Struktur der innerklinischen Notfallversorgung in niederländischen Kliniken unterschiedlicher Versorgungsstufen

Background

Throughout the world there are so-called cardiac arrest teams (CAT) for in-hospital emergency care. In addition medical emergency teams (MET) are integrated for the prevention of in-hospital emergency situations. The present investigation investigated the structure of emergency care in Dutch hospitals.

Methods

The investigation was performed using structured interviews (mixed methods design). The survey covered the structure of in-hospital emergency care as well as the training of the CAT members. A total of 9 university hospitals (group 1), 9 secondary care hospitals (group 2) and 9 primary care hospitals (group 3) were included in the investigation.

Results

A total of 25 physicians agreed to be interviewed (93%) of which 21 were included in the present investigation (78%). Regardless of the level of care, all examined hospitals had at least one CAT and 4 of the 21 hospitals had, in addition, a MET for the prevention of in-hospital emergencies (19%). With respect to the in-hospital emergency night time medical care and the skills of the staff, there were differences between the examined hospitals.

Conclusions

In all hospitals there was a structured emergency care by special emergency teams. The in-hospital emergency prevention by MET needs improvement. A possibility to improve the emergency care of hospitalized patients is to train the staff on normal wards.     

Understanding How Orthopaedic Surgery Practices Generate Value for Healthcare Systems

Background

Orthopaedic surgery practices can provide substantial value to healthcare systems. Increasingly, healthcare administrators are speaking of the need for alignment between physicians and healthcare systems. However, physicians often do not understand what healthcare administrators value and therefore have difficulty articulating the value they create in discussions with their hospital or healthcare organization. Many health systems and hospitals use service lines as an organizational structure to track the relevant data and manage the resources associated with a particular type of care, such as musculoskeletal care. Understanding service lines and their management can be useful for orthopaedic surgeons interested in interacting with their hospital systems.

Questions/purposes

We provide an overview of two basic types of value orthopaedic surgeons create for healthcare systems: financial or volume-driven benefits and nonfinancial quality or value-driven patient care benefits.

Methods

We performed a search of PubMed from 1965 to 2012 using the term “service line.” Of the 351 citations identified, 18 citations specifically involved the use of service lines to improve patient care in both nursing and medical journals.

Results

A service line is a structure used in healthcare organizations to enable management of a subset of activities or resources in a focused area of patient care delivery. There is not a consistent definition of what resources are managed within a service line from hospital to hospital. Physicians can positively impact patient care through engaging in service line management.

Conclusions

There is increasing pressure for healthcare systems and hospitals to partner with orthopaedic surgeons. The peer-reviewed literature demonstrates there are limited resources for physicians to understand the value they create when attempting to negotiate with their hospital or healthcare organization. To effectively negotiate for resources to provide the best care for patients, orthopaedic surgeons need to claim and demonstrate the value they create in healthcare organizations.     

Trauma System Evaluation in Developing Countries: Applicability of American College of Surgeons/Committee on Trauma (ACS/COT) Basic Criteria

Background

Trauma continues to be a major health problem worldwide, particularly in the developing world, with high mortality and morbidity. Yet most developing countries lack an organized trauma system. Furthermore, developing countries do not have in place any accreditation process for trauma centers; thus, no accepted standard assessment tools exist to evaluate their trauma services.

Aim

The aims of this study were to evaluate the trauma system in Albania, using the basic trauma criteria of the American College of Surgeons/Committee on Trauma (ACS/COT) as assessment tools, and to provide the Government with a situational analysis relative to these criteria.

Materials and methods

We used the ACS/COT basic criteria as assessment tools to evaluate the trauma system in Albania. We conducted a series of semi-structured interviews, unstructured interviews, and focus groups with all stakeholders at the Ministry of Health, at the University Trauma Hospital (UTH) based in Tirana (the capital city), and at ten regional hospitals across the country.

Results

Albania has a dedicated national trauma center that serves as the only tertiary center, plus ten regional hospitals that provide some trauma care. However, overall, its trauma system is in need of major reforms involving all essential elements in order to meet the basic requirements of a structured trauma system.

Conclusion

The ACS/COT basic criteria can be used as assessment tools to evaluate trauma care in developing countries. Further studies are needed in other developing countries to validate the applicability of these criteria.     

Orthopaedic Surgeon-hospital Alignment at Geisinger Health System

Background

There is broad recognition that the healthcare crisis in the United States is going to require a response and change in clinical practice. The management structure of Geisinger Health System is unique, and this has the potential to change the dynamics of surgeon-administration alignment.

