[Standardized collection of presenting complaints in the emergency room : Integration of coded presenting complaints into the electronic medical record system of an emergency department and their value for health care research]

[Structured triage in the emergency department via intelligent assistant service OPTINOFA : Results of a multicenter, cluster-randomized and controlled interventional study in Germany]

In Germany, a substantial reform of emergency care is strictly recommended. Regulation of patient flows into the ambulatory and stationary sectors remains a major issue.In the OPTINOFA project funded by Innovationsfunds, a new triage system was developed for a structured primary evaluation of both urgency and care level of emergency cases. OPTINOFA was evaluated in a cluster-randomized, controlled multicenter trial using a stepped-wedge design in eight emergency departments (ED) from 1 July 2019 to 31 May 2021. Additionally, data from one ED were used for comparison of temporal changes without intervention. The primary study endpoint represented the increase of patient transfers to the ambulatory sector; secondary endpoints included the outcome, process and quality indicators as well as mean emergency care costs.In the study, 46,558 emergency cases were included in the control period and 37,485 emergency cases in the intervention period. Concerning the primary endpoint, a significant increase of transfers to the ambulatory sector were detected in the per-protocol EDs (p < 0.001, odds ratio = 10.59). Waiting times were significantly reduced by an average 20 min in the intervention phase. Furthermore, a stable admission rate was found within 3 days after initial ED presentation. Cost analysis revealed no increase of treatment expenses within 28 days after ED admission.In this project a valid assistant service for structured primary evaluation of urgency and care level was successfully developed for emergency cases and served as a digital triage instrument with interoperable format. Clinical trial results revealed great potential for the OPTINOFA triage system to control patient flows in emergency and acute medicine.

Evaluation of an Automated Decision Aid for the Further Referral of Emergency Room Patients—A Prospective Cohort Study

BACKGROUND

Instruments for the initial evaluation of emergency room patients as an aid to their onward referral to ambulatory care structures are a matter of current interest. In this study, we assess the safety of the software application SmED-Kontakt+ for this purpose. SmED is an abbreviation for Strukuturierte Medizinische Ersteinschätzung Deutschland, "structured initial medical evaluation in Germany."

METHODS

In this prospective cohort study, we compared the recommendations of SmED-Kontakt+ concerning the time and place of further care with those of the treating physicians. The subjects were adult patients who were able to walk and had presented themselves to the emergency room. Whenever SmED-Kontakt+ assessed the situation less critically than the physicians, and in 5% of the remaining cases, the potential endangerment of patient safety was assessed by an expert panel (expected value <1%).

RESULTS

In a total of 1840 cases, SmED-Kontakt+ agreed with the physicians' assessment in 353 (19%). The assessment of SmED-Kontakt+ was more critical in 1221 cases (66%) and less critical in 266 (15%; potential undertriage). There was potential endangerment in 49 cases (2.7%; 95% confidence interval [2.0; 3.5]). Potential endangerment was less common among patients in the more urgent recommendation categories [0.1; 2.6] and more common in the categories of a recommended outpatient physician visit or telephone consultation within or beyond 24 hours [2.4; 17.2].

CONCLUSION

SmED-Kontakt+ generally assessed these patients' needs for further care as more urgent than the treating physicians did. Nevertheless, the percentage of potentially endangered patients was higher than expected. We conclude that further care should be provided in timely fashion with an obligatory appointment. The sites of further ambulatory care should be immediately accessible and properly equipped. Patients should not be referred for further care at later times on the basis of an SmED-Kontakt+ assessment.

External Validation of the SMART Medical Clearance Form for Emergency Patients With Psychiatric Manifestations

BACKGROUND

The SMART Medical Clearance Form, developed in the USA, is used to standardize the medical evaluation of emergency patients with primarily psychiatric manifestations. The goal of this study was external validation of the use of this form.

METHODS

Data were collected retrospectively on emergency patients with psychiatric manifestations. The combined primary clinical endpoint consisted of hospitalization, repeated presentation to the emergency room, and/or death within 30 days.

RESULTS

From September 2019 to June 2022, 2404 patients presented with psychiatric manifestations to the emergency room of the Cantonal Hospital of Lucerne, Switzerland, of whom 674 were included in the study. 134 did not satisfy any of the parameters of the SMART Medical Clearance Form (the nSMART group), while 540 satisfied at least one parameter (the pSMART group). In the nSMART group, there were no hospitalizations for a medical indication, no repeated presentations for medical reasons, and no deaths within 30 days. In the pSMART group, there were 90 hospitalizations, 4 repeated presentations, and 4 deaths within 30 days. Although 44% of the patients in the nSMART group underwent further diagnostic studies, such as imaging or laboratory tests, none of these studies led to any change in these patients' further clinical management.

