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Lefering R, Waydhas C. Prediction of prolonged length of stay on the intensive care unit in severely injured patients-a registry-based multivariable analysis. Front Med (Lausanne) 2024; 11:1358205. [PMID: 38903820 PMCID: PMC11188296 DOI: 10.3389/fmed.2024.1358205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 05/22/2024] [Indexed: 06/22/2024] Open
Abstract
Purpose Mortality is the primary outcome measure in severely injured trauma victims. However, quality indicators for survivors are rare. We aimed to develop and validate an outcome measure based on length of stay on the intensive care unit (ICU). Methods The TraumaRegister DGU of the German Trauma Society (DGU) was used to identify 108,178 surviving patients with serious injuries who required treatment on ICU (2014-2018). In a first step, need for prolonged ICU stay, defined as 8 or more days, was predicted. In a second step, length of stay was estimated in patients with a prolonged stay. Data from the same trauma registry (2019-2022, n = 72,062) were used to validate the models derived with logistic and linear regression analysis. Results The mean age was 50 years, 70% were males, and the average Injury Severity Score was 16.2 points. Average/median length of stay on ICU was 6.3/2 days, where 78% were discharged from ICU within the first 7 days. Prediction of need for a prolonged ICU stay revealed 15 predictors among which injury severity (worst Abbreviated Injury Scale severity level), need for intubation, and pre-trauma condition were the most important ones. The area under the receiver operating characteristic curve was 0.903 (95% confidence interval 0.900-0.905). Length of stay prediction in those with a prolonged ICU stay identified the need for ventilation and the number of injuries as the most important factors. Pearson's correlation of observed and predicted length of stay was 0.613. Validation results were satisfactory for both estimates. Conclusion Length of stay on ICU is a suitable outcome measure in surviving patients after severe trauma if adjusted for severity. The risk of needing prolonged ICU care could be calculated in all patients, and observed vs. predicted rates could be used in quality assessment similar to mortality prediction. Length of stay prediction in those who require a prolonged stay is feasible and allows for further benchmarking.
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Affiliation(s)
- Rolf Lefering
- Institute for Research in Operative Medicine, Faculty of Health, University Witten/Herdecke, Cologne, Germany
| | - Christian Waydhas
- Department of Trauma Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Lucas B, Meng M, Schirrmeister W, Pliske G, Walcher F, Schüttrumpf JP. Lessons learned during the sliding gantry CT implementation in a trauma suite. Eur J Trauma Emerg Surg 2024; 50:643-647. [PMID: 35988107 PMCID: PMC11249429 DOI: 10.1007/s00068-022-02080-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 08/08/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Early detection of bleeding is important for managing trauma cases in the emergency department (ED). Several trauma suites are equipped with computed tomography (CT) scanners to reduce the time to CT. In the last decade, sliding gantry CT has been implemented in trauma suites, highlighting conventional techniques' advantages. We investigated the change in the time to CT and the challenges faced during the implementation. METHODS Trauma suite treatments with a conventional CT scanner between January and December 2016 formed the control group. From January to April 2017, trauma suites were modified, and treatment was outsourced to an interim trauma suite. By May 2017, trauma suites were equipped with a sliding gantry CT scanner. Treatments from May to July 2017 formed the transition group, and those from August to December 2017 formed the routine use group. We evaluated the time to CT in all groups and considered the reasons for the delays in the transition and routine use groups. RESULTS On sliding gantry CT implementation, although time to CT remained unaffected in the transition group, it significantly reduced in the routine use group, independent of injury severity score. The incidence of cable management problems was significantly higher in the latter group. CONCLUSIONS We have demonstrated a decrease in the time to CT with the implementation of a sliding gantry CT. However, due to a higher number of cable management problems in the routine use group, we recommend regular refresher team training with routine use.
