Early in-hospital course of critically ill nontrauma patients in a resuscitation room of a German emergency department (OBSERvE2 study).

BACKGROUND: Management of critically ill nontrauma (CINT) patients in the resuscitation room of the emergency department (ED) is very challenging. Detailed data describing the patient characteristics and management of this population are lacking. This observational study describes the epidemiology, management and outcome in CINT ED patients in the resuscitation room. METHODS: This prospective, single center observational study included all adult patients who were consecutively admitted to the ED resuscitation room during 2 periods of 1 year (September 2014-August 2015 vs. September 2017- August 2018). Patient characteristics, out-of-hospital/in-hospital treatment, admission-related conditions, time intervals for diagnostics and interventions and outcome were recorded using a self-developed questionnaire. RESULTS: A total of 34,303 patients in the first and 35,039 patients in the second study period were admitted to the ED, of whom 532 and 457 patients, respectively, were admitted to the nontrauma resuscitation room due to acute life-threatening conditions. The patient characteristics did not differ significantly between the study periods (male: 58% vs. 59%, age: 68 ± 17 years vs. 65 ± 17 years). Time intervals for diagnostic and therapeutic interventions were similar. The CINT patients during the second study period were treated faster compared to the first study period (end of ED management: 53 ± 33 min vs. 41 ± 24 min, p < 0.0001). The 30-day all-cause mortality was comparable (34.0% vs. 36.3%). CONCLUSION: Observation of critically ill patient management in the ED resuscitation room showed reliable results between both study periods. Structured ED management guidelines for CINT patients may provide comparable results at one institution.

[Cannabinoid hyperemesis as a differential diagnosis of nausea and vomiting in the emergency department]. / Cannabinoidhyperemesis als Differenzialdiagnose von Übelkeit und Erbrechen in der Notaufnahme.

Cannabinoid hyperemesis syndrome (CHS) is caused by regular cannabis consumption and marked by cyclic episodes of severe emesis, often years after the beginning of cannabis consumption. Classical antiemetic treatment often shows no effect and fatal outcomes have sometimes also been reported. This article describe the case of a young man in whom the diagnosis was made after four presentations due to the typical anamnesis. At this point in time he had already undergone an abdominal computed tomography (CT) and gastroscopy, both with no pathological findings. The symptoms completely receded 6 months after presentation by maintaining cannabis abstinence.

[Workload in emergency departments : A Problem for personnel and patients?] / Arbeitsbelastung in der Notaufnahme : Ein Problem für Personal und Patienten?

Apart from operating theaters, intensive care units and diagnostic services, the central emergency department is one of the areas of any hospital with a high workload, which is very susceptible to risk. The following aspects of routine daily work can lead to a great strain on the personnel working in the central emergency department: the need for quick, targeted decisions, especially for patients with life-threatening disorders, a high number of patients with insufficient available resources, dissatisfaction of patients with low treatment priority and longer waiting times and delayed inpatient admissions with long stays. Interruptions in the individual work process during activities are not uncommon but represent additional disruptive factors for employees and can lead to treatment errors. Furthermore, a workload that is permanently perceived as too high leads to psychological and physical disturbances for the team members. Suitable structural, organizational and personnel prerequisites as well as solution strategies for the central emergency department are necessary to avoid corresponding treatment errors and also as a duty of care for employees.

[Restructuring of inpatient emergency treatment : What will change?] / Neustrukturierung der stationären Notfallversorgung : Was ändert sich?

The resolution on the restructuring of inpatient emergency treatment was passed by the Federal Joint Committee (G-BA) on 19 April 2018 based on the Hospital Structure Act and became binding with the publication in the Bundesanzeiger on 18 May 2018. The resolution describes the future structural and qualitative prerequisites for participation of hospitals in the provision of emergency treatment in three levels: basic emergency treatment, extended emergency treatment and comprehensive emergency treatment. Furthermore, a level of nonparticipation is also planned. In addition, there are special modules, e.g. for the treatment of children and auxiliary modules for specifically equipped hospitals with highly specialized patient treatment (e.g. stroke unit). A transition regulation period of 3-5 years provides hospitals with the possibility to adjust to the new minimum requirements. The German Hospital Federation (DKG) and the National Association of Statutory Health Insurance Funds (GKV-SV) will negotiate the assessment of surcharges and deductions subsequent to the resolution.