Questions/purposes

Our goal is to summarize and clarify the relationship between orthopaedic surgeons and the healthcare system at Geisinger, evaluate the positive and negative aspects, and consider which components may be reproducible.

Methods

This overview arises from a review of management publications, discussions with orthopaedic attendings and administrators, and personal observations and comparison with my previous 15-year university-based practice.

Results

The Geisinger Health System has always been physician-run. The overall efficiency and pragmatic approach found at Geisinger relies heavily on changing surgeon behavior to match what is optimal for the system rather than the individual. This approach appears to bring greater stability and more consistent outcomes, but only by removing what some see as the art of medicine and at the loss of perceived provider autonomy. Despite the rigid demands placed on the surgeon, the system remains adaptable to change and appears to retain faculty at a high rate.

Conclusions

The Geisinger System is unique in its ability to control an insurance plan, multiple hospitals, and a large physician group. Through clear protocols and behavioral pressure, it demands surgeon alignment with the system as a whole and in return provides a stable work environment. It is not ideal for all surgeons and it is unclear whether it can be reproduced in a less structured setting.     

Impact of a centralized osteoporosis coordinator on post-fracture osteoporosis management: a cluster randomized trial

Summary

We conducted a cluster randomized trial evaluating the effect of a centralized coordinator who identifies and follows up with fracture patients and their primary care physicians about osteoporosis. Compared with controls, intervention patients were five times more likely to receive BMD testing and two times more likely to receive appropriate management.

Introduction

To determine if a centralized coordinator who follows up with fracture patients and their primary care physicians by telephone and mail (intervention) will increase the proportion of patients who receive appropriate post-fracture osteoporosis management, compared to simple fall prevention advice (attention control).

Methods

A cluster randomized controlled trial was conducted in small community hospitals in the province of Ontario, Canada. Hospitals that treated between 60 and 340 fracture patients per year were eligible. Patients 40?years and older presenting with a low trauma fracture were identified from Emergency Department records and enrolled in the trial. The primary outcome was ??appropriate?? management, defined as a normal bone mineral density (BMD) test or taking osteoporosis medications.

Results

Thirty-six hospitals were randomized to either intervention or control and 130 intervention and 137 control subjects completed the study. The mean age of participants was 65?±?12?years and 69% were female. The intervention increased the proportion of patients who received appropriate management within 6?months of fracture; 45% in the intervention group compared with 26% in the control group (absolute difference of 19%; adjusted OR, 2.3; 95% CI, 1.3?C4.1). The proportion who had a BMD test scheduled or performed was much higher with 57% of intervention patients compared with 21% of controls (absolute difference of 36%; adjusted OR, 4.8; 95% CI, 3.0?C7.0).

Conclusions

A centralized osteoporosis coordinator is effective in improving the quality of osteoporosis care in smaller communities that do not have on-site coordinators or direct access to osteoporosis specialists.     

Clinical value of total white blood cells and neutrophil counts in patients with suspected appendicitis: retrospective study

Background

Severe chest wall injuries are potentially life-threatening injuries which require a standardized multidisciplinary management strategy for prevention of posttraumatic complications and adverse outcome.

Case presentation

We report the successful management of a 55-year old man who sustained a complete ??bony disruption?? of the thoracic cage secondary to an ??all-terrain vehicle?? roll-over accident. The injury pattern consisted of a bilateral ??flail chest?? with serial segmental rib fractures, bilateral hemo-pneumothoraces and pulmonary contusions, bilateral midshaft clavicle fractures, a displaced transverse sternum fracture with significant diastasis, and an unstable T9 hyperextension injury. After initial life-saving procedures, the chest wall injuries were sequentially stabilized by surgical fixation of bilateral clavicle fractures, locked plating of the displaced sternal fracture, and a two-level anterior spine fixation of the T9 hyperextension injury. The patient had an excellent radiological and physiological outcome at 6?months post injury.

Conclusion

Severe chest wall trauma with a complete ??bony disruption?? of the thoracic cage represents a rare, but detrimental injury pattern. Multidisciplinary management with a staged timing for addressing each of the critical injuries, represents the ideal approach for an excellent long-term outcome.     

Decision making in urological surgery

Context

Non-technical skills are important behavioural aspects that a urologist must be fully competent at to minimise harm to patients. The majority of surgical errors are now known to be due to errors in judgment and decision making as opposed to the technical aspects of the craft.

Evidence acquisition

The authors reviewed the published literature regarding decision-making theory and in practice related to urology as well as the current tools available to assess decision-making skills. Limitations include limited number of studies, and the available studies are of low quality.