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Affiliation(s)
- Benjamin Lucas
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
| | - Matthias Meng
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Wiebke Schirrmeister
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Gerald Pliske
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Felix Walcher
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Jan Philipp Schüttrumpf
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
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3
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Pivetta LGA, Antunes PDESL, Shimoda GM, Parreira JG, Perlingeiro JAG, Assef JC. Trauma Registry: Trauma Quality indicators analysis in hospitalized patients. Rev Col Bras Cir 2024; 51:e20243604. [PMID: 38597571 PMCID: PMC11185059 DOI: 10.1590/0100-6991e-20243604-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 12/04/2023] [Indexed: 04/11/2024] Open
Abstract
PURPOSE to consolidate a Trauma Register (TR) trough REDCap data acquisition platform and to validate, in this context, local Quality Indicators (QI) as improvement opportunities in trauma management. METHODS continuous data acquisition of all patients admitted in Irmandade da Santa Casa de Misericórdia de São Paulo adult Trauma bay and it's validation in REDCap platform; 6 months retrospective cohort of QI impact in length of hospitalar stay, complications and mortality. Fisher, Chi-squared, Wilcoxon and Kruskal-Wallis tests were used to correlate QIs fails with the endpoints, considering p<0.05 and CI <95% as statically significant. RESULTS 465 were admitted in Trauma bay, with 137 patients hospitalized (29.5%); the number of QIs compromised were related with more complications (p=0.075) and increased length of stay (p=0.028), especially the delay in open fracture's surgical management, which increased the severe complications' incidence (p=0.005). CONCLUSION the REDCap data acquisition platform is useful as a tool for multi center TR implementation, from ethical and logistical point of view; nevertheless, the proposed QIs are validated as attention points in trauma management, allowing improvements in traumatized patients treatment.
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Affiliation(s)
| | | | | | - José Gustavo Parreira
- Irmandade da Santa Casa de Misericórdia de São Paulo, Serviço de Emergência - São Paulo - SP - Brasil
| | | | - Jose Cesar Assef
- Irmandade da Santa Casa de Misericórdia de São Paulo, Serviço de Emergência - São Paulo - SP - Brasil
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4
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Yongqiang D, Lin W. Application of multidisciplinary collaboration in the operating room for orthopedic surgery. Asian J Surg 2023; 46:5698-5699. [PMID: 37640642 DOI: 10.1016/j.asjsur.2023.08.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023] Open
Affiliation(s)
- Dai Yongqiang
- Department of Nursing, Cangzhou Clinical College of Integrated Traditional Chinese and Western Medicine of Hebei Medical University, Cangzhou, 061000, China.
| | - Wu Lin
- Department of Nursing, Cangzhou Clinical College of Integrated Traditional Chinese and Western Medicine of Hebei Medical University, Cangzhou, 061000, China
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5
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Lefering R, Waydhas C. Process times of severely injured patients in the emergency room are associated with patient volume: a registry-based analysis. Eur J Trauma Emerg Surg 2022; 48:4615-4622. [PMID: 35546201 PMCID: PMC9712366 DOI: 10.1007/s00068-022-01987-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/16/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Hospitals involved in the care of severely injured patients treat a varying number of such cases per year. Large hospitals were expected to show a better performance regarding process times in the emergency room. The present investigation analyzed whether this assumption was true, based on a large national trauma registry. METHODS A total of 129,193 severely injured patients admitted primarily to one of 675 German hospitals and documented in the TraumaRegister DGU® were considered for this analysis. The analysis covered a 5 years time period (2013-2017). Hospitals were grouped by their average number of annually treated severe trauma patients into five categories ranging from 'less than 10 patients' to '100 or more'. The following process times were compared: pre-hospital time; time from admission to diagnostic procedures (sonography, X-ray, computed tomography), time from admission to selected emergency interventions and time in the emergency room. RESULTS Seventy-eight high volume hospitals treated 45% of all patients, while 30% of hospitals treated less than ten cases per year. Injury severity and mortality increased with volume per year. Whole-body computed tomography (WB-CT) was used less frequently in small hospitals (53%) as compared to the large ones (83%). The average time to WB-CT fell from 28 min. in small hospitals to 19 min. in high volume hospitals. There was a linear trend to shorter performance times for all diagnostic procedures (sonography, X-ray, WB-CT) when the annual volume increased. A similar trend was observed for time to blood transfusion (58 min versus 44 min). The median time in the emergency room fell from 74 min to 53 min, but there was no clear trend for the time to the first emergency surgery. Due to longer travel times, prehospital time was about 10 min higher in patients admitted to high volume hospitals compared to patients admitted to smaller local hospitals. CONCLUSION Process times in the emergency room decreased consistently with an increase of patient volume per year. This decrease, however, was associated with a longer prehospital time.
