[Degree of implementation of structured answering of emergency calls in German emergency dispatch centers and effects of the introduction in daily practice]. / Implementierungsgrad der strukturierten Notrufabfrage in deutschen Leitstellen und Auswirkungen ihrer Einführung.

BACKGROUND: The emergency call-taking process is crucial for the adequate disposition of emergency vehicles and the provision of first aid instructions. Moreover, it has a direct impact on the quality of out-of-hospital emergency care. Organizations such as the European Resuscitation Council, the German Federal Association of Emergency Medical Directors and the German Association of Emergency Dispatch Centers call for the nationwide implementation of a formal call-taking process in emergency dispatching. This is required for the provision of telephone-assisted cardiopulmonary resuscitation (T-CPR). METHODS: This article presents the results of an online survey among members of the German Association of Emergency Dispatch Centers on the implementation of structured call-taking programs. The survey comprised data on the implementation of a structured call-taking process, its effects on important quality indicators such as the frequency of T­CPR and employee satisfaction. RESULTS: Of the 100 participants who completed the survey, 49 already used formal call-taking systems and 24 (47%) of the remaining 51 emergency dispatch centers intended to implement such a system. Formal call-taking systems were mainly used in the dispatch of emergency medical services (98% of emergency dispatch centers using a formal call-taking system) and fire brigades (83.7% of emergency dispatch centers using a formal call-taking system). In 42 (85.7%) of the 49 emergency dispatch centers using a formal call-taking process, this process is mandatory; however, only 27 (64.3%) reported compliance rates of more than 95% in medical emergencies. Comparing the pre-post results after the introduction of a structured approach, the quality of the inquiries improved for almost all emergency dispatch centers. On the other hand, important quality indicators, e.g. mean dispatch initiation time or the necessity of subsequently alerting an advanced life support unit to the scene, were not recorded in 42.9% and 49.0% of the dispatch centers, respectively. Of the emergency dispatch centers that analyzed the frequency of T­CPR, 94.3% could show an increase in T­CPR. Moreover, 79.5% of the respondents reported improved employee satisfaction. Whereas the demand for dispatchers remained nearly static, 24 out of the 49 dispatch centers that used a formal call-taking system set up new posts for quality management (maximum: 3 posts in dispatch centers handling more than 250,000 missions annually). CONCLUSION: Structured emergency call-taking has not yet been comprehensively implemented in German emergency dispatch centers. Wherever it is used consistently, important quality parameters are improved. Further investigations should aim to identify crucial factors for its implementation and to analyze additional quality parameters.

[Knowledge of the population about leading symptoms of cardiovascular emergencies and the responsibility and accessibility of medical facilities in emergencies : Results of the KZEN study in Western Palatinate]. / Kenntnisstand der Bevölkerung über Leitsymptome kardiovaskulärer Notfälle und Zuständigkeit und Erreichbarkeit von Notrufeinrichtungen : Ergebnisse der KZEN-Studie in der Westpfalz.

