Intensivtherapie in der Notaufnahme: Überflüssiger Luxus oder sinnvolle Kompetenz?

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.

„C-Probleme“ des nichttraumatologischen Schockraummanagements

Im Rahmen des nichttraumatologischen Schockraummanagements zur Versorgung kritisch kranker Patienten werden akute Störungen der Vitalfunktionen rasch detektiert und behandelt. Beim „primary survey“ (Erstversorgung) dient das etablierte ABCDE-Schema der strukturierten Untersuchung aller relevanten Vitalparameter. Akute Störungen werden hierbei unmittelbar detektiert und therapiert. „C-Probleme“ stellen den größten Anteil der ABCDE-Störungen bei nichttraumatologischen Schockraumpatienten dar und zeichnen sich durch eine hämodynamische Instabilität infolge hypovolämischer, obstruktiver, distributiver oder kardiogener Schockformen aus. Abhängig von den lokalen Versorgungsstrukturen umfasst die nichttraumatologische Schockraumversorgung hierbei auch die Stabilisierung von Patienten mit akutem Koronarsyndrom oder nach prähospitaler Reanimation (Cardiac Arrest Center).

[Nontraumatic resuscitation room management of critically ill patients]

Critically ill patients are often initially treated by out-of-hospital emergency medicine services. A major challenge-especially at the interface between out-of-hospital and in-hospital care-is to continue patient care without wasting time, while maintaining a high level. These include the stabilization of vital functions (e.g., airway management, noninvasive/invasive ventilation, circulatory stabilization) and implementation of a suitable diagnostic and therapeutic strategy (e.g., laboratory examinations, sonography, radiological imaging). In recent years, therefore, interest and research has focused on the topic of "nontraumatic resuscitation room care". The first monocentric data recently became available and work is ongoing to develop nontraumatic resuscitation room management for optimal care of critically ill patients in the emergency department. Based on initial studies, experiences and expert opinions, this paper describes a structured approach to nontraumatic resuscitation room management.

[The conservative emergency room - care of acutely critically ill non-trauma patients]

Treatment of critically ill non-trauma patients is challenging, due to the broad spectrum of underlying diseases in this clinical setting. It has been shown that outcome in these patients is poor due to high age, comorbidities and severeness of acute disease. In most cases it is crucial to establish diagnosis and start specific treatment immediately to improve patients' outcome. In contrast to the management of severely injured patients, general guidelines for the initial diagnostic and therapeutic approaches in these patients have been lacking until now. As a consequence, little is known about both: patients' characteristics and outcome. This article provides an overview of the current information available on this group of patients.All critically ill patients should first be managed in the resuscitation room, as it is necessary to provide the optimal infrastructure, including material and personal resources, to maintain high quality care. For non-trauma patients, indication can be defined using the ABCDE approach. Expertise in emergency ultrasound as a key diagnostic tool, profound knowledge of intensive care treatment and of diagnostic and therapeutic approaches according to current specific guidelines are required. These requirements can be implemented by assembling nursery and medical staff trained in emergency care, supported by accredited continued professional development and regular simulation trainings.The best transition from preclinical to in-hospital care is achieved through detailed preparation and the use of standardized handover tools. Subsequent patient management can be organized using the primary and secondary survey. These aim to detect and treat life threatening pathologies first and, within a second step, to expand the diagnosis and therapy according to the individual case. Special focus should be put on communication, using crew resource management training, and on the provision on an open and constructive approach to making mistakes.

[Aspects of intensive care medicine in emergency medicine]

Emergency medicine and intensive care medicine have many similarities. In this review, we will first discuss the terminology of emergency medicine in a hospital in terms of a uniform designation as a department for emergency medicine or emergency department. Emergency medicine and intensive care medicine are a location-independent concept of patient care in the sense of the recognition, treatment and diagnosis of acute health disorders. Emergency medicine covers the entire range of disease severity, while intensive care medicine focuses on organ replacement and organ preservation, uses highly specialized technology for this purpose and treats only the seriously ill. The treatment of seriously ill patients in the emergency departments requires special intensive care medical knowledge both by the physicians and nursing staff. In the medical field, the curriculum for the European emergency medicine specialist takes into account all aspects necessary for the diagnosis and treatment of critically ill patients. For the nursing sector, Germany has had its own recognized specialty training program in emergency medicine for several years. However, the treatment of critically ill patients in emergency departments also requires that the emergency departments be adequately equipped. In this regard, there is an urgent need for statutory quality criteria that are concrete and structured. We know from the literature that intensive care competence in emergency departments reduces the admission rate to intensive care units and the mortality of all emergency patients. The concept of intensive care units in the emergency department is gaining popularity in the USA and should also be evaluated for implementation in the German-speaking countries.

