[Supply of Medical Aids in home Mechanical Ventilation: needs-Based and Safe? - The Views of Stakeholders Related to the Care Process on the Current Status and Perspectives]. / Beatmungsspezifische Hilfsmittelversorgung ­ bedarfsgerecht und sicher?

INTRODUCTION: The supply of medical aids is essential for patients with home mechanical ventilation. However, it is largely unclear to what extent this supply is needs-based and safe. METHODS: As part of a health services research project, 20 expert interviews were conducted with a heterogeneous group of stakeholders related to ventilation-specific medical aids supply. The interviews were analysed using qualitative content analysis. RESULTS: The interviewees pointed to challenges and problems regarding structural, procedural and personal aspects at all levels of medical aids supply. In particular, deficits in task performance, coordination and cooperation between the stakeholders and authorities involved became apparent. Such might result in avoidable safety risks and hinder needs-oriented supply of medical aids. CONCLUSION: Further development in ventilation-associated medical aids supply is needed, with focus on evidence-based practices, a comprehensive, cross-sectoral and cross-professional design as well as systematic evaluation.

["Ensuring patient safety is one of our primary responsibilities." - Results of a qualitative study on maintaining safety in ventilation-associated technical aid supply]. / "Es ist eine unserer Hauptaufgaben, die Sicherheit der Patienten zu gewährleisten." ­ Ergebnisse einer qualitativen Studie zur Gewährleistung von Sicherheit in der beatmungsspezifischen Hilfsmittelversorgung.

BACKGROUND: Maintaining safety is critical in home mechanical ventilation (HMV). It is co-determined by the availability of reliable technical aids and their correct application. Ensuring safe aid supply is part of the aid providers'́ legal mandate. However, whether and how this is achieved is largely unknown. Therefore, the tasks of technical aid providers, associated requirements and challenges with special regards to educational and safety aspects were investigated. METHODS: For this purpose, episodic interviews were conducted between July and December 2020 with a purposive sample of field representatives of eleven technical aid providers. Between one and six persons participated in each of the interviews, resulting in a total sample of 25 persons (14 field representatives without management function, ten with management function, one director). Given the conditions during the COVID-19 pandemic, six interviews took place face-to-face and five as web meetings. Interviews were analysed using qualitative content analysis. RESULTS: From the interviewees'́ perspective, the most important safety-related measure is the legally required and individually tailored initial instruction in a safe aid application. Additional safety-related tasks comprise counselling, e. g. for prescribing physicians and users (patients, relatives, nursing service employees), regular home visits, and the provision of a technical emergency service. Interviewees indicate that safety risks emerge primarily from a lack of skills and a high staff turnover among professional caregivers. This, they state, challenges building up and maintaining competencies among nursing staff. Other safety risks arise from healthcare fragmentation, lacking coordination, cooperation, and accountability of the professionals involved. Respondents address these challenges pragmatically by providing additional services, like ongoing caregiver training, care coordination and support roles. DISCUSSION: Maintaining safety in ventilation-associated technical aid supply must be considered a crucial component of the overall HMV care processes, in which safety currently cannot be taken for granted. Field representatives of technical aid providers address the existing challenges with selective and intuitive strategies, some of which exceed their legal mandate. CONCLUSION: Improving safety in home care can be supported by establishing Advanced Nursing Practice roles in nursing services. The systematic further development of roles and tasks of staff of technical aid providers should be clarified within an overarching discourse on viable approaches to cross-sectoral and interprofessional HMV care.

"The Devices Themselves Aren't the Problem"-Views of Patients and Their Relatives on Medical Technical Aid Supply in Home Mechanical Ventilation: An Explorative Qualitative Study.

(1) The supply of medical technical aids and the instructions on using them is critical for home-mechanically ventilated patients and their relatives. However, limited evidence exists on the needs-based nature of this care. (2) Aim: To gain insights into users' views on this form of care, to identify key challenges, and to derive empirically sound preliminary recommendations for its future design. (3) Methods: An explorative qualitative interview study was performed in Germany. Semi-structured interviews were conducted with home-mechanically ventilated patients and their relatives. Patients were selected through purposive sampling. Interviews were audio-recorded, transcribed, and analysed using a content analysis approach. (3) Results: 27 patients and 9 relatives were interviewed. From their point of view, ventilation-specific equipment is generally reliable and is seen as a belonging of the patient. However, if the patient lacks competence in using the technology or if information or instructions are neglected, ambiguous and unsafe situations easily arise. (4) Conclusions: The present study is one of the first to provide insights into technical aid supply in home-mechanical ventilation from the users' point of view. It highlights the need for continuous professional support and for evidence-based educational strategies that promote safety among the users of technical aids in home care.

[Safety in Intensive Home Care for Ventilated Patients: Professional Players' Perspective]. / Sicherheit in der häuslichen Intensivversorgung beatmeter Patienten aus Sicht professioneller Akteure.

INTRODUCTION: There is an increasing number of ventilated and other technology-dependent patients, cared for in their own homes or in shared apartments in Germany. Issues of patient safety have hardly been examined in this context. In this follow-up of a survey of patients and their relatives, the perspective of professional players on the subject of safety in intensive home care is explored. METHODS: Professional players in 6 heterogeneous, non-natural focus groups were faced with experiences and perspectives of ventilated patients and their relatives in a qualitative health care services research. These players were asked for their perspectives on the issue of patient safety in intensive home care. The collected data were analyzed in terms of discourse as well as content. RESULTS: The subjective safety dimensions addressed by the ventilated patients and their relatives was considered as important by the professional players in many respects. However, demands from relatives for more participation were considered with skepticism. Safety in intensive home care was perceived as under threat by a lack of cooperation and coordination, skills shortage and skills gaps. In particular, caregivers with key tasks of care provision and thus with special responsibility for patient safety see these corresponding challenges. CONCLUSION: The results provide a basis for safety work in intensive home care. Among other things they point out the need to develop user-centered safety concepts, a safety culture at the organizational level as well as accompanying legal regulation.