CONCLUSION

Use of the SMART Medical Clearance Form apparently enables safe standardized processing of patients with psychiatric manifestations in the emergency room.

Assessment of Patient Matters in Healthcare Facilities

BACKGROUND AND OBJECTIVES

Ensuring the sustainability of healthcare facilities requires the evaluation of patient matters with appropriate methods and tools. The objective of this research is to develop a new tool for assessing patient matters as a component of social responsibility requirements that contribute to the sustainability of healthcare facilities.

MATERIALS AND METHODS

We carried out an analytical observational study in which, starting from the domains of the reference framework for the sustainability of health facilities (economic, environmental, social, provision of sustainable medical care services and management processes), we designed indicators that describe patient matters. To achieve this, we extracted from the scientific literature the most recent data and aspects related to patient matters that have been reported by representative hospitals from all over the world. These were organized into the four sequences of the quality cycle. We designed the method of evaluating the indicators based on the information couple achievement degree-importance of the indicator. In the experimental part of the study, we validated the indicators for the evaluation of patient matters and the evaluation method at an emergency hospital with an orthopedic profile.

RESULTS

We developed the patient matters indicator matrix, the content of the 8 indicators that make it up, questions for the evaluation of the indicators, and the evaluation grids of the indicators. They describe five levels for each variable of the achievement degree-importance couple. The practical testing of the indicators at the emergency hospital allowed the calculation of sustainability indicators and the development of a prioritization matrix for improvement measures.

CONCLUSIONS

Indicators designed in this research cover social responsibility requirements that describe patient matters. They are compatible and can be used by health facilities along with other implemented national and international requirements. Their added value consists in promoting social responsibility and sustainable development of healthcare facilities.

Regional Anesthesia for Acute Pain Treatment in Pre-Hospital and In-Hospital Emergency Medicine

BACKGROUND

More than half of all emergency department patients seek help for acute pain, which is usually of musculoskeletal origin. Acute pain is often inadequately treated even today, particularly in children and in older patients. In this study, we assess the potential role of regional anesthetic methods in improving the treatment of pain in the preclinical and clinical emergency setting.

METHODS

Pain-related reasons for admission were identified and quantified from emergency admission data. A structured literature search was carried out for clinical studies on the treatment of pain in the emergency setting, and a before-and-after comparison of the pain relief achieved with established vs. newer regional anesthetic methods was performed.

RESULTS

43% of emergency patients presented with acute musculoskeletal pain. The literature search yielded 3732 hits for screening; data on entity-specific pain therapy spectra were extracted from 153 studies and presented for the main pain regions. The degree of pain relief obtained through regional anesthetic procedures, on a nominal rating scale from 0 to 10, was 4 to 7 points for acute back and chest wall pain, >6 for shoulder pain, 5 to 7 for hand and forearm injuries, and >4 for hip fractures. These results were as good as, or better than, those obtained by analgesia/sedation with strong opioids.

CONCLUSION

Modern regional anesthetic techniques can improve acute pain management in the emergency department and, to some extent, in the pre-hospital setting as well. Pain relief with these techniques is quantifiably better than with strong opioids in some clinical situations; moreover, there is evidence of further advantages including process optimization and fewer complications. Data for comparative study remain scarce because of a lack of standardization.

Patients pathways before and after treatments in emergency departments: A retrospective analysis of secondary data in Germany

Increasing emergency department (ED) utilization induces considerable pressure on ED staff and organization in Germany. Reasons for certain ED attendances are seen partly in insufficient continuity of care outside of hospitals. To explore the health care patterns before and after an ED attendance in Germany, we used claims data from nine statutory health insurance funds, covering around 25 % of statutory health insurees (1). We descriptively analyzed ED attendances for adult patients in 2016 according to their sociodemographic characteristics and diagnoses (2). Based on the ED attendance as initial event, we investigated health care provider utilization 180 days before and after the respective ED treatment and are presented by means of Sankey diagrams. In total, 4,757,536 ED cases of 3,164,343 insured individuals were analyzed. Back pain was the most frequent diagnosis in outpatient ED cases (5.0 %), and 80.2 % of the patients visited primary care physicians or specialists 180 days before and 78.8 % 180 days after ED treatment. Among inpatient cases, heart failure (4.6 %) was the leading diagnosis and 74.6 % used primary care physicians or specialists 180 days before and 65.1 % 180 days after ED treatment. The ED re-attendance slightly increased for back pain (4.9 % to 7.9 %) and decreased for heart failure (13.4 % to 12.6 %).

