Auf dem Weg zur integrierten Qualitätssicherung im Rettungsdienst: Stand − Bedarf − Vision

Understanding health care pathways of patients with sepsis: protocol of a mixed-methods analysis of health care utilization, experiences, and needs of patients with and after sepsis

BACKGROUND

Sepsis is associated with about 20% of deaths worldwide. It often presents with non-specific initial symptoms, making its emergency treatment an interdisciplinary and cross-sectoral challenge. Three in four sepsis survivors suffers from new cognitive, psychological, or physical sequelae for which specific treatment concepts are scarce. The AVENIR project aims to improve the understanding of patient pathways, and subjective care experiences and needs along the entire healthcare pathway before, with and after sepsis. Based on this, concrete recommendations for the organization of care and patient information materials will be developed with close patient participation.

METHODS

Mixed-methods study including (1) analysis of anonymized nationwide health claims data from Germany, (2) linkage of health claims data with patient care reports (PCR) of emergency medical services from study regions in two federal states within Germany, and (3) qualitative exploration of the patient, relative, and care provider perspective on sepsis care. In (1), we analyze inpatient and outpatient health care utilization until 30 days pre-sepsis; clinical sepsis care including intra- and inter-hospital transfers; and rehabilitation, inpatient and outpatient aftercare of sepsis survivors as well as costs for health care utilization until 24 months post-sepsis. We attempt to identify survivor classes with similar health care utilization by Latent Class Analyses. In (2), PCR are linked with health claims data to establish a comprehensive database outlining care pathways for sepsis patients from pre-hospital to follow-up. We investigate e.g., whether correct initial assessment is associated with acute (e.g., same-day lethality) and long-term (e.g., new need for care, long-term mortality) outcomes of patients. We compare the performance of sepsis-specific screening tools such as qSOFA, NEWS-2 or PRESEP in the pre-clinical setting. In (3), semi-structured interviews as well as synchronous and asynchronous online focus groups are conducted and analyzed using qualitative content analyses techniques.

DISCUSSION

The results of the AVENIR study will contribute to a deeper understanding of sepsis care pathways in Germany. They may serve as a base for improvements and innovations in sepsis care, that in the long-term can contribute to reduce the personal, medical, and societal burden of sepsis and its sepsis sequelae.

TRIAL REGISTRATION

Registered at German Clinical Trial Register (ID: DRKS00031302, date of registration: 5th May 2023).

Digitale Systeme zur Unterstützung von präklinischen Notfalleinsätzen

Hintergrund und Fragestellung

Steigende Anforderungen an Dokumentation und sektorenübergreifende Kommunikation führen zu vermehrtem organisatorischem Aufwand im Notarzt- und Rettungsdienst. Die Verwendung digitaler Informationssysteme im präklinischen Einsatz kann sowohl dazu beitragen, Einsatzkräfte bei diesen Aufgaben zu unterstützen als auch neue Behandlungsmöglichkeiten für Patienten eröffnen. Die Arbeit versucht, ein möglichst umfassendes Bild der derzeitigen Verbreitung und Nutzung von Informations- und Kommunikationssystemen zur Einsatzunterstützung in Deutschland zu erstellen.

Material und Methoden

Die Querschnittsstudie wurde als deutschlandweite, explorative Online-Befragung unter Notärzten und Rettungsdienstfachpersonal von Juli bis August 2020 durchgeführt. Die anschließende Datenanalyse erfolgte durch deskriptive Statistikmethoden. Betrachtet wurden u. a. Lösungen für die digitale Dokumentation und Krankenhausvoranmeldung, für den Versorgungsnachweis und Telenotarztdienst sowie der Digitalfunk.

Ergebnisse

Es wurden 821 Antwortbogen von 481 Rettungswachen aus insgesamt 382 Städten in der Auswertung berücksichtigt. Die Verfügbarkeit von 16 untersuchten Systemen variiert deutschlandweit je nach Bundesland und Anwendungsbereich. Befragte Einsatzkräfte zeigen sich gegenüber neuen Technologien und Möglichkeiten grundsätzlich offen, wenngleich die aktuelle Umsetzung als nicht zufriedenstellend bewertet wird. Herausforderungen zeigen sich v. a. hinsichtlich Verlässlichkeit, Hardware, Benutzerfreundlichkeit und Interoperabilität.

Diskussion

Eine weitreichende Digitalisierung der präklinischen Notfallmedizin wurde in Deutschland bislang nicht erreicht. Die ganzheitliche Betrachtung und vernetzte Implementierung aller am Einsatz beteiligten Systeme und Prozesse kann dazu beitragen, digitale Lösungen für die Präklinik zu verbessern und weiter zu verbreiten.

