Überfüllte Notaufnahme: Ursachen, Folgen und Lösungen

Who, When, Why?-Traumatological Patients in the Emergency Department of a Maximum Care Provider

Nationwide, there is an annual increase in the number of patients in German emergency departments resulting in a growing workload for the entire emergency department staff. Several studies have investigated the situation in emergency departments, most of which were interdisciplinary, but there are no data on a solely traumatological patient population. The present study therefore aims to investigate the situation in a university-based trauma surgery emergency department. A total of 8582 traumatological patients attending a university hospital from 1 January 2019 to 31 December 2019 were studied. Various variables, such as reason for presentation, time of accident, diagnosis, and diagnostic as well as therapeutic measures performed were analyzed from the admission records created. The mean age was 36.2 years, 60.1% were male, 63.3% presented on their own to the emergency department, and 41.2% presented during regular working hours between 8:00 a.m. and 6:00 p.m., Monday through Friday. The most common reason for presentation was outdoor falls at 17.4%, and 63.3% presented to the emergency department within the first 12 h after the sustained trauma. The most common diagnosis was bruise (27.6%), and 14.2% of patients were admitted as inpatients. Many of the emergency room patients suffered no relevant trauma sequelae. In order to reduce the number of patients in emergency rooms in the future, existing institutions in the outpatient emergency sector must be further expanded and effectively advertised to the public. In this way, the emergency medical resources of clinics, including staff, can be relieved to provide the best possible care for actual emergency patients.

[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.

Length of stay as quality indicator in emergency departments: analysis of determinants in the German Emergency Department Data Registry (AKTIN registry)

Several indicators reflect the quality of care within emergency departments (ED). The length of stay (LOS) of emergency patients represents one of the most important performance measures. Determinants of LOS have not yet been evaluated in large cohorts in Germany. This study analyzed the fixed and influenceable determinants of LOS by evaluating data from the German Emergency Department Data Registry (AKTIN registry). We performed a retrospective evaluation of all adult (age ≥ 18 years) ED patients enrolled in the AKTIN registry for the year 2019. Primary outcome was LOS for the whole cohort; secondary outcomes included LOS stratified by (1) patient-related, (2) organizational-related and (3) structure-related factors. Overall, 304,606 patients from 12 EDs were included. Average LOS for all patients was 3 h 28 min (95% CI 3 h 27 min-3 h 29 min). Regardless of other variables, patients admitted to hospital stayed 64 min longer than non-admitted patients. LOS increased with patients' age, was shorter for walk-in patients compared to medical referral, and longer for non-trauma presenting complaints. Relevant differences were also found for acuity level, day of the week, and emergency care levels. We identified different factors influencing the duration of LOS in the ED. Total LOS was dependent on patient-related factors (age), disease-related factors (presentation complaint and triage level), and organizational factors (weekday and admitted/non-admitted status). These findings are important for the development of management strategies to optimize patient flow through the ED and thus to prevent overcrowding.

Psychische Beeinträchtigungen infolge erhöhter Belastungen bei Notärzten

Hintergrund

Die Tätigkeit als Notarzt ist mit hohen psychischen und emotionalen Belastungen im Arbeitsalltag verbunden, die zu gesundheitlichen Beeinträchtigungen führen können. Ziel der Studie war es, die Belastungen von Notärzten einerseits und die damit möglicherweise verbundenen psychischen gesundheitlichen Beeinträchtigungen andererseits zu erfassen.

Methodik

An der Studie nahmen 33 Notärzte (14 Frauen, 19 Männer) im Alter von 38,2 ± 7,2 Jahren freiwillig teil. Neben den Belastungsfaktoren wurden gesundheitliche bzw. psychische Beeinträchtigungen mit folgenden standardisierten Fragebögen erfasst: die psychische Gesundheit mit der Kurzversion des General Health Questionnaire (GHQ-12) und das Burn-out-Risiko mit dem Maslach Burnout Inventory (MBI). Die Rücklaufquote liegt bei 22 %.

