Sepsis in der prähospitalen Notfallmedizin

Notfall + Rettungsmedizin - Die Sepsis ist eine notfallmedizinische Herausforderung – denn diese lebensbedrohliche Organdysfunktion, verursacht durch eine dysregulierte Wirtsantwort...     

Einführung eines Patientendatenmanagementsystems

Background

Patient data management systems (PDMS) enable digital documentation on intensive care units (ICU) and have positive effects on completness, quality and quantity of documented information. A commercial PDMS was implemented in a 25-bed ICU replacing paper-based patient charting. The ICU electronic patient record is completely managed inside the PDMS. IT compiles data from vital signs monitors, ventilators and further medical devices and facilitates some drug dose and fluid balance calculations as well as data reuse for administrative purposes. Ventilation time and patient severity scoring as well as coding of diagnoses and procedures is supported. Billing data transferred via interface to the central billing system of the hospital. Such benefits should show in measurable parameters, such as documented ventilator time, number of coded diagnoses and procedures and others. These parameters influence reimbursement in the German DRG system. Therefore, measurable changes in cost and reimbursement data of the ICU were expected.

Material and methods

A retrospective analysis of documentation quality parameters, cost data and mortality rate of a 25-bed surgical ICU within a German university hospital 3 years before (2004–2006) and 5 years after (2007–2011) PDMS implementation. Selected parameters were documented electronically, consistently and reproducibly for the complete time span of 8 years including those years where no electronic patient recording was available. The following parameters were included: number of cleared DRG, cleared ventilator time, case mix (CM), case mix index (CMI), length of stay, number of coded diagnoses and procedures, detailed overview of a specific procedure code based on daily Apache II and TISS Core 10 scores, mortality, total ICU costs and revenues and partial profits for specific ICU procedures, such as renal replacement therapy and blood products.

Results

Systematic shifts were detected over the study period, such as increasing case numbers and decreasing length of stay as well as annual fluctuations in severity of disease seen in the CM and CMI. After PDMS introduction, the total number of coded diagnoses increased but the proportion of DRG relevant diagnoses dropped significantly. The number of procedures increased (not significantly) and the number of procedures per case did not rise significantly. The procedure 8-980 showed a significant increase after PDMS introduction whereas the DRG-relevant proportion of those procedures dropped insignificantly. The number of ventilator-associated DRG cases as well as the total ventilator time increased but not significantly. Costs and revenues increased slightly but profit varied considerably from year to year in the 5 years after system implementation. A small increase was observed per case, per nursing day and per case mix point. Additional revenues for specific ICU procedures increased in the years before and dropped after PDMS implementation. There was an insignificant increase in ICU mortality rate from 7.4?% in the year 2006 (before) to 8.5?% in 2007 (after PDMS implementation). In the following years mortality dropped below the base level.

Conclusion

The implementation of the PDMS showed only small effects on documentation of reimbursement-relevant parameters which were too small to set off against the total investment. The method itself, a long-term follow-up of different parameters proved successful and can be adapted by other organizations. The quality of results depends on the availability of long-term parameters in good quality. No significant influence of PDMS on mortality was found.     

Qualit?tssicherung in der Einf��hrung neuer operativer Methoden

Robot assistance in the surgical treatment of urological malignancies is gaining increasing importance. As is the case in already established surgical procedures, the quality of robot-assisted surgery needs to be controlled and evaluated by appropriate measures. Baseline-parameters of treated patients should be documented precisely. General and operation type-specific parameters should be evaluated in short- as well as in mid-term follow-up. Appropriate and validated instruments should be used. Only by using these measures will it be possible to compare robot-assisted procedures of different institutions and historical data of conventional surgery with regard to oncological and functional efficacy.     

Kontinuierliche Qualitätsverbesserung in der präklinischen Notfallmedizin

In this article the first implementation step of a quality management (QM) model for continuous quality improvement (CQI), in particular the PDCA cycle, by using the example of the Medical University Innsbruck emergency department and the Austrian Red Cross, Freiwillige Rettung (Voluntary Rescue) Innsbruck (FRI) is described. Using two questionnaires concerning personnel satisfaction main problem areas were identified and improvements suggested. The results serve to discuss whether the two organizations involved fulfil the necessary conditions for the QM approach of CQI.     

