[Position paper on working in the intensive care unit during pregnancy : DIVI recommendations for improving the situation of pregnant employees in the ICU]. / Positionspapier zum Arbeiten in der Schwangerschaft auf der Intensivstation : DIVI-Empfehlungen zur Verbesserung der Lage von schwangeren Mitarbeiterinnen auf einer Intensivstation.

The Maternity Protection Act is intended to protect the mother and the child from hazards, excessive demands and damage to health in the workplace, and from financial disadvantages and loss of employment. However, the objectives defined by the Maternity Protection Act-the safety and health of the pregnant employee on the one hand and the prevention of disadvantages in working life on the other-are not yet adequately achieved in the intensive care unit (ICU). Implementation of the Maternity Protection Act to the benefit of all involved parties should also be promoted in the specialist areas represented by the DIVI, in particular the work of pregnant physicians and nursing staff and other working specialists (respiratory therapists, physiotherapists, speech therapists, psychotherapists, and social workers) in the ICU. The aim of this paper is to raise awareness of the need to consider each pregnant and breastfeeding staff member individually and to work together to find a personal solution for continuing to work in the ICU. Possible ways and solutions to achieve this goal are outlined and practical examples are given for implementation in everyday clinical routine. These are also based on comprehensive presentation of activities according to a traffic light color-code system for all occupational groups. Arguments against pregnant employees working in the ICU are discussed and possible solutions are presented.

[Position paper on working in the intensive care unit during pregnancy : DIVI recommendations for improving the situation of pregnant employees in the ICU]. / Positionspapier zum Arbeiten in der Schwangerschaft auf der Intensivstation : DIVI-Empfehlungen zur Verbesserung der Lage von schwangeren Mitarbeiterinnen auf einer Intensivstation.

The Maternity Protection Act is intended to protect the mother and the child from hazards, excessive demands and damage to health in the workplace, and from financial disadvantages and loss of employment. However, the objectives defined by the Maternity Protection Act-the safety and health of the pregnant employee on the one hand and the prevention of disadvantages in working life on the other-are not yet adequately achieved in the intensive care unit (ICU). Implementation of the Maternity Protection Act to the benefit of all involved parties should also be promoted in the specialist areas represented by the DIVI, in particular the work of pregnant physicians and nursing staff and other working specialists (respiratory therapists, physiotherapists, speech therapists, psychotherapists, and social workers) in the ICU. The aim of this paper is to raise awareness of the need to consider each pregnant and breastfeeding staff member individually and to work together to find a personal solution for continuing to work in the ICU. Possible ways and solutions to achieve this goal are outlined and practical examples are given for implementation in everyday clinical routine. These are also based on comprehensive presentation of activities according to a traffic light color-code system for all occupational groups. Arguments against pregnant employees working in the ICU are discussed and possible solutions are presented.

[Recommendations for Education in Sonography in Prehospital Emergency Medicine (pPOCUS): Consensus paper of DGINA, DGAI, BAND, BV-ÄLRD, DGU, DIVI and DGIIN]. / Empfehlungen zur Sonografieausbildung in der prähospitalen Notfallmedizin (pPOCUS): Konsensuspapier von DGINA, DGAI, BAND, BV-ÄLRD, DGU, DIVI und DGIIN.

Point-of-care sonography is a precondition in acute and emergency medicine for the diagnosis and initiation of therapy for critically ill and injured patients. While emergency sonography is a mandatory part of the training for clinical acute and emergency medicine, it is not everywhere required for prehospital emergency medicine. Although some medical societies in Germany have already established their own learning concepts for emergency ultrasound, a uniform national training concept for the use of emergency sonography in the out-of-hospital setting is still lacking. Experts of several professional medical societies have therefore joined forces and developed a structured training concept for emergency sonography in the prehospital setting. The consensus paper serves as quality assurance in prehospital emergency sonography.

[Recommendations for Education in Sonography in Prehospital Emergency Medicine (pPOCUS): Consensus paper of DGINA, DGAI, BAND, BV-ÄLRD, DGU, DIVI and DGIIN]. / Empfehlungen zur Sonografieausbildung in der prähospitalen Notfallmedizin (pPOCUS): Konsensuspapier von DGINA, DGAI, BAND, BV-ÄLRD, DGU, DIVI und DGIIN.