[Training in clinical acute and emergency medicine - Supraspeciality in Germany : A concept for nationwide implementation!]

At the 121st German Physicians Conference 2018 in Erfurt a resolution to accept the full amendment of the (draft) further training regulations (MWBO) was adopted and the State Medical Councils were requested to include them in their respective areas of responsibility. Therefore, the nationwide implementation of the supraspeciality (ZWB) for clinical acute and emergency medicine has been officially finalized. After consultation with the German Medical Council (BÄK) concerning the format, both the new MWBO 2018 and now the content of the ZWB are available as of 15 November 2018.The Physicians Conference resolution and anchoring of the new ZWB clinical acute and emergency medicine in the MWBO were preceded by a process lasting approximately 10 years. The concept of the ZWB clinical acute and emergency medicine, which was scrutinized by the Standing Committee on "medical further training" and the board of the BÄK and presented for approval, was essentially developed by representatives of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) and the German Society for Interdisciplinary Emergency and Acute Medicine (DGINA) in consultation with the BÄK. A consensus was finally reached in September 2017 in cooperation with those German specialist societies with a high proportion of emergency patients.In addition to the title, definition, and minimum requirements for applying the ZWB, the content was processed according to the European curriculum for emergency medicine. The structural prerequisites have now been approved, the Standing Committee has configured the content, and the complete MWBO 2018 has been successfully presented, such that the ZWB clinical acute and emergency medicine is expected to be implemented in the individual Federal States within the next 1-2 years.This article describes the history and development of ZWB clinical acute and emergency medicine in Germany and outlines future perspectives.

[Emergency departments--2016 update]

Acute medical care in hospital emergency departments has experienced rapid development in recent years and gained increasing importance not only from a professional medical point of view but also from an economic and health policy perspective. The present article therefore provides an update on the situation of emergency departments in Germany. Care in emergency departments is provided with an increasing tendency to patients of all ages presenting with varying primary symptoms, complaints, illnesses and injury patterns. In the process, patients reach the emergency department by various routes and structural provision. Cross-sectional communication and cooperation, prioritization and organization of emergency management and especially medical staff qualifications increasingly play a decisive role in this process. The range of necessary knowledge and skills far exceeds the scope of prehospital medical emergency care and the working environment differs substantially. In addition to existing structural and economic problems, the latest developments, as well as future proposals for the design of in-hospital emergency medical care in interdisciplinary emergency departments are described.

[Position paper for a reform of medical emergency care in German emergency departments]

The hospital emergency departments play a central role for the in- and outpatient care of patients with medical emergencies in Germany. In this position paper we point out some general financial and organizational problems of German emergency departments and urge for a higher significance of emergency care in the German health system as an element of public services. The corresponding reform proposals include a change in hospital financing towards a more budget-based system for the emergency departments, an improved structural planning for regional and transregional emergency care, an intensified cooperation with the emergency services of the ambulatory care physicians, a better organizational representation of emergency care within the hospitals and an advancement of emergency medicine in postgraduate medical education.

[Management of critically ill patients in the resuscitation room. Different than for trauma?]

The general approach to the initial resuscitation of non-trauma patients does not differ from the ABCDE approach used to evaluate severely injured patients. After initial stabilization of vital functions patients are evaluated based on the symptoms and critical care interventions are initiated as and when necessary. Adequate structural logistics and personnel organization are crucial for the treatment of non-trauma critically ill patients although there is currently a lack of clearly defined requirements. For severely injured patients there are recommendations in the S3 guidelines on treatment of multiple trauma and severely injured patients and these can be modeled according to the white paper of the German Society of Trauma Surgery (DGU). However, structured training programs similar to the advanced trauma life support (ATLS®)/European resuscitation course (ETC®) that go beyond the current scope of advanced cardiac life support training are needed. The development of an advanced critically ill life support (ACILS®) concept for non-trauma critically ill patients in the resuscitation room should be supported.