Einführung eines Patientendatenmanagementsystems

Background

Patient data management systems (PDMS) enable digital documentation on intensive care units (ICU) and have positive effects on completness, quality and quantity of documented information. A commercial PDMS was implemented in a 25-bed ICU replacing paper-based patient charting. The ICU electronic patient record is completely managed inside the PDMS. IT compiles data from vital signs monitors, ventilators and further medical devices and facilitates some drug dose and fluid balance calculations as well as data reuse for administrative purposes. Ventilation time and patient severity scoring as well as coding of diagnoses and procedures is supported. Billing data transferred via interface to the central billing system of the hospital. Such benefits should show in measurable parameters, such as documented ventilator time, number of coded diagnoses and procedures and others. These parameters influence reimbursement in the German DRG system. Therefore, measurable changes in cost and reimbursement data of the ICU were expected.

Material and methods

A retrospective analysis of documentation quality parameters, cost data and mortality rate of a 25-bed surgical ICU within a German university hospital 3 years before (2004–2006) and 5 years after (2007–2011) PDMS implementation. Selected parameters were documented electronically, consistently and reproducibly for the complete time span of 8 years including those years where no electronic patient recording was available. The following parameters were included: number of cleared DRG, cleared ventilator time, case mix (CM), case mix index (CMI), length of stay, number of coded diagnoses and procedures, detailed overview of a specific procedure code based on daily Apache II and TISS Core 10 scores, mortality, total ICU costs and revenues and partial profits for specific ICU procedures, such as renal replacement therapy and blood products.

Results

Systematic shifts were detected over the study period, such as increasing case numbers and decreasing length of stay as well as annual fluctuations in severity of disease seen in the CM and CMI. After PDMS introduction, the total number of coded diagnoses increased but the proportion of DRG relevant diagnoses dropped significantly. The number of procedures increased (not significantly) and the number of procedures per case did not rise significantly. The procedure 8-980 showed a significant increase after PDMS introduction whereas the DRG-relevant proportion of those procedures dropped insignificantly. The number of ventilator-associated DRG cases as well as the total ventilator time increased but not significantly. Costs and revenues increased slightly but profit varied considerably from year to year in the 5 years after system implementation. A small increase was observed per case, per nursing day and per case mix point. Additional revenues for specific ICU procedures increased in the years before and dropped after PDMS implementation. There was an insignificant increase in ICU mortality rate from 7.4?% in the year 2006 (before) to 8.5?% in 2007 (after PDMS implementation). In the following years mortality dropped below the base level.

Conclusion

The implementation of the PDMS showed only small effects on documentation of reimbursement-relevant parameters which were too small to set off against the total investment. The method itself, a long-term follow-up of different parameters proved successful and can be adapted by other organizations. The quality of results depends on the availability of long-term parameters in good quality. No significant influence of PDMS on mortality was found.     

Papilledema and echographically detectable retro-orbital dilatation of the sub-arachnoidal space with open fontanelle - six case reports

This paper analyses the case reports for three children in which a papilledema occurred before the age of one year. Furthermore, an analysis is also given of three further case reports for children aged less than one year in which, in spite of open fontanelle, no papilledema was found, however, a dilatation of the sub-arachnoidal space was demonstrated echographically. Even in children less than one year of age in which an open fontanelle still exists and in whom a neuro-paediatric clarification of internal hydrocepalus is made, in spite of opththalmoscopically inconspicuous findings for the papilla an echography is indispensable for the evaluation of the sub-arachnoidal space. Here, the early recognition of a dilatation of the retro-bulbar sub-arachnoidal space can possibly prevent the occurrence of a consecutive optic atrophy. At the present time, the data available do not allow the recommendation of an upper age limit for an echographic examination.     

Telemedicine in pediatric oncology

The telemedicine project of the Competence Net Pediatric Oncology of the German/Austrian Gesellschaft für P?diatrische Onkologie und H?matologie (GPOH) has as an initial step of its work-programme sent out a questionnaire to the 54 largest pediatric hematology/oncology units in Germany. Institutions were asked for their experience, motivation, existing infrastructure, and anticipated benefits and obstacles regarding the implementation of telemedicine in patient care and research. Of the 54 largest German Pediatric Oncology institutions asked, 46 completed the questionnaire (85 %). Results: 1. The need for further detailed information on implementation and for help in technical realization of telemedicine applications was expressed by all participants. 2. The majority expected practical advantages from telemedicine communication and anticipated that telemedicine will increase quality in treating children with cancer. 3. Expert consultation (study chairman, reference radiologists) is stated as to be most important. 4. Thirty-three of 46 physicians (72 %) believe that telemedicine will reduce costs in medical care within the next years. 5. It is anticipated that the introduction of telemedicine is time consuming. 6. The lack of available medical informatics competence and manpower was regarded as the most important obstacle. 7. Data security and standardization, transfer speed and transmission quality are considered most important. 8. Most of the institutions (91 %) use computers in the management of patients. Fourty-four (96 %) are connected to the Internet. 9. Thirty-seven of 46 institutions were prepared to invest in the implementation of telemedicine. This analysis demonstrates that the use of telemedicine is expected to become standard in pediatric oncology, while the existing infrastructure and status of information regarding this subject at present are insufficient. The most pressing practical need for telemedicine applications is seen in the field of electronic expert consultation. Hence, the Telemedicine-Project of the GPOH Competence Net will focus on this aspect first.     