Evidence synthesis

Decision making is the psychological process of choosing between alternative courses of action. In the surgical environment, this can often be a complex balance of benefit and risk within a variable time frame and dynamic setting. In recent years, the emphasis of new surgical curriculums has shifted towards non-technical surgical skills; however, the assessment tools in place are far from objective, reliable and valid. Surgical simulators and video-assisted questionnaires are useful methods for appraisal of trainees.

Conclusion

Well-designed, robust and validated tools need to be implemented in training and assessment of decision-making skills in urology. Patient safety can only be ensured when safe and effective decisions are made.     

Akuter Schlaganfall

Background

Ambulance services??dispatch centres need to identify and triage patients through telephone-based interviews in order to send the appropriate ambulance.

Materials and methods

Over a period of 11?months a structured protocol with yes or no answers adapted from the face-arm-speech test was applied to all emergency calls where acute stroke was suspected. Results were compared to a subjective assessment applied to calls in the same period the previous year. The vital signs of suspected stroke patients were compared to those of all other patients treated by emergency physicians.

Results

A total of 109?calls using the structured protocol were available for analysis. The previous year 274?calls were available for anaylsis. Suspected stroke following the structured protocol could be confirmed by emergency physicians??diagnoses in 77% of the cases (previous year 70%). A potentially or immediately life-threatening situation was found in 16% of the patients (previous year 20%). No patient received immediate treatment (cardiopulmonary resuscitation or endotracheal intubation) by the emergency physician (previous year 1.5%).

Discussion

There was a high correlation between dispatch codes and emergency physicians??diagnoses for stroke. The use of a structured protocol did not lead to significantly higher agreement of call-takers??suspected diagnoses with the emergency physicians??diagnoses. By following a structured protocol the number of acutely life-threatened patients with the chief complaint ”stroke??could be reduced. Patients with suspected stroke presented with life-threatening conditions to the same extent as all patients seen by emergency physicians in our ambulance service. Thus, it seems justified to dispatch the highest level of ambulance response for stroke patients even in times of financial cutbacks.     

Digital stitching errors and the scoliosis clinic

Background

Radiographic evaluation of the spine is an essential part of outpatient management of scoliosis. The full-length radiographs are obtained by combining or ‘stitching’ several exposures together. The stitching process can be a source of errors resulting in delays in the outpatient clinic.

Methods

We describe two cases of stitching errors on full-length spine radiographs of patients seen in the outpatient scoliosis clinic.

Conclusion

High-quality reproducible radiographs are necessary to reliably monitor the progression of deformity. Stitching errors cause delays in the scoliosis clinic and may impact the management of patients if not recognised.     

Teaching patients clean intermittent self-catheterisation prior to anti-incontinence or prolapse surgery: is it necessary in women with obstructive voiding dysfunction?

Purpose

To determine the value of pre-operative teaching of clean intermittent self-catheterisation (CISC) in women who undergo anti-incontinence and/or prolapse surgery and who are at ??high risk?? to have post-operative incomplete bladder emptying.

Methods

Out of the 402 patients who underwent anti-incontinence and/or prolapse surgery at our institute (March 2008?CMarch 2009), 48 patients had at least one obstructive lower urinary tract symptom and one obstructive urodynamic parameter before surgery and were considered at ??high risk?? to have post-operative incomplete bladder emptying. They were taught CISC pre-operatively.

Results

Out of the 48 patients, 7 (14.6%) had incomplete bladder emptying. The incidence of post-operative incomplete bladder emptying was higher in the older women (P?Conclusions Routine teaching of the technique of CISC to ??high risk?? patients prior to anti-incontinence and/or prolapse surgery appears to be an unnecessary use of valuable nursing time as well as being an invasive intervention which is unlikely to be required post-operatively.     

Describing variation in the delivery of secondary fracture prevention after hip fracture: an overview of 11 hospitals within one regional area in England

Summary

There is variation in how services to prevent second fractures after hip fracture are organised. We explored this in more detail at 11 hospitals. Results showed that there was unwarranted variation across a number of aspects of care. This information can be used to inform service delivery in the future.

Introduction

Hip fractures are usually the result of low impact falls and underlying osteoporosis. Since the risk of further fractures in osteoporotic patients can be reduced by between 20 and 70 % with bone protection therapy, the NHS is under an obligation to provide effective fracture prevention services for hip fracture patients to reduce risk of further fractures. Evidence suggests there is variation in service organisation. The objective of the study was to explore this variation in more detail by looking at the services provided in one region in England.

Methods

A questionnaire was designed which included questions around staffing, models of care and how the four components of fracture prevention (case finding, osteoporosis assessment, treatment initiation and adherence (monitoring) were undertaken. We also examined falls prevention services. Clinicians involved in the delivery of osteoporosis services at 11 hospitals in one region in England completed the questionnaire.

