Kerndatensatz „Notaufnahme“ der DIVI

The pattern of emergency department length of stay in Saudi Arabia: an epidemiological Nationwide analyses of secondary surveillance data

Background

Emergency department length of stay is a vital performance indicator for quality and efficiency in healthcare. This research aimed to evaluate the length of stay patterns in emergency departments across Saudi Arabia and to identify predictors for extended stays. The study used secondary data from the Ministry of Health's Ada'a program.

Methods

Using a retrospective approach, the study examined data from the Ada'a program on emergency department length of stay from September 2019 to December 2021. These data covered 1,572,296 emergency department visits from all regions of Saudi Arabia. Variables analyzed included quality indicators, year of visit, shift time, hospital type, and data entry method. The analysis was conducted using multiple linear regression.

Results

The study found that the median length of stay was 61 min, with significant differences among related predictors. All associations were significant with a value of p of less than 0.001. Compared to 2019, the length of stay was notably shorter by 28.5% in 2020 and by 44.2% in 2021. Evening and night shifts had a shorter length of stay by 5.9 and 7.8%, respectively, compared to the morning shift. Length of stay was lower in winter, summer, and fall compared to spring. Patients in levels I and II of the Canadian Triage and Acuity Scales had longer stays than those in level III, with those in level I reaching an increase of 20.5% in length of stay. Clustered hospitals had a longer length of stay compared to the non-clustered ones. Pediatric hospitals had a 15.3% shorter stay compared to general hospitals. Hospitals with data entered automatically had a 14.0% longer length of stay than those entered manually. Patients admitted to the hospital had a considerably longer length of stay, which was 54.7% longer compared to non-admitted patients. Deceased patients had a 20.5% longer length of stay than patients discharged alive.

Conclusion

Data at the national level identified several predictors of prolonged emergency department length of stay in Saudi Arabia, including shift time, season, severity level, and hospital type. These results underline the necessity of continuous monitoring and improvement efforts in emergency departments, in line with policy initiatives aiming to enhance patient outcomes in Saudi Arabia.

[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.

The impact of a qualified medical documentation assistant on trauma room management

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.

Der AKTIN-Monatsbericht: Plädoyer für ein standardisiertes Reporting in der Notaufnahme

Hintergrund

Vor dem Hintergrund der steigenden Inanspruchnahme und aktuellen Veränderungen in der Notfallversorgung ist eine standardisierte Erfassung relevanter Kennzahlen in Notaufnahmen zwingend erforderlich.

Ziel der Arbeit

Es werden die Konsentierung von Inhalten und technische Umsetzung eines automatisierten Reportings für Notaufnahmen des AKTIN-Notaufnahmeregisters beschrieben. Ziel war ein aussagefähiger Monatsbericht zur Prozesssteuerung und Qualitätssicherung.

Material und Methoden

Datengrundlage ist der Datensatz Notaufnahme V2015.1 der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin e. V. (DIVI). Die Konsentierung der Inhalte erfolgte auf Basis von externen Referenzen und fachlicher Expertise; die technische Entwicklung erfolgte anhand eines Testdatensatzes. Mit der Software R und Apache Formatting Objects Processor (FOP) wird der finale Bericht im PDF-Format automatisiert erstellt.

Ergebnisse

Der Bericht enthält unter anderem Angaben zu Fallzahlen, Demografie der Patienten, Vorstellungsgründen, Ersteinschätzung, Verbleib und ausgewählten Prozesszeiten in Form von Tabellen und Grafiken. Er wird monatsweise automatisch oder auf Anforderung aus den Routinedaten generiert. Fehlende Werte und Ausreißer werden zur Abschätzung der Datenqualität separat ausgewiesen.

Diskussion

Beim AKTIN-Monatsbericht handelt es sich um ein Instrument, welches das Versorgungsgeschehen aufbereitet und visualisiert. Die konsentierten Kennzahlen sind praxistauglich und bilden auch die Vorgaben des Gemeinsamen Bundesausschusses zur Ersteinschätzung ab. Die Nutzung von Interoperabilitätsstandards erlaubt eine automatische Erfassung im Alltag, gewährleistet eine Unabhängigkeit von einzelnen IT-Systemen und kann als Grundlage für ein klinikübergreifendes Benchmarking dienen.

[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]

Hintergrund

Die Notfallversorgung befindet sich im Umbruch. In Notaufnahmen werden Patienten ausgehend von Symptomen und Dringlichkeit versorgt; dies bildet sich jedoch in den etablierten Routinedaten der gesetzlichen Sozialversicherung nicht ab. Ziel des AKTIN-Projekts war der Aufbau einer datenschutzkonformen Registerinfrastruktur zur Nutzung von klinischen Routinedaten aus Notaufnahmen.

Methoden

Über eine standardisierte Schnittstelle werden aus den verschiedenen Dokumentationssystemen kontinuierlich Daten der Notaufnahmebehandlung in ein lokales Data Warehouse exportiert. Dort stehen sie sowohl für lokale Nutzungen, wie interne Berichte und Qualitätsmanagement, als auch gleichzeitig datenschutzkonform für multizentrische Auswertungen zur Verfügung.

Anhand der Registerpopulation wird die Ersteinschätzung sowie die Erhebung von Vitalparametern in Abhängigkeit von Vorstellungsgründen für einen 12-Monats-Zeitraum analysiert.

Ergebnisse

Für den Zeitraum 04/2018 bis 03/2019 wurden 436.149 gültige Fälle aus 15 Notaufnahmen übermittelt. In 86,0 % der Fälle ist eine Ersteinschätzung dokumentiert.

