Kostenfaktor „ambulante Wundversorgung“ in der Notaufnahme

Die Unfallchirurgie - Die Erstversorgung von Wunden und kleinere chirurgische Eingriffe gehören neben der hochspezialisierten Medizin zu den allgemein notwendigen Grundleistungen der...     

„Intermediate-risk-“ und „High-risk-Prostatakarzinompatienten“

Introduction

We examined the quantity and localization of pelvic lymph node (LN) metastases in patients undergoing extended pelvic lymphadenectomy (ePLND).

Materials and methods

A total of 174 patients with intermediate and high-risk prostate cancer underwent radical prostatectomy (RP) and ePLND. We analyzed the relationship between the number of LNs removed and the number, frequency and topography of LN metastases.

Results

In group 1 (intermediate risk patients, n=115) the average number of LNs removed was 20.5, LN metastases were found in 15 patients (13 %) and the localizations were in the external iliac artery 19 %, the internal iliac artery 32 %, the obturator foramen 36 %, the common iliac artery 7 %, Marcille’s triangle 3 % and sacral regions 3 %. In group 2 (high-risk patients, n=59) the average number of LNs removed was 23.9, LN metastases were found in 19 patients (32 %) and the localizations were the external iliac artery 15 %, the internal iliac artery 26 %, the obturator foramen 19 %, the common iliac artery 29 %, Marcille’s triangle 6 % and sacral regions 5 %. The full number of metastases was detected only if more than 15 LNs were removed in group 1 and 18 LNs in group 2.

Conclusions

At least 15 LNs in the intermediate risk group and at least 18 LNs in high risk group should be removed. The ePLND should include the common iliac artery, the internal iliac artery, Marcille’s triangle and sacral regions.     

Überfüllte Notaufnahme

Background

The majority of patients in hospital arrive through the emergency admission. Everyone working there knows the phenomenon of overcrowding in emergency rooms. Many factors have been and are still held responsible, for example emergency rooms are too small, too many non-emergency patients, bad triage, long examination times per patient and higher patient volumes.

Materials and methods

In this literature review based on international reviews, meta-analyses, original research papers and consensus papers, the definition of overcrowding in the emergency room is given and reasons are pointed out.

Results

It was found that the main factor responsible for the overcrowding of emergency admission departments is the so-called access block, the lack of patient discharge to hospital beds and not the reasons previously considered. Studies have shown that the long stay of emergency patients in the emergency department has deleterious consequences for the patient and can result in patient death. To eliminate the access block an optimized bed and discharge management is required.     

Interdisziplin?re zentrale Notaufnahme

The treatment of emergencies in a hospital should be organized in a central interdisciplinary emergency department (ER). It is the main entrance for all patients with acute illness or injuries. There are multiple advantages of such a central unit. Quality of treatment and economic efficiency is improved. The interdisciplinary diagnostics and treatment at one place prevents time-consuming and unnecessary transport. The fact that more complex diseases and injuries need specialized doctors in specific disciplines should be considered in personnel planning of the ER. To reinsure that the entire medical staff of the hospital is familiar with the daily routine and clinical pathways of the ER, doctors from other departments of the hospital should always be part of the ER team.     

„Zweitmeinungszentren“

According to estimations of the German Cancer Research Center in Heidelberg, the management of germ cell tumors in Germany is characterized by a marked difference between the actual mortality and the mortality to be expected with adequate implementation of the therapy standard. Our aim is to reduce the mortality rate by introducing a treatment procedure supported by a second opinion center.     