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Affiliation(s)
- Rolf Lefering
- Institute for Research in Operative Medicine, University Witten/Herdecke, Ostmerheimer Strasse 200, (Building 38), 51109, Cologne, Germany.
| | - Christian Waydhas
- Department of Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
- Medical Faculty, University Duisburg-Essen, University Hospital, Essen, Germany
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6
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Kovoor JG, Jacobsen JHW, Balogh ZJ. Quality improvement strategies in trauma care: review and proposal of 31 novel quality indicators. Med J Aust 2022; 217:331-335. [PMID: 36088604 PMCID: PMC9825967 DOI: 10.5694/mja2.51699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 06/15/2022] [Accepted: 06/23/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Joshua G Kovoor
- Australian Safety and Efficacy Register of New Interventional Procedures – SurgicalRoyal Australasian College of SurgeonsAdelaideSA,University of AdelaideAdelaideSA,Queen Elizabeth HospitalAdelaideSA
| | - Jonathan Henry W Jacobsen
- Australian Safety and Efficacy Register of New Interventional Procedures – SurgicalRoyal Australasian College of SurgeonsAdelaideSA
| | - Zsolt J Balogh
- John Hunter HospitalNewcastleNSW,University of NewcastleNewcastleNSW
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Lucas B, Mathieu SC, Pliske G, Schirrmeister W, Kulla M, Walcher F. The impact of a qualified medical documentation assistant on trauma room management. Eur J Trauma Emerg Surg 2022; 48:689-696. [PMID: 33025169 PMCID: PMC8825361 DOI: 10.1007/s00068-020-01513-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 09/25/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To improve quality of trauma room management, intra- and inter-hospital benchmarking are important tools. However, primary data quality is crucial for benchmarking reliability. In this study, we analyzed the effect of a medical documentation assistant on documentation completeness in trauma room management in comparison to documentation by physicians involved in direct patient treatment. METHODS We included all patients treated in the trauma room from 2016/01/01 to 2016/12/31 that were documented with the trauma module of the German Emergency Department Medical Record V2015.1. We divided the data into documentation by medical documentation assistant (DA, 07:00 to 17:00), physician in daytime (PD, 07:00 to 17:00), and physician at night (PN, 17:00 to 07:00). Data were analyzed for completeness (primary outcome parameter) as well as diagnostic intervals. RESULTS There was a significant increase in complete recorded data for DA (74.5%; IQR 14.5%) compared to PD (26.9%; IQR 18.7%; p < 0.001) and PN (30.8%; IQR 18.9; p < 0.001). The time to whole-body computed tomography (WBCT) significantly decreased for DA (19 min; IQR 8.3) compared to PD (24 min; IQR 12.8; p = 0.007) or PN (24.5 min; IQR 10.0; p = 0.001). CONCLUSION In presence of a qualified medical documentation assistant, data completeness and time to WBCT improved significantly. Therefore, utilizing a professional DA in the trauma room appears beneficial for data quality and time management.
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Affiliation(s)
- Benjamin Lucas
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany
| | - Sophie-Cecil Mathieu
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany
- Department of Orthopaedic Surgery, Otto-Von-Guericke University Magdeburg, 39120 Magdeburg, Germany
| | - Gerald Pliske
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany
| | - Wiebke Schirrmeister
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany
| | - Martin Kulla
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Bundeswehrhospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Felix Walcher
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany
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Zhang W, An Y, Xiu H, Dou C, Wang Z, Wei Y, Gu T, Leng M, Wei H. Applying a Psychological Nursing Care Quality Evaluation Index in hospitalized patients: A pilot study. Nurs Forum 2021; 57:26-33. [PMID: 34473356 DOI: 10.1111/nuf.12646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 08/04/2021] [Accepted: 08/16/2021] [Indexed: 12/01/2022]
Abstract
Psychological problems have become a significant public health problem. Appropriate mental health care is crucial in promoting patient care quality. This study aimed to test the feasibility of a Psychological Nursing Quality Evaluation Index in hospitalized patients. This is a pilot study with patients hospitalized with myocardial infarction from July to September 2020 in China. The researchers used an observational approach to examine nurses' psychological health care performance based on the Psychological Nursing Quality Evaluation Index. The results indicated high compliance rates of nurses' psychological care performance, which provides references for evaluating and monitoring inpatient psychological nursing care.