Hyperlactatemia on ICU admission : Comparison between direct admissions and inpatient transfers.

BACKGROUND: Hyperlactatemia is associated with increased mortality. Possible differences between patients directly admitted via the emergency department to the intensive care unit (ICU) and inpatient transfers to the ICU have not yet been investigated. MATERIALS AND METHODS: In this retrospective analysis, characteristics and outcomes between critically ill medical inpatient transfers and direct admissions with hyperlactatemia on ICU admission, defined as a blood lactate >2 mmol/l, were compared. RESULTS: A total of 1042 patients were included, with 424 inpatient transfers and 618 direct admissions. The median age of inpatient transfers and direct admissions was 67.0 and 70.5 years, respectively (P = 0.03). The median APACHE II score was 25 for inpatient transfers and 23 for direct admissions (P = 0.01). The median blood lactate on ICU admission for inpatient transfers and direct admissions was similar (3.6 vs. 3.5 mmol/l). Sepsis was more common among inpatient transfers than direct admissions (53.5 vs. 31.6%, P = 0.001). The ICU (39.6 vs. 28.8%, P < 0.001), hospital (56.8 vs. 38.3%, P < 0.001) and 28-day mortality (46.5 vs. 35.4%, P < 0.001) was significantly higher for inpatient transfers than direct admissions. Among the sepsis cohort, inpatient transfer, APACHE II score and elevated blood lactate were independent predictors of ICU mortality. CONCLUSION: Among medical ICU patients with admission hyperlactatemia, the median blood lactate was not significantly different between direct admissions and inpatient referrals. Inpatients with sepsis may have been referred to the ICU late.

[Training in clinical acute and emergency medicine - Supraspeciality in Germany : A concept for nationwide implementation!] / Zusatz-Weiterbildung Klinische Akut- und Notfallmedizin in Deutschland : Ein Konzept vor der bundesweiten Einführung!

At the 121st German Physicians Conference 2018 in Erfurt a resolution to accept the full amendment of the (draft) further training regulations (MWBO) was adopted and the State Medical Councils were requested to include them in their respective areas of responsibility. Therefore, the nationwide implementation of the supraspeciality (ZWB) for clinical acute and emergency medicine has been officially finalized. After consultation with the German Medical Council (BÄK) concerning the format, both the new MWBO 2018 and now the content of the ZWB are available as of 15 November 2018.The Physicians Conference resolution and anchoring of the new ZWB clinical acute and emergency medicine in the MWBO were preceded by a process lasting approximately 10 years. The concept of the ZWB clinical acute and emergency medicine, which was scrutinized by the Standing Committee on "medical further training" and the board of the BÄK and presented for approval, was essentially developed by representatives of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) and the German Society for Interdisciplinary Emergency and Acute Medicine (DGINA) in consultation with the BÄK. A consensus was finally reached in September 2017 in cooperation with those German specialist societies with a high proportion of emergency patients.In addition to the title, definition, and minimum requirements for applying the ZWB, the content was processed according to the European curriculum for emergency medicine. The structural prerequisites have now been approved, the Standing Committee has configured the content, and the complete MWBO 2018 has been successfully presented, such that the ZWB clinical acute and emergency medicine is expected to be implemented in the individual Federal States within the next 1-2 years.This article describes the history and development of ZWB clinical acute and emergency medicine in Germany and outlines future perspectives.

[Development of ground-based physician-staffed emergency missions in the city of Leipzig from 2003 to 2013]. / Entwicklung bodengebundener Notarzteinsätze im Stadtgebiet Leipzig von 2003 bis 2013.

