Katheterassoziierte Infektionen

Katheter-assoziierte Infektionen mit dem Schwerpunkt
ZVK
Walter Popp
Krankenhaushygiene, Universitätsklinikum Essen
Deutsche Anästhesie-Congress, 10. Mai 2009, Leipzig
Interaktiver Workshop Critical Care - facts, news and
perspectives,
organisiert von Baxter Deutschland GmbH
1
Hochrechnung der Anzahl nosokomialer Infektionen auf der Basis des
Krankenhaus-infektions-Surveillance-Systems (KISS)
Harnwegsinfektionen:
155.000
postoperative Wundinfektionen:
225.000
untere Atemweginfektionen:
davon Pneumonien:
80.000
60.000
primäre Sepsis:
20.000
andere (ca. 13 %):
70.000
Summe:
550.000
Gastmeier, Geffers: DMW 2008, 133, 1111
2
KRINKO (2002):
ZVKs sind für 90 % aller durch Gefäßzugänge verursachten
Infektionen verantwortlich.
Mittlere Septikämierate: 2,2 / 1.000 Kathetertage.
Zusätzliche Letalität durch Venenkatheterinfektionen: 4 – 25
%.
Mehr als 50 % könnten verhindert werden.
(Gastmeier, Geffers: J Hosp Infect 2006, 64, 326)
3
KISS-Daten 2003-2007
ZVK-assoziierte Sepsis
Stationen
Infektionen
Infektionen/1.000 DeviceTage
Mittelwert Median
Device-KISS
ITS-KISS
75%Quantil
49
107
2,58
0,00
0,95
Nur
Innere:20
92
3,37
0,00
3,36
482
4.977
1,60
1,09
2,21
4
KISS-Daten 2003-2007
ZVK-assoziierte Sepsis
Koagulase neg. Staph.
33 %
S. aureus
14 %
Davon MRSA: 38 %
Enterococcus spp.
14 %
Klebsiella spp.
5%
Candida albicans
4%
P. aeruginosa
4%
E. coli
4%
Enterobacter spp.
4%
Proteus spp.
1%
5
Hansen et al:
National influences on catheterassociated bloodstream infection rates:
practices among national surveillance
networks participating in the European
HELICS project
J Hosp Infect 2009, 71, 66-73
526 ICUs from 10 countries
CVC-BSI rates from 288 ICUs from 5
countries
1935 CVC-BSI cases
Figure 1. Central venous catheter (CVC)associated bloodstream infection (BSI)
rates of the five analysed countries
6
Mortalität und Liegedauer der Sepsis
Literatur
Fälle
Liegedauer
Mortalität
Laupland: J Hosp
Infect 2006, 63,
124-132
144
+ 2 Tage stationär (sign.)
+ 5 % (sign.)
Warren: Crit Care
Med 2006, 34,
2084-2089
41
+ 2,5 Tage stationär ICU (sign.)
+ 7,5 Tage stationär generell (sign.)
Wyllie: BMJ online,
2006;333:281
111
+ 50 % MRSA vs. MSSA
Laupland: JID 2008,
198, 336
1.508
+ 15 % MRSA vs. MSSA (sign.)
Sheng: J Hosp
Infect 2005, 59, 205
73
+ 15-17 Tage stationär
Orsi: Infect Control
Hosp Epidemiol
2002, 23, 190
105
+ 13-20 Tage stationär
Pittet: JAMA 1994,
271, 1598
86
+ 24 Tage stationär
+ 35 %
7
Kosten der Sepsis
n
Sepsis
Kosten
Land
Pittet: JAMA 1994, 271, 1598
86
Sepsis
Zusatzkosten pro Fall
40.000 $
USA
McHugh: Infect Control Hosp
Epidemiol 2004, 25, 424
20 MRSA
Decice-ass.
MRSA vs. MSSA
5.900 vs. 2.000 $
USA
Zusatzkosten bei
Case-Mix > 2
5.300 $
Shannon: Am J Med Qual
2006, 21, suppl, 7S
54
Decice-ass.
Zusatzkosten pro Fall
27.000 $
USA
Warren: Crit Care Med 2006,
34, 2084
41
Decice-ass.
Zusatzkosten pro Fall
12.000 $
USA
Kilgore: Am J Infect Control
2008, 36, S172e1
12.578
Sepsis
Kosten pro Fall
10.000 – 20.000 $
USA
Device-ass.
