A model to predict difficult airway alerts after videolaryngoscopy in adults with anticipated difficult airways - the VIDIAC score.

A model to classify the difficulty of videolaryngoscopic tracheal intubation has yet to be established. The videolaryngoscopic intubation and difficult airway classification (VIDIAC) study aimed to develop one based on variables associated with difficult videolaryngoscopic tracheal intubation. We studied 374 videolaryngoscopic tracheal intubations in 320 adults scheduled for ear, nose and throat or oral and maxillofacial surgery, for whom airway management was expected to be difficult. The primary outcome was whether an anaesthetist issued a 'difficult airway alert' after videolaryngoscopy. An alert was issued after 183 (49%) intubations. Random forest and lasso regression analysis selected six intubation-related variables associated with issuing an alert: impaired epiglottic movement; increased lifting force; direct epiglottic lifting; vocal cords clearly visible; vocal cords not visible; and enlarged arytenoids. Internal validation was performed by a 10-fold cross-validation, repeated 20 times. The mean (SD or 95%CI) area under the receiver operating characteristic curve was 0.92 (0.05) for the cross validated coefficient model and 0.92 (0.89-0.95) for a simplified unitary score (VIDIAC score with component values of -1 or 1 only). The calibration belt for the coefficient model was consistent with observed alert probabilities, from 0% to 100%, while the unitary VIDIAC score overestimated probabilities < 20% and underestimated probabilities > 70%. Discrimination of the VIDIAC score for patients more or less likely to be issued an alert was better than discrimination by the Cormack-Lehane classification, with mean (95%CI) areas under the receiver operating characteristic curve of 0.92 (0.89-0.95) vs. 0.75 (0.70-0.80), respectively, p < 0.001. Our model and score can be used to calculate the probabilities of difficult airway alerts after videolaryngoscopy.

[Effectiveness of interventions to strengthen cognitive resources in nursing home residents : A systematic review and network meta-analysis]. / Wirksamkeit von Interventionen zur Stärkung kognitiver Ressourcen bei Bewohnenden in Pflegeheimen : Eine systematische Übersichtsarbeit und Netzwerkmetaanalyse.

BACKGROUND: Strengthening cognitive resources of residents in nursing homes is an important goal of preventive activities. The aim of this systematic review was to answer the question which intervention is most effective for nursing home residents to strengthen their cognitive resources. METHOD: A systematic literature search was carried out in the Cochrane Library and the MEDLINE (PubMed), Embase, CINAHL, PsycINFO and PEDro databases. Reference lists of publications classified as relevant were checked and trial registries were searched. The literature selection, data extraction and assessment of the study quality were carried out by two reviewers independently. A frequentist network meta-analysis was conducted using a random effects model. RESULTS: A total of 29 studies with 1816 participants were included. Both physical activity (standardized mean difference [SMD] = 0.70, 95%-confidence interval [CI] 0.35-1.06, p < 0.001) and cognitive activity (SMD = 0.61, 95%-CI 0.22-1.01, p < 0.01) were statistically significantly superior in strengthening cognitive resources compared to usual care. Physical and cognitive activities did not differ statistically significantly from each other. In addition, neither physical activity nor cognitive activity showed statistically significantly better cognitive resources in nursing home residents compared to social activities. CONCLUSION: The findings imply that physical activity as well as cognitive activity could be effective to strengthen cognitive resources of nursing home residents. Considering the low-quality of available evidence, performance of high-quality studies is essential in order to verify the robustness of the statistical results.

[Interventions for promoting physical activity in nursing homes : Systematic review of the effectiveness of universal prevention]. / Interventionen zur Förderung der körperlichen Aktivität in Pflegeheimen : Systematische Übersicht der Wirksamkeit universeller Prävention.

BACKGROUND: Among residents of nursing homes, physical activity might be beneficial in maintaining health-related quality of life because impairment is caused in particular by functional decline. The aim is the evaluation of the effectiveness of universal preventive interventions directed at increasing physical activity on activities of daily living in nursing home residents. MATERIAL AND METHODS: Relevant studies were identified through database searching in MEDLINE, the Cochrane library, EMBASE, CINAHL, PsycINFO and PEDro. Two review authors independently selected articles, assessed the risk of bias and extracted data. Results were combined in random effects meta-analyses. RESULTS: By including 14 primary studies, nursing home residents participating in physical activities showed a statistically significant greater physical functioning compared to controls (standardized mean difference [SMD] = 0.48, 95% confidence interval [95% CI] 0.26-0.71, p < 0.0001). Subgroup analyses suggest that especially nursing home residents with severe physical and cognitive impairment might benefit from participation in physical activities. Results after non-training periods substantiate the necessity of a sustained implementation. Due to the high risk of bias in included studies, the results must be interpreted with caution. CONCLUSION: Physical activity for nursing home residents can be effective. Considering the low-quality evidence, performance of high-quality studies is essential in order to verify the statistical results.

