Medizinische Klinik-Intensivmedizin Und Notfallmedizin最新文献

Background: The use of emergency medical services (EMS) in Germany has increased substantially over the last few decades. While current reform efforts aim to increase effectiveness and efficiency of the German hospital and EMS systems, there is lack of data on characteristics of hospital cases using EMS.

Objectives: To analyze and compare the characteristics of cases hospitalized with and without the use of EMS.

Materials and methods: The BARMER health insurance data on more than 2 million hospital cases admitted in 2022 were analyzed. The distributions of age, clinical complexity (measured by patient clinical complexity levels, PCCL), main diagnoses, costs for EMS and hospital treatment, and multiple severity indicators were described. The overall severity of hospital cases was classified as "low or moderate" or "high" based on a combined severity indicator. All analyses were stratified by use of EMS and EMS type.

Results: A total of 28% of all included hospital cases used EMS. Relative to hospital cases without use of EMS, hospital cases with use of EMS were older (physician-staffed ambulance: 75 years, interquartile range [IQR] 59-84, double-crewed ambulance: 78 years, IQR 64-85) and had a higher clinical complexity. The severity of more than 30% of the cases using EMS (except for patient transport service ambulance) was classified as "low or moderate". The distributions of main diagnoses differed by severity and use of EMS.

Conclusions: The high proportion of cases with low or moderate severity using EMS may indicate a substantial potential to avoid the use of EMS in the context of hospital admissions in Germany. Further investigation is required to explore whether the proportion of cases using EMS could be reduced by optimizing preclinical service.

Background: The advance directive and lasting power of attorney are instruments to strengthen patients' autonomy. A hospital-based palliative care consultation service can advise patients and family members about these instruments. This study investigates the need for such consultation among patients with life-limiting illness.

Methods: This prospective observational study on intensive and non-intensive care units includes patients with a request for palliative care consultation. Patient-related factors were evaluated for their possible association with the presence or absence of advance directives or power of attorney. In addition, focus group interviews with members of the palliative care consultation team were carried out to identify barriers which prevent patients from drawing up such documents.

Results: A total of 241 oncological and 53 non-oncological patients were included with a median age of 67 years; 69 (23%) patients were treated in the intensive care unit (ICU). Overall, 98 (33%) patients had advance directives, and 133 (45%) had determined a legal health care proxy in advance. A total of 52 patients died in hospital (17.7%). Only age and relationship status were associated with directives. In interviews, the following barriers were identified: information deficit, concern regarding discontinuation of treatment, loss of autonomy and wish to avoid a burden for the family.

Conclusion: The majority in this severely ill patient population lack advance directives. In order to remove barriers, more effective information and counseling is required about such directives. In particular, guidance should include potential clinical situations in which such directives are potentially beneficial.

Background: Gustav Mahler was a composer of the late Romantic period, one of the most famous conductors of his time and, as opera director, one of the most important reformers of musical theatre. Mahler's life, illnesses, death and dying are little or not at all known to many.

Objectives: Which illnesses determined Mahler's life? Could his early death have been avoided? From today's point of view, could modern intensive care medicine have helped him?

Material and methods: A detailed analysis of Mahler's diseases was performed using scientific databases (medline, pubmed). All published articles were examined in detail.

Results: Gustav Mahler was born in 1860 in Kalischt (Bohemia) and learned to play the accordion and piano at an early age. He studied music at the Vienna Conservatory from 1875 and completed his composition studies in 1878. Kapellmeister positions followed in several cities, from 1887 at the Vienna Court Opera and from 1908 at the Metropolitan Opera in New York. Mahler suffered from many illnesses, especially tonsillitis and haemorrhoids. In 1907 he was diagnosed with a mitral valve defect, in 1911 he developed bacterial endocarditis caused by streptococci, as a result of which Mahler died in Vienna in 1911. His life was marked by personal and health tragedies.

Discussion: Mahler was an outstanding personality who left behind an extensive oeuvre. Among the compositional highlights are his 10 symphonies and the song compositions. Recurrent streptococcal infections led to mitral valve disease and endocarditis, the consequences of which caused Mahler's untimely death. Today's modern cardiology and intensive care medicine could have prolonged his life, but unfortunately this was not possible at the time when he was diagnosed with endocarditis.