„Fast-track-Kolonchirurgie“

OBJECT: The aim of multimodal perioperative treatment concepts is to lower the extent of general complications after elective colonic resection and "traditional" perioperative therapy and to allow hospital discharge only a few days following the operation. MATERIALS AND METHODS: In this prospective study, we examined a new perioperative treatment plan for accelerating postoperative recovery and evaluated the results. This so-called "fast-track" program employs combined thoracal peridural analgesia, forced mobilization, and rapid renourishment within the clinic. RESULTS: Sixty-four consecutive patients with benign or malignant disease of the large intestine aged an average of 66 years (range 54-71) were operated on. Thirty received conventional resection and 34 were operated on laparoscopically and treated perioperatively using the fast-track program. The hospital diet was given in all cases on the 1st postoperative day, and the first bowel movement occurred on the 2nd day (range 2-3). The patients could be released on the 4th postresection day (range 4-5). General and local postoperative complications were observed in five patients each (8%), including two cases of anastomotic insufficiency. CONCLUSION: In colonic surgery, the "fast-track" method accelerated convalescence, lowered the number of general complications, and reduced the duration of hospital stay. Therefore, evaluation of "fast-track" concepts is warranted in other types of elective abdominal surgery.     

Zentrale Notaufnahme – Update 2016

Acute medical care in hospital emergency departments has experienced rapid development in recent years and gained increasing importance not only from a professional medical point of view but also from an economic and health policy perspective. The present article therefore provides an update on the situation of emergency departments in Germany. Care in emergency departments is provided with an increasing tendency to patients of all ages presenting with varying primary symptoms, complaints, illnesses and injury patterns. In the process, patients reach the emergency department by various routes and structural provision. Cross-sectional communication and cooperation, prioritization and organization of emergency management and especially medical staff qualifications increasingly play a decisive role in this process. The range of necessary knowledge and skills far exceeds the scope of prehospital medical emergency care and the working environment differs substantially. In addition to existing structural and economic problems, the latest developments, as well as future proposals for the design of in-hospital emergency medical care in interdisciplinary emergency departments are described.     

„Human factors“ und „crisis resource management“

A continuing high number of patients suffer harm from medical treatment. In 60-70% of the cases the sources of harm can be attributed to the field of human factors (HFs) and teamwork; nevertheless, those topics are still neither part of medical education nor of basic and advanced training even though it has been known for many years and it has meanwhile also been demonstrated for surgical specialties that training in human factors and teamwork considerably reduces surgical mortality. Besides the medical field, the concept of crisis resource management (CRM) has already proven its worth in many other industries by improving teamwork and reducing errors in the domain of human factors. One of the best ways to learn about CRM and HFs is realistic simulation team training with well-trained instructors in CRM and HF. The educational concept of the HOTT (hand over team training) courses for trauma room training offered by the DGU integrates these elements based on the current state of science. It is time to establish such training for all medical teams in emergency medicine and operative care. Accompanying safety measures, such as the development of a positive culture of safety in every department and the use of effective critical incident reporting systems (CIRs) should be pursued.     

Simulationstraining zwischen „human factors“ und „technical skills“

Background

Complexity in clinical medicine has induced a higher consciousness for patient safety and clinical risk management. Technical progress has enabled transposition of learning progress towards a low-risk simulation-based environment. This has changed the former strategy in acquiring clinical abilities away from “see one, do one, teach one”.

Objective

Hereby, mobile full-scale simulators are able not only to provide an opportunity in training technical clinical skills but more often display whole chains of medical care, complex scenarios and clinical team trainings. Due to the technical advances, there is a shift in simulation-based trainings from technical to non-technical skills. Especially in the area of simulator-based team training, there is a broad heterogeneity, causing difficulties to acquire scientific evidence for their effectiveness.

Future

Essential for the establishment and the sustainable effect of simulator-based training is routine obligatory clinical training, participation of scientific associations, and integration into a clinical risk management system. Predefinition of learning targets and the selective, outcome driven use of simulation-based training are of importance.     

„Soft skills“

Leading positions not only require excellent professional expertise but also strong soft skills in order to be successful. Factors such as personality traits, communication and management style are important for self-achievement or employee job satisfaction. The article reviews the definition of soft skills, the instruments for measuring such skills and furthermore possibilities for development in the medical context.     