[Expectations from the TraumaNetwork DGU®: Which goals have been achieved? What can be improved?]. / Erwartungen an das TraumaNetzwerk DGU®: Welche Ziele wurden erreicht? Was kann verbessert werden?

INTRODUCTION: Following the establishment of the first trauma networks in 2009 an almost nationwide certification could be achieved. Despite the impressive number of 46 certified networks, little is known about the actual improvements and the satisfaction of the participating hospitals. OBJECTIVES: This article aims to give a first representative overview of the expectations and actual achievements. MATERIAL AND METHODS: An online survey with a total of 36 questions was conducted in 884 hospitals. The questionnaire could be filled out online, sent by post or fax to the AKUT- Office. Descriptive statistical analyses were performed with Microsoft Excel. RESULTS: With 326 responses, a response rate of 48.9% of all active hospitals was achieved. Of the participating hospitals 64.1% (209) were certified and had taken part in the project for an average of 3.9 years. The average score for satisfaction was 2.3, 72.4% (236) felt that there was a need for improvement in the care of severely injured patients and 46.6% (152) in the transfer of patients. In 47.2% (142) no improvement in cooperation with the ambulance service could be determined, 25.2% (82) documented an increase in the number of severely injured patients since participating in the trauma network (TNW-DGU) and 93.9% (306) of all hospitals wanted to participate in the trauma network in the future. DISCUSSION: It could be shown that important goals, such as simplification of patient transfer or general improvement in cooperation have been achieved. Overall there was a high level of satisfaction among the participating hospitals; however, the survey has identified some points which need to be improved by further intensive work.

[Patient safety in education and training of healthcare professionals in Germany]. / Wie lernen wir, Patienten sicher zu versorgen? Patientensicherheit in der Ausbildung der Gesundheitsberufe.

In order to improve patient safety, healthcare professionals who care for patients directly or indirectly are required to possess specific knowledge and skills. Patient safety education is not or only poorly represented in education and examination regulations of healthcare professionals in Germany; therefore, it is only practiced rarely and on a voluntary basis. Meanwhile, several training curricula and concepts have been developed in the past 10 years internationally and recently in Germany, too. Based on these concepts the German Coalition for Patient Safety developed a catalogue of core competencies required for safety in patient care. This catalogue will serve as an important orientation when patient safety is to be implemented as a subject of professional education in Germany in the future. Moreover, teaching staff has to be trained and educational and training activities have to be evaluated. Patient safety education and training for (undergraduate) healthcare professional will require capital investment.

[Interim results for the Patients' Rights Act and Infection Protection Act]. / Zwischenbilanz Patientenrechtegesetz und Infektionsschutzgesetz.

BACKGROUND: The Patient Rights Act has converted court rulings into legal paragraphs. Two new aspects have been introduced: the duty to hand over a copy of the signed written consent form to the patient (in which detailed recommendations are offered) and the obligation of a thorough documentation of findings and treatments within patient files. In addition the legislators, through the Joint Federal Committee (Gemeinsamer Bundesausschuss, GBA) have made the introduction of clinical risk management mandatory. The Infection Protection Act and its regulations have elevated the prerequisites of hygiene within hospitals and private practices with a parallel increase in liability. RESULTS AND DISCUSSION: Both laws and regulations offer no reference as to who (and to what extent) is financially responsible for the excessive increase in personnel costs, which are as yet not included in the German diagnosis-related groups (G-DRG) system. Despite all additional measures within the area of risk management, mistakes (avoidable or unavoidable) will nevertheless occur. In order to avoid longstanding legal battles the authors recommend an open and rapid communication with the patient and family. The wall of silence should be a thing of the past.

