More than a quarter of hospitals in Germany were not meeting hygiene recommendations in 2014, according to new research by CORRECTIV and the ARD magazine "Plusminus". The Berlin Ministry of Health puts the responsibility on federal states and individual clinics. The board of the health insurance company BKK has criticised what it calls "serious deficits".

Dangerous bacteria have an easy time of it in German clinics. Doctors don’t wash their hands often enough, which means that their surgical instruments become contaminated. Above all, there are too few skilled hygiene workers on the ground – in the hospitals – who understand the proper hygiene procedures which could help to fix the problem.

These are the conclusions of a joint evaluation of hospital quality reports and data from the BKK Landesverband Nordwest by CORRECTIV and the ARD magazine "Plusminus". According to the analysis, in 2014 more than a quarter of clinics in Germany did not have the recommended number of hygiene personnel. The worst state was Bremen, where 43 per cent of hospitals didn’t meet requirements. Next was Thuringia with 42 per cent, followed by Berlin with 37 per cent. Hamburg came the closest to meeting requirements, with only 10 percent of hospitals falling short on hygiene standards.

Dirk Janssen, vice-chancellor of the BKK-Landesverband Nordwest, considers the results alarming. They show the "serious deficiencies" of many hospitals in the handling of hygiene, he said, and if nothing changes "it costs [the lives of] thousands of patients every year".

Quality reports from the hospitals were the starting point for the analysis. Every year, every hospital in Germany must give an account of its facilities, standards and medical procedures. However, the reports are written in-house – and the reality could be even worse.

According to the recommendations of the national infection control agency, the Robert-Koch-Institute (RKI), if a hospital has more than 400 beds it should hire at least one person from each of these four professional groups:

1. Hospital hygienists - doctors who have undergone special training. They are responsible for hygiene in the hospital. They must be up-to-date with their training, have the time in their schedules to educate the other employees, and if there are problems inform the hospital's management and, hopefully, implement solutions.

2. Hygiene specialists - nurses who implement the hygienists' guidelines and who work closely with hospital staff.

3. Hygiene officers - responsible for setting the hygiene guidelines in each medical profession, and act as a contact point for staff.

4. Hygiene staff at nursing homes - responsible for setting the requirements among the carers at nursing homes.

If a hospital has fewer than 400 beds a full-time hospital hygienist is not required, though staff from the three other professions must be present.

The recommendations were made in 2009 and were then incorporated into the Federal Law on Infection Protection, as well as the hygiene regulations of each individual state. At the beginning of 2015 the Federal Minister for Health, Hermann Gröhe, presented a ten-point plan to fight hospital infections and resistant pathogens, which received a lot of media attention. One of the few concrete points in this is a funding program which should be used to recruit additional hygiene personnel by the end of 2016. After this transitional period, the hygiene regulations were finally binding.

But it did not go according to plan. The deadline was extended from the end of 2016 until the end of 2019. The recruitment of new staff has been sluggish. Why? The Ministry of Health says that this is the responsibility of the clinics and each federal state.

"The respective carriers or heads of the hospitals and medical facilities are responsible for implementing the plan", writes Sebastian Gülde, Ministry of Health press officer, by email. At the request of the Länder, the deadline has been extended to better attract sufficiently qualified staff.

"The hospitals have launched the initiative," said Walter Popp, vice president of the German Society for Hospital Hygiene. If sanctions weren’t used, the clinics could simply continue as before – and save the money meant for recruiting hospital hygienists. The salaries offered to hospital hygienists are also not adequate, Popp added.

There are also not enough training opportunities. Specialist training to be a hospital hygienist is only offered at the larger hospitals.

"Hospital hygiene has been neglected in Germany for decades," says Popp. It’s estimated there are at the most 300 hygiene doctors in Germany – but there are more than 350 hospitals, which should each have at least one hygiene doctor. In their quality reports many hospitals say that they employ a hospital hygienist. However these are often not in the required full-time positions, but are external consultants who only work part time. According to our data, at least 16 per cent of clinics with 400 beds or more only employ an external consultant, instead of a hospital hygienist in a full time position.

The data shows the names of the external hygiene consultants, which can be used to calculate how many different hospitals a single hygienist is advising. Andreas Schwarzkopf is the top performer of these flying physicians, he works in at least ten clinics in the south of Germany. And this is only the voluntary information in the quality reports. In fact the hygienists look after even more clinics than the data shows: Walter Popp says that according to his own data, Schwarzkopf has advised 12 clinics externally in 2014.

How is this achieved? Schwarzkopf is chauffeur driven about 2,000 km a week from clinic to clinic, and writes hygiene protocols and plans in the car. He tries to visit every clinic at least twice a year – he says that the bigger the hospital, the more often he visits. In order to try and ensure quality,he relies on the local staff, who can also reach him by mobile phone. He tells the hospitals that they are responsible if something goes wrong. His business is going well, he says. Schwarzkopf would like to hire additional hygienists, but currently can’t find the staff. "This job is not for everyone," he says.

Popp says that hiring external consultants comes at a high cost for the hospitals. The price is negotiable, so it can vary greatly. Popp does not want to say what his rates are. But he will say that there are no big profit margins if you pay attention to quality. For some other colleagues though, this could be a lucrative business. It is not sensible for a hygienist to take on too many hospitals.

Petra Gastmeier, head of the Institute for Hygiene at the Charité Hospital in Berlin, has also worked as an external hygiene consultant in the past. But not any more. "My head has only a certain storage capacity," she says. When a call comes from a hospital, you have to know immediately what the situation on the ground is, and who is part of the team dealing with the situation. As an external consultant this is only possible to a limited extent.

This is also the view of Franz Sitzmann, who’s worked as a hygienist for many years and has written several specialist books on the subject. "A hospital hygienist must be present and accessible," says Sitzmann, "hygiene cannot be prescribed from above“.  It’s not enough to have someone who passes through a few times a year.  

Johanna Knüppel, spokeswoman of the German Professional Association for Nursing Care, says it’s important to have sufficient hygiene staff. "What do hygiene specialists do? They monitor the staff who are working with the patients. Without them ‘everyday’ conditions return." And all too often this means a single carer in an intensive care unit that has to deal with several patients at the same time.

"Often a nurse has to cope with four or five patients," says Knüppel. They literally have their hands full – and because of this, perhaps they might not manage to disinfect their hands in between treating different patients.

Janssen is now calling for a binding commitment on the numbers of personnel who specialise in hygiene, nursing and cleaning. In addition, he wants there to be more stringent hygiene controls. Finally there is also a need for comprehensive reporting of antibiotic-resistant hospital pathogens, which so far only exists for a few of the germs.

If these changes are not made, writes Janssen, it might mean that thousands of people will die each year in Germany because they become infected with dangerous and sometimes resistant germs while they’re in hospital. Estimates range from 500,000 to one million infections a year – with 15,000 to 30,000 deaths, of which between a third and a half would be avoidable with better hygiene in hospitals. So between 5,000 and 15,000 peoples lives could be saved every year through better hygiene. Consider how much has been done to reduce the number of traffic incidents to 3,500 per year. Meanwhile, German hospitals are scrambling to get enough hygiene staff.

Translation: Victoria Parsons

We investigate multiresistant germs long term: correctiv.org/superbugs. Tips and questions to: hristio.boytchev@correctiv.org.

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