[Acute dyspnea]

ACUTE DYSPNEA

The leading symptom "acute dyspnea" and the causal underlying diseases have a high risk potential for an unfavorable course of treatment with a high letality. This overview of possible causes, diagnostic procedures and guideline-based therapy is intended to help implement a targeted and structured emergency medical care in the emergency department. The leading symptom "acute dyspnea" is present in 10% of prehospital and 4-7% of patients in the emergency department. The most common conditions in the emergency department with the leading symptom "acute dyspnea" are heart failure in 25%, COPD in 15%, pneumonia in 13%, respiratory disorders in 8%, and pulmonary embolism in 4%. In 18% of cases, the leading symptom "acute dyspnea" is sepsis. The in-hospital letality is high and amounts to 9%. In critically ill patients in the non-traumatologic resuscitation room, respiratory disorders (B-problems) are present in 26-29%. In addition to cardiovascular disease, noncardiovascular disease may underlie "acute dyspnea" and requires differential diagnostic consideration. A structured approach can contribute to a high degree of certainty in the clarification of the leading symptom "acute dyspnea".

[The way to routine data from 16 emergency departments for cross-sectoral health services research : Experiences, challenges and solution approaches from the extraction of pseudonymous data for the INDEED project]

BACKGROUND

In Germany there is currently no health reporting on cross-sectoral care patterns in the context of an emergency department care treatment. The INDEED project (Utilization and trans-sectoral patterns of care for patients admitted to emergency departments in Germany) collects routine data from 16 emergency departments, which are later merged with outpatient billing data from 2014 to 2017 on an individual level.

AIM

The methodological challenges in planning of the internal merging of routine clinical and administrative data from emergency departments in Germany up to the final data extraction are presented together with possible solution approaches.

METHODS

Data were selected in an iterative process according to the research questions, medical relevance, and assumed data availability. After a preparatory phase to clarify formalities (including data protection, ethics), review test data and correct if necessary, the encrypted and pseudonymous data extraction was performed.

RESULTS

Data from the 16 cooperating emergency departments came mostly from the emergency department and hospital information systems. There was considerable heterogeneity in the data. Not all variables were available in every emergency department because, for example, they were not standardized and digitally available or the extraction effort was judged to be too high.

CONCLUSION

Relevant data from emergency departments are stored in different structures and in several IT systems. Thus, the creation of a harmonized data set requires considerable resources on the part of the hospital as well as the data processing unit. This needs to be generously calculated for future projects.

Hospital Emergency Departments—Utilization and Resource Deployment in the Hospital as a Function of the Type of Referral

BACKGROUND

Inpatient admission rates and the resources required upon admission to the hospital were studied as a function of the type of referral to the emergency department (ED) of a university hospital.

METHODS

We retrospectively analyzed data concerning patients who were treated in the ED of the University of Leipzig Medical Center in 2019. The following data were recorded: process data, type of referral, hospital admission vs. discharge from the ED, and leading symptom according to classification as "trauma" or "non-trauma." For all admitted patients, the Patient Clinical Complexity Level (PCCL), length of hospital stay, and intensive care (yes/no) with or without ventilation were recorded.

RESULTS

Data on 34 178 patients (50.9 ± 22.2 years, 53.8% male) were analyzed; 28.8% of patients were referred because of "trauma," and the remaining 71.2% for "non trauma". The most common sources of referral were the rescue and emergency medical services (47.7%) and the patients themselves (self-referrals, 44.7%); 7.6% of the patients were referred by a resident doctor or general practitioner (physician). 62.6% were discharged from the ED after diagnosis and treatment, while 37.4% were admitted to the hospital. In comparison with self-referred patients as a baseline, the likelihood of inpatient admission was higher when the patient was referred by a physician (adjusted odds ratio [OR] 2.2), by the emergency rescue service without an emer - gency physician (OR 3.4), by an emergency physician (OR 9.3), or by the helicopter rescue service (OR 44.1). 49.1% of patients with trauma referred themselves to the ER, and 36% were referred by the emergency rescue service. Older and male patients were more likely to be admitted to the hospital, especially for non-trauma. 30.4% of the admitted patients required intensive care, and 35.5% of the patients in intensive care required ventilation.