Pädiatrische Notfälle in der prähospitalen Notfallmedizin

Background

In emergency medical services (EMS) systems, life-threatening pediatric emergencies comprise a rare indication but represent a particularly emotional and stressful situation for the personnel involved. This study aimed at evaluating the incidence of pediatric emergencies and the measures performed in ground-based and air-based German EMS systems and deriving the necessary skills and qualification of emergency physicians working within EMS systems.

Method

In a retrospective, multicenter study at three physician-staffed EMS systems with four ground based vehicles and one air-based EMS system the patient charts of patients over 18 years of age in 2005 and 2006 were analyzed regarding demography, the type and severity of emergency (NACA score), state of awareness (GCS) and emergency measures performed.

Results

Overall 20,386 patient charts were evaluated. Pediatric emergencies in the air-based EMS system comprised 11.5% of all missions, which is 2-3 fold higher compared to ground-based EMS system with 4.3%. The percentages of children with a NACA score of IV-VII or a GCS<9 in air-based EMS services (55.4% and 13.9%, respectively) exceeded by far the corresponding figures observed in the ground-based EMS systems (20.4%, p<0.01 and 5.8%, p<0.01). Non-traumatic emergencies represented the majority of missions in children aged <1 year and 1?? years. However, with increasing age injuries had a rising impact in the type of rescue mission. Whereas the frequency of certain emergency measures rose in both systems with increasing age of the pediatric patients, others remained constant, intubation of the trachea (7%) and emergency anesthesia (7%), or even declined along with increasing age, CPR (4% vs. 0.3%) and intraosseous access (3% vs. 0.0%). In comparison to the ground-based EMS systems, in the air-based EMS system the ECG monitoring (77% vs 32%, p<0.01), manual blood pressure measurement (80% vs. 51%, p<0.01), pulsoxymetry (96% vs. 73%, p<0.01)] and i.v. access (79% vs. 46%, p<0.01) were used more often and oxygen (73% vs. 32%, p<0.01) and drugs (80% vs. 49%, p<0.01) were administered more often. Also the frequency of intubation of the trachea and emergency anesthesia (17% vs 2%, p<0.01) was higher in air-based EMS systems than in ground-based EMS systems.

Conclusion

Ground-based and air-based EMS systems differ significantly regarding the incidence and the type of pediatric emergency missions. Despite the lower incidence of certain life-saving invasive emergency measures in ground-based EMS systems, the data indicate the necessity for both air-based as well as ground-based emergency physicians to undergo comprehensive and repetitive training in pediatric advanced life support.     

Patientenzufriedenheit in der pr?klinischen Notfallmedizin

Introduction

The study primarily aimed to develop a standardized, psychometrically tested and validated questionnaire to assess patient satisfaction with out-of hospital emergency care. The second aim was to analyze the quality of care provided by emergency medical services (EMS).

Methods

Accomplishment of tasks was designed in three sections a) interviews of focus groups to specify four quality categories (emergency call, emergency treatment, transport, admission to hospital) and development of a questionnaire, b) conduction of the main study and c) psychometric analysis and evaluation of the questionnaire regarding practicability, validity and reliability.

Results

A total of 437 questionnaires were evaluated and the four quality categories showed high satisfaction rates (means: 84?C94 points on a 0?C100 scale). The values correlated with the total quality score (r=0.6-0.81). In the main study transport showed the highest impact in total satisfaction, followed by emergency treatment. The item social support showed high dissatisfaction scores.

Conclusions

The psychometrically tested and validated questionnaire proved to be valuable for benchmarking studies. From the patient point of view satisfaction with out-of hospital emergency care can be improved regarding social environment and training of social and emotional skills of rescue personnel.     

