Zentrale Auswertung von Notarzteinsätzen im Rahmen externer Qualitätssicherung

[Prediction of further hospital treatment for emergency patients by emergency medical service physicians]

INTRODUCTION

Prehospital assessment of illness and injury severity with the National Advisory Committee for Aeronautics (NACA) score and hospital pre-arrival notification of a patient who is likely to need intensive care unit (ICU) or intermediate care unit (IMC) admission are both common in Germany's physician-staffed emergency medical services (EMS) system.

AIM

This study aimed at comparing the prehospital evaluation of severity of disease or injuries by EMS physicians and the subsequent clinical treatment in unselected emergency department (ED) patients.

MATERIAL AND METHODS

This study involved a prospective observational analysis of patients transported to the ED of an academic level I hospital escorted by an EMS physician over a period of 6 months (February-July 2011). The physician's qualification and the patient's NACA score were documented and the EMS physician was asked to predict whether the patient would need hospital admission and, if so, to the general ward, IMC or ICU. After the ED treatment, discharge or admission, outcome and length of hospital and ICU or IMC stay were documented.

RESULTS

A total of 378 mostly non-trauma patients (88 %) treated by experienced EMS physicians could be enrolled. The number of patients discharged from the ED decreased, while the number of patients admitted to the ICU increased with higher NACA scores. Prehospital prediction of discharge or admission, IMC or ICU treatment by EMS physicians was accurate in 47 % of the patients. In 40 % of patients a lower level of care was sufficient while 12 % needed treatment on a higher level of care than that predicted by EMS physicians. Of the patients 39 % who were predicted to be discharged after ED treatment, were admitted to hospital and 48 % of patients predicted to be admitted to the IMC were admitted to the general ward. Patients predicted to be admitted to the ICU were admitted to the ICU in 75 %. Higher NACA scores were associated with increased mortality and a longer hospital IMC or ICU length of stay, but significant differences were only found between patients with NACA V versus VI scores or patients predicted to be treated on the IMC versus the ICU.

CONCLUSIONS

Prehospital NACA scores indicate the need for inpatient treatment, but neither hospital discharge or admission nor need of IMC or ICU admission after initial ED treatment could be sufficiently predicted by EMS physicians. Thus, hospital prenotification in order to predispose IMC or ICU capacities does not seem to be useful in cases where an ED can reassess admitted EMS patients.

The quality of emergency medical care in baden-württemberg (Germany): four years in focus

BACKGROUND

In 2004, the German federal state of Baden-Württemberg implemented a quality management system for pre-hospital emergency care. Since then, there has been a semi-annual assessment of the frequency of different types of emergency medical interventions and the quality of care.

METHODS

The frequencies of different types of intervention were determined and reported both in absolute numbers and as incidence figures, i.e., interventions per 1000 inhabitants per year. The quality of care was rated with the Mainz Emergency Evaluation Score (MEES), and analyses of resuscitation outcomes and guideline implementation were performed.

RESULTS

From 2004 to 2008, there were a total of 524,833 pre-hospital emergency medical interventions in Baden-Württemberg. The annual incidence of emergency interventions rose by 22% over this period (from 16.2 to 19.9 interventions per 1000 inhabitants per year), and the percentage of patients who were severely ill or severely injured rose as well, from 47.3% to 51.1%. The percentage of patients over age 75 rose from 29.1% to 31.3%. 11,858 patients with myocardial infarction (MI) were treated in 2008; the incidence of treatment for MI rose by 60% from 2004 to 2008, from 0.907 to 1.448 interventions per 1000 inhabitants per year. A major improvement in the diagnostic evaluation of MI came about through the purchase of more 12-channel ECG machines. In 2008, the emergency medical teams succeeded in improving the patient's condition in 69.07% of all cases (77.9% for MI, 63.2% for stroke, 74.4% for multiple trauma). 21 patients per 100,000 inhabitants per year arrived in the hospital alive after out-of-hospital cardiac arrest and pre-hospital resuscitation.

CONCLUSIONS

Even in the face of increasing utilization, the quality of emergency medical care in Baden-Württemberg has remained high. Since a quality management system was introduced in 2004, the physicians in charge of emergency medical teams have had access to the data that they need in order to evaluate and further develop the services that they provide.

[Paper-assisted digital Mission documentation in air rescue services. Quality management in preclinical emergency medicine]

BACKGROUND

Recording of adequate mission data is of utmost importance in prehospital emergency medicine. For this, a nationwide uniform core dataset for prehospital data reporting, the so-called MIND 2, was introduced. With this procedure adequate information about structure and outcome quality, but only little information about process quality, can be obtained. Regarding the quality of data recording, primarily computer-based techniques are superior to other techniques. Against this background, the aim of this study was to develop a documentation system, which sets new standards regarding documentation dataset and documentation quality.

