Who, When, Why?-Traumatological Patients in the Emergency Department of a Maximum Care Provider.

Nationwide, there is an annual increase in the number of patients in German emergency departments resulting in a growing workload for the entire emergency department staff. Several studies have investigated the situation in emergency departments, most of which were interdisciplinary, but there are no data on a solely traumatological patient population. The present study therefore aims to investigate the situation in a university-based trauma surgery emergency department. A total of 8582 traumatological patients attending a university hospital from 1 January 2019 to 31 December 2019 were studied. Various variables, such as reason for presentation, time of accident, diagnosis, and diagnostic as well as therapeutic measures performed were analyzed from the admission records created. The mean age was 36.2 years, 60.1% were male, 63.3% presented on their own to the emergency department, and 41.2% presented during regular working hours between 8:00 a.m. and 6:00 p.m., Monday through Friday. The most common reason for presentation was outdoor falls at 17.4%, and 63.3% presented to the emergency department within the first 12 h after the sustained trauma. The most common diagnosis was bruise (27.6%), and 14.2% of patients were admitted as inpatients. Many of the emergency room patients suffered no relevant trauma sequelae. In order to reduce the number of patients in emergency rooms in the future, existing institutions in the outpatient emergency sector must be further expanded and effectively advertised to the public. In this way, the emergency medical resources of clinics, including staff, can be relieved to provide the best possible care for actual emergency patients.

Health Economic Challenge: Geriatric Trauma-An Age-Based Observational Analysis of Treatment Costs and Reimbursement Issues.

Demographic change is having a major impact on the economic and structural development of the healthcare system. People stay active longer and the number of mild traumatic brain injury [mTBI] in patients ≥ 65 years of age consequently increases. The aim of this comparative analysis is to illustrate the impact of demographic change and the increasing treatment of geriatric trauma patients on the cost structure of the health care system using mTBI as an example diagnosis. Patients and Methods: The 12-month retrospective analysis included 220 in-patients treated with mTBI and remunerated under the German Diagnosis Related Group [G-DRG] B80Z. For comparative analysis, the patient population was divided into two study groups according to age [U65 18−64 years, G65 ≥ 65 years]. For the cost and proceeds calculation, itemized cost reports (personnel, supply, material, and equipment costs, etc.) were created. Results: 163 patients U65 and 57 patients G65 were included. In the G65 group, the most frequent accident mechanism was a fall from a short distance (84.1 vs. U65 36.7%; p = 0.007). For the inpatient admission of G65, the use of anticoagulants (p < 0.001) and comorbidity (p = 0.002) played a primary role, while for younger patients it was more neurological symptoms (p < 0.001) and alcohol (p < 0.001) that led to inpatient monitoring. The mean length of hospitalization of G65 patients was significantly longer than that of younger patients (G65 2.4 ± 1.9 days > U65 1.7 ± 0.8 days; p = 0.007) and radiological examinations (G65 94.7% > U65 23.3%; p = 0.013) were performed more frequently. Comparing analysis of the cost and proceeds of U65 vs. G65 results in a proceeds difference of €51,753.91 per year for the G-DRG B80Z compared to U65. Conclusions: It has been shown that there is a difference in costs and proceeds when comparing younger and older patients, resulting in a reimbursement deficit. In view of the demographic development in Europe, flat-rate remuneration will lead to a considerable discrepancy between DRG reimbursement and the coverage of hospitals' running costs. Providing health care to an increasingly aging society represents one of the major personnel and financial challenges for the public health system in the coming decades. Further adaptation of the DRG system to the growing costs caused by older patients is imperative.

Local Fixation of Colistin With Fibrin Spray: An in vivo Animal Study for the Therapy of Skin and Soft Tissue Infections.

Objective: Skin and soft tissue infections (SSTI) are a commonly known entity of diseases associated with difficult treatment procedures. The current gold standard when there is a rapidly progressing infection of soft tissues with a risk of sepsis is radical surgical debridement accompanied by systemic antibiotic therapy. In clinical settings, local antibiotics alone or formulated within carrier material are commonly used alongside this therapy regimen. One possibility of local antibiotic application is the fixation of colistin with fibrin glue spray. It is not yet sufficiently researched how the local antibiotic concentrations remain as high as possible over time. Methods: We conducted an animal study including 29 male Wistar rats inducing sterile back sores reaching the muscle fascia. We sprayed only colistin, simultaneously or consecutively, with fibrin glue in different groups in order to measure the tissue concentration of the antibiotic applied locally. Results: After liquid chromatography and quadrupole mass spectrometry analysis, it could be demonstrated that in comparison to the colistin group, tissue concentrations of colistin stayed significantly higher in the wound tissue when it was fixed with fibrin glue. This was observed in both groups, the simultaneous as well as in the consecutively fibrin glue sprayed groups after colistin application. Conclusion: The fixation of colistin with the fibrin-glue-spray technique as a carrier for local antibiotic therapy is an easy and inexpensive method and shows promising potential for the treatment of SSTI.