Datenerfassung in der Anästhesie Erfahrungen bei der Einführung eines neuen Informationssystems

In many institutions information systems are used to process off-line anaesthesia data for invoices, statistical purposes, and quality assurance. Information systems are also increasingly being used to improve process control in order to reduce costs. Most of today’s systems were created when information technology and working processes in anaesthesia were very different from those in use today. Thus, many institutions must now replace their computer systems but are probably not aware of how complex this change will be. Modern information systems mostly use client-server architecture and relational data bases. Substituting an old system with a new one is frequently a greater task than designing a system from scratch. This article gives the conclusions drawn from the experience obtained when a large departmental computer system is redesigned in an university hospital. Methods: The new system was based on a client-server architecture and was developed by an external company without preceding conceptual analysis. Modules for patient, anaesthesia, surgical, and pain-service data were included. Data were analysed using a separate statistical package (RS/1 from Bolt Beranek), taking advantage of its powerful precompiled procedures. Results: Development and introduction of the new system took much more time and effort than expected despite the use of modern software tools. Introduction of the new program required intensive user training despite the choice of modern graphic screen layouts. Automatic data-reading systems could not be used, as too many faults occurred and the effort for the user was too high. However, after the initial problems were solved the system turned out to be a powerful tool for quality control (both process and outcome quality), billing, and scheduling. The statistical analysis of the data resulted in meaningful and relevant conclusions. Conclusions: Before creating a new information system, the working processes have to be analysed and, if possible, made more efficient; a detailed programme specification must then be made. A servicing and maintenance contract should be drawn up before the order is given to a company. Time periods of equal duration have to be scheduled for defining, writing, testing, and introducing the program. Modern client-server systems with relational data bases are by no means simpler to establish and maintain than previous mainframe systems with hierarchical data bases, and thus, experienced computer specialists need to be close at hand. We recommend collecting data only once for both statistics and quality control. To verify data quality, a system of random spot-sampling has to be established. Despite the large investments needed to build up such a system, we consider it a powerful tool for helping to solve the difficult daily problems of managing a surgical and anaesthesia unit.     

Einführung der präklinischen Notfallsonographie in einem ländlichen Notarztdienst-Bereich

Die Anaesthesiologie - Die Notfallsonographie im ärztlichen Rettungsdienst mit mobilen Geräten bringt, bei ansonsten präklinisch eingeschränkten diagnostischen...     

Qualitative Forschungsmethoden in der pr?klinischen Notfallmedizin

Qualitative research methods such as focus group interviews are rarely conducted in out-of-hospital emergency medicine, but such interviews are an important tool to evaluate patient satisfaction concerning the emergency treatment. Besides the medical skills of the emergency team, social, emotional and communicative skills increase the satisfaction of emergency patients and such skills can be analyzed more easily in a face-to-face contact with patients. The evaluation and improvement of these skills would enhance the quality of the emergency treatment, in particular from the perspective of emergency patients.     

Einführung des Emergency-Severity-Index in der Zentralen Notaufnahme

Background

Triage in the emergency department is a necessary tool in order to briefly evaluate and prioritize the acuity of patient symptoms. Despite the reliability and validity of this triage tool in the literature, a successful reorganization of the admission process by implementing the emergency severity index (ESI) could only be reached by the positive perception and acceptance of this tool in the daily routine. Therefore a staff attitude survey was conducted.

Methods

After implementation of the triage tool, the entire professional staff was interviewed by a standardized questionnaire 6 months later. In the emergency department of the Fürth Clinic a tertiary care level III hospital, questions to the emergency service (R), the nursing staff (P) and the physicians (Ä) before and after ESI implementation and about the training program were evaluated and categorized in the following categories: 0 not true, 1 sometimes true, 2 generally true, 3 always true. Mean values were considered (x??????).

Results

Prior to the implementation of ESI most patients were treated according to the waiting time (x??????_Ä 1.9; x??????_P 2.0; x??????_R 2.3), which led to a perceived dissatisfaction of waiting patients (x??????_P 2.1). The reorganization by implementing the triage tool was rated positively across all professions (x??????_Ä 2.2; x??????_P 2.7; x??????_R 2.5), as the interprofessional collaboration and perceptions of actual improvement in emergency service function, effect on own job and effect on patient care were all positively rated (x??????_Ä 1.9; x??????_P 2.2; x??????_R 2.1). Waiting patients were perceived to feel and act in a more satisfied manner (x??????_P 2.2). The triage training concept was considered from the triage nursing point of view as reasonable, necessary and effective (x??????_P 2.7). Both emergency services staff and physicians indicated a general acceptance of the triage tool (x??????_R 2.2; x??????_Ä 2.3) but felt that the individual expertise was not restricted (x??????_Ä 0.3; x??????_R 0.7).