Zusatzkosten pro Fall
36.000 $
USA
ICU-ass.
Zusatzkosten pro Fall
12.000 $
Canada
Decice-ass.
Zusatzkosten pro Fall
6.200 £
UK
10-state project, 2009
Laupland: J Hosp Infect 2006,
63, 124
144
Zit. N. Jones: Br J Nursing
2006, 15, 362
Sheng: J Hosp Infect 2005, 59,
205
73
Sepsis
Zusatzkosten pro Fall
5.100 – 5.300 $
Taiwan
Orsi: Infect Control Hosp
Epidemiol 2002, 23, 190
105
Sepsis
Zusatzkosten pro Fall
16.400 €
Italien
8
Aktueller DRG-Katalog (Daten des Jahres 2007, Kalkulation durch das DRG-Institut InEK
6 DRGs, die spezifisch für die Hauptdiagnose Sepsis angesteuert werden.
9
Aus: Safdar, Maki: Inten Care Med 2004, 30, 62-67
10
KRINKO (2002) – ZVK legen
Regelmässige Schulungen (I A).
ZVKs aus Silikon und Polyurethan zu bevorzugen gegenüber PVC und Polyethylen (I
A).
Möglichst Single-Lumen-Katheter (I B).
Keine Aussage zu antimikrobiell oder antiseptisch beschichteten Kathetern (III). Keine
Aussage zu silberbeschichteten Kollagenmanschetten (III).
V. Subclavia (I B).
Keine Antibiotikaprophylaxe (III).
Hygienische Händedesinfektion vor Anlegen der Schutzkleidung (I A).
MNS, Haube, steriler Kittel, sterile Handschuhe (I A).
Desinfektion der Einstichstelle (I B).
Abdeckung mit grossem sterilen Tuch (I A).
Fixierung, Abdeckung…
11
KRINKO (2002) – ZVK legen
Regelmässige Schulungen (I A).
ZVKs aus Silikon und Polyurethan zu bevorzugen gegenüber PVC und Polyethylen (I
A).
Möglichst
Single-Lumen-Katheter
(I B).
Im
Jahr 2003
lagen auf 16
% der KISS-Intensivstationen keine
schriftlich
fixiertenoder
Standards
die ZVK-Anlage
Keine Aussage
zu antimikrobiell
antiseptisch für
beschichteten
Kathetern (III).vor.
Keine
Aussage zu silberbeschichteten Kollagenmanschetten (III).
Nur 43 % führten alle angeratenen Standards durch.
V. Subclavia (I B).
Keine Antibiotikaprophylaxe (III).
Hygienische Händedesinfektion vor Anlegen der Schutzkleidung (I A).
MNS, Haube, steriler Kittel, sterile Handschuhe (I A).
Vonberg et al: Anaesthesist 2005, 54, 975-982
Desinfektion der Einstichstelle (I B).
Abdeckung mit grossem sterilen Tuch (I A).
Fixierung, Abdeckung…
12
KRINKO (2002) – ZVK legen
Regelmässige Schulungen (I A).
ZVKs aus Silikon und Polyurethan zu bevorzugen gegenüber PVC und Polyethylen (I
A).
MöglichstCompliance
Single-Lumen-Katheter
(I B).
Niedrigste
mit Händedesinfektion
nach Beobachtung im
Rahmen
der
Saubere
Händebeschichteten
bei aseptischen
Keine Aussage
zu Aktion
antimikrobiell
oder antiseptisch
Kathetern Tätigkeiten.
(III). Keine
Aussage zu silberbeschichteten Kollagenmanschetten (III).
V. Subclavia (I B).
Ähnlich auch andere Studien.
Keine Antibiotikaprophylaxe (III).
Hygienische Händedesinfektion vor Anlegen der Schutzkleidung (I A).
MNS, Haube, steriler Kittel, sterile Handschuhe (I A).
Reichardt, Ulmer Symposium Krankenhausinfektionen, April 209
Desinfektion der Einstichstelle (I B).
Abdeckung mit grossem sterilen Tuch (I A).
