Are hospitals a dangerous place for infection?

Everyday clinical practice : At the germ front

The public is terrified every time. In the past five years there have been repeated reports of premature babies being infected with dangerous germs in the hospital. That happened in Bremen, Mainz or at the Charité. And each time the question arises: How did this happen, what went wrong in the system?

These events on premature baby wards are only a very small part of a huge problem, albeit one that has an impact on the public, and which in principle can affect any hospital patient. Because the risk of contracting a pathogen in the hospital when the body is already weakened by another disease is a very real one - and so common that medical professionals have a technical term for it: nosocomial infection. New studies have shown that around 3.5 percent of all patients in the hospital become infected with bacteria or viruses. In Berlin alone that would be statistically 25,000 patients annually. These are, for example, urinary tract infections or inflamed surgical wounds, respiratory diseases or even sepsis, blood poisoning that can lead to kidney failure and death.

The pathogens drag the sick into the house themselves, but also visitors and staff. "Everyone has around two kilograms of bacteria in their intestines and billions on their skin," says Petra Gastmeier, chief hygienist at the Charité. "If these bacteria get into sterile areas of the body, for example via vascular or urinary tract catheters or ventilation tubes, an infection can occur." What are harmless microorganisms for most microorganisms can, under certain circumstances, be fatal for an immunocompromised hospital patient. A problem that the experts are well aware of: That is why every year in May there is the “Clean Hands Day”. On this day, clinic managers, politicians, doctors, nurses and nurses will find out what it means to be pore-deep. The World Health Organization has declared the day of action. In doing so, I want to point out a problem that is becoming an ever greater risk factor in hospitals around the world: dangerous microbes that pose a fatal risk to patients in hospital corridors, instruments and even on the hands of doctors and nursing staff. And how you can fight it: most effectively with regularly disinfected hands.

A real event is this day of action in some houses. UV lamps show how many stains on a hand remain unwetted if the disinfectant is incorrectly used and thus provide dangerous hiding places for pathogens on the skin of visitors and staff - a shock effect for some, and forgotten the next day for most. The message must therefore be repeated over and over again. It's about studying automatisms: “Disinfect your hands! Before every patient contact. "

A disinfectant dispenser should always be in the immediate vicinity of a hospital, say hygiene experts such as Klaus-Dieter Zastrow, board member of the German Society for Hospital Hygiene. “A donor costs 20 or 30 euros. Buying something like that in bulk makes sense. ”And hang them up in the right places. These things belong next to the bed, says Zastrow, who is also the chief hygienist of the state-owned clinic group Vivantes.

Other experts believe that visitor toilets and patient bathrooms should also be equipped with disinfectant dispensers. And every doctor and nurse can always carry a bottle with disinfectant in their smock.

And the patients themselves can also keep an eye on whether the nurse or doctor is disinfecting their hands before they deal with them.

Because hand disinfection As important as it is, one tries to capture and control it. That is why, for this book, regular participation in the Clean Hands campaign and the consumption of hand disinfectants on the wards were evaluated as quality indicators for the clinical hygiene comparison table (see page 26).

This overview appears for the second time after 2013 - now completely updated to the data from 2014. And it is still unique in Germany that hospitals in an entire region have voluntarily compared key data on clinical hygiene. This is not a matter of course, because these data, which are collected as part of the monitoring system for hospital infections with the rather cute name KISS (Hospital Infection Surveillance System), were previously only accessible to the facilities that were also involved .

Almost all of the Berlin hospitals listed in “Tagesspiegel KLINIKEN 2016” that supply data to the KISS have now released this internal information for publication. Once again more than when it was first published. A strong sign of the willingness to be transparent - that alone is a quality feature.

KISS was launched in 1997. The system is used for continuous monitoring of hospital infections and also for countermeasures. This includes, for example, the documentation of wound infections after operations, the number of patients who became infected with antibiotic-resistant germs in the hospital or the consumption of hand disinfectants.

Participation in the system is voluntary. The initially 20 hospitals involved have now grown to around 1,000 - out of 1,700 acute clinics in Germany. However, by far not all hospitals take part in the system in full; many only do so with individual specialist departments.