[Quality of case allocation of orthopedics and trauma surgery in the 2004 and 2014 versions of the German DRG system. An interim assessment of the development process]. / Abbildung orthopädisch-unfallchirurgischer Leistungen in den G-DRG-Systemversionen 2004 und 2014. Eine Zwischenbilanz des Weiterentwicklungsprozesses.

BACKGROUND: Since 2004 the German diagnosis-related groups (DRG) system has been applied nationwide in all German somatic hospitals. The G-DRG system is updated annually in order to increase the quality of case allocation. What developments have occurred since 2004 from the perspective of orthopedics and trauma surgery? This article takes stock of the developments between 2004 and 2014. METHODS: Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2004 and 2014 based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS: The number of G-DRGs in the whole system increased by 45.1 % between 2004 and 2014. The number of G-DRGs in the major diagnostic category (MDC) 08 that contains the majority of orthopedic and trauma surgery categories increased in the same period by 61.6 %. The reduction of variance of inlier costs in the MDC 08 category, a statistical measure of the performance of the G-DRG system, was below the corresponding value of the total system in 2004 as well in 2014. However, the reduction of variance of inlier costs in MDC 08 (+ 30.0 %) rose more from 2004 to 2014 than the corresponding value of the overall system (+ 21.5 %). CONCLUSION: Many modifications of the classification systems of diagnoses (ICD-10-GM) and medical procedures (OPS) and the structures of the G-DRG system could significantly improve the quality of case allocation from the perspective of orthopedics and trauma surgery between 2004 and 2014. Th assignment of cases could be differentiated so that complex cases with more utilization of resources were allocated to higher rated G-DRGs and vice versa. However, further improvements of the G-DRG system are necessary. Only correct and complete documentation and coding can provide a high quality of calculation of costs as a basis for a correct case allocation in future G-DRG systems.

[More patients in a shorter inpatient stay with better outcome in treatment of femoral neck fracture: external quality assurance in Westfalia-Lippe on 50,354 patients]. / Mehr Patienten in kürzerer Zeit bei besserer Qualität in der Behandlung der Schenkelhalsfraktur : Externe chirurgische Qualitätssicherung in Westfalen-Lippe an über 50.354 Patienten.

BACKGROUND: We show a comparison between two patient groups of the inpatient population suffering from femoral neck fractures registered in the external quality assurance between 1993 and 1997 and between 2005 and 2009. RESULTS: The comparison between two patient groups showed the following developments: an increase in patient numbers per year from 4,229 to 5,842 where the average age remained constant but the proportion of elderly patients over 70 years old increased; the period of hospitalization was clearly shorter (from 27 days to 18 days); an increase in comorbidities (according to the ASA classification) with simultaneous decrease of the complication rate (from 11.1% to 7.6%). The inhospital mortality remained constant at 5.3%. At the same time the number of hospitals which treat patients with femoral neck fractures decreased from 166 to 150. Concurrently the number of patients per hospital and year increased from 23.6 to 41.3 cases. CONCLUSION: The technique of operative treatment changed and while during the 1990s many patients with femoral neck fractures were treated by implanting a total endoprosthesis, in the 2000s treatment was dominated by the hemi prosthesis. During the two periods of study use of the osteosynthesis technique decreased. In conclusion, the study showed an obvious compression of performance in trauma surgery but despite everything there was a clear improvement of treatment quality with respect to complication rates.

[Medial femoral neck fractures: possible reasons for delayed surgery. Part 2: Results of data from external inpatient quality assurance within the framework of secondary data evaluation]. / Mediale Schenkelhalsfraktur: mögliche Gründe für eine verzögerte operative Versorgung. Teil 2: Ergebnisse der Daten der externen stationären Qualitätssicherung im Rahmen sekundärer Datennutzung.