Fixierung, Abdeckung…
13
Reservelæge Aline Iskandar, reservelæge Ngan Nguyen & professor Hans Jørn Kolmos
(Odense Universitetshospital, Forskningsenhed for Klinisk Mikrobiologi, Hygiejneorganisationen og
Klinisk Mikrobiologisk Afdeling)
Dispersal of Staphylococcus Aureus from nasal carriers
Ugeskr Læger 2009, 171, 420-423
Introduction: Staphylococcus aureus (Sa) is an important cause of hospital-acquired infections,
and nasal carriage of Sa is common among health care workers. This study was designed to
measure the airborne dispersal of Sa and other bacteria from such carriers and to investigate
whether the use of cap, gown, gloves, and mask could reduce this dispersal.
Material and methods: A total of 13 nasal Sa carriers were identified among 63 persons screened
for Sa nasal carriage. The volunteers were studied for airborne dispersal of Sa in four different
situations; quiet breathing, movements of the arms, whispering and loud talking. These
activities were performed with and without gown, gloves, mask and cap upon street clothes.
Results: The study showed that the highest number of Sa and bacteria in total was dispersed
into the air when the volunteers were moving and wearing only their street clothes. The
dispersal of Sa into the air was reduced into a minimum by wearing cap, gown and gloves,
and no further significant decrease was achieved by wearing a mask. This applied for all
volunteers except for one, who had to wear a mask in order to reduce his dispersal of Sa to a
minimum. The total dispersal of bacteria was significantly reduced by wearing cap, gown and gloves;
however, to reduce this dispersal to a minimum, volunteers also had to wear a mask.
Conclusion: Our study supports the rational basis that gown, cap, gloves and mask should be
used not only in the operating theatre, but also while e.g. inserting central venous catheters.
14
KRINKO (2002) – ZVK pflegen
Täglich inspizieren, bei Gazeverbänden palpieren (Druckschmerz, Fieber!) (I B).
Täglicher Verbandwechsel von Gazeverbänden bei eingeschränkter Kooperation des
Patienten (I B).
Wechsel der Transparentverbände spätestens nach 7 Tagen (I B).
Alkoholische Antiseptika auf Insertionsstelle bei Verbandwechsel (II).
Keine Salben bei Transparentverbänden (I B).
Kein routinemäßiger Wechsel (I A).
Wechsel bei Entzündung bzw. Tunnelinfektion sowie nach Notfallanlage (I B).
Indikation täglich neu prüfen (I B).
Spülung ggfs. mit steriler physiologischer Elektrolylösung (I A).
Keine Aussage zu „antibiotic lock technique“ oder
Heparinspülungen (III).
Keine Aussage zum „Ruhen“ (III).
15
Shapey et al: Central venous catheterrelated bloodstream infections: improving
post-insertion catheter care. J Hosp Infect
2009, 71, 117-122
Prospektiv über 28 Tage
Fragebogen und Beobachtung
Fehlerrate 45 %
Figure 1. Breach rate according to ward and aspect of
care. HDU, high-dependency unit; ICU, intensive care
unit.
16
HICPAC 2002 – zusätzliche interessante Empfehlungen
(Infect Control Hosp Epidemiol 2002, 23, 759-769)
Appropiate nursing staff levels in ICUs (category IB).
SHEA 2008: unresolved – nurse to patient ratio at least 2:1 (from observational studies)
Encourage patients to report any changes in their catheter site or any new discomfort (category II =
suggested for implementation).
Designate trained personnel for insertion and maintenance of IVCs (category IA).
SHEA 2008: Use a checklist – stop procedure if breaches in aseptic technic are observed
Conduct surveillance in ICUs and other patient populations (category IA).
Similar SHEA 2008
Investigate events leading to unexpected life-threatening or fatal outcomes (category IC = required by
state or federal regulations).
Antimicrobial or antiseptic-impregnated CVC in adults (expected catheter > 5 days) in ICUs with
infection rates above goal (category IB).
Similar SHEA 2008
Also use Chlorhexidine sponge dressings
SHEA/IDSA Practice Recommendation: Infect Control Hosp Epidemiol 2008, 29, suppl. 1, S22-S30)
17
Pronovost et al: An intervention to decrease catheter-related
bloodstream infections in the ICU. N Engl J Med 355, 2006,
2725-2732
103 ICUs, vorwiegend in Michigan
Bundle, u.a.
Ein Arzt und ein Pflegekraft als Team-Leader,
Kenntnisse verbreiten,
Telefonkonferenzen jede Woche,
Schulung durch Projektleitung,
zentrale Treffen zweimal im Jahr.