CONCLUSION

Whether a patient is admitted to the hospital depends on the source of the referral and the leading symptom on arrival in the ED. One in every six self-referred patients is admitted to the hospital, particularly when the reason for presenting to the ER is non-traumatic and some of them go on to receive intensive care. The high percentage (around 95%) of self-referred trauma patients that are discharged from the ED presumably indicates that they were referred mainly for the exclusion of dangerous conditions, and/or that appropriate care options are lacking in the community setting.

[Structure and Organization of an Emergency Department]

The more diverse the German hospital landscape, the more important it is to define tasks and processes in order to ensure a uniform standard of care at the highest level for the population. With the introduction of additional training in clinical acute and emergency medicine and specifications for inpatient emergency care, important foundations for the necessary structure of emergency rooms have been given.

[AKTIN - The German Emergency Department Data Registry - real-time data from emergency medicine : Implementation and first results from 15 emergency departments with focus on Federal Joint Committee's guidelines on acuity assessment]

BACKGROUND

Emergency care in Germany is in transition. Emergency departments (EDs) treat their patients based on symptoms and acuity. However, this perspective is not reflected in claims data. The aim of the AKTIN project was to establish an Emergency Department Data Registry as a data privacy-compliant infrastructure for the use of routine medical data.

METHODS

Data from the respective documentation systems are continuously transmitted to local data warehouses using a standardized interface. They are available for several applications such as internal reports but also multicentre studies, in compliance with data privacy regulations. Based on a 12-months period we evaluate the population with focus on acuity assessment (triage) and vital parameters in combination with presenting complaints.

RESULTS

For the period April 2018 to March 2019, 436,149 cases from 15 EDs were available. A triage level is documented in 86.0% of cases, and 70.5% were triaged within 10 min of arrival. Ten EDs collected a presenting complaint regularly (82.3%). The respective documentation of vital signs shows plausible patterns.

CONCLUSIONS

The AKTIN registry provides an almost real-time insight into German EDs, regardless of the primary documentation system and health insurance claims data. The Federal Joint Committee's requirements are largely met. Standardized presenting complaints allow for symptom-based analyses as well as health surveillance.

[Using emergency department routine data for the surveillance of suicide attempts and psychiatric emergencies]

BACKGROUND

The occurrence of suicide attempts is a key indicator of the population's mental health and therefore belongs in the domain of Mental Health Surveillance at the Robert Koch Institute. No data source is currently being used systematically for the continuous observation of psychiatric emergencies (including suicide attempts) in Germany. Therefore, the use of routine data from emergency departments will be explored in this work.

METHODS

We included routine data from 12 emergency departments between 1 January 2018 and 28 March 2021. We developed syndrome definitions for suicide attempts, psychiatric emergencies based on combinations of chief complaints, and diagnoses from patients presenting with psychopathological symptoms. A descriptive analysis over time was presented and stratified by age and sex.

RESULTS

In total 1,516,883 emergency department attendances were included, among which we identified 5,133 cases (0.3%) as suicide attempts, 31,085 (2.1%) as psychiatric emergencies, and 34,230 (2.3%) as cases with psychiatric symptoms. Among psychiatric emergencies, 16.5% presented because of a suicide attempt. Of cases presenting with a suicide attempt, 53.4% were male and 20.2% were aged between 25 and 34 years. Cases identified by all 3 syndrome definitions and their temporal variations could be displayed over the entire observation period.

CONCLUSION

Syndromic surveillance using emergency department data indicates a potential for continuous surveillance of suicide attempts and psychiatric emergencies and provides a basis for further validation and analysis. The display of changes in real time extends the current research opportunities for psychiatric emergencies in Germany. Systematic surveillance of suicide attempts can contribute to evidence-based suicide prevention.

[Reasons for Encounter in Out-of-Hours Care in Emergency Departments and Emergency Practices - A Mixed Methods Trial]

OBJECTIVE

Since 2006, with the opening of emergency practices (EP) in Germany, out-of-hours patient care has been carried out by general practitioners. Additionally, emergency departments (ED) of the hospitals ensure acute care. Thus, optimal coordination of care is a much discussed subject. The aim of this study was to provide reasons for encounter and subjective reasons to visit each of these institutions.

METHODS

In a mixed method trial, patients with non-urgent conditions (Manchester Triage System level 4 and 5) were interviewed in 2 ED in Schleswig-Holstein and 2 EP in Baden-Württemberg regarding their reasons for encounter from July 2015 to August 2016 during the out of hours primary care practices. Data collection was carried out using a paper-based questionnaire and a semi-structured interview. The statistical program SPSS was used for descriptive analysis, text data analysis was carried out with the method of qualitative content analysis.