[Linking Health Claims Data and Records of Emergency Medical Services: Building a Bridge via Patient's Health Insurance Number?]

INTRODUCTION

In Germany, Emergency Medical Services (EMS) were involved in a total of 7.3 million emergency cases in 2016/2017. Information on prehospital care is stored in several secondary data sources, yet combined analysis of these data at the level of individual patients or EMS cases happens rarely. Research is needed on which methods and variables are suitable for the linkage of these data sources.

METHODS

We linked EMS records from five Bavarian emergency service districts to health claims data belonging to ten statutory health insurers (data from 2016). Two linkage approaches at the level of individual patient's EMS case/reimbursement case were demonstrated. First, a deterministic linkage was conducted based on the patient's unique identifying health insurance number. The second linkage was probabilistic. As linkage variables, it comprised the only partially available health insurance number plus several non-unique key variables, the latter being a patient's health insurance provider, sex, year of birth and distance travelled. In order to verify the deterministic and the probabilistic linkages' quality, rates of accordance of several variables present in both data sources were calculated.

RESULTS

The starting point for our data linkage were 106,371 EMS records (independent of certain health insurance companies) and 432,693 EMS services reimbursed by health insurers (independent of specific EMS providers). 4,327 EMS records could be linked to health claims data - out of 5,921 EMS records that coded a health insurance company contributing claims data to Inno_RD. With a probabilistic linkage, it was possible to increase this number to a total of 5,379 linked EMS records. All checks carried out indicated a high linkage quality for both the deterministic and the probabilistic approach.

CONCLUSION

A linkage of EMS records with health claims data is possible. In Inno_RD, a probabilistic approach has proven a valuable alternative to deterministic linkage via health insurance number since EMS records can be linked meaningfully even if the health insurance number is unavailable or where a minority of non-unique key variables show non-accordance or missing values.

Which health-related reasons lead to prehospital emergency care and how does subjective emergency status connect to subsequent care?

Objectives/Background

In many countries, the use of emergency medical services (EMS) increases steadily each year. At the same time, the percentage of life-threatening complaints decreases. To redesign the system, an assessment and consideration of the patients’ perspectives is helpful.

Methods

We conducted a paper-based survey of German EMS patients who had at least one case of prehospital emergency care in 2016. Four health insurance companies sent out the questionnaire to 1312 insured persons. We linked the self-reported data of 254 respondents to corresponding claims data provided by their health insurance companies. The analysis focuses a.) how strongly patients tend to call EMS for themselves and others given different health-related scenarios, b.) self-perceived health complaints in their own index case of prehospital emergency care and c.) subjective emergency status in combination with so-called “objective” characteristics of subsequent EMS and inpatient care. We report principal diagnoses of (1) respondents, (2) 57,240 EMS users who are not part of the survey and (3) all 20,063,689 inpatients in German hospitals. Diagnoses for group 1 and 2 only cover the inpatient stay that started on the day of the last EMS use in 2016.

Results

According to the survey, the threshold to call an ambulance is lower for someone else than for oneself. In 89% of all cases during their own EMS use, a third party called the ambulance. The most common, self-reported complaints were pain (38%), problems with heart and circulation (32%), and loss of consciousness (17%). The majority of respondents indicated that their EMS use was due to an emergency (89%). We could detect no or only weak associations between patients’ subjective urgency and different items for objective care.

Conclusion

Dispatchers can possibly optimize or reduce the disposition of EMS staff and vehicles if they spoke directly to the patients more often. Nonetheless, there is need for further research on how strongly the patients’ perceived urgency may affect the disposition, rapidness of the service and transport targets.

[Health and Social Status in Hamburg's Urban Quarters - An Approach to Mapping Social Status with Health-Related Routine Data]

AIM OF THE STUDY

The aim of this study was to test an innovative approach to the small-scale and social situation-sensitive localisation and analysis of health-related routine data. For this purpose, SHI billing data and deployment data of the ambulance service were supplemented with a small-scale neighbourhood-related indicator of the social situation of the place of residence and/or deployment as a proxy for the personal social situation.

METHODS

Anonymised accounting data from three statutory health insurances and deployment data from the rescue service of the Hamburg fire brigade, each from the year 2017, were used. The social situation of the place of residence of the insured or transported persons (in the case of the rescue service data, also the deployment location) was mapped with the help of the so-called status index classes (high - medium - low - very low) of the Hamburg social monitoring. The allocation via the addresses of the persons concerned was carried out by the respective data owners with the help of an allocation procedure developed in the project.

RESULTS

Exemplary results of descriptive analysis of accident occurrence and acute inpatient care of children and adolescents showed that known social situation dependencies from primary studies can also be depicted in the secondary data used. This would speak for the suitability of the social indicator, e. g. in the context of extended social and health reporting.

