Zeitschrift fur Evidenz Fortbildung und Qualitaet im Gesundheitswesen最新文献

Introduction

Discharge from hospital is a risk to drug continuity and medication safety. In Germany, new legal requirements concerning the management of patient discharge from the hospital came into force in 2017. They set minimum requirements for the documentation of medications in patient discharge summaries, which are the primary means of communication at transitions of care. Six years later, data on their practical implementation in routine care are lacking.

Methods

Within the scope of an explorative retrospective observational study, the minimum requirements were operationalized and a second set of assessment criteria was derived from the recommendation “Good Prescribing Practice in Drug Therapy” published by the Aktionsbündnis Patientensicherheit e.V. as a comparative quality standard. A sample of discharge summaries was drawn from routine care at the University Hospital Heidelberg and assessed according to their fulfilment of the criteria sets. In addition, the potential influence of certain context factors (e. g., involvement of clinical pharmacists or software usage) was evaluated.

Results

In total, 11 quality criteria were derived from the minimum requirements. According to the eligibility criteria (i. e., three or more discharge medications) 352 discharge summaries (42 wards; issued in May–July 2021), containing in total 3,051 medications, were included. The practical implementation of the minimum requirements for documenting medications in patient discharge summaries differed considerably depending on the criterion and defined context factors. Core elements (i. e., drug name, strength, and dosage at discharge) were fulfilled in 82.8 %, while further minimum requirements were rarely met or completely lacking (e. g., explanations for special pharmaceutical forms). Involvement of clinical pharmacists and usage of software were shown to be a facilitator of documentation quality, while on-demand medication (compared to long-term medication) as well as newly prescribed medication (compared to home medication or medication changed during hospitalisation) showed poorer documentation quality. In addition, the documentation quality seemed to depend on the department and the day of discharge.

Conclusion

To date, the wording of the German legal requirements allows for different interpretations without considering the respective clinical setting and the medication actually prescribed. For future clarification of the requirements, implications of the wording for the clinical setting should be considered.

Introduction

In the German rehabilitation system, gaps in care exist that particularly affect people with complex impairments under 60 years of age. Home-based rehabilitation, an outreach form of outpatient rehabilitation, could bridge this gap by providing access to rehabilitation for this group of patients. Corresponding facilities so far barely exist in Germany. In view of the likely complexity and the associated problems of this group of people, needs-based care may also require a cross-indication approach in order to adequately address rehabilitation needs across different organ systems. The aim of this study is to assess 1) the general need for home-based rehabilitation and associated potentials, 2) attitudes towards a cross-indication approach, and 3) indication and allocation criteria for this approach from an expert perspective.

Methods

Data was collected from 08/2022 to 10/2022 through semi-structured individual telephone interviews with experts in the field of rehabilitation. Data were analyzed using qualitative content analysis according to Kuckartz and Rädiker.

Results

A total of n = 22 experts were interviewed. The experts see a high need for home-based rehabilitation for people with complex health impairments under the age of 60 in order to counteract existing care gaps within current rehabilitative offers. The potentials offered by home-based rehabilitation include, amongst others, flexibility, participation orientation and involvement of the social environment (e. g., of relatives). A cross-indication approach is considered relevant by the majority of the experts, especially in order to meet more complex needs (e. g., in the case of multimorbidity) in a holistic and needs-based manner.

Conclusion

The results demonstrate the relevance of this topic and the necessity of expanding (cross-indication) home-based rehabilitation in Germany. According to the experts, (cross-indication) home-based rehabilitation can help to ensure the participation of a group of patients with complex and severe impairments under the age of 60.

Objectives

The aim of the study was to explore the subjective views of general practitioners on the applicability of the Adult ADHD Self-Report Screening Scale for DSM-5 (ASRS-5) as a screening tool for attention-deficit/hyperactivity disorder (ADHD) in adults in general practice.

Method

Eleven general practitioners, who had participated in the validation study of the German version of the ASRS-5, were interviewed. For this purpose, a semi-structured interview guide was designed using the Consolidated Framework for Implementation Research (CFIR). The interviews were audio-recorded, transcribed, and analyzed using qualitative content analysis according to Kuckartz.

Results

The ASRS-5 seems to work well in general medical practice. But there is evidence for a lack of knowledge about ADHD in adults among general practitioners and a demand for further training in this area. Moreover, insufficient possibilities for subsequent treatment after a positive ADHD screening were claimed.

