Akutschmerztherapie in deutschen Krankenhäusern als Wettbewerbsfaktor

Background

Due to the implementation of the diagnosis-related groups (DRG) system, the competitive pressure on German hospitals increased. In this context it has been shown that acute pain management offers economic benefits for hospitals. The aim of this study was to analyze the impact of the competitive situation, the ownership and the economic resources required on structures and processes for acute pain management.

Material and methods

A standardized questionnaire on structures and processes of acute pain management was mailed to the 885 directors of German departments of anesthesiology listed as members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin).

Results

For most hospitals a strong regional competition existed; however, this parameter affected neither the implementation of structures nor the recommended treatment processes for pain therapy. In contrast, a clear preference for hospitals in private ownership to use the benchmarking tool QUIPS (quality improvement in postoperative pain therapy) was found. These hospitals also presented information on coping with the management of pain in the corporate clinic mission statement more often and published information about the quality of acute pain management in the quality reports more frequently. No differences were found between hospitals with different forms of ownership in the implementation of acute pain services, quality circles, expert standard pain management and the implementation of recommended processes. Hospitals with a higher case mix index (CMI) had a certified acute pain management more often. The corporate mission statement of these hospitals also contained information on how to cope with pain, presentation of the quality of pain management in the quality report, implementation of quality circles and the implementation of the expert standard pain management more frequently. There were no differences in the frequency of using the benchmarking tool QUIPS or the implementation of recommended treatment processes with respect to the CMI.

Conclusion

In this survey no effect of the competitive situation of hospitals on acute pain management could be demonstrated. Private ownership and a higher CMI were more often associated with structures of acute pain management which were publicly accessible in terms of hospital marketing.

     

Qualitätssicherung in der Akutschmerztherapie

A detailed documentation system is essential for an effectively working acute pain service. Patient-related documentation aids the physician with check lists and algorithms and may thus further improve clinical practice. As adequate software was missing, we developed a database that was first adapted to the in-house conditions, but can also be adjusted to other surroundings. By integrating “one-click documentation” and new codes for clinical observations, a user-friendly software was created that notably improved the quality of documentation. In the first test period more than 30,000 ward rounds were collected, and a considerably improved documentation quality could be achieved.     

Schmerzchronifizierung bei Rückenschmerzpatienten in der stationären Rehabilitation

Background

Criterion-related validity of the Mainz Pain Staging System (MPSS) was examined.

Patients and methods

The effect of staging of pain on pain-related and psychosocial measures was investigated in a cross-sectional design among 478 patients with chronic low back pain in inpatient orthopedic rehabilitation (ICD-10 diagnoses: M45.4/M45.5, M54.4/M54.5). Pain-related measures were selected from the German Pain Questionnaire of the International Association for the Study of Pain (DGSS). The psychosocial measures depression (ADS), anxiety (HADS-D), somatization (SCL-90-R), quality of life (SF-12), functional capacity (FFbH-R), pain sensation (SES) as well as pain experience and strategies of coping with pain (FESV) were assessed. Furthermore, the frequency distribution of scores in the clinical range in pain-related and psychosocial measures depending on the staging of pain was examined. Finally, initial indications of the predictive validity of the MPSS were investigated among 116 inpatients.

Results

Staging of pain had a significant impact both on levels of measures and proportion of clinically referred patients. Patients in stage III, but also those in stage II showed significantly impaired levels. Patients in stage III also showed more scores in the clinical range than expected in the lowest pain intensity, ADS depression, somatization of the SCL, functional capacity, and pain sensation. The MPSS before rehabilitation, together with mental health, seem to be a good predictor of depressive symptoms 6 months after rehabilitation.

Conclusion

The results support criterion validity of the MPSS, however, they also corroborate the concept that identification of medium and high grade pain by the MPSS has to be followed by a psychological diagnostic assessment. By this stepwise diagnostic process, therapy aims and treatment regimens can be designed more adequately.     

