Universit?res Benchmarking f��r die Unfallchirurgie Deutschland

Benchmarking is a very popular business process and meanwhile is used in research as well. The aim of the present study is to elucidate key numbers of German university trauma departments regarding research and teaching. The data set is based upon the monthly reports given by the administration in each university. As a result the study shows that only well-known parameters such as fund-raising and impact factors can be used to benchmark university-based trauma centers. The German federal system does not allow a nationwide benchmarking.     

Die Unfallchirurgie und die Deutsche Gesellschaft für Unfallchirurgie

Die Unfallchirurgie -     

Netzwerk Traumaforschung der Deutschen Gesellschaft f��r Orthop?die und Unfallchirurgie

A first meeting of the recently founded "Trauma Research Net" of the German Society for Orthopaedics and Trauma Surgery (DGOU e.V.) took place at the Reisensburg Castle, Günzburg, from 24 to 26 February 2011. Numerous representatives of trauma-related Research Institutes and University Hospitals in Germany demonstrated their main research foci. There was also an open discussion of current problems in trauma research, especially the lack of junior researchers and nationwide collaborations as well as limited information about the research topics of individual research groups. The overall research efforts of the "Trauma Research Net" apparently focus on fracture, multiple injury and inflammation on an organ and cellular level. Furthermore, an up-to-date matrix of the existing methods has been generated which is now provided for the networker. The common middle-term goal of the "Trauma Research Net" is the inclusive, intensive scientific exchange as well as the generation and workup of common hypotheses using standard operating procedures. In the long term, the resulting clustered research activities are intended to address and resolve clinically relevant questions in the field of trauma research.     

Entwicklung eines Schockraumalgorithmus f��r die Polytraumaversorgung

Within the framework of restructuring for the certification to a regional trauma centre of the DGU (German Society for Casualty Surgery), a uniform algorithm for multiple trauma was developed in the medical centre of Wolfsburg. The Wolfsburg multiple trauma algorithm is based on ATLS (advanced trauma life support) with integration of FAST (focused assessment with sonography for trauma), as well as the white paper of the DGU and regional-specific features. Thus structural, instrumental, organizational and personnel conditions were created to improve the care of multiply traumatized patients even further. The conditions for transition to a regional trauma centre of the DGU were confirmed by a successful audit.     

Bildgebungstechniken f��r die radiologische Gef??darstellung

This review article summarizes 14 recent studies from 2010 dealing with improvements and innovations of non-invasive vascular imaging with a focus on magnetic resonance angiography (MRA) and computed tomography angiography (CTA). The field of MRA comprises several studies concerning the diagnostic accuracy and a new low-dose regime for MR contrast agents. Furthermore different non-enhanced MRA techniques are introduced which might become increasingly more important in the future. An article about parallel imaging is summarized as an already widespread technical improvement. In addition several clinical applications, economic aspects and new potential applications are introduced in the field of CTA.     

Blick in und Wünsche für die Zukunft der Unfallchirurgie

Die Unfallchirurgie -     

DRG-Anpassungsvorschläge der Fachgebiete Orthopädie und Unfallchirurgie für 2004

The introduction of the DRG system in Germany-optional since 1 January 2003 and mandatory for all hospitals as of 1 January 2004-has resulted in great uncertainty, particularly on the part of hospitals, since apprehension prevails that the diagnostic and therapeutic measures practiced in Germany will not be appropriately represented and remunerated by a DRG system. The G-DRG version 1.0 prepared within the framework of substitutive execution is largely identical to the Australian AR-DRG version 4.1. Adjustments that do justice to the realities of German treatment modalities were at most insignificant. It is therefore essential that stock be taken for each medical specialty to determine to what extent treatment procedures commonly followed in Germany are adequately reflected in this G-DRG system or whether adjustments are necessary to make allowances for German realities.To be able to provide qualified statements on the problems involved, scientific analysis of possible problems is necessary utilizing German data. Thus, we undertook an evaluation of how the special fields of orthopedics and accident surgery are represented in the G-DRG system. The resultant data form the basis for evidence of presumable deficits in the representation of orthopedic and accident surgery cases in the G-DRG system.The German Association for Trauma Surgery and the German Association for Orthopedics and Orthopedic Surgery have undertaken a DRG evaluation project together with the Organization of Directors for Accident Surgery (chairperson: Professor Dr. Mischkowsky, Kempten), the Organization of Directors for Orthopedics (chairperson: Professor Dr. Puhl, Ulm), the DRG Working Group of the German Association for Accident Surgery, and the Joint Commission of the Professional Association of German Surgeons and the German Association for Surgery in cooperation with the DRG Research Group of the University Clinic Muenster, the German Hospital Association, and the German Medical Association with the goal of examining the medical and economic homogeneity of the case groups. A total of 12,645 orthopedic and trauma surgery cases were collected from 23 clinics-11 university hospitals and 12 non-university hospitals-and assessed. On the basis of this database and when too few cases were evaluable also based on clinical considerations, 14 adjustment proposals were formulated and submitted on schedule on 31 March 2003 to the Institute for Hospital Remuneration.The results of the DRG evaluation project illustrated the problems involved in representing the exceedingly heterogeneous and complex activities of orthopedic and trauma surgery departments in a flat rate financing system that is not attuned to the realties of German treatment procedures. Version 1.0 of the G-DRG system is not sufficiently differentiated to represent the multifaceted diagnostic and therapeutic services provided by trauma surgery and orthopedic departments in Germany.     