[Descriptive Analysis of Health Economics of Intensive Home Care of Ventilated Patients]. / Gesundheitsökonomische deskriptive Analyse der häuslichen Intensivversorgung beatmeter Patienten.

INTRODUCTION: Long-term ventilated patients in Germany receive intensive care mainly in the patients' home or in assisted-living facilities. There is a lack of knowledge about the nature and extent of resource use and costs associated with care of this small, heterogeneous but overall growing patient group. METHODS: A sub-study in the context of a research project SHAPE analyzed costs of 29 patients descriptively from a social perspective. Direct and indirect costs of intensive home care over a period of three months were recorded and analyzed retrospectively. Standardized recorded written self-reports from patients and relatives as well as information from the interviewing of nursing staff and from nursing documentation were the basis for this analysis. RESULTS: There was an average total cost of intensive home care for three months per patient of 61194 € (95% CI 53 884-68 504) including hospital stays. The main costs were directly linked to outpatient medical and nursing care provided according to the Code of Social Law V and XI. Services provided by nursing home care service according to § 37(2) Code of Social Law V (65%) were the largest cost item. Approximately 13% of the total costs were attributable to indirect costs. CONCLUSIONS: Intensive home care for ventilated patients is resource-intensive and cost-intensive and has received little attention also from a health economics perspective. Valid information and transparency about the cost structures are required for an effective and economic design and management of the long-term care of this patient group.

[Patient safety in home care : A review of international recommendations]. / Patientensicherheit in der häuslichen Versorgung ­ Eine Übersichtsarbeit zu internationalen Handlungsempfehlungen.

BACKGROUND: In recent years there has been a growing trend towards nursing care at home in general as well as towards intensive home care being provided by specialized home care services in Germany. However, resulting challenges for patient safety have rarely been considered. Against this background we aimed to explore whether international recommendations for patient safety in home care in general and in intensive home care in particular already exist and how they can stimulate further practice development in Germany. METHODS: A review of online English documents containing recommendations for patient safety in intensive home care was conducted. Available documents were analyzed and compared in terms of their form and content. RESULTS: Overall, a small number of relevant documents could be identified. None of these documents exclusively refer to the intensive home care sector. Despite their differences, however, the analysis of four selected documents showed similarities, e. g., regarding specific topics of patient safety (communication, involvement of patients and their relatives, risk assessment, medication management, qualification). Furthermore, strengths and weaknesses of the documents became apparent: e. g., an explicit understanding of patient safety, a literature-based introduction to safety topics or an adaptation of the recommendations to the specific features of home care were occasionally lacking. CONCLUSIONS: This document analysis provides interesting input to the formal and content-related development of specific recommendations and to practice development in Germany to improve patient safety in home care.

Everything safe? ­ Risk situations in advanced home care from the point of view of ventilated patients and their relatives / Alles sicher? ­ Risikosituationen in der häuslichen Intensivpflege aus Sicht beatmeter Patienten und ihrer Angehörigen.

Background: The number of home mechanically ventilated (HMV) patients has been growing for years. However, little is known about requirements, processes and effects of advanced home care, provided in distance from clinics and doctors. To date, safety related aspects of the above mentioned issues have scarcely been examined. Aim: Users of advanced home care were asked about their experiences and about situations in which they felt safe or unsafe. The aim was to gain insights into the daily care provision, explore safety risks from the users' point of view, and to develop new approaches to enhance patient safety in home care for the severely ill. Method: A qualitative explorative study has been carried out, based on semi-structured interviews (ventilated patients N = 21; relatives N = 15). Sampling, data collecting and data analysis were guided by principles of Grounded Theory. Results: Risk situations occur when (non-)verbal communication offers of HMV patients are overseen or misunderstood, patient- or technology related monitoring tasks are neglected, if coordination and collaboration requirements are undervalued and if negotiation processes as well as education and supervision needs are disregarded. Furthermore, nurses' lack of competence, self-confidence and professionalism may produce risk situations. Conclusion: Listen carefully to patients and relatives can help to identify quality shortcomings in advanced home care, to prevent risk situations and to develop patient-centered safety concepts for this particular setting.

Updated stomatal flux and flux-effect models for wheat for quantifying effects of ozone on grain yield, grain mass and protein yield.

Field measurements and open-top chamber experiments using nine current European winter wheat cultivars provided a data set that was used to revise and improve the parameterisation of a stomatal conductance model for wheat, including a revised value for maximum stomatal conductance and new functions for phenology and soil moisture. For the calculation of stomatal conductance for ozone a diffusivity ratio between O(3) and H(2)O in air of 0.663 was applied, based on a critical review of the literature. By applying the improved parameterisation for stomatal conductance, new flux-effect relationships for grain yield, grain mass and protein yield were developed for use in ozone risk assessments including effects on food security. An example of application of the flux model at the local scale in Germany shows that negative effects of ozone on wheat grain yield were likely each year and on protein yield in most years since the mid 1980s.