Point-of-care sonography is a precondition in acute and emergency medicine for the diagnosis and initiation of therapy for critically ill and injured patients. While emergency sonography is a mandatory part of the training for clinical acute and emergency medicine, it is not everywhere required for prehospital emergency medicine. Although some medical societies in Germany have already established their own learning concepts for emergency ultrasound, a uniform national training concept for the use of emergency sonography in the out-of-hospital setting is still lacking. Experts of several professional medical societies have therefore joined forces and developed a structured training concept for emergency sonography in the prehospital setting. The consensus paper serves as quality assurance in prehospital emergency sonography.

Recommendations on the structure, personal, and organization of intensive care units.

Background: Intensive care units (ICU) are central facilities of medical care in hospitals world-wide and pose a significant financial burden on the health care system. Objectives: To provide guidance and recommendations for the requirements of (infra)structure, personal, and organization of intensive care units. Design and setting: Development of recommendations based on a systematic literature search and a formal consensus process from a group of multidisciplinary and multiprofessional specialists from the German Interdisciplinary Association of Intensive Care and Emergency Medicine (DIVI). The grading of the recommendation follows the report from an American College of Chest Physicians Task Force. Results: The recommendations cover the fields of a 3-staged level of intensive care units, a 3-staged level of care with respect to severity of illness, qualitative and quantitative requirements of physicians and nurses as well as staffing with physiotherapists, pharmacists, psychologists, palliative medicine and other specialists, all adapted to the 3 levels of ICUs. Furthermore, proposals concerning the equipment and the construction of ICUs are supplied. Conclusion: This document provides a detailed framework for organizing and planning the operation and construction/renovation of ICUs.

[DIVI-Recommendations on the infrastruture of adult intensive care units]. / DIVI-Empfehlung zur Struktur und Ausstattung von Intensivstationen 2022 (Erwachsene).

This document on the Structure and Equipment for Intensive Care Units of the German Association for Intensive and Emergency Care (DIVI) aims at providing guidance and recommendations for the requirements of (infra)structure, personal, and organization of intensive care units. The recommendations are based on a systematic literature search and a formal consensus process from a group of multi-disciplinary and multiprofessional specialists from the DIVI. The recommendations comprise a 3-staged level of intensive care units, a 3-staged level of care with respect to severity of illness, the staffing requirement of physicians, nurses, physiotherapists, pharmacists, psychologists, and other specialists. Furthermore, proposals concerning the equipment and the construction of ICUs are supplied.

[Conservative management of distal radius fractures]. / Konservative Behandlung der distalen Radiusfraktur.

Distal radius fractures are the third most frequent fractures in Germany. The decision for conservative treatment and the weighing up of surgical treatment need an exact consideration of the indications based on instability criteria and the extent of possible articular involvement. Indications for an emergency operation must be excluded. In cases of stable fractures or multimorbid patients in a poor general condition conservative treatment is indicated. The principles for a successful treatment are the precise reduction and stable retention in a plaster splint. In the further course, fractures are closely monitored by biplanar radiography. This is necessary to rule out a secondary displacement until the swelling of the soft tissues has subsided and the plaster splint is changed to a circular cast approximately 11 days after the traumatic event. The total duration of immobilization is 4 weeks. Physiotherapy and ergotherapy including adjacent joints, starts after 2 weeks of treatment. This treatment is extended to the wrist after removal of the circular cast.

[Innovative facultative seminar concepts regarding clinical teaching and preparing practice-oriented phases, such as medical clerkships and the final clinical internship from a surgical perspective]. / Innovative fakultative Seminarkonzepte besonders klinisch-praktisch ausgerichteter Lehre zur Famulatur- und PJ-Vorbereitung aus spezifisch chirurgischer Sicht.

BACKGROUND: Practice-oriented phases, such as the mandatory clinical traineeships and the final clinical internship, are of great importance in the teaching curriculum and skilful learning of medical students. AIM: With respect to the practical phases, such as clinical clerkship and medical internship, the concept of two innovative courses to prepare and evaluate these crucial training sections is presented including initial experiences from teaching practice. METHOD: A narrative review is given. RESULTS: A common aim of facultatively initiated lectures is a better qualification of medical students to fulfil the requirements of clerkship and the last practical year of the study of human medicine to facilitate taking first steps towards professional work as a clinical physician, in particular, the self-confidence of the medical students is to be substantially increased. The experiences obtained during clerkship and the last practical year influence interest, motivation and final choice for a certain medical speciality. In that respect, this period is of great importance for the whole professional career. The content of the preparation courses for the first medical clerkships and the final clinical internship provide a valuable contribution to prepare for challenging clinical work as a physician with sole responsibility. In particular, they aim to introduce students to the concept of a multiprofessional and extensive patient care. Taking into account the different practical experiences obtained in previous study sections, students are taught according to the overall aim to achieve an interdisciplinary competence in clinical care. CONCLUSION: The improvement of teaching and optimized preparation for practical phases in medical studies promotes a more successful learning process during the clerkship and last practical year.