18
Pronovost et al: An intervention to decrease catheter-related
bloodstream infections in the ICU. N Engl J Med 355, 2006,
2725-2732
103 ICUs in Michigan
Bundle, u.a.
Ein Arzt und ein Pflegekraft als Team-Leader,
Kenntnisse verbreiten,
Telefonkonferenzen jede Woche,
Schulung durch Projektleitung,
Zentrale Treffen zweimal im Jahr.
19
Pronovost et al: An intervention to decrease catheter-related
bloodstream infections in the ICU. N Engl J Med 355, 2006,
2725-2732
Results A total of 108 ICUs agreed to participate in the study, and 103
reported data. The analysis included 1981 ICU-months of data and
103
ICUs in Michigan
375,757
catheter-days.
The median rate of catheter-related bloodstream
infection per 1000 catheter-days decreased from 2.7 infections at
baseline to 0 at 3 months after implementation of the study intervention (P
0.002),Bundle,
and theu.a.
mean rate per 1000 catheter-days decreased from 7.7 at
und
Pflegekraft
als Team-Leader,
baseline toEin
1.4Arzt
at 16
to ein
18 months
of follow-up
(P<0.002). The regression
Kenntnisse
verbreiten,
model showed
a significant
decrease in infection rates from baseline, with
Telefonkonferenzen
jede
Woche, from 0.62 (95% confidence
incidence-rate
ratios continuously
decreasing
Schulung
durchatProjektleitung,
interval [CI],
0.47 to 0.81)
0 to 3 months after implementation of the
Zentrale
zweimal
Jahr.
intervention
to 0.34 Treffen
(95% CI,
0.23 toim
0.50)
at 16 to 18 months.
20
Warren et al: The Effect of an Education Program on the Incidence of Central Venous
Catheter-Associated Bloodstream Infection in a Medical ICU. Chest 2004, 126, 16121618
Setting: The 19-bed medical ICU in a 1,400-bed university-affiliated urban teaching hospital.
Intervention: A mandatory education program directed toward ICU nurses and physicians was
developed by a multidisciplinary task force to highlight correct practices for the
prevention of catheter-associated bloodstream infection. The program consisted of a 10page self-study module on risk factors and practice modifications involved in catheterrelated bloodstream infections and in-services at scheduled staff meetings. Each
participant was required to complete a pretest before reviewing the study module and an
identical test after completion of the study module. Fact sheets and posters reinforcing
the information in the study module were also posted throughout the ICU.
21
Copyright ©2006 BMJ Publishing Group Ltd.
Hospital Policy for the Prevention of CatheterAssociated Bloodstream Infection Described in
the Study Module and Presented in the
Preintervention
and Postintervention
Warren et al: The Effect of an Education Program
on the Incidence
of Central Venous Tests
Catheter-Associated Bloodstream Infection in a Medical ICU. Chest 2004, 126, 16121.
Wash hands thoroughly or use an alcohol-based
1618
waterless disinfectant before and after patient contact.
2.
Disinfect hands and wear sterile gloves when
touching
or changing the
dressing
on the
catheter.
Setting: The 19-bed medical ICU in a 1,400-bed
university-affiliated
urban
teaching
hospital.
3.
Femoral catheters should be avoided. When placed
an emergency
situation,
femoral
catheter
Intervention: A mandatory education programindirected
toward ICU
nursesthe
and
physicians
was
should
be
discontinued
as
soon
as
feasible.
developed by a multidisciplinary task force to highlight correct practices for the
The person
placing
catheter
must wear
prevention of catheter-associated 4.
bloodstream
infection.
Thethe
program
consisted
of asterile
10gown,
sterile
gloves,
a
mask,
and
a
cap.
page self-study module on risk factors and practice modifications involved in catheterExcessive
hair around
insertion
siteEach
can be removed
related bloodstream infections and5.in-services
at scheduled
staff
meetings.
with scissors
clippers the
only.
participant was required to complete a pretest
before or
reviewing
study module and an
6.
The
insertion
site
and
an
area
of at reinforcing
least 15 cm in
identical test after completion of the study module. Fact sheets and posters
diameter
around
the site shall
be cleared with the
the information in the study module were
also posted
throughout
the ICU.
appropriate skin antiseptic.
7.
Drape the insertion site using full sterile drape.
