ABSTRACT
BACKGROUND: The number of patients depending on home mechanical ventilation (HMV) has increased substantially in Germany in recent years. These patients receive long-term care in different nursing facilities (nursing home, shared living community, private home). However, there are limited data available on the quality of care of HMV patients. The aim of the OVER-BEAS project was to identify quality indicators (QIs) of HMV care using an evidence-based approach. METHODS: A multidisciplinary board consisting of professionals and experts of HMV provision compiled a set of QIs between March and September 2019. In a structured, transparent process a set of QIs covering structures, processes and outcome of HMV patient's care were proposed and evaluated based on the best available evidence. QIs were defined as relevant, reliable and valid measurements of the quality of HMV care and furthermore to be comprehensive and applicable in practice. RESULTS: The experts proposed 40 QIs and consented a final set of 26 QIs. Based on the final set, questionnaires to document the QIs were developed: (1) to assess the quality and describe the structure of the nursing facility; and (2) to gather information on patient-related processes and outcomes. The feasibility of the questionnaires was tested in 5 nursing facilities treating HMV patients. The remarks from the nursing specialists were categorised in three groups: (1) term missing accuracy, (2) problem of understanding, and (3) not documented or documented elsewhere. Mean documentation time by the nursing specialists for one patient was 15 min. Based on this feedback, the questionnaires were finalised. CONCLUSIONS: We proposed a set of QIs relating to long-term HMV care and developed two questionnaires to collect this information. In a pilot study, we found the set of questionnaires to be feasible in assessing the quality of HMV care according to current evidence. The development of standardised evidence-based QIs to evaluate HMV care is a step towards implementing a standardised quality assurance program to document the quality of care of HMV patients.
Subject(s)
Quality Indicators, Health Care , Respiration, Artificial , Humans , Pilot Projects , Long-Term Care , Nursing HomesABSTRACT
Arterial catheterization is considered to be standard procedure for patients undergoing general anesthesia. The most common puncture site is the radial artery (RA), which carries a risk of RA occlusion. Several pieces of literature still recommend the performance of the Allen test (AT) to assess the circulation of the palmar arch. However, the result of the AT differs largely depending on the examiner and the test is not able to predict ischemic events correctly. Thus it appears that the performance of an AT is not mandatory before arterial cannulation.
Subject(s)
Catheterization, Peripheral , Radial Artery , Humans , Catheterization , Hand/blood supply , IschemiaABSTRACT
OBJECTIVE: To investigate the effect of a cognitive aid on the visual attention distribution of the operator using the Salience Effort Expectancy Value (SEEV) model. BACKGROUND: Cognitive aids aim to support an operator during the execution of a task. The effect of cognitive aids on performance is frequently evaluated but whether a cognitive aid improved, for example, attention distribution has not been considered. METHOD: We built the Expectancy Value (EV) model version which can be considered to indicate optimal attention distribution for a given event. We analyzed the eye tracking data of emergency physicians while using a cognitive aid application versus no application during a simulated in-hospital cardiac arrest scenario. RESULTS: The EV model could fit the attention distribution in such a simulated emergency situation. Partially supporting our hypothesis, the cognitive aid application group showed a significantly better EV model fit than the no application group in the first phases of the event, but a worse fit in the last phase. CONCLUSION: We demonstrated that a cognitive aid affected attention distribution and that the SEEV model provides the means of capturing these effects. We suggest that the aid supported and improved visual attention distribution in the stressful first phases of a cardiopulmonary resuscitation but may have focused attention on objects that are relevant for lower priority goals in the last phase. APPLICATION: The SEEV model can provide insights into expected and unexpected effects of cognitive aids on visual attention distribution and may help to design better artifacts.