Discussion

In general medicine, the introduction of a screening using ASRS-5 in cases of clinical suspicion could be the first step towards improving the management of adult patients with ADHD.

Conclusion

Optimizing the management of adults with ADHD requires additional information and training initiatives to support early diagnosis especially in the primary care setting, and to reveal treatment options and care concepts for adults with ADHD.

Having dealt with Martini's understanding of causality and his procedural elements of evidence in the third part, the concluding article once again takes a historical perspective. It (1) traces the positionings and contexts of Martini’s methodology in a sort of historical longitudinal section and (2) discusses the reasons for the rather reluctant response to his research programme in German and international medicine. We then focus (3) on Martini’s understanding and concept of clinical research, the specific challenges he faced in post-war German medicine – and what remains of it today. Finally, we summarise the key findings of our article series and reflect on Martini’s work in terms of its special nature and significance for clinical medicine in the 20^th century.

Clinical Risk Management (CRM) is an important instrument to continuously improve safety of health care delivery. In Germany, hospitals are required by law to implement CRM and incidence reporting systems. Since 2010, nation-wide surveys have been conducted periodically to evaluate implementation of CRM in hospitals. The instrument used in these surveys is constantly being updated to reflect previous experiences, as well as to adapt to ongoing trends and developments in CRM practices. The survey instrument used in 2022 consisted of up to 200 items and took up to an hour to complete. In this study, we aimed to develop a short instrument to measure the level of CRM implementation in hospitals, evaluate its psychometric properties, and to offer benchmarking data for health care facilities of different sizes.

We used data collected in 2022 as part of KHaSiMiR study, employing a cross-sectional self-reported online survey. The hospital administrations were invited to designate one CRM manager to participate in the study. Out of 1,411 general hospitals invited, 401 responses were collected (response rate of 28%). After removing the cases with excessive missings, we imputed remaining missing values using multiple imputation, and split the resulting sample (n = 362) in two halves (i.e., exploratory and testing subsamples). A principal component analysis was applied on the first subsample. We validated the resulting model using confirmatory factor analysis in the testing subsample. We evaluated internal consistency, and tested external validity of the established instrument using correlation analysis with two single-item measures: subjective evaluation of CRM implementation compared to similar organizations and compared to own ideal level. The principal component analysis included 45 items from the full instrument. The analysis resulted in a three-factor model with 26 items. In the confirmatory factor analysis, the model demonstrated acceptable fit with the data according to the commonly used fit indices: Chi²/df = 1.36, CFI = 0.941, TLI = 0.930, RMSEA = 0.045 (90% CI = 0.032–0.056), SRMR = 0.049. Cronbach’s alpha of all three factors was good (>0.70). All three factors had statistically significant positive correlations with each other (0.359–0.497) and with the two single items (0.282–0.532). None of the correlations were high enough (>0.7) to indicate multicollinearity.

The proposed short clinical risk management implementation (Short CRiMI) questionnaire is psychometrically valid and can be used to rapidly evaluate CRM implementation in hospitals. Further research can provide evidence of its external validity and association with quality and safety outcomes. Benchmarking data can be used to compare the results with the data from the most recent Germany-wide survey.

Background

During the restrictions on human contact in the COVID-19 pandemic, nursing homes made a great effort to allow relatives, doctors and other persons involved in the care to communicate with residents. For this purpose, the HLTeleheim project offered a practical telemedical support option. This offer was accepted and implemented in a heterogeneous way. The aim of this study was to detect factors that have an influence on the implementation of telemedical applications in long-term care facilities.

Methods

As part of a qualitative evaluation approach, guideline-centered interviews (n = 17) were conducted with nurses, doctors and administrative staff from the facilities invited to participate in the project. These interviews were then transcribed and anonymized. The evaluation was carried out according to Mayring's qualitative analysis. The code system was created deductively and inductively. Two independently working persons analyzed the interviews.

Results

While a high demand for applications of telemedicine in nursing care was seen in the run-up to the project, considerable barriers emerged during the implementation, and acceptance among the interviewees was mixed. The nurses regarded the regular use of telemedicine as being rather unimportant for their work. Technical and organizational problems were seen as barriers by the interviewees, which partly limited the use of telemedicine applications. Compatibility among the applications used was seen as a prerequisite of effective use. Unstable internet connection was an important limiting determinant. It turned out that consultations were used for communication within the team.

