gms | German Medical Science

The new federal regulations for infection control in Germany (“Infektionsschutzgesetz”, Infection Protection Act [IfSG]) will significantly influence options and responsibilities in the fields of hygiene, documentation and billing in the out-patient and in-patient sector. An addition of the Social Insurance Code (Fünftes Buch Sozialgesetzbuch – SGB V), § 87, paragraph 2, for example introduces a compensation for medical diagnostics and outpatient eradication of MRSA carriers and their electronic documentation by 1^st January 2012.

The basis for the management and documentation of MRO in medical facilities are the IfSG and the recommendations given by the Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute (KRINKO).

Since 2006, hospitals can get a payback for additional efforts made in the treatment of MRO-patients. For this purpose, the special operation code OPS 8-987 was introduced. This code can be specified for patients who were diagnosed with multi-resistant pathogens from the code range U80 to U82 of the ICD-10-GM and a strict isolation is made according to the minimum characteristics of the code in terms of the recommendations by KRINKO. This includes the implementation of eradication and an exact-minute documentation of the additional nursing expenditure which has to include at least 2 hours per day [1]. This additional expenditure on maintenance and documentation is not always opposed by a surplus because the code is not necessarily relevant in the billing process.

In the out-patient sector, the situation is quite different: While the antimicrobial treatment of infections with MRO can be settled, the colonization with MRSA and other multidrug-resistant pathogens in Germany is still not defined as a disease and its treatment not yet eligible.

Moreover, extra costs for hygienic measures in medical practice have so far not been separately billable. Similarly, antiseptics necessary for antimicrobial treatment, even for infected patients, cannot be prescribed.

With the Infection Protection Amendment Act an accounting capability for the treatment of patients with MRO will be established in the outpatient care sector. At the same time an electronic documentation has to be introduced. In order to comply with the law demanding that the transfer of data concerning the carrier status of a patient should be done without any delays or errors and with minimal effort, inter-institutional and cross-sectorial standards for documentations should be used. This documentation should be done prompt, unambiguously, short and without redundancy. Transmission errors caused by additional notes, double documentation, ambiguous abbreviation, etc. should be avoided. The results from the documentation should be the following: time of service (when?), content (what?), provision (how?) and provider (who?). The documentation should be standardized and the employees are – concerning industrial law – to be obliged to work in accordance with the appropriate standards.

The documentation of services across multiple providers within a sector or with transition between sectors, i.e. a inter-institutional process documentation, can therefore be well planned in order to keep the effort low and can still meet all the requirements.

Based on these requirements, a cross-sectorial documentation and handover sheet was developed as part of the HICARE-project. In order to minimize double documentation, all aspects were combined into one document which can be used both in inpatient and outpatient care.

In cooperation with the Medical Service of the Health Funds Mecklenburg-West Pommerania (MDK MV e. V.), hospitals and regional networks of registered physicians, Grypsnet and HaffNET, a joint, standardized documentation sheet was developed at the Institute for Hygiene and Environmental Medicine at the University Medicine Greifswald.

This is acknowledged for the additional effort in the documentation by the MDK MV as the OPS 8-987.

Over a period of 6 weeks in the summer of 2011, a common documentation sheet was developed that corresponds to the requirements of all partners (Figure 1 [Fig. 1]). The document allows documentation of the colonization status and eradication based on fixed cycles of 7 days [1] each.

For safe identification of the patient, a large enough field for the patient identification sticker (B) is included. To document the location with the corresponding date, possible colonization sites are given in tabular form, in addition there is a free text field provided (A). The important differentiation for surveillance by colonization or infection by the attending physician can also document in a separate box (D). For documentation of the additional efforts in hospital settings in accordance with OPS 8-987, certain activities with a significant overhead are listed and are documentable by signature once a day (C). The definition of fixed, estimated times instead of individual documentation is a pragmatic compromise between accuracy and feasibility.

If the documentation is completely filled out, the patient's colonization, treatment status and the completed as well as the open tasks are directly visible by all health care workers.

The documentation sheet is meant as direct and freely usable offer for testing in routine use. It will be available for free in two versions on the website of HICARE (http://www.hicare.de).

The general form can be downloaded; a second version contains detailed recommendations for the restoration in the context of hygienic intervention within HICARE (EPIGO study).

Documentation is necessary but it is certainly not the primary task of health care. The sheet developed allows documenting the restoration process across sector and service providers. It was possible to describe the colonization or infection status, the care standard, the status of the restoration process and the control swabs. Thus, the status of the restoration process and necessary further steps can be recognized and requirements of both sectors are taken into account. From this, we expect a significant improvement of quality of documentation, a simplification of the detection performance, better communication between providers and payers and ultimately a higher treatment quality for patients.

Our proposal is subject to restrictions which should be considered:

So far, the documentation form has been accepted only by the MDK MV. When implementing it in other federal states, this should be clarified beforehand. Because the sheet was just introduced it is currently unclear whether further changes due to experiences in practical use will be required. Similarly, the arrangements for the medical documentation requirements in the sector of contract physicians are not yet known. These could still make necessary adjustments to.

Nevertheless, we believe that, with this sheet, we have established an essential basis for the important and legally required cross-sectorial information sharing and information recording.

A documentation which is standardized, cross-sectorial and meeting all relevant aspects is a complex, but manageable challenge. At the same time, it is the prerequisite for therapy success and the avoidance of information loss. Joint activities, such as in HICARE, can help to find pioneering solutions.

The authors would like to thank all participants in the HICARE partner organizations for their support and critical comments while developing this documentation sheet.

This work is supported by the Federal Ministry of Education and Research (BMBF) and the Ministry of Education, Science and Culture of the state Mecklenburg-West Pommerania.