Subject(s)
Cardiopulmonary Resuscitation , Heart Arrest , Humans , Heart Arrest/therapy , Cognition , HospitalsABSTRACT
Complexity of outpatient intensive care for ventilated people: Cross-mapping into the standardised NNN-taxonomy Abstract. Background: In Germany, free text is the preferred method for recording the nursing process in outpatient intensive care, although classification systems could enable a more precise description. Research question: How is nursing care for people with outpatient ventilation represented by the NNN-taxonomy and what are the recommendations for nursing practice? Methods: A qualitative "multiple case" design was applied. Using deductive content analysis (data sources: nursing documentation and secondary analysis of interviews with affected persons), several cases, both individually and across all cases were linked to the NNN-taxonomy (cross-mapping). Results: In total, the nursing documentation of 16 invasively ventilated persons with a mean age of 58.4 years (SD = 16.3) was analysed. Seven persons additionally contributed interview data. Documentation was mainly based on the "Strukturmodell" (14/16) with a moderate to high accuracy (D-Catch Score: 16.6; SD = 4.1). Cross-mapping resulted in 4016 codes: 618 nursing diagnoses, 1956 interventions and 1442 outcomes. Documentation was strongly measure-oriented, not very person-centred and with a lack of differentiation between diagnosis and intervention. Conclusions: To improve nursing practice, a person-centred attitude and the ability to differentiate between nursing diagnoses, interventions and outcomes should be promoted.
Subject(s)
Nursing Process , Outpatients , Humans , Middle Aged , Nursing Records , Nursing Diagnosis , Critical CareABSTRACT
BACKGROUND: People on home mechanical ventilation (HMV) belong to a heterogeneous population with complex care needs. In Germany, outpatient intensive care is provided in people's private home (PH) or in shared living communities (SLC). Increasing patient numbers have led to criticism of the quality of care in recent years. Since quality deficits from the perspective of those affected are largely unclear, the following research question emerged: How do interviews with ventilated individuals and family caregivers explain any differences or similarities in the quality of care between PH and SLC? METHODS: This study used a mixed-methods convergent parallel design, where quantitative and qualitative components were separately collected and analysed. The quantitative component (structured interviews and online survey) included ventilation characteristics, health-related resource use, health-related quality of life (HRQL) measured with the Severe Respiratory Insufficiency Questionnaire (SRI; range 0-100; higher scores indicated higher HRQL) and the Burden Scale of the Family Caregivers short version (BSFC-s; range 0-30; higher scores indicated higher burden). The qualitative component (semi-structured interviews) focused on people's experience of person-centred care. Data were merged using a weaving method and the Picker framework of Person-Centred Care. RESULTS: The quantitative component revealed that ventilated individuals living in PHs were on average 20 years younger than participants living in SLCs (n = 46; PH: 46.86 ±15.40 years vs. SLC: 65.07 ±11.78 years; p = .001). HRQL (n = 27; PH: 56.62 ±16.40 vs. SLC: 55.35 ±12.72; p > .999) and the burden of family caregivers (n = 16; PH: 13.20 ±10.18 vs. SLC: 12.64 ±8.55; p > .999) were not significantly different between living situation. The qualitative component revealed that person-centred care is possible in both care settings (ventilated individuals: n = 13; family caregivers: n = 18). CONCLUSION: This study describes a care situation that is as heterogeneous as the population of people with HMV. HRQL and the burden of family caregivers are highly individual and, like person-centred care, independent of the living situation. Policy decisions that facilitate person-centred care need to recognise that quality of care is highly individual and starts with the free choice of the care setting.
ABSTRACT
Postpartum hemorrhage (PPH) nowadays still represents a severe complication of both a vaginal delivery and a cesarean section. In German-speaking areas a new definition of the term has recently become established and the nomenclature with respect to the severe form of PPH was dropped. The handling of misoprostol as a uterotonic during treatment of PPH is also new, which is available in Germany only as a medical direct import. For adequate diagnostics and targeted treatment interdisciplinary and standardized algorithms should be established and the specialist disciplines involved should be sensitized to this problem. In addition to an adequate hemostasis, a developing coagulopathy must be recognized at an early stage and treated with targeted coagulation management. Through implementation concepts, particularly the second pillar (minimization of blood loss) and the third pillar (rational use of blood transfusions) of patient blood management, various aspects for improvement of treatment of a PPH can be identified.