Acute pulmonary embolism is a common and potentially fatal condition in intensive care and emergency medicine. The mortality rate within the first few hours of its occurrence is particularly high; thus, even in the event of clinical suspicion, immediate initiation of diagnostics and treatment is crucial. The current European and national guidelines on acute pulmonary embolism provide valuable and practical support on this topic and form the basis of this review. A particular focus lies in the presentation of a risk-adapted and algorithm-based diagnostic and therapeutic approach. In particular, there are new recommendations regarding risk stratification and differentiated therapy, which are discussed in this article.

Background: Numerous medications are continuously administered to intensive care patients. To minimize medication errors standardized concentrations and dose adjustment by the infusion rate are recommended. This principle is already widely accepted in German intensive care units (ICUs). However, the active ingredients and concentrations used are still heterogeneous throughout the country.

Aim: The aim of the ADKA/DIVI (Bundesverband Deutscher Krankenhausapotheker/Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) initiative was to create a nationwide standard for adult continuous intravenous infusions in German ICUs by an expert panel.

Materials and methods: A mandated group of experts developed a nationwide standard concentration list for continuous infusion in a two-stage, consensus-based process. In stage 1, the inclusion of active substances was agreed upon, and in stage 2, the standard concentrations to be recommended were decided upon. The decision-making process was based on predefined decision criteria.

Results: The continuous infusion standard contains 41 active substances with 49 standard concentrations (37 substances with 1 concentration [conc.], heparin 2 conc., epinephrine and sufentanil 3 conc., norepinephrine 4 conc.), along with the appropriate vehicle solution, and the physicochemical stability over maximum 24 h.

Conclusion: The resulting continuous infusion standards are practical and evidence-based and represent a central component for improving medication safety in ICUs. Implementation of the standard list in German ICUs should be facilitated by interdisciplinary teams.

Background: Movement training for stroke patients is a crucial component of their treatment. Lack of time and staff are often described as limiting factors for the development of kinaesthetic competence. In contrast, a positive team atmosphere and awareness of kinaesthetics are seen to be beneficial.

Aim: The goal of this quality improvement project was to promote the kinaesthetic competence of a stroke unit (SU) nursing team and to investigate its influence on team dynamics.

Methods: As a team intervention for the project, a basic course in kinaesthetics in nursing, augmented by practical instructions, was conducted exclusively for the SU nursing team. The Kinaesthetics Competence Observation (KCO) instrument was used to determine competence development. The participants rated team dynamics on a scale of 0-10 points.

Results: In all, 88% of the nursing team took part in the quality improvement project and successfully completed the basic course. The kinaesthetic competence improved by 4.2 KCO points and the team dynamics also increased by around 2 points.

Discussion: A basic kinaesthetics course with practical instructions improves kinaesthetic competence. Continuous instruction, long-term process implementation and support from nursing managers are required to establish kinaesthetic competence in the long term.

Conclusion: The results show that a kinaesthetic training project carried out in this way has a positive influence not only on kinaesthetic competence but also on the dynamics of a care team.

Background: Case numbers in central emergency departments (EDs) have risen during the past decade in Germany, leading to recurrent overcrowding, increased risks in emergency care, and elevated costs. Particularly the fraction of outpatient emergency treatments has increased disproportionately. Within the framework of the Optimization of emergency care by structured triage with intelligent assistant service (OPTINOFA, Förderkennzeichen [FKZ] 01NVF17035) project, an intelligent assistance service was developed.

Patients and methods: New triage algorithms were developed for the 20 most frequent leading symptoms on the basis of established triage systems (emergency severity index, ESI; Manchester triage system, MTS) and provided as web-based intelligent assistance services on mobile devices. To evaluate the validity, reliability, and safety of the new OPTINOFA triage instrument, a pilot study was conducted in three EDs after ethics committee approval.

Results: In the pilot study, n = 718 ED patients were included (age 59.1 ± 22 years; 349 male, 369 female). With respect to disposition (out-/inpatient), a sensitivity of 91.1% and a specificity of 40.7%, and a good correlation with the OPTINOFA triage levels were detected (Spearman's rank correlation ρ = 0.41). Furthermore, the area under the curve (AUC) for prediction of disposition according to the OPTINOFA triage level was 0.73. The in-hospital mortality rate of OPTINOFA triage levels 4 and 5 was 0%. The association between the length of ED stay and the OPTINOFA triage level was shown to be significant (p < 0.001).

Conclusion: The results of the pilot study demonstrate the safety and validity of the new triage system OPTINOFA. By definition of both urgency and emergency care level, new customized perspectives for load reduction in German EDs via a closer cooperation between out- and inpatient sectors of emergency care could be established.