BACKGROUND: The annual number of physician-based emergency missions reported is continuously increasing. Data from large cities concerning this development over long periods is sparse. MATERIAL AND METHODS: In this retrospective study the charts of all ground-based physician-staffed emergency missions in the city of Leipzig for the first quarters of 2003 and 2013 were analyzed. Patient characteristics, injury and illness severities, mission location, hospital admission rate, as well as emergency interventions were collated. The emergency mission rate was calculated as rescue missions per 1000 inhabitants per year. RESULTS: The number of physician-staffed emergency missions increased by approximately 24% between 2003 and 2013 (6030 vs. 7470, respectively). The emergency mission rate was 48 vs. 58 in the 2 study periods. The median patient age increased from 66 to 70 years. The number of geriatric patients (age ≥ 85 years: n = 650 (11%) vs. n = 1161 (16%), p < 0.01) also increased. The corresponding number of emergency missions in nursing homes showed a fourfold (n = 175, 3% vs. n = 750, 10%, p < 0.01). The percentage of hospital admissions also increased (n = 3049, 51% vs. n = 4738, 66%, p < 0.01). A change in patient distribution to level I hospitals was noticed (n = 1742, 29% vs. n = 3436, 46%, p < 0.01). CONCLUSION: The findings suggest that the necessity for the high number of physician-staffed emergency missions should be verified, especially in the context of strained emergency healthcare resources. The basis of an optimized use of resources could be a better inclusion of alternative, especially ambulant, healthcare structures and the implementation of a structured emergency call questionnaire accompanied by a more efficient disposition of the operating resources, not least in view of the economic aspects. Taking the concentrated patient allocation to level 1 hospitals into consideration, there is a need for optimized patient distribution strategies to minimize the overload of individual institutions and thereby improve the general quality of care at the interface between preclinical and clinical emergency medicine.

[Future of emergency medicine in Germany 2.0]. / Zukunft der Notfallmedizin in Deutschland 2.0.

In 2003 an article on the future of prehospital emergency medicine in Germany was published in the journal Der Anaesthesist. Emergency medicine in Germany, which at that time was almost exclusively defined as prehospital emergency rescue, has evolved and now in-hospital domains have increasingly moved into the focus. At that time, the primary goal was to connect prehospital management with a smooth transition to hospital admission and further care in the hospital and to further optimize the rescue chain from the actual emergency through to causative treatment. Now after 15 years, the authors have critically assessed the development postulated in 2003 and reevaluated it. Which aspects could be developed further and become firmly established, what is still open and which questions in preclinical and clinical emergency treatment of the population will occupy us in the coming 15 years? With a critical eye to the past, the present contribution aims to capture the essential and new topics and open questions and provide a fresh perspective for the future of emergency medicine. Regulation at the state level or even lower levels of government often stand in contrast to more sweeping and economically effective approaches at the federal level. Prehospital emergency medicine in Germany is on the whole well-positioned with respect to facilities and personnel; however, as far as the economic situation and the utilization of available systems are concerned, there is still substantial room for improvement.

[Practical training for paramedics : Transformation at the Leipzig University teaching hospital]. / Die praktische Ausbildung von Notfallsanitätern : Umsetzung am Universitätsklinikum Leipzig.

BACKGROUND: The "Notfallsanitätergesetz" (the law pertaining to paramedics), which came into effect in January 2014, has fundamentally changed the training of health personnel in German prehospital emergency medicine. The apprenticeship now takes 3 years including 720 h of practical training in eligible hospitals. To date, however, there has been little experience of how the contents of the guidelines for practical training ("Ausbildungs- und Prüfungsverordnung") can be reasonably applied in the teaching hospitals. METHODS: In a total of nine interdisciplinary working group meetings between October 2014 and June 2016, we developed a curriculum concerning the practical training of paramedics to implement the contents of the guidelines for practical training in a didactically and an organizationally meaningful way. RESULTS: The implementation of the practical training of paramedics is an excellent chance for the teaching hospitals to contribute to higher quality prehospital emergency medicine. Otherwise, the teaching hospitals face an organizational and personal effort that is not to be underestimated. Thus, a modular curriculum constitutes the possibility of standardizing practical training and simultaneously reducing the time and expenditure for the participating hospitals. CONCLUSION: The development of a unique curriculum for the practical training of paramedics may contribute to standardized, high-quality, and cost-efficient training.

[Emergency departments--2016 update]. / Zentrale Notaufnahme--Update 2016.

Acute medical care in hospital emergency departments has experienced rapid development in recent years and gained increasing importance not only from a professional medical point of view but also from an economic and health policy perspective. The present article therefore provides an update on the situation of emergency departments in Germany. Care in emergency departments is provided with an increasing tendency to patients of all ages presenting with varying primary symptoms, complaints, illnesses and injury patterns. In the process, patients reach the emergency department by various routes and structural provision. Cross-sectional communication and cooperation, prioritization and organization of emergency management and especially medical staff qualifications increasingly play a decisive role in this process. The range of necessary knowledge and skills far exceeds the scope of prehospital medical emergency care and the working environment differs substantially. In addition to existing structural and economic problems, the latest developments, as well as future proposals for the design of in-hospital emergency medical care in interdisciplinary emergency departments are described.