Intraoperative magnetic resonance imaging during transsphenoidal surgery

OBJECT: The aim of this study was to evaluate whether intraoperative magnetic resonance (MR) imaging can increase the efficacy of transsphenoidal microsurgery, primarily in non-hormone-secreting intra- and suprasellar pituitary macroadenomas. METHODS: Intraoperative imaging was performed using a 0.2-tesla MR imager, which was located in a specially designed operating room. The patient was placed supine on the sliding table of the MR imager, with the head placed near the 5-gauss line. A standard flexible coil was placed around the patient's forehead. Microsurgery was performed using MR-compatible instruments. Image acquisition was started after the sliding table had been moved into the center of the magnet. Coronal and sagittal T1-weighted images each required over 8 minutes to acquire, and T2-weighted images were obtained optionally. To assess the reliability of intraoperative evaluation of tumor resection, the intraoperative findings were compared with those on conventional postoperative 1.5-tesla MR images, which were obtained 2 to 3 months after surgery. Among 44 patients with large intra- and suprasellar pituitary adenomas that were mainly hormonally inactive, intraoperative MR imaging allowed an ultra-early evaluation of tumor resection in 73% of cases; such an evaluation is normally only possible 2 to 3 months after surgery. A second intraoperative examination of 24 patients for suspected tumor remnants led to additional resection in 15 patients (34%). CONCLUSIONS: Intraoperative MR imaging undoubtedly offers the option of a second look within the same surgical procedure, if incomplete tumor resection is suspected. Thus, the rate of procedures during which complete tumor removal is achieved can be improved. Furthermore, additional treatments for those patients in whom tumor removal was incomplete can be planned at an early stage, namely just after surgery.     

Intraoperative magnetic resonance imaging combined with neuronavigation: a new concept

OBJECTIVE: Intraoperative image data may be used not only to evaluate the extent of a tumor resection but also to update neuronavigation, compensating for brain shift. To date, however, intraoperative magnetic resonance imaging (MRI) can be combined only with navigation microscopes that are separated from the magnetic field, thus requiring time-consuming intraoperative patient transport. To help solve this problem, we investigated whether a new navigation microscope can be used within the fringe field of the MRI scanner. METHODS: The navigation microscope was placed at the 5-G line of a 0.2 MRI device. Patients were positioned lying down directly on the table of the scanner, with their heads placed approximately 1.5 m from the center of the magnet, fixed in an MRI-compatible ceramic head holder. Standard operating instruments were used. For intraoperative imaging, we slid the table into the center of the magnet in less than 30 seconds. RESULTS: By use of this setup, we operated on 22 patients. In all patients, anatomic neuronavigation could be used in combination with intraoperative MRI. In addition, in 12 patients, functional data from magnetoencephalographic or functional MRI studies were integrated, resulting in functional neuronavigation. We did not encounter adverse effects of the low magnetic field during navigation. Moreover, intraoperative imaging was not disturbed by the navigation microscope and vice versa. CONCLUSION: Functional neuronavigation and intraoperative MRI can be used essentially simultaneously without the need for lengthy intraoperative patient transport. The combination of intraoperative imaging with functional neuronavigation offers the opportunity for more radical resections and fewer complications.     

Primary spinal germinoma in a patient with concomitant Klinefelter's syndrome

It is known that patients with Klinefelter's syndrome are inclined to develop concomitant malignant tumours, as well as extragonadal germ cell tumours. The association of a primary spinal germinoma in a patient with Klinefelter's syndrome is reported for the first time, and the coincidence of elevated gonadotropin levels and oncogenesis is discussed.     

Electronic documentation in medicine; flexible concepts versus isolated solutions

Computer-based medical documentation so far proved advantageous especially through standardization of data entry and increased access speed. Additional benefits can be achieved through the implementation of integrated, cross-project documentation tools and their integration into the clinical work-flow, which allow data to be used for a wide variety of applications (e.g. quality management, clinical research, clinic management). The presence of incompatible documentation software often complicates the realization of these goals. Implementation of new documentation tools therefore should consider flexibility and multiple-use of data as primary design goals. In the presented paper requirements for flexible documentation tools are introduced. The Entity-Attribute-Value-Model is described as a possible means of implementation. Practical experiences made with a prototype application are reported.     

Visualization Strategies for Major White Matter Tracts for Intraoperative Use

Streamline representation of major fiber tract systems along with high-resolution anatomical data provides a reliable orientation for the neurosurgeon. For intraoperative visualization of these data either on navigation screens near the surgical field or directly in the surgical field applying heads-up displays of operating microscopes, wrapping of all streamlines of interest to render an individual object representing the whole fiber bundle is the most suitable representation. Integration of fiber tract data into a neuronavigation setup allows removal of tumors adjacent to eloquent brain areas with low morbidity.