Versorgung von Diabetikern in station?ren Pflegeeinrichtungen des Kreises Heinsberg

Zusammenfassung Fragestellung: Über die Betreuung von Diabetikern in stationären Pflegeeinrichtungen gibt es bisher kaum Informationen. Ziel dieser Studie war daher, die diabetologische Betreuung dieser Patientengrupe mit Hilfe eines detaillierten Fragebogens zu dokumentieren. Patienten und Methodik: Dazu wurden im Kreis Heinsberg, Nordrhein-Westfalen, nach einvernehmlicher Beschlussfassung in der regionalen Gesundheitskonferenz alle 41 stationären Pflegeeinrichtungen angeschrieben und um Beantwortung spezifischer Fragen gebeten. 39 Heime, die 99,6% aller Heimbewohner im Kreis betreuten, nahmen an der Studie teil. Ergebnisse: Von den 1 936 Bewohnern hatten 507 einen bekannten Diabetes mellitus (Prävalenz: 26,2%), wobei der Anteil der Diabetiker mit steigendem Lebensalter abnahm, 37,0% der Patienten wurden mit Insulin behandelt, 46,7% nahmen orale Antidiabetika ein. Fortgeschrittene Spätkomplikationen waren dagegen nicht auffällig häufig (3,4% Amputationen, 13,6% Erblindungen, 1,0% dialysepflichtige Niereninsuffizienz). Bei der Mehrzahl der Diabetiker wurde der Stoffwechsel mittels Blutzuckermessungen überprüft, allerdings mit niedriger Frequenz bzw. nur sporadisch. Eine augenärztliche Untersuchung in den vorangegangenen zwölf Monaten hatte nur jeder zweite Diabetiker erhalten. Obwohl die hausärztliche Betreuung dieser Patientengruppe intensiv war (48,1% der Diabetiker mit mehr als zwei Arztkontakten/Monat, 48,7% mit ein bis zwei Arztkontakten/Monat), hatten 30,8% der Diabetiker in den letzten zwölf Monaten wenigstens einen Krankenhausaufenthalt. Bemerkenswert war außerdem, dass von den 834 Pflegekräften mit vollständigen Angaben lediglich vier eine spezielle diabetologische Zusatzqualifikation erworben hatten. Schlußfolgerung: Zusammenfassend legen die Ergebnisse dieser Studie nahe, dass die Betreuung von Diabetikern in stationären Pflegeeinrichtungen in einigen Aspekten nicht dem heutigen Kenntnisstand entspricht. Vordringliche Handlungsempfehlungen sind, die diabetologische Ausbildung der Pflegekräfte und die Kommunikation zwischen den Pflegeeinrichtungen und den Hausärzten zu verbessern. Abstract Background and Objective: Little information is available on the diabetes management of elderly people under institutional care. It was therefore aim of this study to assess the quality of diabetes care in this patient group. Patients and Methods: In the county of Heinsberg, North Rhine-Westphalia, after agreement in the local public health conference, all 41 nursing homes were addressed and asked to fill out a structured, detailed questionnaire. Thirty-nine institutions participated in the study representing 99.6% of all patients under such care. Results: Our of the 1936 residents 507 had known diabetes mellitus (prevalence 26.2%) with an age-dependent decrease. 37.0% of the diabetic subjects were treated with insulin, 46.7% received oral hypoglycemic agents. Advanced late complications were reported in a minority of patients (3.4% amputations, 13.6% blindness or severe visual impairment, 1.0% hemodialysis). In the majority of patients, the metabolic control was assessed by blood glucose measurement, but only in low frequency. Eye examination within the previous 12 months was reported for only 50.0% of the diabetic subjects. Although the diabetics were frequently seen by their doctors (48.1% > 2 consultations/month, 48.7% with 1 to 2 consultations/month), 30.8% had at least 1 hospital stay during the previous 12 months. Among the 834 nurses with the full dataset only 4 had a special training in diabetology. Conclusion: The results of this study indicate that the diabetes management of patients living in nursing homes only partially fulfills the current requirements for diabetes care. There appears to be a particular need to improve the nurses training in diabetes as well as the communication between nursing homes and doctors.     

Implementierung eines standardisierten perioperativen Schmerzmanagementkonzepts in drei Krankenhäusern eines Klinikverbundes

BACKGROUND: Provision of sufficient perioperative pain therapy is an obligation in the clinical management of patients suffering from pain. The implementation of a standardized pain management concept was planned to be introduced in the clinical routine. The results of three hospitals are shown. MATERIAL AND METHODS: The concept included tools which gave information about legal aspects and basic fundamentals of pain relief, management modules regarding agreements on the implementation of perioperative pain therapy, instruments to measure pain intensity, assigning accountability and documentation modules. Questionnaires were carried out according to Picker. RESULTS: The project revealed that, according to the Picker questionnaire, about 50% of the patients treated in the hospitals had pain, 30-40% still had intensive pain during the stay in hospital and 90% of the patients received pain relief medication within 10 min of the request. More than 78% of the patients thought the hospital staff did their best to relieve the pain and over 92% found the pain treatment adequate. CONCLUSION: It was possible to implement a standardized perioperative pain therapy concept in three hospitals of a consortium. Whether an adequate pain relief can be improved with the help of standard measurements and documentation, could not be evaluated in this study.     