Subject(s)
Misoprostol , Oxytocics , Postpartum Hemorrhage , Blood Transfusion , Cesarean Section , Female , Humans , Postpartum Hemorrhage/therapy , PregnancyABSTRACT
The implementation of patient blood management (PBM) is increasingly becoming standard in operative medicine. Recently, interest has also been shown for the vulnerable collective of pregnant women and neonates. As the information regarding anesthesiological procedures for pregnant women and the peripartum period including an informed consent process should be carried out long before childbirth, this provides a good possibility in this connection to incorporate PBM. An anesthesiological risk estimation as well as the diagnostic workup and treatment of potential anemia should be carried out during the pregnancy. Furthermore, loss of blood in anticipation of bleeding complications should be reduced by interdisciplinary preventive measures and an individually coordinated postpartum care should be organized. This results in an early diagnosis of anemia or iron deficiency with subsequent treatment also postpartum, analogous to the prepartum period.
Subject(s)
Anemia , Iron Deficiencies , Obstetrics , Anemia/therapy , Blood Transfusion , Female , Humans , Infant, Newborn , Postpartum Period , PregnancyABSTRACT
Hospitals play a crucial role in the management of large-scale emergencies or disasters. This has been clearly demonstrated by the recent terrorist attacks in Europe, by the SARS-CoV-2 pandemic, and currently by the Ukraine war. In order to cope with extraordinary situations and large-scale emergencies, such as mass casualty incidents, hospitals need to be prepared in detail - by preparing and implementing a hospital contingency plan. The article presented here describes in hospital preparation for a mass casualty incident.
Subject(s)
COVID-19 , Disaster Planning , Mass Casualty Incidents , Terrorism , Emergencies , Humans , SARS-CoV-2ABSTRACT
Objectives: In July 2021, the Medical Task Force 47 was deployed to the flood disaster in western Germany as part of the cross-regional disaster relief system. With the aim of deriving possible improvements in disaster management, it was scientifically evaluated. The focus of this study was the strategy to build up and to maintain a responsive and efficient rescue system. Materials and methods: After defining an evaluation process, an interdisciplinary panel of experts reviewed operational documents and relevant concepts of the Bavarian Red Cross. Based on these, strategies and tactics were developed to achieve predefined goals. Results: The performance of the emergency units could be increased by modern vehicles and equipment (eBikes, drones, all-terrain vehicles). To improve the response capability, new rapid response groups could be required that can take over the function of an advance command and can process mission assignments in impassable terrain autonomously. These could be integrated and synchronized into regional and cross-regional disaster relief. Conclusion: In future, it could be difficult for Germany's largely volunteer-organised disaster management to safely deploy the multitude of possible state-of-the-art resources in the highly complex environment of a disaster. Partial professionalization by full-time command and control staff could be one solution for this problem.
ABSTRACT
BACKGROUND: The rapid increase in the use of home mechanical ventilation (HMV) for people with chronic respiratory failure poses extreme challenges for the healthcare system. People on HMV have complex care needs and require support from an interprofessional team. In Germany, HMV is criticised for inadequate quality standards, particularly in outpatient intensive care practice. The objective of this study was to describe the quality of care for people on outpatient HMV in Germany, Bavaria and provide recommendations for improvement from the perspective of healthcare professionals (HCPs). METHODS: Semi-structured qualitative telephone interviews with HCPs (i.e., nurses, equipment providers, therapists, and physicians) were analysed using the framework method. The quality framework of Health Improvement Scotland (HIS), which aims to improve the quality of person-centred care, was used to build a deductive analysis matrix. The framework includes the three key areas: (1) Outcomes and impact, (2) Service delivery, and (3) Vision and leadership. The domains (meta-codes) and quality indicators (sub-codes) of the quality framework were used for deductive coding. RESULTS: Overall, 87 HCPs (51 female, mean age of 44.3 years, mean professional experience in HMV of 9.4 years) were interviewed (mean duration of 31 min). There was a complex interaction between the existing health care system (Outcomes and impact, 955 meaning units), the delivery of outpatient intensive care (Service delivery, 939 meaning units), and improvement-focused leadership (Vision and leadership, 70 meaning units) that influenced the quality of care for people on HMV. The main barriers were an acceleration in transition management, a neglect of weaning potential, a shortage of qualified professionals and missing quality criteria. The central recommendations for promoting person-centred care were training and supervision of staff and an inspiring leadership. An integrated care structure supporting medical home visits and outpatient rehabilitation should be developed. CONCLUSION: This study describes a heterogeneous and partly deficient care situation for people on HMV, but demonstrates that high quality care is possible if person-centred care is successfully implemented in all areas of service provision. The recommendations of this study could inform the development of a person-centred integrated care structure for people on HMV.
