measure it, you can´t control it"

Summary

Staff structure:• Consultant for hospital hygiene

• Hygiene specialist

• Hygiene representatives (doctors)

• Hygiene representives in care

• Qualified training

• Description of tasks

• Regular training

= a rise in working achievement through four-fold increase in working time

Summary

Process structure:• Procedural rules for hygiene-relevant jobs

• Description of data collecting and analysis

• Defined documentation

• Development of measurement and evaluation methods

= rise in quality

Structure of results:

= quality management reports

Conclusion

Nothing has changed in terms of content but through a clearer formulation and an increasing awareness of the problems we can take a big step forward!

DART: The German Strategy for Combating Superbugs

Health & Medicine

Transcript of DART: The German Strategy for Combating Superbugs