Morbus Parkinson,Morbus Alzheimer und onkologische Erkrankungen in der stationären Altenhilfe

Background

Adequate pain management and palliative care structures are of significant importance in residential nursing homes. Whilst professional pain treatment and palliative care measures are frequently implemented for residents with oncological diseases, this is often not the case for residents with neurological disorders. Such a potential undertreatment is even more challenging when the means of interaction and communication with affected persons are aggravated by impairments in cognitive function.

Objective

To examine differences in selected health care service characteristics between nursing home residents with Parkinson’s disease, Alzheimer’s disease and residents diagnosed with cancer.

Material and methods

Secondary data analysis of residents’ survey and medical record data from 13 nursing homes as part of the study “Action Alliance Pain-free City Münster”.

Results

Compared with residents with Parkinson’s disease and cancer, nursing home residents with Alzheimer’s disease exhibited significantly more severe impairment in cognitive function, less additional pain-associated diagnoses, shorter length of stay in nursing homes and more indications of pain.

Conclusion

The generally high level of pain in all observed residents elucidates the principle necessity of adequate pain assessment and an interprofessional pain treatment. Furthermore, there seems to be a still unmet need for specifically adapted pain management strategies especially for the steadily increasing number of people with Parkinson’s disease and Alzheimer’s disease living in nursing homes. This should be a future high priority task for (nursing) practice and research against the background of the vulnerability of nursing home populations.

     

Die Schmerzsituation von Bewohnern in der station?ren Altenhilfe

Background

Little is known about the phenomenon of pain in German nursing homes. In particular, it is unknown to what extent and severity pain occurs among residents and how their pain can be described.

Material and methods

A total of 13 nursing homes located in the city of Münster, Germany, were included as part of the health services research project ??Action Alliance Pain-free City Münster.?? Data were collected from 436 residents over 65 years old via self-report or the observational pain tool pain assessment in advanced dementia, german version (PAINAD-G), according to the cognitive status of the residents.

Results

At the time of the interview, the majority of the residents questioned reported suffering from pain at rest and/or during movement. Approximately one quarter of residents complained about moderate to intolerable pain at rest and nearly 45% during movement. Residents encountered pain most often when standing up, sitting, resting in bed and walking and three quarters of residents had suffered from pain for more than 1 year. Many residents experienced pain in several body regions. Among residents assessed solely by the observational pain scale PAINAD-G, signs indicating pain existed in 21% (???6) or 69% (???2), respectively, depending on the cut-off value chosen on the PAINAD-G scale.

Conclusion

Pain in nursing homes is a challenge that needs more attention as it has considerable negative consequences for the persons concerned. The extent of pain in the studied facilities indicates an urgent need for action on the part of all professionals caring for residents in nursing homes.     

Qualit?tsmanagement in der Akutschmerztherapie

Aim

Systems for and methods of quality management are increasingly being implemented in public health services. The aim of our study was to analyze the current state of the integrated quality management concept “quality management acute pain therapy” of the TüV Rheinland? (TüV) after a 5-year project period.

Material and methods

General characteristics of the participating hospitals, number of departments certified by the TüV and implementation of structures and processes according to the TüV guidelines were evaluated by a mail questionnaire. Furthermore, positive and negative aspects concerning the effects of certification were evaluated by the hospitals’ representatives of certification.

Results

A total of 36?questionnaires were returned. Since 2006 the number of certified hospitals (2011: n?=?48) and surgical departments (2011: n?=?202) has increased continuously. The number of certified medical departments is low (2011: n?=?39); however, in the last 3?years, it has increased by about 200–300% annually. Standard operative procedures for pain therapy and measurement of pain intensity at regular intervals were implemented in all certified clinics (100%). Although 41% take part in the benchmarking project QUIPS (Quality Improvement in Postoperative Pain Therapy), 24% do not systematically check the quality of the outcome of pain management. Acceptance of the new pain therapy concepts among nursing staff was rated positively (ratio positive:negative 16:1); however, acceptance among physicians was rated negatively (1:15).

Conclusion

Certification by the TüV leads to sustainable implementation of quality management principles. Future efforts should focus on better integration of physicians in acute pain therapy and the development of an integrated tool to measure patients’ outcome.     