Results

The service overview showed significant variation in service organisation across all aspects of care examined. All sites provided some form of case finding and assessment. However, interesting differences arose when we examined how these components were structured. Eight sites generally initiated treatment in an inpatient setting, two in outpatients and one in primary care. Monitoring was undertaken by secondary care at seven sites and the remainder conducted by GPs.

Conclusions

The variability in service provision was not explained by local variations in care need. Further work is now needed to establish how the variability in service provision affects key patient, clinical and health economic outcomes.     

Identifying Specific Surgical Tools and Methods for Laparoscopic Colorectal Operations in Obese Patients

Objective

Laparoscopic operations for obese patients remain challenging due to technical difficulties at operation as well as higher comorbidities and high risk of postoperative complications. The aim of this study is to identify specific surgical tools and methods for laparoscopic colorectal operations for obese patients, applying knowledge of previous literature as well as our expertise in both laparoscopic and bariatric operations.

Conclusions

Current knowledge of bariatric surgery is invaluable in establishing a ??customized?? approach for laparoscopic colorectal operations in obese patients. The instruments routinely used during surgery on patients with normal body mass index (BMI) should often be modified and substituted according to the patient??s BMI. We believe such an approach will prove beneficial to surgeons performing laparoscopic operations on obese patients.     

Unterschätzte Gefahr am Notfallort

Background

Recent studies show that critical incidents in prehospital emergency medicine occur more often than expected. Nevertheless, risk and failure management is not mandatory. The aim of this article is to force the obligatory implementation of risk management in prehospital emergency medicine.

Methods

With the help of a case report, the theoretical basis for risk management, including the four phases of the safety circle (i.e., risk identification, risk assessment, risk accomplishment, risk monitoring), is explained.

Results

Using the example of potential medication errors, specific management measures are presented. The practical implementation of ISO NORM 26825 and the corresponding DIVI-2012 standard for the correct color of syringe labels and the revision of the checklists (vehicle and device checks) are thereby at the center of attention.

Conclusion

The case study confirms the importance of the implementation of risk management in prehospital emergency medicine. Raised safety awareness in rescue teams may increase the safety of patients and staff.     

Loveparade 2010 Duisburg �C klinische Erfahrungen in Vorbereitung und Versorgung

Background

Tragic incidents at the 2010 Love Parade attracted significant public attention. As the frequency of similar events increases, more hospitals and practitioners will face the necessities of planning and response to unforeseeable occurrences. Obligatory guidelines for physicians do not exist, so that essential aspects are repeatedly discussed for each new event. This paper summarizes the experience of hospitals and emergency departments and draws conclusions, allowing recommendations for reasonable proposals for hospitals and practitioners.

Methods and material

A structured analysis of data concerning planning, patient flow and injury statistics led to a profile determining personnel, rooms and material which have to be provided by the hospitals. In a consensus conference afterwards and personal interviews with clinical coordinators the preparation of hospitals was evaluated to separate reasonable from needless efforts.

Results

We describe various measures concerning staff, logistics and rooms from the viewpoint of actual application. Reasonable measures for preparation and management of mass panic are analysed and described in detail. Problems are explained and solutions discussed. The result is a qualitative catalogue, which supports the organization of future events.

Conclusion

Knowledge and reflection on the experience of the 2010 Love Parade optimizes local emergency guidelines and planning for similar events. A coordinated cooperation of all involved is essential.     

Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOPS)

Introduction and hypothesis

There seems to be a temporal association between increasing use of ??hands off?? the perineum in labour and reduced use of episiotomy with an increasing rate of anal sphincter injuries. We aimed to determine how common the practice of ??hands off?? the perineum is.

Methods

An observational postal questionnaire study of 1,000 midwives in England in which the main objective was to obtain an estimate of the number of midwives practising either ??hands on?? or ??hands off?? was conducted.

Results

Six hundred and seven questionnaires were returned; 299 (49.3%, 95% CI 45.2?C53.3%) midwives prefer the ??hands-off?? method. Less-experienced midwives were more likely to prefer the ??hands off?? (72% vs. 41.4%, p?p?=?0.001) for indications other than fetal distress.

Conclusions

The ??hands off?? the perineum technique is prevalent in the management of labour. We hypothesise that a possible consequence might be an increased incidence of obstetric anal sphincter injury.     