Subject(s)
Health Personnel , Respiration, Artificial , Adult , Delivery of Health Care , Female , Humans , Qualitative Research , Quality of Health CareABSTRACT
BACKGROUND: Intensive care and ventilator capacities are essential for treatment of COVID-19 patients. Severely injured patients are often in continuous need of intensive care and ventilator treatment. The question arises, whether restrictions related to COVID-19 have led to a decrease in severely injured patients and thus to an increase in intensive care unit (ICU) capacity. MATERIAL AND METHODS: A retrospective analysis of all seriously injured patients with an injury severity score (ISS) ≥16 was performed between 17 March and 30 April 2020 at a level 1 trauma center in Germany. The mechanism of injury and the ISS were recorded. Further data were collected as to whether it was a work-related accident, a documented suicide attempt and if surgery was necessary in the first 24â¯h after arrival in hospital. Data from 2018 and 2019 served as a control group. RESULTS: There was no substantial difference in the total number of seriously injured patients (2018 nâ¯= 30, 2019 nâ¯= 23, 2020 nâ¯= 27). Furthermore, there was no relevant difference in the number of patients needing intensive care or ventilator treatment when leaving the shock room. The number of patients needing an operative intervention within the first 24â¯h after arriving at hospital was slightly higher in 2020. The mean ISS was at a constant level during all 3 years. In 2020 there was no polytraumatized motorbike rider, who did not have a work-related accident (2018 nâ¯= 5, 2019 nâ¯= 4, 2020 nâ¯= 0). A noticeable increase in work-related accidents was observed (2018: 10%, 2019: 26.1%, 2020 44.4%). DISCUSSION: Restrictions related to COVID-19 did not lead to a reduction in seriously injured patients needing ICU care. Due to the monocentric data analysis there is room for misinterpretation. In general, intensive care and operating capacities should be managed with adequate consideration for seriously injured patients even in times of crisis, such as the COVID-19 pandemic. Confirmation through the German Trauma Register is pending.
Subject(s)
COVID-19 , Wounds and Injuries , Germany , Humans , Injury Severity Score , Pandemics , Retrospective Studies , SARS-CoV-2 , Trauma Centers , Wounds and Injuries/epidemiology , Wounds and Injuries/therapyABSTRACT
Disaster medicine faces complex challenges and will play an increasing role in the future. Disaster medicine is dominated by a phased imbalance of available and required resources. Various factors, such as a possible hazard for the rescue forces, inaccessible terrain or even destroyed infrastructure increase the complexity enormously. For casualties, this can mean a concentration of medical care on life-threatening conditions. The primary goal of emergency planning is to ensure standard or contingency care and to avoid crisis care.Hospitals and the preclinical emergency organizations must prepare for possible major emergencies or disasters. Easy-to-understand and just as easy to apply emergency plans are an important prerequisite for successful emergency management. These plans can only be guiding structures; the adaptation to the actual circumstances of the incident and the situation-adapted interpretation of the plans is the responsibility of the operational commanders. A clear leadership structure is essential for both preclinical and clinical operations. In this article, we describe important basic principles of disaster medicine mission planning and management.
Subject(s)
Disaster Medicine , Disaster Planning , Disasters , Emergency Service, Hospital , HospitalsABSTRACT
On March 14, 2020, the first Bavaria-wide exit restriction was imposed and university teaching in its familiar form was drastically restricted. For intensive care physicians and anesthetists, there was a special area of tension in many places due to the extraordinary demand for the treatment of critically ill patients and the restructuring and maintenance of teaching. We report on the realignment of the anesthesia seminar in an online flipped classroom and the development towards a hybrid model. As such, an adequate transfer of knowledge could take place under difficult conditions and at the same time the teaching concept could be further developed.