Conclusions

All professions agreed the need for triage and the positive indications and effectiveness in optimizing the admissions process in the emergency department. By the stepwise introduction and training concept of ESI a positive perception and acceptance of the triage tool could be achieved.     

Durchführung einer prähospitalen Notfallnarkose und Atemwegssicherung

Background

The goal of rapid sequence induction (RSI) in cases of emergency situations is to secure the airway as quickly as possible to prevent pulmonary aspiration of gastric contents; however, the technique itself is not standardized. For example, the choice of drugs, application of cricoid pressure and the patient position remain controversial. A survey of emergency medical services (EMS) physicians throughout Germany was carried out to assess the different RSI techniques used and with respect to complying with the national guidelines for emergency airway management anesthesia and local standard operating procedures (SOP).

Material and methods

Between 1 April 2017 and 31 May 2017, EMS medical directors in Germany were contacted and asked to distribute a 28-question online questionnaire to local EMS physicians. Of the questions 26 were multiple choice and 2 with plain text. After 6 weeks an e?mail reminder was sent. In addition, the survey was distributed via social media to EMS physicians.

Results

In total the survey was opened 2314 times and 1074 completed responses were received (completion rate 46%). Most of the participants were male (78%) and anesthesiologists (70%) and only one quarter had a local SOP for RSI. The most frequently used muscle relaxant was succinylcholine (62%) and over half of the participants reported using cricoid pressure (57%). There was a distinction between the specialist disciplines in the selection of drugs. Propofol was used most by anesthesiologists, while the others still used etomidate on a larger scale. Nearly 100% could fall back on supraglottic devices (one third laryngeal mask, two thirds laryngeal tube) but only 32.8% with the recommended esophageal drainage. A video laryngoscope was available to 51% of all EMS physicians surveyed.

Conclusion

The results of the survey demonstrate heterogeneity in RSI techniques used by EMS physicians in Germany. Medical equipment and safe care practices, such as labeling of syringes varied considerably between different service areas. The recommendations of the S1 national guidelines on emergency airway management and anesthesia should be adhered to together with the implementation of local SOPs.

     

Einführung in das Thema

Trauma und Berufskrankheit -     

Zur Einführung

Ohne Zusammenfassung     

Vorsorgedokumente in der präklinischen Notfallmedizin

Background

The handling of advance directives (AD) in prehospital emergency treatment in Germany is characterized by instability. In the project “Advance directives in preclinical emergency medical aid” (“Patientenverfügungen in der präklinischen Notfallmedizin”) the frequency and quality of ADs in emergency situations was investigated.

Aim

The aim of this study was to fill the gaps in research and to collate data on how consideration of the self-determination of patients in emergency situations can be optimized.

Material and methods

Over a period of 12 months from December 2007 to December 2008 a questionnaire was included in the emergency documentation of the medical emergency service in Aachen. Emergency patients were asked by emergency physicians to provide an AD and the quantitative as well as qualitative features of these ADs were examined. Furthermore, the study recorded what kinds of problems occurred with ADs in emergency situations and what measures were needed to correct this deficiency. The reactions of patients were documented on a numeral rating scale with a score of 1 reflecting a negative and 10 reflecting a positive reaction. In the 12-month period emergency doctors recorded 1,321 missions and after application of the exclusion criteria (e.g. missing signature, incomplete documentation and late delivery) 1,047 documented questionnaires were available for the analysis.

Results

A total of 127 out of 1,047 emergency patients provided an AD, 44 had a durable power of attorney and 27 had appointed a legal representative for healthcare. Of the emergency patients 20 had a legal attendant and 43 out of the 127 ADs could be presented to the emergency team during the emergency mission. The emergency team often encountered difficulties regarding the handling of the ADs due to the time factor and unclear wording. The latter included the following problems: misleading formulation (19.1?%), difficulty with the complexity (14.9?%) and contradicting information (4?%). Only 29 (61.7?%) of the durable powers of attorney were signed and legally binding. From the view of the emergency physicians the following information was lacking but would be helpful in emergency situations: emergency plan, hierarchy of those given power of attorney, knowledge of risks regarding ADs and medication requirements.