8.
Use sterile technique to apply transparent dressing to
insertion site.
9.
Do not apply antimicrobial ointment to the insertion
site unless the central venous catheter is a dialysis
catheter.
10. Avoid changing catheters over a guide wire.
11. Change transparent membrane dressing no more
than every 7 d or when dressing becomes damp,
loosened, or soiled.
12. Follow hospital protocol for changing IV fluid
22
administration sets and cleaning of injection ports with
Copyright ©2006 BMJ Publishing Group Ltd.
appropriate antiseptic prior to accessing.
Monthly rate per 1,000 catheter-days of catheter-associated bloodstream infection from
January 2000 through December 2003
Warren D. K. et.al. Chest 2004;126:1612-1618
23
©2004 by American College of Chest Physicians
Warren et al: The Effect of an Education Program on the Incidence of Central Venous
Catheter-Associated Bloodstream Infection in a Medical ICU. Chest 2004, 126, 16121618
Setting: The 19-bed medical ICU in a 1,400-bed university-affiliated urban teaching hospital.
Intervention: A mandatory education program directed toward ICU nurses and physicians was
developed by a multidisciplinary task force to highlight correct practices for the
prevention of catheter-associated bloodstream infection. The program consisted of a 10page self-study module on risk factors and practice modifications involved in catheterrelated bloodstream infections and in-services at scheduled staff meetings. Each
participant was required to complete a pretest before reviewing the study module and an
identical test after completion of the study module. Fact sheets and posters reinforcing
the information in the study module were also posted throughout the ICU.
Measurements and main results: Seventy-four episodes of catheter-associated bloodstream
infection occurred in 7,879 catheter-days (9.4 per 1,000 catheter-days) in the 24 months
before the introduction of the education program. Following implementation of the
intervention, the rate of catheter-associated bloodstream infection decreased to 41
episodes in 7,455 catheter days (5.5 per 1,000 catheter-days) [p = 0.019]. The estimated
cost savings secondary to the decreased rate of catheter-associated bloodstream
infection for the 24 months following introduction of the education program was between
$103,600 and $1,573,000.
24
Copyright ©2006 BMJ Publishing Group Ltd.
Wyllie, D. H et al. BMJ 2006;333:281
Mortality after Staphylococcus aureus bacteraemia in two hospitals in Oxfordshire,
1997-2003: cohort study
Changes in rates of nosocomial bacteraemia over time.
Regression lines indicate change over time.
Asterisks indicate that the slope of the line is significant (P0.20 for the others)
Copyright ©2006 BMJ Publishing Group Ltd.
25
Figure 1. Trends in Percent MRSA and Incidence of Staphylococcus aureus Central Line–Associated
Bloodstream Infections in Intensive Care Units—National Nosocomial Infections Surveillance System,
1997–2004;
Pooled mean percent methicillin-resistant Staphylococcus aureus (MRSA) is calculated as the MRSA
central line–associated BSI (CLABSI) incidence divided by the sum of the MRSA CLABSI incidence and
the methicillin-susceptible S aureus (MSSA) CLABSI incidence. CLABSI incidence for 2005 is estimated
from log-linear models of the annual CLABSI trend. Error bars indicate 95% confidence intervals.
From: Burton: JAMA, 2009, 301, 727
26
Hospitalizations and Deaths Caused by Methicillin-Resistant Staphylococcus aureus,
United States, 1999–2005
Eili Klein,* David L. Smith,† and Ramanan Laxminarayan
Emerg Infect Dis 2007, 13, 1840
27
Perencevich, Pittet:
Preventing catheter-related bloodstream infections. Thinking outside the checklist.
Editorial.
JAMA 2009, 301, 1285-1287
Approximately 80.000 catheter-related bloodstream infections occur annually in US
intensive care units (ICUs) and are associated with as many as 24 000 patient deaths.
Each of these infections is estimated to have a mean attributable cost of $18 000 and an
associated excess hospital stay of 12 days per episode.
…
To counteract this, since October 2008, the Centers for Medicare & Medicaid Services will
no longer reimburse hospitals for expenses associated with catheter-related bloodstream
infections. Similar strategies have been proposed in some countries in Europe and
elsewhere.
…
starting in January 2010 the Joint Commission's Hospital Accreditation Program National
Patient Safety Goals will require the use of a catheter checklist and a standardized protocol
for central venous catheter (CVC) insertion, along with other measures.
