[Position paper for a reform of medical emergency care in German emergency departments]

[Structured triage in the emergency department via intelligent assistant service OPTINOFA : Results of a multicenter, cluster-randomized and controlled interventional study in Germany]

In Germany, a substantial reform of emergency care is strictly recommended. Regulation of patient flows into the ambulatory and stationary sectors remains a major issue.In the OPTINOFA project funded by Innovationsfunds, a new triage system was developed for a structured primary evaluation of both urgency and care level of emergency cases. OPTINOFA was evaluated in a cluster-randomized, controlled multicenter trial using a stepped-wedge design in eight emergency departments (ED) from 1 July 2019 to 31 May 2021. Additionally, data from one ED were used for comparison of temporal changes without intervention. The primary study endpoint represented the increase of patient transfers to the ambulatory sector; secondary endpoints included the outcome, process and quality indicators as well as mean emergency care costs.In the study, 46,558 emergency cases were included in the control period and 37,485 emergency cases in the intervention period. Concerning the primary endpoint, a significant increase of transfers to the ambulatory sector were detected in the per-protocol EDs (p < 0.001, odds ratio = 10.59). Waiting times were significantly reduced by an average 20 min in the intervention phase. Furthermore, a stable admission rate was found within 3 days after initial ED presentation. Cost analysis revealed no increase of treatment expenses within 28 days after ED admission.In this project a valid assistant service for structured primary evaluation of urgency and care level was successfully developed for emergency cases and served as a digital triage instrument with interoperable format. Clinical trial results revealed great potential for the OPTINOFA triage system to control patient flows in emergency and acute medicine.

[Typical emergencies in otorhinolaryngology-a monocentric analysis of the seasonal course]

Hintergrund

Die Inzidenz der Akutdiagnosen im Hals-Nasen-Ohren(HNO)-Bereich wird durch multiple Parameter beeinflusst, unter anderem meteorologische und saisonale Einflüsse. Durch ein besseres Verständnis dieser Faktoren könnten prophylaktische Ansätze entwickelt werden.

Material und Methoden

Über 6 Jahre erfolgte eine retrospektive Analyse aller Patienten, die sich aufgrund von typischen und weniger komplexen HNO-ärztlichen Krankheitsbildern wie Cerumen obturans, akuter Otitis externa und media, Nasenpyramidenfraktur, Epistaxis nasi, akuter Tonsillitis, akuter Rhinosinusitis oder eines Peritonsillarabszess in einer südwestdeutschen Universitätsklinik vorgestellt haben.

Ergebnisse

32.968 Fälle wurden ausgewertet. Mit 24,5 % (8082 Fälle) war die Epistaxis nasi die häufigste Notfalldiagnose. Diese, wie auch die akute Otitis media und die akute Rhinosinusitis, traten signifikant häufiger in der kälteren Jahreshälfte auf. Es bestand keine signifikante Korrelation der Diagnose Nasenpyramidenfraktur mit besonderen Zeiten wie Feiertagen. Die akute Otitis externa korrelierte signifikant mit dem Zeitraum der Sommerferien. In Kalenderwoche 38 gab es die wenigsten und in der Kalenderwoche 52 die meisten Notfallvorstellungen.

Schlussfolgerung

Saisonale und meteorologische Faktoren spielen eine Rolle in der Krankheitsentstehung verschiedener HNO-ärztlicher Notfalldiagnosen.

Barriers to Integration of Primary Care into Emergency Care: Experiences in Germany

Introduction

In response to emergency department over-crowding primary care practitioners (PCPs) have been incorporated into care pathways to provide integrated care. We consider why a pilot project of PCP-led streaming in a German emergency department failed, the challenges encountered transplanting models between differing systems and cultures, and if the concept constitutes integrated care.

Theory and Methods

The original design was a mixed methods data gather around PCP-streaming of non-urgent self-referrers in an emergency department.

Results

The demand for the PCP-streaming was low, which was at odds with pre-study estimates. The study was stopped prematurely without adequate data; this is an opinion-based article.

Discussion

A fundamental of emergency care is a central emergency department. An emergency department can be the fulcrum from which urgent inter-disciplinary hospital care is initiated and coordinated. Objective triage is fundamental to this and regional healthcare planning. With such fundamentals in place, PCP integration has the potential to facilitate and provide integrated care. Relevant elements of the Rainbow Model of Integrated Care frame the discussion.

Conclusion

The key element deficient in each barrier to our project, yet present in successful studies, was normative integration.

INDEED-Utilization and Cross-Sectoral Patterns of Care for Patients Admitted to Emergency Departments in Germany: Rationale and Study Design

Introduction: The crowding of emergency departments (ED) has been a growing problem for years, putting the care of critically ill patients increasingly at risk. The INDEED project's overall aim is to get a better understanding of ED utilization and to evaluate corresponding primary health care use patterns before and after an ED visit while driving forward processes and methods of cross-sectoral data merging. We aim to identify adequate utilization of EDs and potentially avoidable patient contacts as well as subgroups and clusters of patients with similar care profiles.