Detection of gamma hydroxybutyrate in emergency department: Nice to have or a valuable diagnostic tool?

BACKGROUND: Many patients present to emergency departments (EDs) with an altered state of consciousness. Fast exclusion of gamma hydroxybutyrate (GHB)-associated intoxication in these patients may optimize diagnostic and therapeutic algorithms and decisions in the ED. METHODS: Between January and March 2014, a novel enzymatic test system was used to quantify GHB in blood and urine samples of suspected intoxicated patients in the ED of the University Hospital. The underlying causes for suspected intoxication and the diagnostic and therapeutic measures were documented and analysed retrospectively. RESULTS: GHB measurements were performed in 13 patients with suspected ingestion during a 3-month study period. GHB was positive in six patients showing serum levels between 61.8 mg/l and 254.8 mg/l, and GHB was tested negative in seven patients with a range of 0.3-6.2 mg/l (upper reference limit 6.1 mg/l). Additional intoxication was found in five of six GHB positive (83%, alcohol n = 2 and other drugs n = 5) and in six of seven negative-tested patients (86%, alcohol n = 5 and other drugs n = 1). CONCLUSION: GHB quantification in the ED provides specific additional information for intoxication, which can lead to more precise diagnostic and therapeutic decisions and may also be important for legal aspects. We believe that GHB analysis in unconscious patients with suspected intoxication may improve the efficient treatment of intoxicated patients.

[Position paper for a reform of medical emergency care in German emergency departments]. / Positionspapier für eine Reform der medizinischen Notfallversorgung in deutschen Notaufnahmen.

The hospital emergency departments play a central role for the in- and outpatient care of patients with medical emergencies in Germany. In this position paper we point out some general financial and organizational problems of German emergency departments and urge for a higher significance of emergency care in the German health system as an element of public services. The corresponding reform proposals include a change in hospital financing towards a more budget-based system for the emergency departments, an improved structural planning for regional and transregional emergency care, an intensified cooperation with the emergency services of the ambulatory care physicians, a better organizational representation of emergency care within the hospitals and an advancement of emergency medicine in postgraduate medical education.

Self-poisoning in the acute care medicine 2005-2012.

OBJECTIVE: To describe the trend of acute self-poisoning in the emergency and intensive care. METHODS: Electronic charts of adults who presented to the emergency department of the University Hospital Leipzig with self-poisoning following a suicide attempt (suicide group), intoxication (intoxication group), drug overdose for relief of pain or discomfort (drug overdose group) between 2005 and 2012 were analyzed. RESULTS: 3533 adults (62.6% males) were identified, with the yearly admissions increasing from 305 in 2005 to 624 in 2012. The admission rate in relation to the total emergency department admissions also increased, from 1.2% in 2005 to 1.9% in 2012. 31.7% of the patients were younger than 25 years. The reasons for self-poisoning were suicide attempt (18.1%), intoxication (76.8%) and drug overdose (2.9%). The reason could not be clearly classified in 80 patients. Psychotropic drugs were used in 71.6% of suicide attempts, while alcohol was the sole cause of intoxication in 80.1% of cases in the intoxication group. Self-poisoning using at least two substances was observed in 52.0% of the suicide attempts, 10.3% of those with intoxication and 29.7% of those with drug overdose. While alcohol remains the most common cause of intoxication, there was a drastic increase in the consumption of cannabinoids, Crystal Meth and gamma-hydroxybutyrate in the years 2011 and 2012. ICU admission was necessary in 16.6% of the cases. There were 22 deaths (0.6% of the study population), of whom 15 were in the suicide group (2.3%), four (0.15%) in the intoxication group, and three in the not clearly classified group (3.8%). CONCLUSION: Acute self-poisoning is an increasing medical issue. Psychotropic drugs remain the most common means of suicide attempt. Although alcohol intoxication is very frequent, intake of illicit drugs as the cause of emergency admission is increasing.

[Interdisciplinary management of trauma patients : Update 3 years after implementation of the S3 guidelines on treatment of patients with severe and multiple injuries]. / Interdisziplinäres Traumamanagement : Update 3 Jahre nach Implementierung der S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung.

