[Performance development of a university operating room after implementation of a central operating room management]. / Leistungsentwicklung eines universitären OP-Bereichs nach Implementierung eines zentralen OP-Managements.

The difficult financial situation in German hospitals requires measures for improvement in process quality. Associated increases in revenues in the high income field "operating room (OR) area" are increasingly the responsibility of OR management but it has not been shown that the introduction of an efficiency-oriented management leads to an increase in process quality and revenues in the operating theatre. Therefore the performance in the operating theatre of the University Medical Center Göttingen was analyzed for working days in the core operating time from 7.45 a.m. to 3.30 p.m. from 2009 to 2014. The achievement of process target times for the morning surgery start time and the turnover times of anesthesia and OR-nurses were calculated as indicators of process quality. The number of operations and cumulative incision-suture time were also analyzed as aggregated performance indicators. In order to assess the development of revenues in the operating theatre, the revenues from diagnosis-related groups (DRG) in all inpatient and occupational accident cases, adjusted for the regional basic case value from 2009, were calculated for each year. The development of revenues was also analyzed after deduction of revenues resulting from altered economic case weighting. It could be shown that the achievement of process target values for the morning surgery start time could be improved by 40 %, the turnover times for anesthesia reduced by 50 % and for the OR-nurses by 36 %. Together with the introduction of central planning for reallocation, an increase in operation numbers of 21 % and cumulative incision-suture times of 12% could be realized. Due to these additional operations the DRG revenues in 2014 could be increased to 132 % compared to 2009 or 127 % if the revenues caused by economic case weighting were excluded. The personnel complement in anesthesia (-1.7 %) and OR-nurses (+2.6 %) as well as anesthetists (+6.7 %) increased less compared to the revenues or were slightly reduced. This improvement in process quality and cumulative incision-suture times as well as the increase in revenues, reflect the positive impact of an efficiency-oriented central OR management. The OR management releases due to measures of process optimization the necessary personnel and time resources and therefore achieves the basic prerequisites for increased revenues of surgical disciplines. The method presented can be used by other hospitals as a guideline to analyze performance development.

[OR minute myth : Guidelines for calculation of DRG revenues per OR minute]. / Mythos OP-Minute : Leitfaden zur Kalkulation von DRG-Erlösen pro Op-Minute.

The economic situation in German Hospitals is tense and needs the implementation of differentiated controlling instruments. Accordingly, parameters of revenue development of different organizational units within a hospital are needed. This is particularly necessary in the revenue and cost-intensive operating theater field. So far there are only barely established productivity data for the control of operating room (OR) revenues during the year available. This article describes a valid method for the calculation of case-related revenues per OR minute conform to the diagnosis-related groups (DRG).For this purpose the relevant datasets from the OR information system and the § 21 productivity report (DRG grouping) of the University Medical Center Göttingen were combined. The revenues defined in the DRG browser of the Institute for Hospital Reimbursement (InEK) were assigned to the corresponding process times--incision-suture time (SNZ), operative preparation time and anesthesiology time--according to the InEK system. All full time stationary DRG cases treated within the OR were included and differentiated according to the surgical department responsible. The cost centers "OR section" and "anesthesia" were isolated to calculate the revenues of the operating theater. SNZ clusters and cost type groups were formed to demonstrate their impact on the revenues per OR minute. A surgical personal simultaneity factor (GZF) was calculated by division of the revenues for surgeons and anesthesiologists. This factor resembles the maximum DRG financed personnel deployment for surgeons in German hospitals.The revenue per OR minute including all cost types and DRG was 16.63 €/min. The revenues ranged from 10.45 to 24.34 €/min depending on the surgical field. The revenues were stable when SNZ clusters were analyzed. The differentiation of cost type groups revealed a revenue reduction especially after exclusion of revenues for implants and infrastructure. The calculated GZF over all surgical departments was 2.2 (range 1.9-3.6). A calculation of this factor at the DRG level can give economically relevant information about the case-related personnel deployment.This analysis shows for the first time the DRG-conform calculation of revenues per OR minute. There is a strong dependency on the considered cost type and the performing surgical field. Repetitive analyses are necessary due to the lack of reference values and are a suitable tool to monitor the revenue development after measures for process optimization. Comparative analyses within different surgical fields on this data base should be avoided. The demonstrated method can be used as a guideline for other hospitals to calculate the DRG revenues within the OR. This enables pursuing cost-effectiveness analysis by comparing these revenues with cost data from the cost unit accounting at a DRG or case level.