Conclusion

The results show that for an AD to apply in an emergency situation certain standards are necessary that assure the practicability, especially if a patient does not wish to be resuscitated. Most difficulties with ADs occurred with imprecise formulation, text length and inconsistency of statements. The following instructions were usually missing: hierarchy of those given power of attorney and specification on medication, information about the scope of the ADs, statement about resuscitation, extent and limitations of the desired treatment, especially with patients certified as terminally ill and instructions on who should decide about medical treatment in a conflict situation. A so-called emergency instruction which gives on a single page the patient’s statement on resuscitation would have been very helpful in individual cases. The results suggest that patients may need more information and education about AD to guarantee patients rights and self-determination.     

9. Einführung

Zusammenfassung Bei der Beantwortung der Frage Manuelle Naht oder Maschinennaht müssen heute zwei Fakten berücksichtigt werden: 1. Die Verbesserung der Stapler und 2. das Vorliegen zahlreicher Studien mit klaren Aussagen. Danach haben Stapler eine hohe reproduzierbare Nahtsicherheit. Die Operationszeit lässt sich durch ihren Gebrauch verkürzen, insbesondere bei Rekonstruktionsverfahren nach Magenresektionen. Die operative Indikation wird durch ihre Anwendung erweitert, insbesondere bei der tiefen Rectumresektion. Ihr Einsatz birgt auch Gefahren und Fehlermöglichkeiten, auf die sich jeder Chirurg einstellen muss.     

66. Einführung

Ohne Zusammenfassung     

98. Einführung

Schlüsselwörter Das Magencarcinom ist durch das duale TNM- und das R-(Residualtumor)-System vergleichbar geworden. Davon hat auch die chirurgische Methodenwahl profitiert. Durch systematische Ausdehnung der Operation versucht man, auch beim ausgedehnteren Tumor (T₂, N₂, M₀) die örtliche Umschriebenheit operativ zu kompensieren. Besonderes Augenmerk gilt der radikalen Lymphadenektomie der Kompartimente 1 und 2. Durch bessere Techniken und geminderte Risiken nimmt der Trend zur kurativen Gastrektomie deutlich zu. Adjuvante Massnahmen und Forschung der Tumorzellbiologie machen aktuelles klinisches Interesse notwendig. Die angeblich festgefahrene Chirurgie des Magencarcinoms hat eine vielfältige erfreuliche Belebung erfahren.     

Erratum zu: Durchführung einer prähospitalen Notfallnarkose und Atemwegssicherung

Die Anaesthesiologie - Erratum zu: Anaesthesist 2018 https://doi.org/10.1007/s00101-018-0466-x In dem ursprünglich publizierten Artikel wurde im Namen des Autors T.K.&nbsp;Becker das...     

Blutstillung mittels Tourniquet in der präklinischen Notfallmedizin

Background

Until recently the use of tourniquets was considered to be obsolete due to the known side effects and complications. Tourniquet application was seen as a last resort to stop life-threatening extremity bleeding by placing “life before limb”. In the past the main reasons for complications were application errors and the use of poorly designed products.

Present situation

The actual loss of a limb due to tourniquet use is a rarity and now the positive experiences of the military conflicts in Iraq and Afghanistan are throwing a new light on this method to “stop the bleeding”. The SOP-based application of modern trusted and tested tourniquets by trained users for a period up to 2 h is considered to be a fast, safe and life-saving procedure.

Conclusions

This evidence is reflected by the current data; therefore, the civilian emergency services should be provided with commercially manufactured tourniquets. To prevent potential complications it is important that civilian medical personnel are regularly trained in the correct SOP-based use of tourniquets. Special police units should have personnel trained in tactical combat casualty care in the units who can control massive limb bleeding in a “care under fire” situation by tourniquet use before the civilian emergency medical services take over casualty care. In Germany the Tactical Rescue and Emergency Medicine Association (TREMA) has developed specific guidelines for tactical casualty care.