RESULTS

In total, 398 patients were interviewed. Most frequently, reasons for encounter in ED and EP were related to musculoskeletal complaints (39%, n=116 and 23%, n=23, respectively). Within technical examination services, the laboratory diagnostics were used as a priority in ED (59%, n=175). In the EP, one patient (2%) underwent laboratory diagnostics. The main reasons for encounter in both facilities were increasing complaints (50%, n=147 in ED; 70%, n=70 in EP) and a desire for quick diagnosis (73%, n=217 in ED; 48%, n=48 in EP). In total, 112 patients (28%) had a medication plan, and 67 (60%) brought it into the facility. Two-thirds of ED patients (n=197) were handed over to outpatient care. In EP, 89% (n=89) continued as outpatient. Qualitative content analysis revealed similar complaint categories in both facilities, but with significant differences in the severity and experienced urgency. In both facilities, patients expected to have their symptoms clarified. In ED, the desire for a rapid and specific diagnosis was expressed more frequently.

CONCLUSION

Indications for medical treatment were seen in most consultations in both care facilities. There was a distinction between the ED and EP in the urgency of the consultations.

Evaluation of outcome relevance of quality indicators in the emergency department (ENQuIRE): study protocol for a prospective multicentre cohort study

INTRODUCTION

Quality of emergency department (ED) care affects patient outcomes substantially. Quality indicators (QIs) for ED care are a major challenge due to the heterogeneity of patient populations, health care structures and processes in Germany. Although a number of quality measures are already in use, there is a paucity of data on the importance of these QIs on medium-term and long-term outcomes. The evaluation of outcome relevance of quality indicators in the emergency department study (ENQuIRE) aims to identify and investigate the relevance of QIs in the ED on patient outcomes in a 12-month follow-up.

METHODS AND ANALYSIS

The study is a prospective non-interventional multicentre cohort study conducted in 15 EDs throughout Germany. Included are all patients in 2019, who were ≥18 years of age, insured at the Techniker Krankenkasse (statutory health insurance (SHI)) and gave their written informed consent to the study.The primary objective of the study is to assess the effect of selected quality measures on patient outcome. The data collected for this purpose comprise medical records from the ED treatment, discharge (claims) data from hospitalised patients, a patient questionnaire to be answered 6-8 weeks after emergency admission, and outcome measures in a 12-month follow-up obtained as claims data from the SHI.Descriptive and analytical statistics will be applied to provide summaries about the characteristics of QIs and associations between quality measures and patient outcomes.

ETHICS AND DISSEMINATION

Approval of the leading ethics committee at the Medical Faculty of the University of Magdeburg (reference number 163/18 from 19 November 2018) has been obtained and adapted by responsible local ethics committees.The findings of this work will be disseminated by publication of peer-reviewed manuscripts and presentations as conference contributions (abstracts, poster or oral presentations).Moreover, results will be discussed with clinical experts and medical associations before being proposed for implementation into the quality management of EDs.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry (DRKS00015203); Pre-results.

Medical Emergencies During the COVID-19 Pandemic

BACKGROUND

In this study, we investigate the number of emergency room consultations during the COVID-19 pandemic of 2020 in Germany compared to figures from the previous year.

METHODS

Case numbers from calendar weeks 1 through 22 of the two consecutive years 2019 and 2020 were obtained from 29 university hospitals and 7 non-university hospitals in Germany. Information was also obtained on the patients' age, sex, and urgency, along with the type of case (outpatient/inpatient), admitting ward, and a small number of tracer diagnoses (I21, myocardial infarction; J44, COPD; and I61, I63, I64, G45, stroke /TIA), as well as on the number of COVID-19 cases and of tests performed for SARS-CoV-2, as a measure of the number of cases in which COVID-19 was suspected or at least included in the differential diagnoses.

RESULTS

A total of 1 022 007 emergency room consultations were analyzed, of which 546 940 took place in 2019 and 475 067 in 2020. The number of consultations with a positive test for the COVID-19 pathogen was 3122. The total number of emergency room consultations in the observation period was 13% lower in 2020 than in 2019, with a maximum drop by 38% coinciding with the highest number of COVID-19 cases (calendar week 14; 572 cases). After the initiation of interpersonal contact restrictions in 2020, there was a marked drop in COVID-19 case numbers, by a mean of -240 cases per week per emergency room (95% confidence interval [-284; -128]). There was a rise in case numbers thereafter, by a mean of 17 patients per week [14; 19], and the number of cases of myocardial infarction returned fully to the level seen in 2019.