[Acute pain therapy in German hospitals as competitive factor. Do competition, ownership and case severity influence the practice of acute pain therapy?]. / Akutschmerztherapie in deutschen Krankenhäusern als Wettbewerbsfaktor. Wird die Praxis der Akutschmerztherapie von Wettbewerb, Trägerschaft und Fallschwere beeinflusst?

BACKGROUND: Due to the implementation of the diagnosis-related groups (DRG) system, the competitive pressure on German hospitals increased. In this context it has been shown that acute pain management offers economic benefits for hospitals. The aim of this study was to analyze the impact of the competitive situation, the ownership and the economic resources required on structures and processes for acute pain management. MATERIAL AND METHODS: A standardized questionnaire on structures and processes of acute pain management was mailed to the 885 directors of German departments of anesthesiology listed as members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin). RESULTS: For most hospitals a strong regional competition existed; however, this parameter affected neither the implementation of structures nor the recommended treatment processes for pain therapy. In contrast, a clear preference for hospitals in private ownership to use the benchmarking tool QUIPS (quality improvement in postoperative pain therapy) was found. These hospitals also presented information on coping with the management of pain in the corporate clinic mission statement more often and published information about the quality of acute pain management in the quality reports more frequently. No differences were found between hospitals with different forms of ownership in the implementation of acute pain services, quality circles, expert standard pain management and the implementation of recommended processes. Hospitals with a higher case mix index (CMI) had a certified acute pain management more often. The corporate mission statement of these hospitals also contained information on how to cope with pain, presentation of the quality of pain management in the quality report, implementation of quality circles and the implementation of the expert standard pain management more frequently. There were no differences in the frequency of using the benchmarking tool QUIPS or the implementation of recommended treatment processes with respect to the CMI. CONCLUSION: In this survey no effect of the competitive situation of hospitals on acute pain management could be demonstrated. Private ownership and a higher CMI were more often associated with structures of acute pain management which were publicly accessible in terms of hospital marketing.

[Implementation of a new emergency room protocol at a University Medical Center in Germany: basis for improved flow of information, adequate quality management and scientific assessment]. / Implementierung eines neuen Schockraumprotokolls an einem Universitätsklinikum in Deutschland: Grundlage für einen verbesserten Informationsfluss, adäquates Qualitätsmanagement und wissenschaftliche Auswertungen.

BACKGROUND: After analyzing the existing documentation protocol for the emergency room (ER), the department of anesthesiology of the Medical University of Göttingen (UMG) developed a new department-specific ER protocol. AIM: The objective was to improve the flow of patient information from the preclinical situation through the emergency room to the early inpatient period. With this in mind a new emergency protocol was developed that encompasses the very heterogeneic patient collective in the ER as well as forming a basis for quality management and scientific investigation, taking user friendliness and efficiency into consideration. MATERIAL AND METHODS: A strategical development of a new emergency room protocol is represented, which was realized using a self-developed 8-step approach. Technical support and realization was carried out using the Scribus 1.4.2 open source desktop and GIMP 2.8.4 GNU image manipulation graphic programs. RESULTS: The new emergency room protocol was developed based on scientific knowledge and defined targets. The following 13 sections represent the contents of the new protocol: general characteristics, emergency event, initial findings and interventions, vital parameters, injury pattern, vascular access, hemodynamics, hemogram/blood gas analysis (BGA), coagulopathy, diagnostics, emergency interventions, termination of ER treatment and final evaluation. CONCLUSION: The structured and elaborated documentation was limited to the target of two sides and succeeds in incorporating trauma patients as well as non-trauma patients in the ER.

[Pre-existing pain as comorbidity in postoperative acute pain service]. / Vorbestehender Schmerz als Komorbidität im postoperativen Akutschmerzdienst.