PROBLEM: In Germany a disproportionate number of patients with a femoral neck fracture still experience a delay in surgery. In 2008 delays of more than 48 h after admission occurred for 15.4 % of patients. This leads to increases in surgical and general complications as well as pressure sores. OBJECTIVE: Possible reasons that lead to delayed operations were investigated in a nationwide study. DATA AND METHODS: Using nationwide data from the German inpatient external quality assurance program from the year 2008 the reasons for performing operations later than 48 h after hospital admission were examined both exploratory and analytically using a multiple logistic regression model considering combined effects. RESULTS: Surgery was more frequently delayed for patients who were admitted to hospital on Friday or Saturday, patients with a higher American Society of Anesthesiologists (ASA) classification, men, patients with malignant diseases, in the presence of infectious diseases and patients with heart disease. Operations carried out within the first 48 h were more frequent with displaced fractures and in the presence of hypertension or mental illness. The volume per hospital had no consistent effect on the time delay of surgery. During the week no significant differences between the departments were detected. On Friday or Saturday surgery was delayed more often when patients were admitted to a department of general surgery than to a department of trauma surgery or orthopedics. CONCLUSIONS: There are medical and non-medical reasons for delayed surgery of femoral neck fractures. Studies have confirmed that delayed surgery for femoral neck fracture harms the patients. Organizational reasons which prevent an immediate operation, e.g. admission on Friday or Saturday, should therefore be eliminated by improvements in hospital organization and staffing. These can be measures of individual hospitals or of several hospitals in cooperation. The target should be to ensure a comprehensive and timely provision of the highest quality care even at the weekend.

[TraumaregisterTraumaNetwork DGU® und TraumaRegister DGU®. Success by cooperation and documentation]. / TraumaNetzwerk DGU® und TraumaRegister DGU®. Erfolge durch Kooperation und Dokumentation.

BACKGROUND: The TraumaNetwork DGU® (TNW) connects hospitals with different capacities for the treatment of severely injured patients who work together as superregional (STC), regional (RTC) and local trauma centres (LTC). The standards of treatment and equipment are defined on the basis of current guidelines as published in the"White book of the Treatment of Severely Injured Patients". An external audit process evaluates the organisation and structure of participating hospitals as well as the cooperation of the trauma centres within a regional TNW. RESULTS: In May 2013 a total of 618 hospitals were visited and assessed according to the White book and 39 fully certified regional TNWs covered around 85% of the area of Germany. Treatment quality in the certified TCs was analyzed on the basis of 25,249 severely injured patients in the TraumaRegister DGU® (2008-2011) and significant differences between the expected and observed mortality rates were found. These differences were most obvious in superregional and regional trauma centres. CONCLUSION: The TraumaNetwork represents an innovative, cooperative project for successfully improving the treatment of severely injured patients.

[Description of the severely injured in the DRG system: is treatment of the severely injured still affordable?]. / Abbildung von Schwerverletzten im DRG-System : Wird die Schwerverletztenversorgung doch bezahlbar?

BACKGROUND: Due to the heterogeneity of severely injured patients (multiple trauma) it is difficult to assign them to homogeneic diagnosis-related groups (DRG). In recent years this has led to a systematic underfunding in the German reimbursement system (G-DRG) for cases of multiply injured patients. This project aimed to improve the reimbursement by modifying the case allocation algorithms of multiply injured patients within the G-DRG system. METHODS: A retrospective analysis of standardized G-DRG data according to §21 of the Hospital Reimbursement Act (§ 21 KHEntgG) including case-related cost data from 3,362 critically injured patients from 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals was carried out. For 1,241 cases complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of multiply injured patients within the G-DRG system. Analysis of coding and grouping, performance of case allocation and the homogeneity of costs in the G-DRG versions 2008-2012 was carried out. RESULTS: The results showed systematic underfunding of trauma patients in the G-DRG version 2008 but adequate cost covering in the majority of cases with the G-DRG versions 2011 and 2012. Cost coverage was foundfor multiply injured patients from the clinical viewpoint who were identified as multiple trauma by the G-DRG system. Some of the overfunded trauma patients had high intensive care costs. Also there was underfunding for multiple injured patients not identified as such in the G-DRG system. CONCLUSIONS: Specific modifications of the G-DRG allocation structures could increase the appropriateness of reimbursement of multiply injured patients. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical specialist societies.

[The challenge of adequate reimbursement for the seriously injured patient in the German DRG system]. / Die Herausforderung der sachgerechten Vergütung von Schwerverletzten im deutschen DRG-System.