The most frequently cited bundle of interventions includes appropriate hand hygiene, use of
chlorhexidine for skin antisepsis, use of maximal sterile barrier precautions (mask, sterile
gown, sterile gloves, and large sterile drapes) during catheter insertion, avoidance of the
femoral vein, and prompt removal of unnecessary catheters. Adherence to these basic
infection control practices was tracked using a checklist and was associated with a 66%
reduction in catheter-related bloodstream infections in a quasi-experimental study.
28
Copyright ©2006 BMJ Publishing Group Ltd.
The Joint Commission
Accreditation Program: Hospital
National patient safety goals
2008
Goal 7: Reduce the risk of health care associated infections.
NPSG.07.04.01
Implement best practices or evidence-based guidelines to prevent
central line-associated bloodstream infections
Beginn in 2009,
Tests (milestones) in 3-Monats-Abständen,
Volle Implementierung 2010, u.a.:
Schulung benannter Mitarbeiter,
Unterrichtung der Patienten und ihrer Angehörigen,
periodische Erfassung von Infektionen und Compliance,
Standardprotokoll beim Legen und Checkliste,
routinemäßige tägliche Evaluation der Notwendigkeit des Liegens.
29
Copyright ©2006 BMJ Publishing Group Ltd.
Institute for Healthcare Improvement, 2007
Central line bundle elements
1.
2.
3.
4.
5.
Hand hygiene
Maximal barrier precautions
Chlorhexidine skin antisepsis
Optimal catheter site selection, with avoidance of
using the femoral vein for central venous access in
adult patients
Daily review of line necessity with prompt removal
of unnecessary lines
30
Key Change: Central Line Checklist
• Have the nurse document compliance with the insertion criteria
at the time of insertion.
• Create a culture of safety and prevention:
☺
empower nurses to stop line placement if improper
techniques are used
• Instruct nurses in use of critical communication strategies to
facilitate important exchanges.
e.g. “the sterile field has been contaminated,” rather than
“You contaminated the catheter!”
31
How patients and family members can help:
Watch the hospital staff to make sure they wash their hands
before and after working with the patient. Do not be afraid to
remind them to wash their hands!
Ask the doctors and nurses lots of questions before you agree
to a line.
Questions can include: Which vein will you use to put in the
line? How will you clean the skin when the line goes in? What
steps are you taking to lower the risk of infection?
Make sure the doctors and nurses check the line every day for
signs of infection. They should only replace the line when
needed and not on a schedule.
(Infoflyer für Patienten)
32
Copyright ©2006 BMJ Publishing Group Ltd.
Erfolge in Frankreich
Nationales Programm 1999-2004:
Krankenhaushygienische Struktur: 1 Facharzt für 800 Betten, eine
Fachkraft für 400 Betten.
Empfehlungen bekanntmachen.
Surveillance in allen Häusern alle 5 Jahre und Meldung ernster NI an
zentrale Institution.
Patienten und Öffentlichkeit besser informieren.
Nationales Programm 2005-2008:
Punktesystem für Erfüllung krankenhaushygienischer Anforderungen.
Erfassung von Wundinfektionen.
Erfassung Händedesinfektionsmittelverbrauch.
MRSA/1.000 Patiententage.
Antibiotikaverbrauch/1.000 Patiententage.
Hajjar: J Hosp Infect 2008, 70, 17-21
33
Copyright ©2006 BMJ Publishing Group Ltd.
Eurosurveillance, Volume 13, Issue 46, 13 November 2008
34
Copyright ©2006 BMJ Publishing Group Ltd.
Daten von 170 NHS trusts
35
Copyright ©2006 BMJ Publishing Group Ltd.
Was tun?
Bundle?
Checkliste?
Personal!
Hand hygiene
Maximal barrier precautions
Skin antisepsis
Optimal catheter site selection, not femoral vein
Daily review of line necessity with prompt removal of unnecessary lines
Surveillance?
Zahl der Blutkulturen Antibiotika früh Personalaufwand!
Underreporting mit der Zeit?
Evtl. Meldepflicht von MRSA in Blutkulturen ab 2009?
Nutzung von Routineparametern BQS?
Pay for performance?
Aber: Medicare steigt aus
Neue Produkte, z.B. Beschichtungen
36