BACKGROUND: The recommendations still have to be implemented 3 years after publication of the S3 guidelines on the treatment of patients with severe and multiple injuries. AIM: This article reiterates some of the essential core statements of the S3 guidelines and also gives an overview of new scientific studies. MATERIAL AND METHODS: In a selective literature search new studies on airway management, traumatic cardiac arrest, shock classification, coagulation therapy, whole-body computed tomography, air rescue and trauma centers were identified and are discussed in the light of the S3 guideline recommendations. RESULTS: The recommendations on airway management are up to date; however, recommendations on difficult airway evaluation tools, e.g. the LEMON law, should be included. The first pass success (i.e. intubation success at the first attempt) must be considered as a quality marker in the future. Video laryngoscopy is identified as a leading airway procedure in order to reach this aim. Recently estimated learning curves for endotracheal intubation and supraglottic airway devices should be implemented in qualification statements. Life-saving emergency interventions have to be performed in the prehospital setting as they do not prolong the complete treatment period for severely injured patients up to discharge from the resuscitation room. The outcome of patients suffering from traumatic cardiac arrest is better than expected. Recently developed algorithms for trauma patients have to be implemented. The prehospital trauma life support (PHTLS) and advanced trauma life support (ATLS) shock classification does not reflect the clinical reality; therefore, lactate, lactate clearance and base deficit should be used for evaluating the shock state in the resuscitation room. Concerning coagulation therapy, tranexamic acid is easy to administer, safe and effective as an antifibrinolytic therapy and should not be restricted to the most severely injured patients. Numerous studies have shown the positive effect of whole-body computed tomography on treatment time and outcome; however, clear indications for the use of whole-body computed tomography are lacking. Further investigations supported the positive effects of air rescue on the treatment outcome of trauma patients. CONCLUSION: The recommendations on interdisciplinary trauma management contained in the S3 guidelines on the treatment of patients with severe and multiple injuries should be implemented into the clinical routine. Additionally, the knowledge gained from more recent scientific studies is necessary for anesthetists and emergency physicians to be able to adequately implement the core statements of the S3 guidelines for the treatment of patients with severe and multiple injuries.

[Interdisciplinary emergency room - key to success?]. / Interdisziplinäre Notaufnahme - Schlüssel zum Erfolg?

In Germany, which is also faced with a scarcity of resources, the concept of central, interdisciplinary emergency rooms ("Zentrale Notfallaufnahme", ZNA) is being developed as an answer to the complex demands of modern emergency medicine with increasing numbers of patients and complexity of the medical conditions. This autonomous institution is the first point of contact for all emergency patients. The central tasks of the ZNA are triage and the interdisciplinary primary treatment of patients. The establishment of the ZNA includes specific facilities (treatment rooms, short stay units, resuscitation rooms, triage and management areas, integration of the premises on site) as well as specific processes (triage systems, specific standard operating procedures) and training for the staff (European Curriculum for Emergency Medicine). It could be shown that by establishing a ZNA along with all its structures the satisfaction of the patients (including shorter waiting times), resource management (intensive care capacity), and patient outcome could be significantly improved.

Prehospital airway management using the laryngeal tube. An emergency department point of view.

BACKGROUND: Competence in airway management and maintenance of oxygenation and ventilation represent fundamental skills in emergency medicine. The successful use of laryngeal tubes (LT, LT-D, LTS II) to secure the airway in the prehospital setting has been published in the past. However, some complications can be associated with the use of a laryngeal tube. METHODS: In a nonconsecutive case series, problems and complications associated with the use of the laryngeal tube in prehospital emergency medicine as seen by independent observers in the emergency room are presented. RESULTS: Various problems and possible complications associated with the use of a laryngeal tube in eight case reports are reported: incorrect placement of the laryngeal tube in the trachea, displacement and/or incorrect placement of the laryngeal tube in the pharynx, tongue and pharyngeal swelling with subsequently difficult laryngoscopy, and inadequate ventilation due to unrecognized airway obstruction and tension pneumothorax. CONCLUSION: Although the laryngeal tube is considered to be an effective, safe, and rapidly appropriable supraglottic airway device, it is also associated with adverse effects. In order to prevent tongue swelling, after initial prehospital or in-hospital placement of laryngeal tube and cuff inflation, it is important to adjust and monitor the cuff pressure. Article in English.