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Affiliation(s)
- Wenwen Zhang
- Affiliated Hospital of Qingdao University, Shandong, China
| | - Yi An
- Affiliated Hospital of Qingdao University, Shandong, China
| | - Hong Xiu
- Affiliated Hospital of Qingdao University, Shandong, China
| | - Chao Dou
- Affiliated Hospital of Qingdao University, Shandong, China
| | - Zhongxin Wang
- Affiliated Hospital of Qingdao University, Shandong, China
| | - Yuling Wei
- Affiliated Hospital of Qingdao University, Shandong, China
| | - Tingting Gu
- School of Nursing, Qingdao University, Shandong, China
| | - Min Leng
- Affiliated Hospital of Qingdao University, Shandong, China
| | - Holly Wei
- School of Nursing, University of Louisville, Kentucky, USA
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Flohé S, Bieler D, Ruchholtz S. [Measurability of the quality of care of the severely injured]. Chirurg 2021; 92:881-890. [PMID: 34223917 DOI: 10.1007/s00104-021-01445-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2021] [Indexed: 11/26/2022]
Abstract
The care of severely injured patients is characterized by the heterogeneity of the clinical picture and the time-critical aspects of many forms of treatment in the acute phase, so that quality measurement and assessment is always complex. In order to be able to operate a meaningful and structured quality management the quality must be validly measured and it must be defined what quality is. To handle this complex picture the quality of care for the severely injured is divided into three levels: structural quality, process quality and outcome quality. With respect to structural quality there are clear guidelines for personnel and structural equipment of hospitals for the optimal care of severely injured patients. This is regularly checked in Germany through trauma center certification as part of the TraumaNetzwerk DGU®. Process quality can also be measured in the care of severely injured patients. With the TraumaRegister DGU® annual report in 2017, 14 newly developed quality indicators were introduced. Due to the comprehensive participation of hospitals in the TraumaRegister DGU® structured external quality assurance is possible in addition to internal process analysis. With respect to the quality of the outcome patient reported outcome measures (PROM) have become increasingly more important in addition to the mortality. The PROMs that are used to assess the consequences of injuries are typically multidimensional and capture not only aspects of physical health but also enable self-assessment of the mental health status by the patient.
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Affiliation(s)
- S Flohé
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Städtisches Klinikum Solingen, Solingen, Deutschland
| | - D Bieler
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs‑, Hand- und Plastische Chirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Deutschland.
| | - S Ruchholtz
- Universitätsklinikum Gießen und Marburg, Standort Marburg, Zentrum für Orthopädie und Unfallchirurgie, Marburg, Deutschland
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10
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[Development of a new module for the TraumaRegister DGU ® : Better collation of the sequelae of severe injuries during pregnancy]. Unfallchirurg 2020; 123:954-960. [PMID: 33048210 DOI: 10.1007/s00113-020-00890-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Life-threatening injuries during pregnancy are a rare occurrence. The TraumaRegister DGU® (TR-DGU) has been recording whether seriously injured women were pregnant since 2016. This information is not sufficient to enable a differentiated assessment of the quality of care because parameters, such as gestational age, state of pregnancy at discharge and survival of the child are missing. The TraumaRegister working group of the committee on emergency medicine, intensive care and severe trauma management (section NIS) of the German Trauma Society (DGU) therefore came to the conclusion that the fetal outcome or the intactness of the pregnancy after acute treatment is an important measure of the quality of care of pregnant women. They commissioned a task force to work out a suitable data set for a better analysis of such cases. This article presents the so-called fetus module in detail. METHODS The data set was developed in an interdisciplinary process together with accredited experts from the German Society for Gynecology and Obstetrics (DGGG), the German Society for Perinatal Medicine (DGPM) and the Society for Neonatology and Pediatric Intensive Care Medicine (GNPI). RESULTS The fetus module comprises 20 parameters describing the pregnancy, the condition of the mother and child on admission and discharge. CONCLUSION The fetus module will provide important data to make the process and outcome quality of care of severely injured pregnant women measurable and to develop prognostic instruments with which predictions about high-risk constellations for the outcome of mother and child can be made.