Ergebnisse

Als Belastungsfaktoren wurden neben räumlicher Enge im Rettungswagen hauptsächlich Faktoren psychischer Belastung auf kommunikativer sowie organisationaler Ebene des Rettungsdiensts genannt. Psychische gesundheitliche Beeinträchtigungen wurden von einem Drittel der Studienteilnehmer berichtet, einige Burn-out-Symptome lagen bereits bei 12 Notärzten (37,5 %) vor.

Schlussfolgerung

Aufgrund erhöhter Belastung bei Notärzten ist die psychische Gesundheit bei ihnen gefährdet. Präventive Maßnahmen wie die Verbesserung der Kommunikationsstrukturen sowie der Organisation können sinnvoll sein, um gesundheitliche Beeinträchtigungen zu vermeiden bzw. zumindest einzudämmen.

[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.

Cross-sectional study in an out-of-hours primary care centre in northwestern Germany - patient characteristics and the urgency of their treatment

Background

Due to the increasing number of non-urgent visits to emergency departments, it is becoming increasingly important to also investigate emergency care in out-of-hours (OOH) primary care. The aim of this study was to provide an insight into the care structures of an OOH primary care centre, to evaluate the reasons for encounter (RFE) and to assess the urgency of the treatment from the physicians´ point of view.

Methods

In the summer of 2017, we conducted a cross-sectional study over four weeks in the OOH primary care centre of Oldenburg, a city in Lower Saxony with about 160,000 inhabitants. We collected socio-demographic data, RFE and the duration of the complaints. The International Classification for Primary Care 2nd Edition (ICPC-2) was used to categorize symptoms. The attending physicians supplemented information on further treatment (including hospitalization) and the urgency of consultation in the OOH primary care centre.

Results

A total of 892 of the 1098 OOH patients which were visiting the OOH primary care centre took part in the study (participation: 81.2%). More than half of the patients were between 18 and 39 years old. A quarter of all RFE named by study participants were in the ICPC-2 category “skin”. More than 60% of patients had the symptoms for more than two days before visiting the OOH primary care centre. In 34.5% of all cases no medication was prescribed and one in six patients received further diagnostic tests such as urinalysis and blood tests (15.8%). From the physicians’ point of view, 26.3% of all study participants could have been treated by the family doctor during the regular consultation hours.

Conclusion

The study shows that in the OOH primary care centre about a quarter of all patients could have waited until regular consultation hours. Mostly young patients used the easily accessible and free care in the OOH primary care centre. Further studies are necessary to better understand the individual reasons of patients to use the OOH primary care centre.

[Focal point emergency departments]

The number of patients treated in hospital emergency departments in Germany has risen in recent years to approximately 20 million. This escalation also applies to the increasing numbers of patients presenting with neurological symptoms and diseases, which occur in approximately 20 % of emergency patients. In addition to patients with stroke, inflammatory or degenerative central nervous system (CNS) and peripheral nervous system (PNS) disorders who need urgent treatment, more and more patients with nonspecific complaints or conditions attend emergency departments for elective treatment, not least because timely appointments with specialist neurologists in practices could not be obtained. Neurological expertise and presence in emergency departments at the level of specialist standard are therefore indispensable for providing a professional level of treatment, which also corresponds to current legal requirements. The implementation of a generalist emergency physician in Germany, as introduced in some European countries, would mean a retrograde step for neurological expertise in emergency admission management. The discipline of neurology must work together with other emergency disciplines to improve the financing of emergency departments and provide neurologists working there with a substantive curriculum of further and continuing education in emergency-related aspects of neurology. The discipline of neurology has a responsibility to emergency patients within its range of competencies and must, therefore, strengthen and improve its role in healthcare politics and concerning organizational and personnel aspects of neurological emergencies.

[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.

[Treatment duration of trauma and orthopedic patients in an emergency department]

INTRODUCTION

The majority of emergency patients are admitted to hospital via the emergency department. Overcrowding in emergency departments results in dissatisfied patients, increased complication rates, and negative medicoeconomic consequences. To overcome these problems, sufficient personnel strength should be available depending on treatment duration and the patients' characteristics.