Discussion

Although the advantages of video consultations are being recognized among nursing staff, they are still little used. In order to promote the use of telemedicine applications, it is important to repeatedly point out their individual advantages in internal and external communication. Another approach to further implementation, in addition to financial and technical aspects, is to directly address the nursing profession in the software products to be used.

Conclusion

The implementation of telemedicine applications in long-term care facilities faces structural barriers, such as insufficient internet coverage and a lack of billing options, as well as personal hurdles, such as a low affinity for technology and a lack of knowledge on the subject of telemedicine.

Background

In order to evaluate whether the new rescue means “community emergency paramedics” (Gemeindenotfallsanitäter [G-NFS]) relieves the emergency medical service (EMS) in the care of low-priority emergencies, the perspective of general practitioners and patients was also surveyed in a written questionnaire as part of an innovation fund project. Recruitment for participation in the study proved to be difficult. The aim of this study is to evaluate why the G-NFS decided against providing information on study participation and what measures would be necessary to include more emergency patients in surveys in the future.

Methods

Retrospective analysis of the assignment protocols from April 1, 2021 to June 30, 2022. In addition to patient characteristics, data on treatments, interventions and recommendations to patients as well as reasons for non-participation in the patient survey were collected.

Results

5,395 G-NFS protocols that contained information on non-participation were included in the analysis. The average age of the patients was 62.4 years (SD 22.7), and 50.2 % were female. 57.4 % of the cases were categorised as non-urgent, and 35.2 % of the cases required an additional ambulance to be alerted. 404 (7.5 %) patients used the EMS more than once, 1,120 (20.8 %) did not have sufficient language skills, 1,012 (18.8 %) patients declined study participation, and 2,975 (55.1 %) patients were not able to participate according to the G-NFS assessment. Dementia/neurocognitive impairment (35 %), acute/emergency situation (26.5 %), mental health impairment (10.3 %), and substance abuse (6.5 %) were given as reasons for non-participation from the G-NFS perspective.

Discussion

The results show that more than half of the patients were unable to take part in a written survey for various reasons, even though there was no need for urgent care. This could be due to a high demand for care and the complex consent procedure. In addition, further resources are required to provide needs-based care for these patients in order to relieve the burden on emergency medical care. Over half of the patients were unable to take part in a written survey for various reasons. Further research is needed to determine what consent procedures are appropriate to facilitate patients’ study participation.

Introduction

Structured emergency room concepts have been shown to contribute to patient safety. Until now there has been no uniform emergency room concept for critically ill and seriously injured children and adolescents in the emergency room at the Altona Children's Hospital in Hamburg. This concept has been newly developed in interdisciplinary cooperation and includes the use of new clinical premises as well as new responsibilities and team compositions. The introduction of new processes and rooms for handling emergencies is associated with a risk of overlooking latent safety deficiencies or detecting them only after the process has been implemented. This may have a direct impact on patient safety. Before moving to new clinical premises, in situ simulation can be helpful to identify and to resolve latent safety threats in advance. Therefore, this method was chosen to test the newly created emergency room concept in the future emergency room at the Altona Children's Hospital.

Methods

Two in situ simulations were carried out in the future real emergency room. Latent safety threats detected by the observation team and the participants (medical and nursing staff of the Altona Children's Hospital from the departments of pediatric surgery, traumatology, orthopedics, pediatrics, anesthesia, intensive care medicine, radiology, emergency medicine) were collected using free text notes after the simulations and evaluated retrospectively. In order to better deal with these latent safety threats, the observations were classified into different categories: working environment (e. g., lack of equipment, unfavorable positioning of material), process (e. g., lack of defined responsibilities in the team) and other safety threats that did not fall into one of the two categories defined.

Results

A total of 51 latent safety threats were identified during the two in situ simulations. Of these, 22 (43.1 %) were assigned to the “working environment” category, 20 (39.2 %) to the “process” category and 9 (17.7 %) to the “other safety threats” category.

Of the latent safety threats identified, 46 (90.2 %) could be resolved before the emergency room was put into operation. For the non-recoverable safety threats, safety concepts were developed in order to further minimize the risk of patient hazard.

Discussion

With the help of this study, it could be shown that the implementation of in situ simulation before the commissioning of new clinical premises and the introduction of new processes can contribute to the detection of latent safety threats in an interdisciplinary German pediatric emergency department.