CONCLUSION

In Germany, the COVID-19 pandemic led to a significant drop in medical emergencies of all kinds presenting to the nation's emergency departments. A recovery effect began to be seen as early as calendar week 15, but the levels seen in 2019 were not yet reached overall by calendar week 22; only the prevalence of myocardial infarction had renormalized by then. The reasons for this require further investigation.

[Restructuring of inpatient emergency treatment : What will change?]

The resolution on the restructuring of inpatient emergency treatment was passed by the Federal Joint Committee (G-BA) on 19 April 2018 based on the Hospital Structure Act and became binding with the publication in the Bundesanzeiger on 18 May 2018. The resolution describes the future structural and qualitative prerequisites for participation of hospitals in the provision of emergency treatment in three levels: basic emergency treatment, extended emergency treatment and comprehensive emergency treatment. Furthermore, a level of nonparticipation is also planned. In addition, there are special modules, e.g. for the treatment of children and auxiliary modules for specifically equipped hospitals with highly specialized patient treatment (e.g. stroke unit). A transition regulation period of 3-5 years provides hospitals with the possibility to adjust to the new minimum requirements. The German Hospital Federation (DKG) and the National Association of Statutory Health Insurance Funds (GKV-SV) will negotiate the assessment of surcharges and deductions subsequent to the resolution.

[Disease spectrum among guests and staff of an international luxury beach resort in the tropics]

BACKGROUND

Diseases of travelers upon returning home are described in numerous publications. However, we have limited data on the disease spectrum and the reasons for medical consultations during a trip.

METHODS

Over the period of one year, we analyzed all patient visits to the inhouse medical center of a major 5‑star beach resort of an international chain in the Maldives.

RESULTS

Around 6% of all guests sought medical consultation at least once during their stay. The main reasons for consultation were sea water induced external otitis and-in some cases-severe (2nd degree) sunburn. Staff presented mainly with viral nasopharyngitis in 20%, whereby guests had symptoms of the common cold in only 7% of all consultations. The occurrence of gastroenteritis was similar in both groups and was associated in most cases with seawater but was much lower compared to the region's epidemiological data. A high incidence of allergic reactions (7%) was recognized in both groups, being more than doubled among guests compared to staff. A considerable number of complaints caused by insects and sea organisms as well as a few drowning accidents were recorded.

CONCLUSION

Despite the high international 5‑star standards, there is a considerable probability for a medical consultation during the stay in a tropical beach hotel setting. However, environmental and behavioral factors are the main causes of sickness among guests.

[Even low-acuity patients prefer hospital-based emergency care : A survey of non-urgent patients in an emergency department with unique regional position]

BACKGROUND

Besides increasing numbers of cases in German emergency departments (ED), the spectrum of attending patients is also changing. Patients with acute illnesses tend to prefer EDs to ambulatory care as primary contact point. This study examines the motives for use and use behavior of low-urgent ED-patients.

METHODS

Anonymous patient survey in the ED of Wolfsburg Hospital between 12/2015 and 03/2016 with descriptive analysis. All patients with low urgency (Manchester-Triage-System (MTS), levels blue and green) were eligible.

RESULTS

81.5% of respondents (729 evaluable out of 7000 questionnaires distributed) attended the ED between 8:00 a. m. and 5:00 p. m., 70.1 % of them were walk-in patients. The motive most frequently cited was that they would receive better care in the ED (48.3 %). Contrary to acuity assessment, 67.8 % of respondents considered themselves a medium to life-threatening emergency. As alternative option, 49.2 % would choose a nearby clinic in the region for their complaints.

CONCLUSION

Self-assessed urgency differs with acuity assessment according to MTS. Patients who fear an acute threat to their health do not use services provided in the ambulatory sector such as the emergency practice of the Association of Statutory Health Insurance Physicians in the immediate proximity sufficiently. Previous approaches for patient navigation do not seem to be successful in this setting. Strengthening of EDs as a single 24/7 access point for emergency care with simultaneous abolition of parallel care structures should be discussed.

[Routine Data from Emergency Departments: Varying Documentation Standards, Billing Modalities and Data Custodians at an Identical Unit of Care]

Hintergrund Nicht nur im Kontext der Neuordnung der Notfallversorgung in Deutschland besteht derzeit ein hoher Bedarf an Daten aus Notaufnahmen. Für die Versorgungsforschung bieten sich Daten an, welche auf gesetzlicher Grundlage generiert werden. Unterschiedliche Kostenträger und Abrechnungsmodi stellen eigene Anforderungen an die Dokumentation dieser Routinedaten.