Medical and cardio-vascular emergency department visits during the COVID-19 pandemic in 2020: is there a collateral damage? A retrospective routine data analysis.

BACKGROUND: In this retrospective routine data analysis, we investigate the number of emergency department (ED) consultations during the COVID-19 pandemic of 2020 in Germany compared to the previous year with a special focus on numbers of myocardial infarction and acute heart failure. METHODS: Aggregated case numbers for the two consecutive years 2019 and 2020 were obtained from 24 university hospitals and 9 non-university hospitals in Germany and assessed by age, gender, triage scores, disposition, care level and by ICD-10 codes including the tracer diagnoses myocardial infarction (I21) and heart failure (I50). RESULTS: A total of 2,216,627 ED consultations were analyzed, of which 1,178,470 occurred in 2019 and 1,038,157 in 2020. The median deviation in case numbers between 2019 and 2020 was - 14% [CI (- 11)-(- 16)]. After a marked drop in all cases in the first COVID-19 wave in spring 2020, case numbers normalized during the summer. Thereafter starting in calendar week 39 case numbers constantly declined until the end of the year 2020. The decline in case numbers predominantly concerned younger [- 16%; CI (- 13)-(- 19)], less urgent [- 18%; CI (- 12)-(- 22)] and non-admitted cases [- 17%; CI (- 13)-(- 20)] in particular during the second wave. During the entire observation period admissions for chest pain [- 13%; CI (- 21)-2], myocardial infarction [- 2%; CI (- 9)-11] and heart failure [- 2%; CI (- 10)-6] were less affected and remained comparable to the previous year. CONCLUSIONS: ED visits were noticeably reduced during both SARS-CoV-2 pandemic waves in Germany but cardiovascular diagnoses were less affected and no refractory increase was noted. However, long-term effects cannot be ruled out and need to be analysed in future studies.

Lessons learned during the sliding gantry CT implementation in a trauma suite.

PURPOSE: Early detection of bleeding is important for managing trauma cases in the emergency department (ED). Several trauma suites are equipped with computed tomography (CT) scanners to reduce the time to CT. In the last decade, sliding gantry CT has been implemented in trauma suites, highlighting conventional techniques' advantages. We investigated the change in the time to CT and the challenges faced during the implementation. METHODS: Trauma suite treatments with a conventional CT scanner between January and December 2016 formed the control group. From January to April 2017, trauma suites were modified, and treatment was outsourced to an interim trauma suite. By May 2017, trauma suites were equipped with a sliding gantry CT scanner. Treatments from May to July 2017 formed the transition group, and those from August to December 2017 formed the routine use group. We evaluated the time to CT in all groups and considered the reasons for the delays in the transition and routine use groups. RESULTS: On sliding gantry CT implementation, although time to CT remained unaffected in the transition group, it significantly reduced in the routine use group, independent of injury severity score. The incidence of cable management problems was significantly higher in the latter group. CONCLUSIONS: We have demonstrated a decrease in the time to CT with the implementation of a sliding gantry CT. However, due to a higher number of cable management problems in the routine use group, we recommend regular refresher team training with routine use.

Using Explainable Artificial Intelligence Models (ML) to Predict Suspected Diagnoses as Clinical Decision Support.

The complexity of emergency cases and the number of emergency patients have increased dramatically. Due to a reduced or even missing specialist medical staff in the emergency departments (EDs), medical knowledge is often used without professional supervision for the diagnosis. The result is a failure in diagnosis and treatment, even death in the worst case. Secondary: high expenditure of time and high costs. Using accurate patient data from the German national registry of the medical emergency departments (AKTIN-registry, Home - Notaufnahmeregister (aktin.org)), the most 20 frequent diagnoses were selected for creating explainable artificial intelligence (XAI) models as part of the ENSURE project (ENSURE (umg.eu)). 137.152 samples and 51 features (vital signs and symptoms) were analyzed. The XAI models achieved a mean area under the curve (AUC) one-vs-rest of 0.98 for logistic regression (LR) and 0.99 for the random forest (RF), and predictive accuracies of 0.927 (LR) and 0.99 (RF). Based on its grade of explainability and performance, the best model will be incorporated into a portable CDSS to improve diagnoses and outcomes of ED treatment and reduce cost. The CDSS will be tested in a clinical pilot study at EDs of selected hospitals in Germany.