MATERIALS AND METHODS

First, trauma and orthopedic patients were classified into six categories: ABT (history, findings, and therapy), RABT (X-ray and ABT), WABT (wound care and ABT), WRABT (wound care and RABT), STAT (hospital admission), and SR (trauma life support). Furthermore, the duration of medical treatment was correlated with the physicians' educational level (specialist or physician in training after or during the common trunk period). Not included were waiting periods and nursing care measures. After analyzing the frequency of each category, the mean duration of treatment for an"average patient" was determined.

RESULTS

The duration of treatment of 900 patients was recorded. The average times were 9.5 min (ABT), 13.8 min (RABT), 17.3 min (WABT), 24.5 min (WRABT), 38.4 min (STAT), and 84.2 min (SR). The frequencies for the different categories were: ABT 18.8%; RABT 50.2%; WABT 14.5%; WRABT 4.4%; STAT 10.6%, and SR 1.4%. Thus, an average duration of medical treatment of 17.6 min was calculated. Especially in the RABT category, significant differences between specialists and physicians in training were evident. In children and adolescents, the duration of treatment was 12.5 min.

CONCLUSION

The duration of treatment of an average trauma and orthopedic patient depends on the level of care of the hospital and the qualification of the physician in charge. In order to avoid negative consequences of overcrowding in emergency departments, adequate personnel strength is essential. Personnel strength should be calculated based on the average duration of medical treatment of about 18 min.

[Validity of admission diagnoses as process-driving criteria : influence on length of stay and consultation rate in emergency departments]

BACKGROUND

Primary care physicians and specialists often refer patients to the emergency department with a specific diagnosis and request for admission. Such an external diagnosis frequently influences the initial evaluation in the emergency department. The present study aimed to evaluate the accuracy of such external diagnoses and to assess the consequences of incorrect diagnoses on length of stay and number of specialty consultations in the emergency department.

MATERIAL AND METHODS

This was a prospective observational study over the course of 3 months in the emergency department of a tertiary care center. External admission diagnoses made by primary care physicians and specialists were categorized as "accurate", "partially accurate" and "inaccurate". A special analysis of the external admission diagnosed was performed for patients admitted directly to an intermediary care unit and intensive care unit or patients who were transferred directly from the emergency department to the operating room.

RESULTS

Data for 784 patients were analyzed. Patients were on average 63.1 ± 19.5 years old (minimum-maximum 18-97 years, median 68 years) and 54 % were male. After emergency department evaluation and treatment 57.8 % of external diagnoses were categorized as accurate, 23.6 % as partially accurate and 18.6 % as inaccurate. Patients with partially accurate and inaccurate diagnoses had a 3 and 6.5 times higher rate of specialty consultations in the emergency department, respectively, when compared with patients with an accurate diagnosis (number of specialty consultations n = 0: 77.3 % vs. 54.1 % vs. 92.9 %, p < 0.05; n = 1: 20.0 % vs. 40.4 % vs. 6.2 %, p < 0.05; n = 2: 2.7 % vs. 5.5 % vs. 0.9 %, p < 0.05, respectively. Patients with an accurate diagnosis had a shorter total length of stay than patients with a partially accurate or inaccurate diagnosis [mean ± SD (min-max; median): 192 ± 108 min (10-707 min; 181 min) vs. 246 ± 126 min (27-1,026 min; 214 min) vs. 258 ± 138 min (22-700 min; 232 min), p < 0.001], respectively. Out of 85 patients admitted directly to an intermediary care unit, intensive care unit and patients who were transferred directly from the emergency department to the operating room the diagnosis was accurate, partially accurate and inaccurate in 56.5 %, 24.7 % and 18.8 %, respectively.

CONCLUSIONS

Admission diagnoses made by primary care physicians and specialists who subsequently refer patients to the emergency department are subject to certain inaccuracies. Inaccurate admission diagnoses are associated with an increased length of stay and a considerably higher rate of specialty consultation in the emergency department. Standardized operating procedures, treatment algorithms and triage systems are important to identify such incorrect diagnoses so that these patients can undergo appropriate diagnostic investigation and treatment.