Methodische Herausforderungen Aufgrund der sektoralen Trennung gibt es keinen Datensatz oder Datenhalter, der Auskunft über alle Notaufnahmebehandlungen geben kann. Aus administrativer Sicht gilt die gesamte Notaufnahmebehandlung als ambulant oder stationär, tatsächlich wird die Entscheidung darüber erst während der Versorgung getroffen. Für die stationäre Versorgung existiert ein administratives Notfallkennzeichen, allerdings kein direktes Merkmal für Notaufnahmebehandlungen. Bei Abrechnung ambulanter Fälle über die kassenärztlichen Vereinigungen ist mindestens eine Diagnose (ICD-10-Kode) zu erfassen, versehen mit einem Kennzeichen zur Diagnosesicherheit. Es können mehrere ICD-10-Kodes ohne Hierarchie angegeben werden. Bei stationär behandelten Patienten ist eine Aufnahmediagnose und nach Behandlungsende die Hauptdiagnose und ggf. Nebendiagose(n) an die zuständige Krankenkasse zu übermitteln. Die gesetzliche Unfallversicherung hat eigene Dokumentationsanforderungen.

Lösungsansätze Je nach Forschungsfrage und Studiendesign sind unterschiedliche Vorgehensweisen erforderlich. Stammen die Daten unmittelbar aus Notaufnahmen bzw. Kliniken ist eine Information über den Kostenträger und den Abrechnungsmodus hilfreich. Bei Nutzung von Krankenkassendaten muss die Identifikation von stationär behandelten Patienten in einer Notaufnahme aktuell indirekt erfolgen. Dazu können unter anderem die Parameter Aufnahmegrund und definierte „eindeutige“ Notfall-Diagnosen herangezogen werden. Die fallpauschalenbezogene Krankenhausstatistik hat eigene Limitationen, enthält dafür aber die stationären Fälle aller Kostenträger.

Diskussion Die divergierenden Anforderungen an die administrative Dokumentation verursachen einen hohen Aufwand in den Kliniken. Perspektivisch ist eine Vereinheitlichung der Leistungserfassung und Dokumentation von Notfallbehandlungen aller Kostenarten auch zur Generierung von validen, vergleichbaren und repräsentativen Daten für die Versorgungsforschung erstrebenswert. Die Einführung eines eigenen Fachabteilungsschlüssels würde zur Identifikation von Notaufnahmebehandlungen beitragen.

[Teledermatology for emergency patient care : Two-year experience with teledermatological emergency care]

BACKGROUND

Internationally telemedicine has become an important element of health care. Up to now it plays, however, a minor role in the German health care system. Taking skin diseases as an example we examined over a 2‑year period whether teledermatology is appropriate to care for patients presenting to the emergency department (ED) with symptomatic skin diseases.

METHODS

During 2016 and 2017, 190 patients aged between 18 and 88 years with skin diseases who presented to the ED of the University Medicine Greifswald (UMG) were cared for by a core team consisting of surgeons who were supported by the on-call dermatologist of the UMG via teledermatology (mSkin Doctor®, InfoKom, Neubrandeburg, Germany). Patients presented nearly exclusively outside the regular working hours: 59% on weekends and public holidays, 39% after 4 p.m. on working days. Furthermore, 33% of patients came from rural areas (<10,000 inhabitants), 41% from regional centres or mid-sized centres. Patients travelled 23 km (median) from their homes to the emergency department.

RESULTS

In all, 59 of the 190 patients immediately assessed the teledermatology-based care they received in the emergency department: 76% of the patients felt that they had received adequate care, 81% trusted the medical decisions. The teledermatologically based care outside normal working hours was deemed appropriate by 68% of the patients; 32% of the patients, however, wanted the dermatologist to be present at any time at day and night.

CONCLUSION

Patients with skin diseases were cared for safely by the core team of the ED which was supported by the on-call dermatologist via teledermatology. The use of teledermatology within the context of emergency-based care has gained a high degree of patients' acceptance and confidence.

The way from pen and paper to electronic documentation in a German emergency department

Background

Some of the advantages of implementing electronic emergency department information systems (EDIS) are improvements in data availability and simplification of statistical evaluations of emergency department (ED) treatments. However, for multi-center evaluations, standardized documentation is necessary. The AKTIN project (“National Emergency Department Register: Improvement of Health Services Research in Acute Medicine in Germany”) has used the “German Emergency Department Medical Record” (GEDMR) published by the German Interdisciplinary Association of Intensive and Emergency Care as the documentation standard for its national data registry.