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Hilbert-Carius P, Struck MF, Hofer V, Hinkelbein J, Rognås L, Adler J, Christian MD, Wurmb T, Bernhard M, Hossfeld B. Mechanical ventilation of patients in helicopter emergency medical service transport: an international survey. Scand J Trauma Resusc Emerg Med 2020; 28:112. [PMID: 33208195 PMCID: PMC7672415 DOI: 10.1186/s13049-020-00801-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 10/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mechanical ventilation in helicopter emergency medical service (HEMS) environments is a procedure which carries a significant risk of complications. Limited data on the quality and performance of mechanical ventilation in HEMS are available in the literature. METHOD We conducted an international survey to evaluate mechanical ventilation infrastructure in HEMS and collect data of transported ventilated patients. From June 20-22, 2019, the participating HEMS bases were asked to provide data via a web-based platform. Vital parameters and ventilation settings of the patients at first patient contact and at handover were compared using non-parametric statistical tests. RESULTS Out of 215 invited HEMS bases, 53 responded. Respondents were from Germany, Denmark, United Kingdom, Luxembourg, Austria and Switzerland. Of the HEMS bases, all teams were physician staffed, mainly anesthesiologists (79%), the majority were board certified (92.5%) and trained in intensive care medicine (89%) and had a median (range) experience in HEMS of 9 (0-25) years. HEMS may provide a high level of expertise in mechanical ventilation whereas the majority of ventilators are able to provide pressure controlled ventilation and continuous positive airway pressure modes (77%). Data of 30 ventilated patients with a median (range) age of 54 (21-100) years and 53% male gender were analyzed. Of these, 24 were primary missions and 6 interfacility transports. At handover, oxygen saturation (p < 0.01) and positive end-expiratory pressure (p = 0.04) of the patients were significantly higher compared to first patient contact. CONCLUSION In this survey, the management of ventilated HEMS-patients was not associated with ventilation related serious adverse events. Patient conditions, training of medical crew and different technical and environmental resources are likely to influence management. Further studies are necessary to assess safety and process quality of mechanical ventilation in HEMS. TRIAL REGISTRATION The survey was prospectively registered at Research Registry ( researchregistry2925 ).
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Affiliation(s)
- Peter Hilbert-Carius
- BG Klinikum Bergmannstrost Halle gGmbH, Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, and HEMS "Christoph 84" and "Christoph 85", DRF-Luftrettung, Halle (Saale), Germany
| | - Manuel F Struck
- Department of Anesthesiology and Intensive Care Medicine, and HEMS "Christoph 33" and "Christoph 71" Senftenberg, University Hospital Leipzig, Leipzig, Germany.