BACKGROUND: The Westpfalz is a mainly rural region in the southwestern part of the German state of Rhineland-Palatinate with 527,000 inhabitants and demonstrates a higher than average cardiovascular mortality compared to the rest of Germany. The reasons are not known. Our study attempted to investigate whether significant deficits in knowledge of the population on cardiovascular emergencies, the accessibility of emergency medical services (EMS) or the different responsibilities and abilities of the medical facilities could be held responsible for this. These factors are of the utmost importance for the timely initiation and administration of curative therapeutic strategies. METHODS: We conducted standardized telephone interviews with 1126 inhabitants of Westpfalz as a representative sample of the population in the study area. The interviewees were asked about demographic data, participation in first aid courses, knowledge of emergency telephone numbers and the different responsibilities of preclinical emergency physicians which are a part of the EMS and the doctor-on-call system for non-life-threatening conditions (ÄBD). Moreover, we asked about the leading symptoms of myocardial infarction and stroke. Finally, we enquired how the respondents would react in fictitious cardiovascular emergencies. RESULTS: Of the participants 651 (57.8%) were female and 475 (42.2%) male. The mean age in our study was 51 ± 18 years and 1002 of the participants (89%) had some formal first aid training. The current telephone number of the EMS system (112) was known to 29.5% of the interviewees and 15.4% could only recall the old number (19222) which is no longer in use. In the case of participants who gave the correct telephone number the first aid course took place 10 years ago (median), whereas for participants who did not know the correct number, the course dated back 15 years (median, p < 0.01). The telephone number 116117 of the ÄBD, usually a family physician, was familiar to only 23 of the people interviewed (2.0%). The basic differences in the functions and responsibilities of the ÄBD and the emergency physician within the EMS were known to only 235 participants (20.2%), 231 (20.5%) were not able to name a single leading symptom of a myocardial infarction and 354 did not know a leading symptom (31.4%) of stroke. In the fictitious case report of an unconscious patient with respiratory arrest (as a sign of cardiac arrest) 96.8% of the interviewees would have correctly informed the EMS, for patients with acute coronary syndrome 81.8% and for a stroke patient 76.8% (cardiac arrest vs. acute coronary syndrome: p < 0.001, cardiac arrest vs. stroke: p < 0.001, acute coronary syndrome vs. stroke: p = 0.005). CONCLUSION AND RECOMMENDATIONS: A large proportion of the population were found to be ignorant about the telephone numbers for medical emergency calls and the different functions of the ÄBD and emergency physicians within the EMS. Moreover, our results indicate that a significant percentage of the population would neither be in a position to recognize a stroke or myocardial infarction in an emergency situation nor be informed enough to communicate with the correct part of the emergency system. The association of these deficits with the time elapsed since the last first aid course should be reason enough to continuously motivate the population, especially at risk patients and their relatives, to repeat such courses several times. Furthermore, digital media should be used more intensively in providing first aid instructions. In our opinion, this study clearly shows that in Germany a uniform number for medical emergency calls is mandatory.

Evaluating sepsis training for medical students and nonphysicians in Malawi.

STUDY OBJECTIVE: This study aimed to evaluate whether (regarding the Surviving Sepsis Campaign [SSC] guidelines) the training of Malawis scarce medical staff is adequate. Hospitals in Malawi have a severe shortage of human resources and therefore rely heavily on junior staff. Sepsis is a leading cause of admission to hospitals particularly in resource poor countries. It is associated with a high mortality rate. The SSC guidelines have been developed to help frontline staff diagnose and treat patients with sepsis. DESIGN: A questionnaire consisting of 10 multiple choice questions, which was to be completed before and after a teaching module. SETTING: Anesthesia courses at the University of Malawi. INTERVENTION: Participants had to answer the questionnaire before and after their teaching block on anesthetics and critical care. The medical students have a 2-week teaching block, and the nonmedical staff have an intensive 3-day training course. MBBS 1 was asked only once as a baseline. PARTICIPANTS: 168 medical students and 31 nonphysician staff returned 345 questionnaires (return rate, 97.1%). MEASUREMENTS: A total of 345 anonymous multiple choice questionnaires were completed. The same questionnaire was then repeated after their teaching block on anesthesia and critical care (not MBBS 1). The aim was for us to assess the knowledge the students had of sepsis. Overall 67% of the questions were answered correctly (2299 correct answers of 3450). The MBBS IV students had an average score of 68% to 72%, and the MBBS I students had a score of 42%. The highest score was achieved by the nonphysician clinical staff after their teaching as they improved by 11% (65%-76%). CONCLUSIONS: Medical students and health care workers have a lack of knowledge regarding the SSC guidelines which needs to be addressed via training. The medical student teaching was not as effective as the nonphysician clinical staff course, and therefore, we need to think about restructuring their teaching block by having an intensive "Sepsis Day" that focuses on the SSC guidelines.

[Preclinical fibrinolysis in patients with ST-segment elevation myocardial infarction in a rural region]. / Präklinische Fibrinolyse bei Patienten mit ST-Hebungsinfarkt in einer ländlich geprägten Region.