Interdisziplinäres Schmerzassessment im stationären Setting

Background

Chronic pain is characterized by a complex interaction of somatic, mental and social factors. Assessing these factors in patients with chronic pain is vital during the diagnostic work-up and when making a structured treatment plan. Interdisciplinary pain assessment (ISA) is the most promising method to deal with these challenges. This article presents our experience in performing pain assessments in the hospital setting and also illustrates the characteristic features of chronic pain patients undergoing such assessments.

Methods

This study reviews and evaluates patient data from 2704 ISAs performed at the Interdisciplinary Pain Centre of the Zentralklinik Bad Berka, Germany, between 2008 and 2015.

Results

The majority of our ISA patients are severely handicapped and show distinct signs of chronic disease. A large proportion of patients is either unable to work or receiving benefits (invalidity pension or retirement pension). In addition, patients reported long disease durations and high emotional distress. Treatment recommendations were based on the patients’ individual clinical presentations and examination results. More than half of the patients required multimodal pain management, while adjustments or therapeutic withdrawal of pain medications, in particular of opioids, were indicated in many patients.

Discussion

Our study shows that ISA enables fast, high-quality diagnostic assessments of chronic pain while taking the biopsychosocial model of pain in particular into account. In addition, ISA is not biased with regard to outcome results and recommends the further treatment that appears best for the individual patient. ISA leads not only to inpatient treatment, but also to treatment in other therapeutic settings and, as such, is not merely a door-opener to multimodal pain therapy.

     

Neuropathischer Schmerz im stationären Bereich

Background

Neuropathic pain is a common symptom of many diseases among in-patients in hospitals and neuropathic pain itself often requires hospitalisation. It was the aim of this study to examine epidemiological key data related to neuropathic pain among hospital in-patients.

Methods

The source of the data used was the ICD-10 coded main diagnoses with neuropathic pain of a complete data set of discharges obtained for every Austrian hospital for the year 2002.

Results

A total of 49,412 cases (614/100,000 inhabitants) with diagnoses always associated with neuropathic pain were recorded, representing 2.0% of all discharges from Austrian hospitals. Furthermore, there were as many as 353,893 cases with diagnoses which are possibly associated with neuropathic pain, like cancer, diabetes mellitus and stroke, representing 14.3% of all cases discharged from hospitals. Applying the proportion of those suffering from neuropathic pain among patients with these three diagnoses which is known from the literature would result in 5.8% of all hospital in-patients suffering from neuropathic pain.

Conclusion

These data represent a first step in the assessment of the epidemiology of neuropathic pain and show the high extent of neuropathic pain in the Austrian in-patient setting.     

Psychosoziale Faktoren der Schmerzchronifizierung bei Patienten in der stationären orthopädischen Rehabilitation von chronisch unspezifischem Rückenschmerz

Background

The aim of this study was to investigate the criterion validity of the Mainz Pain Staging System (MPSS), considering the four axes of the MPSS separately.

Methods and design

Psychological and pain-related impairments were analysed depending on the stage of axis (I, II, III) for each single axis of the MPSS in a consecutive sample of 280 patients with chronic low back pain in orthopaedic inpatient rehabilitation. In addition, the distribution of frequency of clinically significant symptoms in depression, anxiety and somatisation were examined depending on the stage of axis.

Results

For all axes, an increasing stage was associated with greater psychological and pain-related impairments. Particularly patients assigned to stage III on axis 1 (temporal aspects) and 2 (spatial aspects) and patients assigned to stage II on axis 3 (drug intake) and 4 (utilisation of the health care system) showed enhanced psychosocial impairments and more frequently had clinically relevant symptoms in psychological variables.

Conclusion

Findings confirm the criterion validity of the MPSS for chronic low back pain. In addition, results support the significance of psychosocial factors for the further development of chronicity.     

painApp – mobiles Schmerzmonitoring in der häuslichen Versorgung

Background

The use of a scientifically developed App for pain management in the home care setting is not yet established in Germany. The documentation of pain-specific data by the patients and the transfer into a web portal to be examined by the attending physician can help close the existing communication gap in pain management between consultations.

Objectives

The aim of the study was to develop a mobile health (mHealth) solution for optimizing pain management in the home care setting. The research questions focus on design and technical issues concerning layout and navigation of the painApp as well as user-relevant questions concerning pain management, such as pain at rest and pain during movement, taking pain medication and patient satisfaction with their pain situation.

Materials and methods

Within a 12-month period, the user-centered development and practice-based testing of the application painApp involved patients aged?≥?65 years. Within a formative evaluation, a total of four data collections and a final survey took place. During the same period, a web portal was developed and tested the documentation of the patient pain-specific data from the painApp with the participation of general practitioners.