| | - Veronika Hofer
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Jochen Hinkelbein
- Department of Anesthesiology and Intensive Care Medicine, and HEMS "Christoph Rheinland", University Hospital Cologne, Cologne, Germany
| | | | - Jörn Adler
- Luxembourg Air Rescue A.s.b.l., Sandweiler, Luxembourg
| | | | - Thomas Wurmb
- Department of Anesthesiology, University Hospital Würzburg, Würzburg, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Björn Hossfeld
- Federal Armed Forces Hospital, Ulm, Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, and HEMS "Christoph 22" Ulm, Ulm, Germany
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Kumpf O, Nothacker M, Braun J, Muhl E. The future development of intensive care quality indicators - a methods paper. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2020; 18:Doc09. [PMID: 33214791 PMCID: PMC7656810 DOI: 10.3205/000285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/29/2020] [Indexed: 11/30/2022]
Abstract
Introduction: Medical quality indicators (QI) are important tools in the evaluation of medical quality. Their development is subject to specific methodological requirements, which include practical applicability. This is especially true for intensive care medicine with its complex processes and their interactions. This methods paper presents the status quo and shows necessary methodological developments for intensive care QI. For this purpose, a cooperation with the Association of the Scientific Medical Societies' Institute for Medical Knowledge Management (AWMF-IMWi) was established. Methodology: Review of published German manuals for QI development from guidelines and narrative review of quality indicators with a focus on evidence and consensus-based guideline recommendations. Future methodological adaptations of indicator development for improved operationalization, measurability and pilot testing are presented, and a development process is proposed. Results: The development of intensive care quality indicators in Germany is based on an established process. In the future, additional evaluation criteria (QUALIFY criteria) will be applied to assess the evidence base. In addition, a continuous exchange between the national steering committee of the DIVI responsible for QI development and guideline development groups involved in intensive care medicine is planned. Conclusion: Intensive care quality indicators will have to meet improved methodological requirements in the future by means of an improved development process. Future QI development is intended to improve the structure of the development process, with a focus on scientific evidence and a link to guideline projects. This is intended to achieve the goal of a broad application of QI and to further evaluate its relevance for patient outcome and performance of institutions.
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Affiliation(s)
- Oliver Kumpf
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,National Steering Committee Peer Review, German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), Berlin, Germany
| | - Monika Nothacker
- AWMF-Institute for Medical Knowledge Management c/o Philipps-Universität, Marburg, Germany
| | - Jan Braun
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Martin-Luther-Krankenhaus, Berlin, Germany.,National Steering Committee Peer Review, German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), Berlin, Germany
| | - Elke Muhl
- Groß Grönau, Germany.,National Steering Committee Peer Review, German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), Berlin, Germany
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Hamsen U, Drotleff N, Lefering R, Gerstmeyer J, Schildhauer TA, Waydhas C. Mortality in severely injured patients: nearly one of five non-survivors have been already discharged alive from ICU. BMC Anesthesiol 2020; 20:243. [PMID: 32967620 PMCID: PMC7513498 DOI: 10.1186/s12871-020-01159-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 09/15/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Most trauma patients admitted to the hospital alive and die later on, decease during the initial care in the emergency department or the intensive care unit (ICU). However, a number of patients pass away after having been discharged from the ICU during the initial hospital stay. On first sight these cases could be seen as "failure to rescue" of potentially salvageable patients. A low rate of such patients might be a potential indicator of quality for trauma care on ICUs and surgical wards. METHODS Retrospective analysis of the TraumaRegister DGU® with data from 2015 to 2017. Patients that died during the initial ICU stay were compared to those who were discharged from the initial ICU stay for at least 24 h but died later on. RESULTS A total of 82,313 trauma patients were included in the TraumaRegister DGU®. In total, 6576 patients (8.0%) died during their hospital stay. Out of those, 5481 were admitted to the ICU alive and 972 patients (17.7%) were discharged from ICU and died later on. Those were older (mean age: 77 vs. 68 years), less severely injured (mean ISS: 23.1 vs. 30.0 points) and had a longer mean ICU length of stay (10 vs. 6 days). A limitation of life-sustaining therapy due to a documented living will was present in 46.1% of all patients who died during their initial ICU stay and in 59.9% of patients who died after discharge from their initial ICU stay. CONCLUSIONS 17.7% of all non-surviving severely injured trauma patients died within the hospital after discharge from their initial ICU treatment. Their death can partially be explained by a limitation of therapy due to a living will. In conclusion, the rate of such late deaths may partially represent patients that died of potentially avoidable or treatable complications.