Manikins versus simulated patients in emergency medicine training: a comparative analysis.

PURPOSE: Every physician must be able to sufficiently master medical emergencies, especially in medical areas where emergencies occur frequently such as in the emergency room or emergency surgery. This contrasts with the observation that medical students and young residents often feel insufficiently prepared to handle medical emergencies. It is therefore necessary to train them in the treatment of emergency patients. The aim of this study is to analyze the influence of the assignment of manikin versus simulated patients during a training for undergraduate medical students on learning outcomes and the perceived realism. METHODS: The study had a prospective cross-over design and took place in a 3-day emergency medicine training for undergraduate medical students. Students completed three teaching units ('chest pain', 'impaired consciousness', 'dyspnea'), either with manikin or simulated patient. Using a questionnaire after each unit, overall impression, didactics, content, the quality of practical exercises, and the learning success were evaluated. The gained competences were measured in a 6-station objective structured clinical examination (OSCE) at the end of training. RESULTS: 126 students participated. Students rated simulated patients as significantly more realistic than manikins regarding the possibility to carry out examination techniques and taking medical history. 54.92% of the students would prefer to train with simulated patients in the future. Regarding the gained competences for 'chest pain' and 'impaired consciousness', students who trained with a manikin scored less in the OSCE station than the simulated patients-group. CONCLUSION: Simulated patients are rated more realistic than manikins and seem to be superior to manikins regarding gained competence.

The Implementation of a Complication Avoidance Care Bundle Significantly Reduces Adverse Surgical Outcomes in Orthopedic Trauma Patients.

BACKGROUND: Surgical complications are associated with a significant burden to patients and hospitals and are increasingly discussed in recent literature. This cohort study reviewed surgery-related complications in a Level I trauma center. The effect of a complication avoidance care bundle on the rate of surgical complications was analyzed. METHODS: All complications (surgical and nonsurgical) that occur in our trauma department are prospectively captured using a standardized documentation form and are discussed and analyzed in a weekly trauma Morbidity and Mortality (M&M) conference. Surgical complication rates are calculated using the annual surgical procedure numbers. Based on discussions in the M&M conference, a complication avoidance care bundle consisting of five measures was established: (1) Improving team situational awareness; (2) reducing operating room traffic by staff members and limiting door-opening events; (3) preoperative screening for infectious foci; (4) adapted preoperative antibiotic prophylaxis in anatomic regions with a high risk of infectious complications; and (5) use of iodine-impregnated adhesive drape. RESULTS: The number of surgical procedures steadily increased over the study years, from 3587 in 2015 to 3962 in 2019 (an increase of 10.5%). Within this 5-year study period, the overall rate of surgical complications was 0.8%. Surgical site infections were the most frequently found complications (n = 40, 24.8% of all surgical complications), followed by screw malposition (n = 20, 12.4%), postoperative dislocations of arthroplasties (n = 18, 11.2%), and suboptimal fracture reduction (n = 18, 11.2%). Following implementation of the complication avoidance care bundle, the overall rate of surgical complications significantly decreased, from 1.14% in the year 2016 to 0.56% in the study year 2019, which represents a reduction of 51% within a 3-year time period. CONCLUSIONS: A multimodal strategy targeted at reducing the surgical complication rate can be successfully established based on a transparent discussion of adverse surgical outcomes. The combination of the different preventive measures was associated with reducing the overall complication rate by half within a 3-year time period.

Registry-Based Mortality Analysis Reveals a High Proportion of Patient Decrees and Presumed Limitation of Therapy in Severe Geriatric Trauma.