BACKGROUND: Pre-existing or chronic pain is a relevant risk factor for severe postoperative pain. The prevalence of pre-existing and chronic pain in hospital depends on the time definition used and is approximately 44 % and 33%, at 3 or 6 months, respectively. The aim of this study was to determine the prevalence and importance of pre-existing pain in patients treated by a postoperative acute pain service (APS) and to evaluate the requirements for treatment and resources as well as its quality in this context. MATERIAL AND METHODS: This study involved an evaluation of all visits by the APS of the University Hospital in Göttingen over an 8-week period including patient subjective quality assessment on the basis of the quality improvement in postoperative pain therapy (QUIPS) questionnaire. Pre-existing pain (>12 weeks) was assessed by recording patients history of pain by members of the APS. The results from patients with and without pre-existing pain were compared. RESULTS: A total of 128 patients (38% female, 62% male, aged 15-88 years old, mean age 59.8 ± 14.4 years) were seen by the APS on 633 occasions. Of these patients 91% had been admitted to hospital for surgery (66% for tumor surgery, 8% joint replacement, 9% other joint surgery and 16% other interventions), 50% had acute postoperative pain without pre-existing pain, 50% had had pre-existing pain for at least 12 weeks, 31% had chronic non-cancer pain and 19% pain possibly related to cancer. Patients with pre-existing pain showed no significant differences in the treatment requirements (e.g. adjustment of medication), use of resources (e.g. number of visits to the APS and time spent in hospital) and quality of care (e.g. pain intensity, functional aspects, side effects and complications) in the setting of the APS. However, there was an additional subsequent support by chronic pain and palliative care services. CONCLUSION: Pre-existing pain is a common comorbidity in surgery patients treated by the APS. There were no significant differences in treatment requirements and quality of care between the patients. This is in contrast to other studies of postoperative pain management which showed that patients with pre-existing postoperative pain had higher pain intensity. This indicates indirectly that the presence of pre-existing pain should be further evaluated as a potentially useful indication for the support by an APS. However there is an urgent need for further studies to clarify whether this indirect effect can be replicated at other hospitals or in other patient collectives. Also it has to be clarified what benefits pain patients have from this kind of treatment: if they benefit from the APS in general or from the special technique, if there is a long-term effect lasting beyond treatment in the APS or if this group of patients would benefit in general from multiprofessional and non-invasive concepts of acute pain treatment.

[Age rationing : means of resource allocation in healthcare systems]. / Altersrationierung : Mittel zur Ressourcenverteilung im Gesundheitswesen.

The necessity of limiting resource in healthcare systems is becoming increasingly more evident. The population has requirements especially in the field of healthcare which are principally unlimited. However, there are only limited financial resources which can be used to satisfy the wishes of the population. For this reason rationing models are being discussed increasingly more often. One example of these models is called age rationing which means that defined services are only offered to patients up to a particular age. The aim of this article is to discuss the model of age rationing in the context of an optimized use of resources in the healthcare system.

[The Göttingen manual for OR managers]. / Göttinger Leitfaden für OP-Manager.

Economic pressures are forcing German hospitals to take measures to secure the cost effectiveness of medical care. Surgical facilities are particularly affected as a high-cost segment. As a consequence hospital operators and administrators have begun to hire surgical facility (OR) managers whose task it is to implement efficiency-oriented steps and reorganization measures aimed at increasing productivity and profitability of the surgical services. The OR manager is confronted with high expectations in a complex environment full of potential conflicts. With this in mind, the following article defines and comments on the most important aspects of OR managerial duties and responsibilities. The authors are experienced in OR management and are able to give the reader not only the theoretical fundamentals but also recommendations and guidelines which are particularly valuable to those contemplating a career as OR manager.

Assessment of diaphragmatic function with cervical magnetic stimulation in critically ill patients.

The objective of this study was to evaluate a non-volitional measurement to assess diaphragmatic function in intubated and mechanically ventilated patients in a prospective pilot interventional clinical trial. The study was conducted in an 18-bed postoperative intensive care unit based at a university hospital. Patients were prospectively assigned to two groups. Group 1 consisted of eight patients with ventilator weaning failure. Group 2 consisted of eight intubated and ventilated patients who were studied shortly after major surgery and were successfully extubated there-after The twitch pressure response after cervical magnetic stimulation of the phrenic nerves was measured at the endotracheal tube at different PEEP levels. In group 2 the twitch transdiaphragmatic pressure, defined as the difference between twitch gastric and twitch oesophageal pressure was also evaluated. In group 1 the mean twitch pressure at the endotracheal tube on PEEP 0, 5 and 10 cmH2O was 5.2, 4.5 and 2.6 cmH2O: In group 2 this was significantly higher (15.1 cmH2O on PEEP 0 and 12.2 cmH2O on PEEP 5). A good correlation was found between twitch diaphragmatic pressure and twitch pressure at the endotracheal tube (r2 = 0.96) and between twitch oesophageal pressure and twitch pressure at the endotracheal tube (r2 = 0.98). Patients with weaning failure have significantly lower twitch pressure at the endotracheal tube suggesting diaphragmatic dysfunction. Twitch pressure at the endotracheal tube may be a useful parameter to screen for diaphragmatic dysfunction in intubated critically ill patients. Further studies are needed to confirm these preliminary findings.