BACKGROUND: In the current guidelines for the treatment of patients with ST-segment elevation myocardial infarction (STEMI), the European Society of Cardiology (ESC) recommends preclinical fibrinolysis as a reperfusion therapy if, due to long transportation times, no cardiac catheterisation is available within 90-120 min. However, there is little remaining in-depth expertise in this method because fibrinolysis is presently only rarely indicated. METHODS: In a rural area in southwestern Germany, where an emergency primary percutaneous coronary intervention was not routinely available within 90-120 min, 156 STEMI patients underwent fibrinolysis with the plasminogen activator reteplase, performed by trained emergency physicians. The practicality of the treatment, as well as complications and the mortality of the patients in the preclinical phase until arrival at the hospital, were retrospectively studied. RESULTS: The mean time from onset of the symptoms to first medical contact was 114 ± 116 min. The mean interval to the start of fibrinolysis of 13.5 ± 6.4 min was within the 30 min mandated by the ESC. Patients with inferior STEMI represented the largest subgroup. Occurring in 39 cases (25 %), complications due to infarction were relatively common during the prehospital phase, including 15 cases (9.6 %) of cardiogenic shock, but in all cases the complications were manageable. No patient died before arrival at the hospital. As lysis-associated adverse effects, merely two uncomplicated mucosal haemorrhages and one case of mild allergic skin reactions were seen. CONCLUSION: In emergency situations with long transportation times to the nearest suitable cardiac catheterisation laboratory, preclinical fibrinolysis in STEMI still represents a workable method. Success of this strategy requires particularly strong training of the emergency physicians in ECG and lysis therapy, and co-operation with nearby cardiac centres.

[Sepsis - Knowledge of non-physician personnel in Africa. A cross-sectional study in Malawian district hospitals]. / Sepsis - Kenntnisstand des nichtärztlichen Personals in Afrika. Eine Querschnittstudie in malawischen Distriktkrankenhäusern.

BACKGROUND: Malawi has one of the worst human resource situations in the world and each clinically working doctor has to serve around 50,000 patients. There are almost no Malawian specialists physicians so that in the district hospitals it is usually non-medical staff (e.g. anesthesia clinical officer) who have the responsibility for severely sick patients with sepsis. At the Queen Elizabeth Central Hospital we have organized different courses over the years to support these colleagues. METHODS: Anonymous questionnaires with 10 multiple choice and 4 feedback-related questions were distributed to 115 participants in order to achieve an overview of the basic knowledge related to sepsis in the Malawian setting. RESULTS: In total 64.2 % of the questions were answered correctly with only minor differences between the 4 groups of participants from different professional backgrounds. Despite a relatively good knowledge in practical therapy the question concerning the therapeutic strategies of the Surviving Sepsis Campaign obtained the worst score with 6 %. After the course there was a 17 % increase in correctly answered questions. Besides an overview over the diagnostic and therapeutic situation for sepsis in the districts we received suggestions and critical comments for a better adjustment of our courses towards the reality of rural district hospitals. CONCLUSIONS: Healthcare workers in Malawi are not aware of key recommendations of the Surviving Sepsis Campaign. Guidelines have to be adapted to the specific healthcare structures in underdeveloped countries. We realized the wish and the desire of the participants for more training and more courses in Malawi. In order to be able to support these needs we would like to invite cooperation from interested institutions and colleagues for a special sepsis course on the occasion of the annual World Sepsis Days.

[Progressive paraplegia in a somnolent child]. / Progredienter Querschnitt bei einem somnolenten Kind.

A somnolent small girl with septic symptoms and a progressive paraplegia was initially treated as having meningitis with complications. Subsequently it was discovered through magnetic resonance imaging (MRI) that she was suffering from spinal epidural empyema due to a staphylococcal superinfection on the basis of tuberculous vertebral osteomyelitis. Lacking surgical facilities therapy was carried out by the anesthesia department using multilevel epidural punctures and drainage. This article discusses the agreement of MRI findings with the interventional findings and the clinical features and shows the leading diagnostic role of MRI throughout the clinical course.