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Affiliation(s)
- Uwe Hamsen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Buerkle de la Camp Platz 1, 44789, Bochum, Germany.
| | - Niklas Drotleff
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Buerkle de la Camp Platz 1, 44789, Bochum, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten-Herdecke, Ostheimer Str. 200, 51109, Cologne, Germany
| | - Julius Gerstmeyer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Buerkle de la Camp Platz 1, 44789, Bochum, Germany
| | - Thomas Armin Schildhauer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Buerkle de la Camp Platz 1, 44789, Bochum, Germany
| | - Christian Waydhas
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Buerkle de la Camp Platz 1, 44789, Bochum, Germany.,Medical Faculty University Duisburg-Essen, Essen, Germany
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Drynda S, Schindler W, Slagman A, Pollmanns J, Horenkamp-Sonntag D, Schirrmeister W, Otto R, Bienzeisler J, Greiner F, Drösler S, Lefering R, Hitzek J, Möckel M, Röhrig R, Swart E, Walcher F. Evaluation of outcome relevance of quality indicators in the emergency department (ENQuIRE): study protocol for a prospective multicentre cohort study. BMJ Open 2020; 10:e038776. [PMID: 32948571 PMCID: PMC7500312 DOI: 10.1136/bmjopen-2020-038776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Susanne Drynda
- Department of Trauma Surgery, Otto von Guericke University, Magdeburg, Germany
| | - Wencke Schindler
- Institute of Social Medicine and Health Systems Research, Otto von Guericke University, Magdeburg, Germany
| | - Anna Slagman
- Emergency and Acute Medicine, Charité, Berlin, Germany
| | - Johannes Pollmanns
- Faculty of Health Care, Niederrhein University of Applied Sciences, Krefeld, Germany
| | | | | | - Ronny Otto
- Department of Trauma Surgery, Otto von Guericke University, Magdeburg, Germany
| | - Jonas Bienzeisler
- Institute of Medical Informatics, RWTH Aachen University, Aachen, Germany
| | - Felix Greiner
- Department of Trauma Surgery, Otto von Guericke University, Magdeburg, Germany
| | - Saskia Drösler
- Faculty of Health Care, Niederrhein University of Applied Sciences, Krefeld, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Köln, Germany
| | | | - Martin Möckel
- Emergency and Acute Medicine, Charité, Berlin, Germany
| | - Rainer Röhrig
- Institute of Medical Informatics, RWTH Aachen University, Aachen, Germany
| | - Enno Swart
- Institute of Social Medicine and Health Systems Research, Otto von Guericke University, Magdeburg, Germany
| | - Felix Walcher
- Department of Trauma Surgery, Otto von Guericke University, Magdeburg, Germany
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15
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Franke A, Bieler D, Friemert B, Hoth P, Pape HC, Achatz G. Terrorist incidents: strategic treatment objectives, tactical diagnostic procedures and the estimated need of blood and clotting products. Eur J Trauma Emerg Surg 2020; 46:695-707. [PMID: 32676714 PMCID: PMC7364295 DOI: 10.1007/s00068-020-01399-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 05/16/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Terrorism-related incidents that are associated with mass casualties (mass-casualty terrorist incidents) are a medical and organisational challenge for every hospital because of the special injury patterns involved, the time of the incident, the development of the situation, the initial lack of information, the number of injured, and the number of uninjured survivors who self-refer to a hospital. METHODS The Terror and Disaster Surgical Care (TDSC®) - Course was developed in order to address mass-casualty terrorist incidents and to provide surgeons with the specialist medical and surgical knowledge and skills required for these special situations. The focus of the TDSC® course is on how to provide surgical care and how to deploy scarce resources in a particular tactical situation in such a way that the number of survivors is maximised. RESULTS The effective management of such a tactical situation must be based on priorities and first and foremost requires the standardised sorting and categorisation of the injured at the hospital. The aim of triage, or the sorting of the injured, is to immediately identify patients with life-threatening injuries in environments with strained resources. The medical management of mass-casualty terrorist incidents requires tactical abbreviated surgical care (TASC) teams that have the skills needed to perform a primary survey and to provide care for casualties who need immediate surgery (triage category 1-T1). Initial fluid therapy should be restrictive (permissive hypotension) unless contraindicated. Clotting products are replaced in a standardised manner on the basis of patient requirements, which are calculated using rapidly available surrogates (blood gas analysis). Blood products can be administered or kept available depending on risks and triage categories. The highest priority should be given to the identification and management of haemodynamically unstable patients who require immediate surgery for injuries associated with bleeding into body cavities (T1 + +). CONCLUSION The recommendations and approaches described here should be considered as proposals for hospitals to develop standards or modify well-established standards that enable them to prepare themselves successfully for situations (e.g. mass-casualty terrorist or shooter incidents) in which their resources are temporarily overwhelmed.