The National Reference Center for Hospital Hygiene (NRZ), which is based at the Charité and is headed by the chief hygienist Petra Gastmeier, takes over the analysis of the data supplied.

However, the clinics involved in the KISS have to do more than just fill out questionnaires, says Gastmeier. "At the beginning of the membership there is an introductory course for the clinic hygienists and the hygiene specialists and then every two years in Berlin an exchange of experiences."

The system is now networked across Europe, making it the second largest hygiene network after the USA, where around 11,000 hospitals participate in a comparable control system.

However, there is a deep rift running through the world of hygienists. Because KISS not only has supporters but also opponents. For example in the form of Klaus-Dieter Zastrow, who is also chairman of the professional association of clinical hygienists. His main criticism of KISS is: The system only allows retrospective data evaluation, i.e. only in the long term. And then it is often too late to take countermeasures.

The Bremen State Health Councilor Mathias Stauch sees it similarly. In his investigation report on the deaths in the premature baby ward at the Bremen-Mitte Clinic in 2010, it says: KISS “does not provide timely monitoring of germs.” The data would only be incorporated into the system with a considerable delay: after a child was discharged, subsequent findings would initially be made waited, wrote doctor's letters and closed the files. “Only then is the data entered into the system, sent to the reference system and processed there. The data are only meaningful after a considerable distance. "

KISS also offers the possibility of immediately transferring hygiene data to the NRZ for evaluation via internet access. And the clinics can also draw up-to-date evaluations from this. "So it is up to the hospital itself how quickly it gets the data," says KISS chief hygienist Gastmeier.

The critics but demand that there must be a monitoring system that automatically sounds the alarm after two or three unusual cases of infection have occurred in order to search for the causes immediately. Such a system has been set up for his clinic group, says Vivantes chief hygienist Zastrow. "Every hospital infection must be documented - and the completed registration form is sent to me by fax." If such cases occur frequently anywhere, Zastrow comes to the ward unannounced and looks for reasons. It could be that a nurse regularly does something wrong when changing dressings and thus infects patients.

But this system also calls critics on the scene. Could it not be that the ward doctors simply overlook some infections and do not report them? That is why hygiene specialists on the wards should regularly check the infection situation even without a specific reason, says Zastrow.

These professionals also monitor the air conditioning in the operating rooms. These are important so that a bead of sweat from the doctor, who is bending over the patient, does not drip into the wound with dangerous pathogens. On the other hand, the cool air must be low in germs. The operating theaters are locked during the exam, but the operation still has to be carried out. So everything is planned well in advance.

In earlier times, people like Petra Gastmeier or Klaus-Dieter Zastrow and colleagues were seen as disruptive factors in clinic operations. Many a chief physician grumbled: “I'm a surgeon, I have to be able to operate. I am not interested in hygiene. "And the economists let their supposed cleaners know:" Hygiene - only costs money and is of little use. "

The times have changed. Zastrow can now show a demonstrative self-confidence. He and his employees not only save some sick people from a lengthy and painful, sometimes fatal infection, they also save costs. For a number of years, flat-rate case fees have been in place in Germany, which means that the clinic receives a fixed sum for each illness treated - regardless of how many days the patient stays. The longer he stays in bed, the less the clinic earns from him. Studies have shown that patients who contract an infection of the surgical wound have to stay in the clinic an average of 7.3 days longer. Those who contract pneumonia in the hospital have to stay six days longer.

The authors of a study in the Vivantes Clinic in Friedrichshain have calculated that the treatment of a patient who has become infected with a multi-resistant pathogen (MRSA) in hospital costs an average of 11,000 euros. This was offset by proceeds from the health insurance companies of 3000 euros - a pure loss-making business. The cheapest solution is: listen to your hygienist! The most expensive consequence: a process. Because infections due to poor hygiene in the hospital are considered malpractice. And having to pay damages can be very expensive.

Legal requirements are also motivating. In Berlin, for example, a hygiene ordinance has been in place for all hospitals since 2012 (see page 28). All of this makes their job easier for hygienists. Now even chief physicians say: "Zastrow, come over and see why our patients here have an infection so often."