BACKGROUND: The treatment of severely injured patients, especially in older age, is complex, and based on strict guidelines. METHODS: We conducted a retrospective study by analyzing our internal registry for mortality risk factors in deceased trauma patients. All patients that were admitted to the trauma bay of our level-1-trauma center from 2014 to 2018, and that died during the in-hospital treatment, were included. The aim of this study was to carry out a quality assurance concerning the initial care of severely injured patients. RESULTS: In the 5-year period, 135 trauma patients died. The median (IQR) age was 69 (38-83) years, 71% were male, and the median (IQR) Injury Severity Score (ISS) was 25 (17-34) points. Overall, 41% of the patients suffered from severe traumatic brain injuries (TBI) (AIShead ≥ 4 points). For 12.7%, therapy was finally limited owing to an existing patient's decree; in 64.9% with an uncertain prognosis, a 'therapia minima' was established in consensus with the relatives. CONCLUSION: Although the mortality rate was primarily related to the severity of the injury, a significant number of deaths were not exclusively due to medical reasons, but also to a self-determined limitation of therapy for severely injured geriatric patients. The conscientious documentation concerning the will of the patient is increasingly important in supporting medical decisions.

From two stages to one: acceleration of the induced membrane (Masquelet) technique using human acellular dermis for the treatment of non-infectious large bone defects.

INTRODUCTION: The induced membrane technique for the treatment of large bone defects is a two-step procedure. In the first operation, a foreign body membrane is induced around a spacer, then, in the second step, several weeks or months later, the spacer is removed and the Membrane pocket is filled with autologous bone material. Induction of a functional biological membrane might be avoided by initially using a biological membrane. In this study, the effect of a human acellular dermis (hADM, Epiflex, DIZG gGmbH) was evaluated for the treatment of a large (5 mm), plate-stabilised femoral bone defect. MATERIAL AND METHODS: In an established rat model, hADM was compared to the two-stage induced membrane technique and a bone defect without membrane cover. Syngeneous spongiosa from donor animals was used for defect filling in all groups. The group size in each case was n = 5, the induction time of the membrane was 3-4 weeks and the healing time after filling of the defect was 8 weeks. RESULTS: The ultimate loads were increased to levels comparable with native bone in both membrane groups (hADM: 63.2% ± 29.6% of the reference bone, p < 0.05 vs. no membrane, induced membrane: 52.1% ± 25.8% of the reference bone, p < 0.05 vs. no membrane) and were significantly higher than the control group without membrane (21.5%). The membrane groups were radiologically and histologically almost completely bridged by new bone formation, in contrast to the control Group where no closed osseous bridging could be observed. CONCLUSION: The use of the human acellular dermis leads to equivalent healing results in comparison to the two-stage induced membrane technique. This could lead to a shortened therapy duration of large bone defects.

Prevalence, risk factors and therapeutic aspects of injuries and accidents in women with epilepsy.

BACKGROUND: Epilepsy-related injuries and accidents (ERIA) are a frequent cause of hospitalisation and represent a relevant burden for patients with epilepsy. In particular, osteoporosis and other gender-specific aspects may increase the risk of seizure-related fractures and injuries in women with epilepsy. AIM AND SCOPE: The aim of this analysis is to determine the prevalence and clinical nature of ERIA in a cohort of women with epilepsy, to identify possible determinants including osteoporosis and to give an overview of the current knowledge of clinically important prophylactic and therapeutic aspects. RESULTS: In total, 167 women (mean age 39.0 years, range 18-67 years) with established diagnosis of epilepsy (mean disease duration 18.2 years, range 0-64) were analysed for the occurrence of ERIA. Overall, 22 patients (13.2%) reported at least one ERIA (mean number 3.4, ± 3.1) during the last three months prior to enrollment. The most frequent types of ERIA were lacerations (n = 7/22; 31.8%), abrasions, cuts, bruises or hematoma (n = 6/22, 27.3%), burns (n = 3/22, 13.6%), and fractures (n = 3/22, 13.6%). Moreover, one seizure-related road traffic accident with consecutive trauma (4.5%) was reported. Ictal falls, periictal abnormalities of behaviour and missing seizure freedom were associated with ERIA. Furthermore, female patients with ERIA had a significantly reduced quality of life (QoL, p = 0.002) and increased anxiety (p = 0.008) compared to patients without ERIA. A review of the pertinent literature suggests decreased bone mineral density and use of enzyme-inducing AEDs to be risk factors for ERIA in women with epilepsy. CONCLUSION: ERIA represent relevant complications for women with epilepsy and are associated with a lower QoL and anxiety compared with non-affected controls. Improvement of anticonvulsive treatment and therapy for osteoporosis or osteomalacia may help to decrease ERIA and the associated burden.