Risk Factors of Portal Vein Thrombosis in Crohn’s Disease Patients

Introduction

Patients with inflammatory bowel disease, such as Crohn??s disease (CD), suffer from a threefold increase in the risk of venous thromboembolism. Small bowel, segmental bowel, or ileocolonic resection to treat Crohn??s disease can lead to rare complications of portal vein thrombosis (PVT), which can lead to further poor health outcomes, such as small bowel ischemia. The study attempts to find different risk factors that may be associated with postoperative complications of PVT in Crohn??s disease patients.

Methods

In a 1 to 3 case?Ccontrol study following Institutional Review Board approval, 13 Crohn??s disease patients with documented radiological postoperative diagnosis of PVT from 2004 to 2011 and 39 CD patients who did not have postoperative PVT were matched by retrospective chart review for patient demographics, preoperative course and workup, anticoagulant use, and operative procedure. Univariate analysis was performed to draw correlations on risk factors for the development of PVT.

Results

In the 13 CD patients with PVT, concurrent cancer, liver disease, and dyslipidemia were present in 23.1%, 23.1%, and 15.4% of the population, respectively. Compared to the 39 CD only patients, concurrent cancer, liver disease, and dyslipidemia were present in only 2.6%, 2.6%, and 0% of the population, respectively. Of the CD patients with PVT, 61.5% were on preoperative steroids compared to 28.9% of the CD only patients. PVT development in CD patients is correlated with concurrent cancer (p?=?0.016), liver disease (p?=?0.016), dyslipidemia (p?=?0.012), and preoperative steroid usage (p?=?0.036).

Conclusions

Concurrent cancer, liver disease, dyslipidemia, and preoperative steroid usage were risk factors associated with the development of PVT in Crohn??s patients. Since there is limited literature on PVT in CD, more data needs to be collected, and additional studies should be done to further assess the prevention, diagnosis, and management of the disease.     

Hospital Management Practices and Availability of Surgery in Sub-Saharan Africa: A Pilot Study of Three Hospitals

Background

Sub-Saharan Africa has a high surgical burden of disease but performs a disproportionately low volume of surgery. Closing this surgical gap will require increased surgical productivity of existing systems. We examined specific hospital management practices in three sub-Saharan African hospitals that are associated with surgical productivity and quality.

Methods

We conducted 54 face-to-face, structured interviews with administrators, clinicians, and technicians at a teaching hospital, district hospital, and religious mission hospital across two countries in sub-Saharan Africa. Questions focused on recommended general management practices within five domains: goal setting, operations management, talent management, quality monitoring, and financial oversight. Records from each interview were analyzed in a qualitative fashion. Each hospital’s management practices were scored according to the degree of implementation of the management practices (1 = none; 3 = some; 5 = systematic).

Results

The mission hospital had the highest number of employees per 100 beds (226), surgeons per operating room (3), and annual number of operations per operating room (1,800). None of the three hospitals had achieved systematic implementation of management practices in all 14 measures. The mission hospital had the highest total management score (44/70 points; average = 3.1 for each of the 14 measures). The teaching and district hospitals had statistically significantly lower management scores (average 1.3 and 1.1, respectively; p < .001).

Conclusions

It is possible to meaningfully assess hospital management practices in low resource settings. We observed substantial variation in implementation of basic management practices at the three hospitals. Future research should focus on whether enhancing management practices can improve surgical capacity and outcomes.     

New considerations on the management of osteoporosis in Central and Eastern Europe (CEE): summary of the ��3rd Summit on Osteoporosis��CEE��, November 2009, Budapest, Hungary

Introduction

In November 2009, the ??3rd Summit on Osteoporosis??Central and Eastern Europe (CEE)?? was held in Budapest, Hungary. The conference aimed to tackle issues regarding osteoporosis management in CEE identified during the second CEE summit in 2008 and to agree on approaches that allow most efficient and cost-effective diagnosis and therapy of osteoporosis in CEE countries in the future.

Discussion

The following topics were covered: past year experience from FRAX? implementation into local diagnostic algorithms; causes of secondary osteoporosis as a FRAX? risk factor; bone turnover markers to estimate bone loss, fracture risk, or monitor therapies; role of quantitative ultrasound in osteoporosis management; compliance and economical aspects of osteoporosis; and osteoporosis and genetics. Consensus and recommendations developed on these topics are summarised in the present progress report.

Conclusion

Lectures on up-to-date data of topical interest, the distinct regional provenances of the participants, a special focus on practical aspects, intense mutual exchange of individual experiences, strong interest in cross-border cooperations, as well as the readiness to learn from each other considerably contributed to the establishment of these recommendations. The ??4th Summit on Osteoporosis??CEE?? held in Prague, Czech Republic, in December 2010 will reveal whether these recommendations prove of value when implemented in the clinical routine or whether further improvements are still required.