Subject(s)
Anesthesia , Anesthesiology , COVID-19 , Physicians , Anesthesiology/education , Humans , SARS-CoV-2 , TeachingABSTRACT
Mass critical care caused by the severe acute respiratory syndrome corona virus 2 pandemic poses an extreme challenge to hospitals. The primary goal of hospital disaster preparedness and response is to maintain conventional or contingency care for as long as possible. Crisis care must be delayed as long as possible by appropriate measures. Increasing the intensive care unit (ICU) capacities is essential. In order to adjust surge capacity, the reduction of planned, elective patient care is an adequate response. However, this involves numerous problems that must be solved with a sense of proportion. This paper summarises preparedness and response measures recommended to acute care hospitals.
Subject(s)
Coronavirus Infections/therapy , Critical Care/organization & administration , Disaster Planning/organization & administration , Hospitals , Mass Casualty Incidents , Pandemics , Pneumonia, Viral/therapy , COVID-19 , Coronavirus Infections/epidemiology , Health Services Research , Humans , Pneumonia, Viral/epidemiologyABSTRACT
BACKGROUND: Outpatient intensive care for people with long-term mechanical ventilation is a rapidly growing area with a wide range of care demands. The aim of this Scoping Review is to present the current state of research on the quality of care for people with home mechanical ventilation in Germany and to identify research gaps. METHODS: Based on predefined inclusion criteria, 4 databases were searched for publications dealing with the care of people with home ventilation in Germany. The method of "data driven thematic analysis" led the data extraction and analysis. Distinction was made between research and expert opinion. RESULTS: The search resulted in 493 matches of which 68 publications were included in the this study: two guidelines (3%), 45 (66%) research papers and 21 (31%) expert opinions. The following topics were identified: Organization and control of ventilation (n=43; 63%), nursing (n=23; 34%), medical (n=39; 57%), therapeutic (n=7; 10%) and assistive technologies care (n=24; 35%), as well as the perspective of people with home mechanical ventilation and their relatives (n=33; 49%) and other topics (n=13; 19%). CONCLUSION: Although the debate on the quality of care for people living with home mechanical ventilation is conducted broadly, studies focusing on individual care demands, autonomy and participation depending on the living situation or on the role of specific health professionals within the interprofessional team are missing.
Subject(s)
Critical Care , Quality of Health Care , Respiration, Artificial , Germany , Health Personnel , HumansABSTRACT
BACKGROUND: Due to the increasing threat by terrorism and the resulting range of operations for the emergency medical service, the equipment as well as the rescue strategies are being adapted and expanded. An example is the "Recommended Action for Emergency Medical Services in Special Operations" (REBEL, Handlungsempfehlung für Rettungsdienst bei besonderen Einsatzlagen) of the highest Bavarian rescue service authority. In the following article, three cases are presented using new tools such as hemostyptics, thoracic patches and tourniquet from the REBEL kit in everyday operations. CASES: The first case deals with a seriously injured driver involved in a truck accident suffering from a scalping violation of the facial skeleton with consecutive critical bleeding (use of hemostyptics-coated dressings). The second case describes an accident with a reinforcing steel perforating a builder's chest. After removal of the perforating steel by first aiders, the two open thoracic wounds are supplied with thoracic closure patches. The third case deals with an amputation injury of the lower leg after a traffic accident (use of tourniquet). DISCUSSION: The most common causes of death besides bleeding that can be prevented in patients with severe injuries and multiple trauma are tension pneumothorax and airway obstruction. These diagnoses can be identified and treated properly using the
Subject(s)
Emergency Treatment , Multiple Trauma/therapy , Terrorism , Accidents, Traffic , Adult , Bandages , Glasgow Coma Scale , Hemostatics/therapeutic use , Humans , Male , Middle Aged , Shock, Hemorrhagic/therapy , Thoracic Injuries/therapy , TourniquetsABSTRACT