Results and conclusions

The development of the painApp as a prototype was realized in the study with high acceptability by the patients. The painApp is able to establish digital communication with the general practitioner without any technical problems and allows the physician access to patient data in real time.

     

Erfahrungen mit der retroganglionären Glycerin-Rhizotomie in der Behandlung der Trigeminusneuralgie

From August 1981 to May 1993 a total of 1263 percutaneous retrogasserian glycerol rhizotomies after Hakanson were performed. The intervention was performed with X-ray monitoring under local anaesthesia and rarely lasted longer than 20 min. It achieved good results in the treatment of idiopathic trigeminal neuralgia (TN) and symptomatic trigeminal neuralgia due to multiple sclerosis (TNMS). Some 97% of the TN patients were completely free of pain after the intervention. The recurrence rate within 5 years was 12.8%. Some 94.7% of the TNMS patients were immediately free of pain, but within 2-5 years they experienced a high recurrence rate of 40.2%. The results in the patients with atypical facial pain were more disappointing: only 66.6% were pain-free immediately after the intervention, and the recurrence rate was 31%. With respect to the side effects immediately postoperatively, herpetic eruptions were found in 43.2% of cases. They occurred on the 3rd postoperative day and persisted for 2-3 weeks before being relieved by local virostatic therapy. Hypaesthesia and hypalgesia were present in the early postoperative follow-up in half of our patients. Both these reductions of sensitivity have a tendency to regress. Later, after 2 years, there was reduction in sensitivity of this type in only 20% of cases. In the follow-up 17.5% of our patients complained of dysaesthesia and in 21.4% corneal sensitivity was reduced or lost. We believe that glycerol rhizotomy, owing to its effectiveness, easy applicability, slight distress for the patients and low side effects, should be recommended as a first measure for non-conservative treatment of idiopathic trigeminal neuralgia as well as trigeminal neuralgia in multiple sclerosis.     

Prognose der linksventrikulären Dysfunktion 1998 in einem nichtuniversitären Krankenhaus der MaximalversorgungAnalyse des Ludwigshafener LVD-Registers

Zusammenfassung Einleitung: Daten zur Prognose der Herzinsuffizienz stützen sich bislang auf bev?lkerungsepidemiologische und retrospektive krankenhausepidemiologische Untersuchungen sowie klinische Interventionsstudien. Alle diese Quellen sind nur eingeschr?nkt auf den klinischen Alltag übertragbar. Fragestellung: Wie ist die Prognose von Patienten mit linksventrikul?rer Dysfunktion unter der therapeutischen Bedingungen der neunziger Jahre? Setting: Nichtuniversit?res Herzzentrum der Maximalversorgung. Patienten und Methodik: Seit Januar 1995 konsekutiver und vollst?ndiger Einschlu? von allen station?ren Patienten mit einer linksventrikul?ren Dysfunktion in ein Register und Nachbeobachtung. Einschlu?kriterium: echokardiographisch linksventrikul?re Ejektionsfraktion ≤45% oder mindestens mittelschwer reduziert. Ausschlu?kriterium: keines. Ergebnisse: Patientenzahl 512, Alter 64 Jahre, 77% m?nnlich, mittlere NYHA-Klasse 2,5, linksventrikul?re Ejektionsfraktion 31%, ?tiologie: 58% koronare Herzkrankheit, 28% dilatative Kardiomyopathie. Medikament?se Therapie mit 91% ACE-Hemmern, ACE-Hemmern-Dosis 52% der Zieldosis, 42% β-Blocker, 70 % Diuretika und 63% Digitalis. Nichtmedikament?se Therapie: 15% ICD, 7% Schrittmacher. Nachbeobachtungsvollst?ndigkeit: 95,5 %der Patienten, Einjahresmotalit?t: 64/489 Patienten (13,9%). Determinanten der Mortalit?t: NYHA III/IV, EF <30%, Neoplasma, Alter >75 Jahre. Schlu?folgerung: 1998 betr?gt die Einjahressterblichkeit von Patienten mit linksventrikul?rer Dysfunktion 13,9% unter der oben genannten medikament?sen Therapie und einem hohen Anteil implantierter Defibrillatoren. Die Einjahressterblichkeit ist somit immer noch hoch, wobei die prognoseverbessernde Potenz der medikament?sen Therapie im klinischen Alltag noch nicht vollkommen ausgesch?pft wird. Eingegangen: 30. Juli 1998, Akzeptiert: 19. Oktober 1998