BACKGROUND: Critically injured patients are a very heterogeneous group, medically and economically. Their treatment is a major challenge for both the medical care and the appropriate financial reimbursement. Systematic underfunding can have a significant impact on the quality of patient care. In 2009 the German Trauma Society and the DRG-Research Group of the University Hospital Muenster initialised a DRG evaluation project to analyse the validity of case allocation of critically injured patients within the German DRG system versions 2008 and 2011 with additional consideration of clinical data from the trauma registry of the German Trauma Society. Severe deficits within the G-DRG structure were identified and specific solutions were designed and realised. METHODS: A retrospective analysis was undertaken of standardised G-DRG data (§ 21 KHEntgG) including case-related cost data from 3 362 critically injured patients in the periods 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals. For 1 241 cases of the sample, complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of critically injured patients within the G-DRG system. Analyses of coding and grouping, performance of case allocation, and the homogeneity of costs in the G-DRG versions 2008 and 2011 were done. RESULTS: The following situations were found: (i) systematic underfunding of trauma patients in the G-DRG-Version 2008, especially trauma patients with acute paraplegia; (ii) participation in the official G-DRG development for 2011 with 13 proposals which were largely realised; (ii) the majority of cases with cost-covering in the G-DRG version 2011; (iv) significant improvements in the quality of statistical criteria; (v) overfunded trauma patients with high intensive care costs; (vi) underfunding for clinically relevant critically injured patients not identified in the G-DRG system. CONCLUSION: The quality of the G-DRG system is measured by the ability to obtain adequate case allocations for highly complex and heterogeneous cases. Specific modifications of the G-DRG structures could increase the appropriateness of case allocation of critically injured patients. Additional consideration of the ISS clinical data must be further evaluated. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical societies in this process.

[Orthopedic and trauma surgery in the German DRG system. Recent developments]. / Orthopädie und Unfallchirurgie im deutschen DRG-System. Aktuelle Entwicklungen.

BACKGROUND: Orthopedics and trauma surgery are subject to continuous medical advancement. The correct and performance-based case allocation by German diagnosis-related groups (G-DRG) is a major challenge. This article analyzes and assesses current developments in orthopedics and trauma surgery in the areas of coding of diagnoses and medical procedures and the development of the 2012 G-DRG system. METHODS: The relevant diagnoses, medical procedures and G-DRGs in the versions 2011 and 2012 were analyzed based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS: Changes were made for the International Classification of Diseases (ICD) coding of complex cases with medical complications, the procedure coding for spinal surgery and for hand and foot surgery. The G-DRG structures were modified for endoprosthetic surgery on ankle, shoulder and elbow joints. The definition of modular structured endoprostheses was clarified. CONCLUSION: The G-DRG system for orthopedic and trauma surgery appears to be largely consolidated. The current phase of the evolution of the G-DRG system is primarily aimed at developing most exact descriptions and definitions of the content and mutual delimitation of operation and procedures coding (OPS). This is an essential prerequisite for a correct and performance-based case allocation in the G-DRG system.

Regionalisation of trauma care in Germany: the "TraumaNetwork DGU(®)-Project".

PURPOSE: The care for severely injured patients is a demanding task for all medical professionals involved in both the pre-clinical and the clinical setting. While the overall quality of care in Germany is high, regional differences remain. These are due to geographical and infrastructural variations, as well as different personnel and equipment situations in the hospitals. METHODS: In September 2006, the white paper 'Treatment of the severely injured' was published by the German Society of Trauma Surgery (DGU). The white paper asks for the improvement of comprehensive care and postulates the foundation of networks between trauma centres: a regional TraumaNetwork (TNW). All hospitals within a TNW are classified as local, regional or supraregional trauma centres by distinct criteria regarding personnel and equipment, as well as admission capacity and responsibility. Furthermore, agreements between the trauma centres and the pre-hospital rescue systems regulate the admission and transfer of patients in a TNW. RESULTS: To date, 878 hospitals are registered in 53 regional TNWs. A total of 511 hospitals have already been audited on-site. Preparing for the audit, 54.4% of the hospitals implemented organisational changes (e.g. inter-disciplinary guidelines), while 31.4% introduced personnel and 14.7% structural (e.g. X-ray in the emergency room [ER]) changes. In September 2011, the certification process was completed in 19 TNWs, comprising a mean of 14 (range 5-26) hospitals each. Moreover, international TNWs in co-operation with hospitals in Holland, Luxemburg, Switzerland and Austria were established. CONCLUSIONS: The TraumaNetwork DGU(®) audits all hospitals participating in the care for severely injured patients and establishes a structured network between all the players involved in trauma care. Thirty TNWs will be certified by the end of 2011, covering 75% of Germany. The nationwide covering will be completed by the middle of 2012.