While controlled ventilation is most frequently used during cardiopulmonary resuscitation (CPR), the application of continuous positive airway pressure (CPAP) and passive ventilation of the lung synchronously with chest compressions and decompressions might represent a promising alternative approach. One benefit of CPAP during CPR is the reduction of peak airway pressures and therefore a potential enhancement in haemodynamics. We therefore evaluated the tidal volumes and airway pressures achieved during CPAP-CPR. During CPR with the LUCAS™ 2 compression device, a manikin model was passively ventilated at CPAP levels of 5, 10, 20 and 30 hPa with the Boussignac tracheal tube and the ventilators Evita® V500, Medumat® Transport, Oxylator® EMX, Oxylog® 2000, Oxylog® 3000, Primus® and Servo®-i as well as the Wenoll® diver rescue system. Tidal volumes and airway pressures during CPAP-CPR were recorded and analyzed. Tidal volumes during CPAP-CPR were higher than during compression-only CPR without positive airway pressure. The passively generated tidal volumes increased with increasing CPAP levels and were significantly influenced by the ventilators used. During ventilation at 20 hPa CPAP via a tracheal tube, the mean tidal volumes ranged from 125 ml (Medumat®) to 309 ml (Wenoll®) and the peak airway pressures from 23 hPa (Primus®) to 49 hPa (Oxylog® 3000). Transport ventilators generated lower tidal volumes than intensive care ventilators or closed-circuit systems. Peak airway pressures during CPAP-CPR were lower than those during controlled ventilation CPR reported in literature. High peak airway pressures are known to limit the applicability of ventilation via facemask or via supraglottic airway devices and may adversely affect haemodynamics. Hence, the application of ventilators generating high tidal volumes with low peak airway pressures appears desirable during CPAP-CPR. The limited CPAP-CPR capabilities of transport ventilators in our study might be prerequisite for future developments of transport ventilators.
Subject(s)
Cardiopulmonary Resuscitation/methods , Continuous Positive Airway Pressure , Heart Arrest , Cardiopulmonary Resuscitation/instrumentation , Cross-Over Studies , Hemodynamics , Humans , Manikins , Pressure , Tidal Volume , Ventilators, MechanicalABSTRACT
Terrorist attacks or amok runs may cause "threatening situations" for emergency medical services (EMS), fire fighters and physicians. Cooperation with the police is of paramount importance. In order to minimize the risk to rescue personnel and affected persons, emergency medical care has to follow tactical principles. So, the strategy in such "threatening situations" is "Stop the bleeding and clear the scene". The police define three areas of danger: unsafe, partly safe and secure. Medical care in these areas follows the concept of Tactical Combat Casualty Care. While only police should act in the unsafe area, the EMS can operate in the partly safe area after appropriate arrangements. Safety may only be achieved in emergency departments, which have to be made to secure areas by certain measures.The task force "Tactical Medicine" of the Scientific Working Group Emergency Medicine of the German Association for Anesthesiology and Intensive Care describes in this article essential criteria for a coordinated approach in "threatening situations".
Subject(s)
Disaster Medicine/trends , Disasters , Mass Casualty Incidents , Disaster Planning , Germany , Humans , Military MedicineABSTRACT
Hospitals need to be prepared for any kind of disaster. The terrorist attacks and mass shootings that took place in Europe in recent years impressively demonstrated the capability of hospitals to manage such challenging and disastrous events. To be adequately prepared, the hospital emergency plan is a very important tool. In this article we describe the entire process of drafting the emergency plan. We discuss the theoretical background as well as different models of disaster planning and we give important practical hints and tips for those in charge of the hospital disaster planning.
Subject(s)
Civil Defense , Clinical Alarms , Hospitals , Disaster Planning , Disasters , Hospital Planning , Humans , TerrorismABSTRACT
The train crash of Bad Aibling/Germany in February 2016 and the terrorist attacks of the recent years in Europe have demonstrated the urgent need to be prepared for such disastrous events. Disaster preparedness and disaster control are very important governmental duties, as are civil protection and civil defense. In Germany the responsibility for those tasks are divided between the 16 "Länder" and the Federation. While the Federation takes care of the civil protection and disaster assistance, the Länder are responsible for disaster control. The presented article focuses on these issues and gives valuable insights into the German system of disaster control and civil protection with a focus on health protection.