Length of stay as quality indicator in emergency departments: analysis of determinants in the German Emergency Department Data Registry (AKTIN registry).

Several indicators reflect the quality of care within emergency departments (ED). The length of stay (LOS) of emergency patients represents one of the most important performance measures. Determinants of LOS have not yet been evaluated in large cohorts in Germany. This study analyzed the fixed and influenceable determinants of LOS by evaluating data from the German Emergency Department Data Registry (AKTIN registry). We performed a retrospective evaluation of all adult (age ≥ 18 years) ED patients enrolled in the AKTIN registry for the year 2019. Primary outcome was LOS for the whole cohort; secondary outcomes included LOS stratified by (1) patient-related, (2) organizational-related and (3) structure-related factors. Overall, 304,606 patients from 12 EDs were included. Average LOS for all patients was 3 h 28 min (95% CI 3 h 27 min-3 h 29 min). Regardless of other variables, patients admitted to hospital stayed 64 min longer than non-admitted patients. LOS increased with patients' age, was shorter for walk-in patients compared to medical referral, and longer for non-trauma presenting complaints. Relevant differences were also found for acuity level, day of the week, and emergency care levels. We identified different factors influencing the duration of LOS in the ED. Total LOS was dependent on patient-related factors (age), disease-related factors (presentation complaint and triage level), and organizational factors (weekday and admitted/non-admitted status). These findings are important for the development of management strategies to optimize patient flow through the ED and thus to prevent overcrowding.

German emergency department measures in 2018: a status quo based on the Utstein reporting standard.

BACKGROUND: Compelling data on clinical emergency medicine is required for healthcare system management. The aim of this survey was to describe the nationwide status quo of emergency care in Germany at the healthcare system level using the Utstein reporting template as the guideline to measure the data collected. METHODS: This cross-sectional survey collected standardized data from German EDs in 2018. All 759 of the EDs listed in a previously collected ED Directory were contacted in November 2019 using the online-survey tool SoSci Survey. Exclusively descriptive statistical analyses were performed. Absolute as well as relative frequencies, medians, means, ranges, standard deviations (SD) and interquartile ranges (IQR) were reported depending on distribution. MAIN RESULTS: A total of 150 questionnaires of contacted EDs were evaluated (response rate: 19.8%). Hospitals had a median of 403 inpatient beds (n=147). The EDs recorded a median of 30,000 patient contacts (n=136). Eighty-three EDs (55%) had observation units with a median of six beds. The special patient groups were pediatric patients (< 5 years) and older patients (> 75 years) with a median of 1.7% and 25%, respectively. Outpatients accounted for 55%, while 45% were admitted (intensive care unit 5.0%, standard care unit 32.3%, observation unit 6.3%) and 1.2% transferred to another hospital. CONCLUSIONS: The use of the Utstein reporting template enabled the collection of ED descriptive parameters in Germany. The data can provide a baseline for upcoming reforms on German emergency medicine, and for international comparisons on admission rates, initial triage categories, and patient populations.

The impact of a qualified medical documentation assistant on trauma room management.

PURPOSE: To improve quality of trauma room management, intra- and inter-hospital benchmarking are important tools. However, primary data quality is crucial for benchmarking reliability. In this study, we analyzed the effect of a medical documentation assistant on documentation completeness in trauma room management in comparison to documentation by physicians involved in direct patient treatment. METHODS: We included all patients treated in the trauma room from 2016/01/01 to 2016/12/31 that were documented with the trauma module of the German Emergency Department Medical Record V2015.1. We divided the data into documentation by medical documentation assistant (DA, 07:00 to 17:00), physician in daytime (PD, 07:00 to 17:00), and physician at night (PN, 17:00 to 07:00). Data were analyzed for completeness (primary outcome parameter) as well as diagnostic intervals. RESULTS: There was a significant increase in complete recorded data for DA (74.5%; IQR 14.5%) compared to PD (26.9%; IQR 18.7%; p < 0.001) and PN (30.8%; IQR 18.9; p < 0.001). The time to whole-body computed tomography (WBCT) significantly decreased for DA (19 min; IQR 8.3) compared to PD (24 min; IQR 12.8; p = 0.007) or PN (24.5 min; IQR 10.0; p = 0.001). CONCLUSION: In presence of a qualified medical documentation assistant, data completeness and time to WBCT improved significantly. Therefore, utilizing a professional DA in the trauma room appears beneficial for data quality and time management.

Prehospital FAST reduces time to admission and operative treatment: a prospective, randomized, multicenter trial.