CONCLUSION

The neighbourhood-based indicator we used seems promising and should be validated in further analyses. Based on this, approaches can be developed for its use in the context of health services research and health reporting as well as in the sense of a comprehensive health-in-all-policies strategy for designing health-promoting and needs-oriented political decisions and programmes.

Entwicklung der Frequenz und des Spektrums von Rettungsdiensteinsätzen in Deutschland

Hintergrund

Die Berichterstattung aus einzelnen Bundesländern zeigt über viele Jahre kontinuierlich steigende Einsatzzahlen im bodengebundenen Rettungsdienst.

Fragestellung

Ziel der Arbeit ist es aufzuzeigen, wie stark sich die Einsatzzahlen und das Einsatzspektrum im Rettungsdienst in den letzten Jahren entwickelt haben.

Material und Methode

Die Arbeit führt nach Literaturrecherche geeignete Publikationen synoptisch zusammen, um einen umfassenden Überblick der aktuellen Erkenntnisse zu geben.

Ergebnisse

Vollerhebungen der Einsatzzahlen einzelner Bundesländer sowie Hochrechnungen der Rettungsdiensteinsätze auf Bundesebene zeigen jährliche Zuwachsraten von etwa 5 %. Zudem belegen einzelne Untersuchungen vor allem einen Anstieg nichttraumatologischer Einsatzgründe. Sowohl die Einsatzzunahme als auch die Änderung im Einsatzspektrum können, neben weiteren Einflussfaktoren, u. a. auf den demografischen Wandel zurückgeführt werden.

Schlussfolgerungen

Um dem Anstieg und der Änderung der Inanspruchnahme zu begegnen, erscheint neben der Ausweitung bestehender Angebote der Notfallversorgung die Etablierung alternativer Ansätze (z. B. Telenotarzt) zielführend. Begleitend sollte eine umfassende Datenerfassung und -auswertung erfolgen, um im Rahmen des Qualitätsmanagements ein kontinuierliches Nachsteuern des Systems zu erlauben.

[Analysis of a first responder system for emergency medical care in rural areas: first results and experiences]

BACKGROUND

In emergency situations it is essential to get access to medical treatment as early as possible. In Germany, the time interval from alarm to arrival should be less than 10-15 min. The emergency medical service (EMS) cannot comply with this recommendation in approximately 10% of the emergencies in Baden-Württemberg. In addition to the traditional EMS system, a voluntary system of first responders has been developed over the last years to reduce this interval. They are incorporated into the alarm system of the traditional EMS and are alarmed as soon as an emergency call arrives. Data on process times (from alarm to begin of treatment or duration of treatment until arrival of EMS) and quality are rare. In Baden-Württemberg, the emergency aid "Deutsche Lebens-Rettungs-Gesellschaft e.V. (DLRG)" Nordhardt can only estimate times and quality of primary care. The objective of this analysis was to describe and evaluate such a first responder system.

METHODS

The presented study investigated the emergency responses of a first responder system in Nordhardt, close to Karlsruhe, Germany. A total of 367 emergency data sets from 2017 containing information on operating time, medical history, suspected diagnosis and medical treatment, were evaluated. Of these, 363 anonymized emergency records including the complete information (concerning process time and medical treatment) were analyzed. The focus was on different time intervals from alarm to treatment and until arrival of the EMS. Additionally, the quality of medical treatment and the measured vital data were examined.

RESULTS

The median response time and time to access to the patient was 2 min in both. The patient was reached within approximately 4 min and treated for another 5 min until the EMS arrived. In two thirds of the patients, the vital parameters were measured, 5 patients were resuscitated, 23 received supplementary oxygen, 4 patients were ventilated and 11 patients suffering from hypoglycemia showed a clinical benefit from the early treatment. A total of 50 trauma patients were treated, 5 with cervical spine stabilization and 38 received a body check.

CONCLUSION

The first responders from Nordhardt received an emergency call nearly every day. In two thirds of the calls they were faster than the EMS as they usually have local sites with a shorter distance to the emergency scene where they are able to deal with critical medical cases until the EMS arrives. Despite the small case numbers, it could be concluded that the early medical treatment with respect to resuscitation based on earlier arrival on site may help to increase the survival rate of patients. The first responders were also able to manage airway problems with additional oxygen or other airway devices. Other medical treatment performed by the first responders, such as administration of glucose in hypoglycemic patients positively affected the patient's condition. There is a tactical advantage to include first responders in traditional EMS services. Further studies are needed to examine these questions in larger samples also over a longer time period. Standardization and digitalization of the records could help to gain more data in this field.