RESULTS

A primarily computer-based documentation system based on the "digital paper" technology was achieved. This technology allows conventional data entry via a (digital) pen and documentation on conventional paper. As the core-dataset MIND 2 was realized - furthermore, the measurements performed during prehospital management as well as data on vital signs (blood pressure, heart frequency, S(a)O(2), p(et)CO(2) etc.) were included into routine data recording. Integration of this documentation system into an already existing medical quality management system was achieved via a defined interface. Testing of this new system over a 3-month period at the helicopter emergency medical service (HEMS) "Christoph 22" showed a high degree of functionality and stability of the system. Serious problems, especially a total break-down of the whole system, were not observed during the study period.

CONCLUSIONS

The new data recording concept, which is based on the "digital paper" technology, has proven to be completely satisfactory with respect to functionality and documentation quality during the test period.

Realistic assessment of the physican-staffed emergency services in Germany

In Germany the emergency medical services, which include dispatching emergency physicians to the scene, are considered to be among the best in the world. However, the hospitals admitting these patients still report shortcomings in prehospital care. The quality of an emergency medical service depends on both formal qualification and experience in managing such emergencies. Therefore, we determined how frequently emergency medical service physicians in Germany actually encountered complex and demanding emergency situations outside the hospital and how often they had to carry out emergency interventions. We therefore evaluated data from more than 82,000 ground emergency medical service scene calls registered in the MIND ("minimaler Notarztdatensatz") data base of the state of Baden-Wuerttemberg, Germany and more than 47,000 helicopter emergency medical service scene calls from the "Luftrettungs-, Informations- und Kommunikationssystem" (LIKS) data base of the German ADAC air rescue service. The results, which were unexpectedly distinct, impressively demonstrate that in part emergency medical service staff only encountered some emergencies very rarely. In particular, patients with life-threatening conditions such as acute coronary syndrome, stroke, head trauma, as well as multiple trauma were only treated once every 0.4-14.5 months and cardiopulmonary resuscitation and intubation were only carried out once every 0.5-1.5 months. Furthermore, a time period of 6 months to more than 6 years may pass before a chest tube has to be placed. There are, of course, considerable differences between ground and helicopter emergency medical services. Particularly in areas where the frequency of such emergency cases is low, the clinical experience required to competently manage a demanding emergency situation cannot be gained or maintained just by working in the emergency medical system. As a result of the general pressure to cut costs and also of changes in hospital politics, however, only highly qualified and experienced emergency medical services may survive in Germany in the long term. In addition to formal qualifications and accompanying practice-related courses, future emergency medical service personnel should be drafted from clinical department staff that are experienced in treating severely ill and severely injured patients.

Automated speech recognition for time recording in out-of-hospital emergency medicine-an experimental approach

Precise documentation of medical treatment in emergency medical missions and for resuscitation is essential from a medical, legal and quality assurance point of view [Anästhesiologie und Intensivmedizin, 41 (2000) 737]. All conventional methods of time recording are either too inaccurate or elaborate for routine application. Automated speech recognition may offer a solution. A special erase programme for the documentation of all time events was developed. Standard speech recognition software (IBM ViaVoice 7.0) was adapted and installed on two different computer systems. One was a stationary PC (500MHz Pentium III, 128MB RAM, Soundblaster PCI 128 Soundcard, Win NT 4.0), the other was a mobile pen-PC that had already proven its value during emergency missions [Der Notarzt 16, p. 177] (Fujitsu Stylistic 2300, 230Mhz MMX Processor, 160MB RAM, embedded soundcard ESS 1879 chipset, Win98 2nd ed.). On both computers two different microphones were tested. One was a standard headset that came with the recognition software, the other was a small microphone (Lavalier-Kondensatormikrofon EM 116 from Vivanco), that could be attached to the operators collar. Seven women and 15 men spoke a text with 29 phrases to be recognised. Two emergency physicians tested the system in a simulated emergency setting using the collar microphone and the pen-PC with an analogue wireless connection. Overall recognition was best for the PC with a headset (89%) followed by the pen-PC with a headset (85%), the PC with a microphone (84%) and the pen-PC with a microphone (80%). Nevertheless, the difference was not statistically significant. Recognition became significantly worse (89.5% versus 82.3%, P<0.0001 ) when numbers had to be recognised. The gender of speaker and the number of words in a sentence had no influence. Average recognition in the simulated emergency setting was 75%. At no time did false recognition appear. Time recording with automated speech recognition seems to be possible in emergency medical missions. Although results show an average recognition of only 75%, it is possible that missing elements may be reconstructed more precisely. Future technology should integrate a secure wireless connection between microphone and mobile computer. The system could then prove its value for real out-of-hospital emergencies.