Methods

Until March 2016 the documentation standard in ED was the pen-and-paper version of the GEDMR. In April 2016 we implemented the GEDMR in a timeline-based EDIS. Related to this, we compared the availability of structured treatment information of traumatological patients between pen-and-paper-based and electronic documentation, with special focus on the treatment time.

Results

All 796 data fields of the 6 modules (basic data, severe trauma, patient surveillance, anesthesia, council, neurology) were adapted for use with the existing EDIS configuration by a physician working regularly in the ED. Electronic implementation increased availability of structured anamnesis and treatment information. However, treatment time was increased in electronic documentation both immediately (2:12 ± 0:04 h; n = 2907) and 6 months after implementation (2:18 ± 0:03 h; n = 4778) compared to the pen-and-paper group (1:43 ± 0:02 h; n = 2523; p < 0.001).

Conclusions

We successfully implemented standardized documentation in an EDIS. The availability of structured treatment information was improved, but treatment time was also increased. Thus, further work is necessary to improve input time.

[Older emergency patients in the emergency department : A key performance indicator analysis based on the DIVI emergency department protocol]

BACKGROUND

Overall, there is only little data in health care research on the subject of emergency care in older patients in Germany. The aim of the present study is to assess the older emergency patient in regard to the core data set "Emergency Department" of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI).

MATERIALS AND METHODS

Monocentric, retrospective observational study.

RESULTS

In the observation period, a total of 29,391 emergency patients were treated at the interdisciplinary emergency center. Of these, 8072 emergency patients were ≥65 years old (27.4%). With increasing age, paramedic ambulances (RTW) or physician-led ambulances (NEF) are increasingly used (p < 0.001). Older emergency patients arriving by a physician-led emergency service show a 38.9-fold increase in mortality compared to ambulatory patients (odds ratio = 38.98 [29.22-51.87]). The initial assessment, using the Manchester Triage System (MTS), shows a steady rise towards higher urgency levels with increasing age (p < 0.001). In the multivariate analysis within the individual age clusters, there is a correlation between the triage level and hospital mortality, unrelated to gender (p < 0.001). Likewise the use of consulting physicians can be linked to advanced age (p < 0.001). Also the length of stay in the interdisciplinary emergency center correlates highly with age (p < 0.001).

CONCLUSION

The older emergency patient clearly differs from younger emergency patients in all key performance indicators considered and already poses a special challenge to emergency departments.

Combinations of Symptoms in Emergency Presentations: Prevalence and Outcome

The predictive power of certain symptoms, such as dyspnoea, is well known. However, research is limited to the investigation of single chief complaints. This is in contrast to patients in the emergency department (ED) presenting usually more than one symptom. We aimed to identify the most common combinations of symptoms and to report their related outcomes: hospitalisation, admission to intensive care units, and mortality. This is a secondary analysis of a consecutive sample of all patients presenting to the ED of the University Hospital Basel over a total time course of 6 weeks. The presence of 35 predefined symptoms was systematically assessed upon presentation. A total of 3960 emergency patients (median age 51, 51.7% male) were included. Over 130 combinations of two, 80 combinations of three, and 10 combinations of four symptoms occurred 42 times or more during a total inclusion period of 42 days. Two combinations of two symptoms were predictive for in-hospital mortality: weakness and fatigue (Odds ratio (OR) = 2.45), and weakness and headache (OR = 3.01). Combinations of symptoms were frequent. Nonspecific complaints (NSCs), such as weakness and fatigue, are among the most frequently reported combinations of symptoms, and are associated with adverse outcomes. Systematically assessing symptoms may add valuable information for prognosis and may therefore influence triage, clinical work-up, and disposition.

[Requirements for a sustainable standardization and digitalization in clinical emergency and acute medicine]

Digitalization and standardization of documentation in medicine are increasingly progressing. In the decision of the Federal Joint Committee (G-BA) for a staged system of emergency structures in hospitals and in the report of the expert committee for development in the healthcare system on needs-oriented guidance of healthcare, the actuality of the topic is underlined with concrete naming of future tasks. The section on emergency admission protocols of the German Interdisciplinary Association of Intensive and Emergency Care Medicine (DIVI) has been working for years on this topic and has repeatedly reported on the progress of the topic in clinical emergency care. Standardization and digitalization represent the foundation for health services research spread across locations as well as the possibility for benchmarking. Digitalization makes the secondary use of primary clinical routine data possible. Digitalization decreases redundancies of data transmission by avoiding manual data input in, for example registers.