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Affiliation(s)
- Axel Franke
- Department for Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Rübenacher Straße 170, 56072, Koblenz, Germany
| | - Dan Bieler
- Department for Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Rübenacher Straße 170, 56072, Koblenz, Germany.
- Department of Orthopaedics and Trauma Surgery, Heinrich Heine University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Benedikt Friemert
- Department for Trauma Surgery and Orthopaedics, Reconstructive and Septic Surgery, Sportstraumatology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Patrick Hoth
- Department for Trauma Surgery and Orthopaedics, Reconstructive and Septic Surgery, Sportstraumatology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Gerhard Achatz
- Department for Trauma Surgery and Orthopaedics, Reconstructive and Septic Surgery, Sportstraumatology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
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16
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Lustenberger T, Lefering R. Focus on "The German TraumaRegister DGU ® (TR-DGU)". Eur J Trauma Emerg Surg 2020; 46:447-448. [PMID: 32514734 PMCID: PMC7280174 DOI: 10.1007/s00068-020-01394-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.
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Hörster AC, Kulla M, Bieler D, Lefering R. [Empirical evaluation of quality indicators for severely injured patients in the TraumaRegister DGU®]. Unfallchirurg 2019; 123:206-215. [PMID: 31312854 DOI: 10.1007/s00113-019-0699-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE A systematic assessment of the quality of medical treatment by using key indicators has been required in Germany for many years. These quality indicators (QI) have to satisfy many requirements. Besides an expert review an empirical data-based evaluation is also necessary. The TraumaRegister DGU® (TR-DGU) has reported QI in the annual reports from the beginning. The objective of this study was to validate 40 QI for the treatment of severely injured patients reviewed by experts using data from the TR-DGU. MATERIAL AND METHODS The association of the 40 QI with hospital mortality was verified using healthcare data from the TR-DGU from a 5‑year period (2012-2016). Of these 26 QI consider events while the remaining 14 QI are key indicators, such as time spent in the trauma room. To compensate differences in injury severity, adjusted mortality rates were calculated using the revised injury severity classification (RISC) II score. For this two different approaches were chosen: the hospital-based approach classifies all hospitals into three categories and analyzes the grade of fulfilment of the indicator. The indicator-based approach considers the adjusted mortality depending on the grade of fulfilment of the indicator. RESULTS The analysis was based on 111,656 cases documented in the TR-DGU (mean age 50 years; 70 % male). The data analysis showed an obvious correlation with mortality for half of the QI, including only three procedural times. A clear correlation in both approaches was shown for two QI: prehospital capnometry in intubated patients and sonography used for patients without whole body computed tomography (CT) scans. Of the 20 QI with a positive result 15 were also positively rated by the experts. Of the 14 QI reported annually since 2017 in the TR-DGU report, 8 (57%) showed a clear correlation with mortality. CONCLUSION There is no doubt regarding the necessity of scientifically assessing QI. Approximately half of the evaluated QI showed an empirical association with mortality. Interventions and events showed better results than measurements of procedural times; however, many QI may require a refined definition. The interpretation of the results is still challenging due to differences in the patient groups. Secondary endpoints, such as hospital length of stay and quality of life after trauma were not considered here.
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Affiliation(s)
- A C Hörster
- Institut für Forschung in der Operativen Medizin, Universität Witten/Herdecke, Ostmerheimer Str. 200 (Haus 38), 51109, Köln, Deutschland.
| | - M Kulla
- Klinik für Anästhesie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland
| | - D Bieler
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacher Straße 170, 56072, Koblenz, Deutschland
| | - R Lefering
- Institut für Forschung in der Operativen Medizin, Universität Witten/Herdecke, Ostmerheimer Str. 200 (Haus 38), 51109, Köln, Deutschland
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