MRSA, the multi-resistant Staphylococcus aureus, is the most common multi-resistant pathogen. It can be found in the nose and on the skin, among other things. They are the best known of the antibiotic-insensitive germs, but not the nastiest. So-called gram-negative microbes that are in the patient's intestines have secured this title. "In some cases we are already observing pathogens against which all the antibiotics commonly used are no longer effective," says Charité hygienist Petra Gastmeier. "They put the doctors back in a situation like before the Second World War, when there were no antibiotics."

The only countermeasures are basic hygiene and contact isolation of the patient. Doctors then hang notes on room doors with lots of exclamation marks - “Isolation !!! Smock! Gloves! Hand disinfection when leaving! ”- and put small trolleys in front of them with disposable gloves, smocks and disinfectants.

But despite such countermeasures: the clinics cannot cope with this problem on their own. “For society as a whole, the use of antibiotics must be reduced and optimized in order to avoid the spread of multi-resistant bacteria,” says Gastmeier. “That affects both agriculture and human medicine.” In addition, multi-resistant pathogens are far more common in most countries than in Germany. "This means that there is also a high risk that such pathogens will be ingested unnoticed while traveling abroad and that they will settle in your own intestines for weeks, months or years."

Some hygiene experts cautiously explain whether and how new pathogens can enter the clinics with the refugees. Therefore it is too early to make any statements about it. Others, such as Klaus-Dieter Zastrow, see no problems here, as the tried and tested hygiene rules would also apply in these cases. However, the number of patients who would have to be isolated in the hospital because of bacterial colonization is now increasing. Zastrow also expects more tuberculosis patients to need treatment.

The so-called Legionella, which multiply in water and can cause life-threatening pneumonia in people with a weakened immune system, are also dangerous in hospitals. Special filters under the tap could help. The filter looks like an upside-down blue plastic cup. The filter can be kept for four weeks. Then a new one has to be found - costs: 20 euros each. A hospital cannot afford that for thousands of taps. That quickly adds up to millions of dollars. So it's always about the money ...

But the right use of money can save lives in real life. With consistent prevention, the number of infections in the clinic could be reduced by 30 percent. “No other infectious disease can be as successful as this,” says Vivantes Hygiene Manager Zastrow. His Charité colleague Petra Gastmeier also says: "At the clinics that join KISS and thus deal properly with the topic for the first time, we often observe a decrease in the number of infections by 20, sometimes even 30 percent."

Numbers whose general validity is difficult to prove. Because the clinical hygiene monitoring systems are in a fundamental dilemma when it comes to evaluating the success of the efforts. Actually, there are only two hard facts to judge the quality of hygiene measures in a hospital: the number of patients who have become infected in the hospital and the number of those who have died from it.

But neither of the two systems - neither the KISS nor the Vivantes system - provide such a number, simply because all patients and their infections would have to be constantly monitored. Even the estimates of how many patients die each year from an infection acquired in hospital vary widely. Zastrow speaks of 40,000 dead, Gastmeier 10,000 to 15,000 - and even of that, just a third can be influenced by the hospital. "Despite all the efforts, a certain number of nosocomial infections cannot be avoided," says Petra Gastmeier.

This only reveals one thing: reliable figures are in short supply in this area. Against this background, the Federal Joint Committee, the self-governing body in the German health system in which doctors, health insurers, clinics and patient representatives sit, commissioned a scientific institute to set up a quality indicator system for hospital hygiene. After several delays, among other things due to the change of the commissioned institute, this will probably start in 2016 with the newly founded quality institute. There is great public pressure and the clinics can no longer ignore the topic of infection prevention. Or, as Klaus-Dieter Zastrow puts it: "Hygiene is just part of medical practice - no ifs or buts."

Diseases and treatments

The editors of the magazine "Tagesspiegel Kliniken Berlin 2016" compared the Berlin clinics. For this purpose, the treatment numbers, the hospital recommendations of the outpatient doctors and the patient satisfaction were compiled in clear tables in order to make it easier for the patient to choose a clinic. The magazine costs 12.80 euros and is available in the Tagesspiegel shop.

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