Beispiele für fehlerhafte Kodierung in der Unfallchirurgie

Das G-DRG-System ist komplex und birgt die Gefahr von Fehlern bei der Abrechnung von Patienten. Diagnosen mit Schweregradrelevanz kommt eine besondere Bedeutung zu, da sie sich erl?ssteigernd auswirken k?nnen. Auch Prozeduren generieren h?ufig DRG („Diagnosis Related Groups“) mit h?herem Relativgewicht, so dass ihre Erfassung zwingend erforderlich ist. Grundlegend ist die korrekte ?rztliche und pflegerische Dokumentation. Jedoch müssen hohe Erl?se in Relation zu den Aufwendungen gesehen werden.     

Beispiele für fehlerhafte Kodierung in der Unfallchirurgie

The G-DRG-System is complex, mistakes in accounting are common. Therefore diagnosis with CCL-value are important because of the possibility of increasing revenues. Also procedures may lead to DRGs with a higher cost weight. So their acquisition is mandatory. The exact medical documentation is essential. High revenues have to be understood according to unvoidable expenditures.     

Minimal-invasiver Zugang f��r EVAR

Complications of surgical and percutaneous vascular access are well known and can lead to considerable morbidity and even mortality. This article describes a technique which combines the advantages of surgical open and percutaneous access approaches: minimal surgical exposure of the target vessel followed by fast and safe access by a modified open Seldinger technique under direct tactile and visual control. This unique combination of techniques enhances the safety of vascular access such that local complications can be almost totally avoided. Economic and safety considerations are discussed and a balanced view on the advantages of the described technique will be given.     

Regenerative Therapien f��r Kinderherzen

Nowadays surgical treatment of congenital heart disease can be performed with excellent outcome. However, chronic postoperative cardiac overload cannot always be obviated especially with more complex anomalies. Therefore, regenerative therapeutic concepts may offer promising options for complementary management of congenital heart disease. In this study umbilical cord blood mononuclear cells and erythropoietin were employed in two different models for volume and pressure overload of the right ventricle, respectively. Enhancement of myocardial capillary density seems to be the most significant effect of the intramyocardial application of umbilical cord mononuclear cells for a significant improvement of diastolic properties of the right ventricle after 3 months chronic volume overload. Erythropoietin, which was administered via an intramyocardial and systemic route, has positive effects by enhancing capillary density, limiting fibrosis and augmenting proliferation activity of the myocardium. In addition lower apoptosis and inflammation could be observed at the level of myocardial protein expression. Hence, the elasticity of the chronically pressure overloaded ventricle was superior with erythropoietin treatment than in the control group 3 months postoperatively. These data support the potential of regenerative therapies in the complementary therapy of congenital heart disease.     

Die Bedeutung von Musik f��r die kardiovaskul?re Chirurgie

It is well known that music has effects on heart rate, heart rate variability, and other physiologic parameters. The influence of music on the cardiovascular system has often been described and recently systematic studies have been published. It has been shown that relaxing music significantly decreases the level of anxiety in the preoperative setting (cardiac surgery) to a greater extent than orally administered midazolam (p?<0.001). Greater effectiveness and absence of apparent adverse effects make preoperative relaxing music a useful alternative to midazolam for premedication. In addition, there is sufficient practical evidence of stress reduction to suggest that listening to music while resting in bed after open heart surgery be put into clinical use. Music intervention should also be offered as an integral part of the multimodal regime administered to patients who have undergone cardiovascular surgery. It is a supportive source that increases relaxation. Music is also effective in other conditions and music can be utilized as an effective intervention for depressed or older patients, in the areas of pain, intensive care, or palliative medicine, and should be utilized more often. The selection of music that incorporates a patient??s own preferences may offer an effective method to reduce anxiety and to improve quality of life. The most beneficial effect on health is visible with classic or meditative music, whereas heavy metal music or technosounds are ineffective or even dangerous and can lead to stress and/or life-threatening arrhythmias. There are many composers whose music most effectively leads to an improve quality of life; in particular, Bach, Mozart, and Italian composers can be recommended.     