BACKGROUND: The focused assessment with sonography in trauma (FAST) exam is an established trauma care diagnostic procedure. Ultrasound performed during prehospital care can improve early treatment and management of the patients. In this prospective randomized clinical trial, we wanted to assess whether a pre-hospital FAST (p-FAST) influences pre-hospital strategy and the time to operative treatment. METHODS: We studied 296 trauma victims in a prehospital setting. Inclusion criteria were potential abdominal injuries identified either by clinical examination or suggested by the mechanism of injury. Physician-staffed helicopters and emergency ambulances were equipped with portable ultrasound devices. According to a scheme related to calendar weeks, a clinical exam only (CEX) or a clinical exam together with a p-FAST (CEX-p-FAST) was conducted. Outcome variables were prehospital diagnosis and strategy, the time to admission to the trauma room and to operation theater. The study was approved by the university ethical committee (REB#: 46/06). RESULTS: CEX-p-FAST showed a high sensitivity (94.7%) and specificity (97.6%) in detection of free fluid compared to CEX-only (80.0%, 84.4%). The median time to admission was reduced significantly by 13 min and to operative treatment by 15 min after CEX-p-FAST. We observed a cross-over rate of 30.8% of p-FAST (n = 36) to CEX-p-FAST during the CEX-only weeks. CONCLUSION: According to the experience of the principal investigators, CEX-p-FAST was superior to CEX-only. Despite the time needed for p-FAST, the relevant admission time was significantly shorter. Thus, p-FAST is recommended in addition to CEX if possible for decision-making in prehospital trauma care. TRIAL REGISTRATION: German Clinical Trials Register #DRKS00022117-Registered 10 July 2020-Retrospectively registered, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022117 .

Effect of 4DryField® PH on blood loss in hip bipolar hemiarthroplasty following intracapsular femoral neck fracture - a randomized clinical trial.

BACKGROUND: One of the most common complications of hip arthroplasty is excessive blood loss that could necessitate allogenic blood transfusion, which is further associated with other complications, such as infections, transfusion reactions or immunomodulation. In gynecology, 4DryField®PH, an absorbable polysaccharide-based formulation, is used for hemostasis and adhesion prophylaxis. In this study, we evaluated its hemostatic effect in patients undergoing hip bipolar hemiarthroplasty following intracapsular femoral neck fracture. METHODS: We studied 40 patients with intracapsular femoral neck fractures (Garden III or IV) admitted at our institution between July 2016 and November 2017. We included patients above 60 years with simple fracture and without pathologic fractures. Patients were randomized into intervention and control groups. The intervention group received 5 g of 4DryField® PH (subfascially and subcutaneously) during wound closure. Three drainages were inserted in a standardized manner (submuscular, subfascial, and subcutaneous) and drainage volume was measured immediately before extraction. Total blood loss was calculated using Mercuriali's formula and standard hemograms upon admission and five days after surgery. Volume of postoperative hematoma was measured using point-of-care ultrasound seven days after surgery. RESULTS: Volume of the postoperative hematoma was reduced by 43.0 mL. However, significant reduction of total blood loss and drainage volume was not observed. CONCLUSIONS: We observed that 4DryField® PH had a local hemostatic effect, thereby reducing volume of the postoperative hematoma. However, this reduction was small and had no effect on the total blood loss. Further studies are warranted to improve the application algorithm. TRIAL REGISTRATION: DRKS, DRKS00017452 , Registered 11 June 2019 - Retrospectively registered.

Existence and role of standard operating procedures in the emergency department : A national online survey.

BACKGROUND: In recent years, increases in the number of patients in emergency departments (ED) have led to continuous work intensification. To handle this problem, the treatment effectiveness has to be maximized. One strategy that may help to optimize workflow is the use of standard operating procedures (SOPs). We investigated the existence of SOPs and subjective effects on treatment in German EDs. METHODS: We performed an online survey from February 2015 until June 2016. We collected data regarding the existence of SOPs, health care level, medical field, work experience, and education. All professional groups participating in the treatment of patients were requested to take part in the survey. RESULTS: Seventy-five percent of the 589 participants in the survey confirmed the existence of SOPs in their EDs. SOPs were more frequently available in hospitals with higher health care levels. Participants working in EDs without SOPs felt less confident regarding treatment of patients. More than 85% of these participants were in favor of having SOPs. The absence of SOPs was associated with a subjective delay in patient treatment. CONCLUSION: Most of the EDs had available SOPs. In departments without SOPs, most physicians wanted them to be implemented. SOPs seemed adequate in terms of supporting workflow and satisfaction with patients' treatment.