Simulationsbasiertes „Anaesthesia-Crisis-Resource-Management-Training“

Background

Up to as many as 38,000 people die in German hospitals each year as a result of preventable medical errors. Anesthetic procedures are generally safer than internal medical procedures and the mortality associated with anesthesia is estimated to be 3.3-5 cases per million. However, this is still 10 times higher than the risk associated with civilian aviation for example. Up to 80% of mistakes are attributable to inadequate execution of non-technical skills (NTS) such as communication, teamwork and organization of the working environment. Training in non-technical skills through Anesthesia Crisis Resource Management (ACRM) is an integral part of the Berlin Simulation Training (BeST) curriculum. The aim of this study was to describe the subjective evaluation of change in routine clinical behavior as a result of simulator training using latent outcome variables such as “subjective evaluation of learning outcome”, with special emphasis on communication.

Material and methods

In total 235 doctors with varying levels of professional experience received BeST training between 2001 and 2004. An anonymous postal questionnaire was sent to 228 of these participants and the response rate was 64% The questionnaire contained 13 questions covering evaluation of the workshop and learning outcome with respect to communication in the operating room (OR), teamwork in the OR and medical knowledge. Following factor analysis 3 latent outcome variables (subjective evaluation of the learning outcome, workshop-related change in perception of the value of communication and general value and relevance) were generated. Logistic regression was used to determine whether there was any relationship between the latent outcome variables and a number of independent factors.

Results

It was not possible to demonstrate any relationship between the level of professional training, age or date of the workshop and the variables selected to describe subjective evaluation of behavioral change as a result of the workshop. How realistic the candidates perceived the training scenarios to be (p<0.01) and the sex of the candidates (p=0.03) were both significantly related to evaluation and female candidates were more likely to positively evaluate the simulator training. From the candidates’ perspective the training significantly altered their perception of the value of NTSs, and in particular communication, during the management of critical incidents in the OR.

Conclusion

Well-staged and realistic simulation is associated with better learning outcomes. It may be important to take gender aspects into account in ACRM training.     

„Herztamponade.“

Ohne Zusammenfassung Im Auszuge vorgetragen in der Sitzung der Gesellschaft der Charitéarzte in Berlin am s. October 1883.     

„Energy-based devices“

Journal für Ästhetische Chirurgie -     

„Antibiotic Stewardship“

Antibiotic stewardship (ABS) comprises a bundle of different interventions to improve anti-infective treatment in a hospital setting. An important component of ABS interventions is the interdisciplinary approach to infection management. Besides improving infrastructural aspects on a hospital level, including surveillance of the use of anti-infective agents and nosocomial infections, collation and interpretation of statistics on resistance and formulation of local treatment guidelines, ABS teams go to the wards and advise treating physicians on antibiotic therapy. Frequent approaches for optimization are selection of substances, administration route, dosing of medication and duration of treatment. An important overall objective of ABS is the reduction of resistance induction in order to preserve the therapeutic efficiency of antibiotics. A number of studies have shown that this goal can be achieved in different clinical settings without negatively affecting patient outcome. The strategies of ABS can also be applied with no problems to critically ill patients on the intensive care unit.     

„Shoulder stiffness“

Die Unfallchirurgie -     

„Bionische“ Armprothesen

Background

A new generation of arm prostheses is being developed worldwide. These so-called bionic prostheses are intended to offer additional functions, such as sensory feedback, extended range of possible movement, intuitive movement control as far as possible, and a more natural cosmetic appearance.

State of the art in research and development

In recent years, prosthetic components with much enhanced performance have been developed for use at various levels of the upper limb. Artificial hands that allow for additional grips are are being tested in clinical settings. Innovative methods of signal acquisition and communication with the patient are being intensively researched.

Conclusion

Several patients have been provided with prototypes of new arm prostheses. At the moment, the results are limited by the restricted communication between patient and prosthesis. However, we can expect the options for prosthesis control to be extended in the near future.