Diese fand in 70,5 % innerhalb von 10 min nach Ankunft des Patienten statt. In 10 Kliniken wird regelhaft (82,3 %) ein Vorstellungsgrund erfasst. Die Erfassung von Vitalparametern variiert plausibel zwischen den Vorstellungsgründen.

Schlussfolgerung

Das AKTIN-Notaufnahmeregister bietet einen zeitnahen Einblick in das Versorgungsgeschehen der Notaufnahmen ohne zusätzlichen Dokumentationsaufwand und unabhängig vom primären IT-System, Kostenträger, Fallart und Abrechnungsmodus. Die Vorgaben des Gemeinsamen Bundesausschusses zur Ersteinschätzung werden weitgehend umgesetzt. Durch die Etablierung von standardisierten Vorstellungsgründen werden symptombasierte Analysen und Gesundheitssurveillance ermöglicht.

Zusatzmaterial online

Die Onlineversion dieses Beitrags (10.1007/s00063-020-00764-2) enthält die Abb. S1 und S2. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

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.

Assessing healthcare service quality using routinely collected data: Linking information systems in emergency care

Emergency departments need to continuously calculate quality indicators in order to perform structural improvements, improvements in the daily routine, and ad-hoc improvements in everyday life. However, many different actors across multiple disciplines collaborate to provide emergency care. Hence, patient-related data is stored in several information systems, which in turn makes the calculation of quality indicators more difficult. To address this issue, we aim to link and use routinely collected data of the different actors within the emergency care continuum. In order to assess the feasibility of linking and using routinely collected data for quality indicators and whether this approach adds value to the assessment of emergency care quality, we conducted a single case study in a German academic teaching hospital. We analyzed the available data of the existing information systems in the emergency continuum and linked and pre-processed the data. Based on this, we then calculated four quality indicators (Left Without Been Seen, Unplanned Reattendance, Diagnostic Efficiency, and Overload Closure). Lessons learned from the calculation and results of the discussions with staff members that had multiple years of work experience in the emergency department provide a better understanding of the quality of the emergency department, the related challenges during the calculation, and the added value of linking routinely collected data.

[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.

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.

Lessons learned in applying the International Society for Pharmacoeconomics and Outcomes Research methodology to translating Canadian Emergency Department Information System Presenting Complaints List into German

OBJECTIVES

The patient's presenting complaint guides diagnosis and treatment in the emergency department, but there is no classification system available in German. The Canadian Emergency Department Information System (CEDIS) Presenting Complaint List (PCL) is available only in English and French. As translation risks the altering of meaning, the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) has set guidelines to ensure translational accuracy. The aim of this paper is to describe our experiences of using the ISPOR guidelines to translate the CEDIS PCL into German.

MATERIALS AND METHODS

The CEDIS PCL (version 3.0) was forward-translated and back-translated in accordance with the ISPOR guidelines using bilingual clinicians/translators and an occupationally mixed evaluation group that completed a self-developed questionnaire.

RESULTS

The CEDIS PCL was forward-translated (four emergency physicians) and back-translated (three mixed translators). Back-translation uncovered eight PCL items requiring amendment. In total, 156 comments were received from 32 evaluators, six of which resulted in amendments.

CONCLUSION

The ISPOR guidelines facilitated adaptation of a PCL into German, but the process required time, language skills and clinical knowledge. The current methodology may be applicable to translating the CEDIS PCL into other languages, with the aim of developing a harmonized, multilingual PCL.

[Consideration of guidelines, recommendations and quality indicators for treatment of stroke in the dataset "Emergency Department" of DIVI]

BACKGROUND

The dataset "Emergency Department" of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) has been developed during several expert meetings. Its goal is an all-encompassing documentation of the early clinical treatment of patients in emergency departments. Using the example of the index disease acute ischemic stroke (stroke), the aim was to analyze how far this approach has been fulfilled.

MATERIAL AND METHODS

In this study German, European and US American guidelines were used to analyze the extent of coverage of the datasets on current emergency department guidelines and recommendations from professional societies. In addition, it was examined whether the dataset includes recommended quality indicators (QI) for quality management (QM) and in a third step it was examined to what extent national provisions for billing are included. In each case a differentiation was made whether the respective rationale was primary, i.e. directly apparent or whether it was merely secondarily depicted by expertise. In the evaluation an additional differentiation was made between the level of recommendations and further quality relevant criteria.

RESULTS

The modular design of the emergency department dataset comprising 676 data fields is briefly described. A total of 401 individual fields, divided into basic documentation, monitoring and specific neurological documentation of the treatment of stroke patients were considered. For 247 data fields a rationale was found. Partially overlapping, 78.9 % of 214 medical recommendations in 3 guidelines and 85.8 % of the 106 identified quality indicators were primarily covered. Of the 67 requirements for billing of performance of services, 55.5 % are primarily part of the emergency department dataset. Through appropriate expertise and documentation by a board certified neurologist, the results can be improved to almost 100 %.

CONCLUSION

The index disease stroke illustrates that the emergency department dataset of the DIVI covers medical guidelines, especially 100 % of the German guidelines with a grade of recommendation. All necessary information to document the specialized stroke treatment procedure in the German diagnosis-related groups (DRG) system is also covered. The dataset is also suitable as a documentation tool of quality management, for example, to participate in the registry of the German Stroke Society (ADSR). Best results are obtained if the dataset is applied by a physician specialized in the treatment of patients with stroke (e.g. board certified neurologist). Finally the results show that changes in medical guidelines and recommendations for quality management as well as billing-relevant content should be implemented in the development of datasets for documentation to avoid duplicate documentation.