Neurophysiologische Kennwerte f��r die Funktionsentwicklung in der Fr��hphase nach Implantation einer Schulterendoprothese

Background

The aim of the study was to identify suitable specific measurements of functional development in the early phase after implantation of a shoulder endoprosthesis and to analyze the shoulder in its association with the patient??s ability to walk safely.

Material and methods

Data were collected and analyzed in 50 patients after implantation of a shoulder endoprosthesis on assisted movement magnitude, rest and movement pain, functional self-assessment, timed up & go (TUG) test, 10-m walking test, and grip strength.

Results

Improvement with walking performance is accompanied by improvements in the other functional parameters. Higher grip strength values on the 6th postsurgical day (right hand) are associated with higher values of flexion. Lower values in the 10-m walking test are accompanied by higher grip strength values on the right (r=?C0.355^*), higher grip strength values on the left (r=?C0.303^*), and with higher values of flexion (r=?C0.267⁺). Lower values with the TUG test go along with higher values with grip strength in the right hand (r=?C0.251⁺).

Conclusion

Intact function of the shoulder is a prerequisite for well-directed gripping and, as a component of the postural control, has an effect on the coordination of walking safely. This study points to an increased fall risk in the early postsurgical phase after implantation of a shoulder endoprosthesis.     

TraumaRegister DGU® der Deutschen Gesellschaft für Unfallchirurgie

Background

In the TraumaRegister DGU® of the German Trauma Society (“Deutsche Gesellschaft für Unfallchirurgie”, DGU), data from severely injured patients has been collected since 1993 in order to improve the treatment and the outcome of these patients. The participating hospitals receive extensive audit reports on a regular basis. Furthermore, scientific analyses based on the registry data evaluate the pattern of injury, the use of diagnostic or therapeutic measures, changes over time, and of course the outcome of the trauma victims.

Aim

The purpose of the present paper is to introduce the organization and the data collection process, followed by presentation of important results from the TraumaRegister DGU®.

Material and methods

Data are collected from four consecutive time periods, from prehospital treatment until discharge. The registry collects approximately 100 different items from each case. Multiple plausibility checks are implemented in the online data collection software and help to improve the data quality.

Results

Since 1993, the number of participating hospitals has increased from 5 to more than 600 last year. The number of patients documented has increased to more 25,000 cases/year. In preclinical care there is a trend toward a reduced use of endotracheal intubation, especially in conscious patients. The amount of fluids administered preclinically has also decreased dramatically during the last 10 years.

Conclusion

The TraumaRegister DGU® is a large registry with regional coverage for the documentation of treatment and outcome of severely injured patients. It brings Germany onto an international level, with only few comparable registries worldwide. In areas where classical research methods like randomized controlled trials reach their limits, registries may be able to provide valuable evidence for the improvement of outcome.     

Praxisorientiertes Ausbildungskonzept f��r invasive Notfalltechniken

Background

The practice-oriented training concept INTECH seminar for invasive emergency techniques (IET) was developed and has been offered annually since 2001 to train physicians to place a chest tube, create an intraosseus access (IOA) and to perform cricothyrotomy. The aim of the study was to evaluate the long-term effect of this training concept.

Methods

The participants of the seminars held between 2001 and 2004 were evaluated at the time of the seminar (evaluation) and a second time after a given time interval in November 2005 (reevaluation) using a questionnaire.

Results

Out of 224 prehospital emergency physicians, 134 completed the reevaluation after a mean time interval of 2.4±1.1 years (response rate 60%). Compared with the initial evaluation (n=154) an increased number of IOAs were performed per physician per year (0.1±0.2 vs. 0.2±0.3, p<0.001) after the INTECH seminar. A higher percentage of participants stated they had performed at least one IOA after the seminar (13.4% vs. 23.1%, p=0.03). At both time points of the evaluation more than 92% of the responders stated that participating in the seminar gave them more personal confidence in using IETs. Of the reevaluated physicians 68% stated that hands-on workshops should be a compulsory prerequisite for working in the field and that participating was more effective than theoretical courses and their daily clinical work.

Conclusions

The evaluation of the seminars demonstrated that practice-oriented training increases the willingness and personal confidence with regard to the performance of invasive emergency procedures. Practice-oriented training seems to be a prerequisite for qualified emergency physicians working in the prehospital setting and may represent one step in optimizing prehospital management.