Methods: INDEED is a joint endeavor bringing together research institutions and hospitals with EDs in Germany. It is headed by the Charité–Universitätsmedizin Berlin, collaborating with Otto von Guericke University Magdeburg, Technische Universität Berlin, the Central Research Institute of Ambulatory/Outpatient Health Care in Germany (Zi), and the AOK Research Institute as part of the Federal Association of AOK, as well as experts in the technological, legal, and regulatory aspects of medical research (TMF). The Institute for Information Technology (OFFIS) was involved as the trusted third party of the project. INDEED is a retrospective study of approximately 400,000 adult patients with statutory health insurance who visited the ED of one of 16 participating hospitals in 2016. The routine hospital data contain information about treatment in the ED and, if applicable, about the subsequent hospital stay. After merging the patients' hospital data from 2016 with their outpatient billing data from 2 years before to 1 year after the ED visit (years 2014–2017), a harmonized dataset will be generated for data analyses. Due to the complex data protection challenges involved, first results will be available in 2021.

Discussion: INDEED will provide knowledge on extracting and harmonizing large scale data from varying routine ED and hospital information systems in Germany. Merging these data with the corresponding outpatient care data of patients offers the opportunity to characterize the patient's treatment in outpatient care before and after ED use. With this knowledge, appropriate interventions may be developed to ensure adequate patient care and to avoid adverse events such as ED crowding.

[Allocation of limited resources in intensive and emergency medical care]

BACKGROUND

Demographic change, medical progress, pandemics, and mass casualty events may cause an increased demand for intensive and emergency medical care resources. There is thus a definite need for fair allocation criteria.

OBJECTIVE

The rationale, structure, and criteria for allocation of intensive and emergency medical care resources are presented and discussed.

MATERIALS AND METHODS

Analysis and discussion of German literature about the topic.

RESULTS AND CONCLUSIONS

Decisions on the allocation of intensive and emergency medical care resources are made on different levels (micro-, meso-, and macrolevel). They shall fulfill minimum demands in terms of procedure and content. Consequent and careful examination of indication and evidence of therapeutic decisions as well as consequent and careful examination of the patient's definite or presumed consent helps to take responsibility for fair allocation decisions.

[Intensive care and emergency medicine as part of training in internal medicine]

Intensive care and emergency medicine are extremely important for the treatment of patients with acute and severe medical conditions. While other internal medicine specialties are progressively focused on specific organ systems or diseases, rotations of residents into the intensive care unit (ICU) or the emergency department (ED) are an important part of their training in general internal medicine. Here they can acquire many of the diagnostic and therapeutic skills required in their curriculum. All internal medicine residents in Germany therefore must complete at least a 6 month rotation in the ICU and the ED. For training programs in general internal medicine, the German Society for Medical Intensive Care and Emergency Medicine (Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin) asks the German State Medical Councils to accept rotations in the ICU and the ED for 15 months each. After adding an ICU or ED fellowship, these internists would be ideally qualified for much needed attending and leadership positions in the ICUs and EDs and would have a better perspective for a scientific career in these fields. In addition, ICU and ED fellowships of internists from other specialties should be supported.

[Emergency Medicine : What do we need?]

The timely medical treatment of the population in emergency situations is an enormous challenge for the healthcare system and is becoming increasingly more important. Due to this development clinical acute and emergency medicine has undergone enormous progress and is in the process of further professionalization. Various specialist societies and medical associations have published essential position papers in recent years and demanded fundamentally new healthcare structures and assignments. Additionally, emergency medical healthcare structures and centers have already been established on the initiative of individual emergency medical specialist disciplines. The future challenge is the nationwide establishment, grouping and integration of the structures and processes within definitive healthcare centers. The main objective of all involved must be the optimal care of emergency patients.

[Position paper of the German Society for Medical Intensive Care Medicine and Emergency Medicine (DGIIN) on medical intensive care medicine]

In this paper the German Society for Medical Intensive Care Medicine and Emergency Medicine (DGIIN) provides statements regarding the importance and advancement of Medical Intensive Care Medicine within the structures of Internal Medicine in Germany. Of pivotal importance are the training of medical intensivists, the cooperation with intensivists from other disciplines and the collaboration with emergency departments. In order to fulfil the various and challenging tasks in patient care, training, research and medical education competently and on an international level, more intensivists in leading positions especially in academic institutions are essential.

[Reimbursement of intensive care services in the German DRG system : Current problems and possible solutions]

The reimbursement of intensive care and nursing services in the German health system is based on the diagnosis-related groups (G-DRG) system. Due to the lack of a central hospital planning, the G‑DRG system has become the most important influence on the development of the German health system. Compared to other countries, intensive care in Germany is characterized by a high number of intensive care beds, a low nurse-to-patient ratio, no official definition of the level of care, and a minimal available data set from intensive care units (ICUs). Under the given circumstances, a shortage of qualified intensive care nurses and physicians is currently the largest threat for intensive care in Germany. To address these deficiencies, we suggest the following measures: (1) Integration of ICUs into the levels of care which are currently developed for emergency centers at hospitals. (2) Mandatory collection of structured data sets from all ICUs including quality criteria. (3) A reform of intensive care and nursing reimbursement under consideration of adequate staffing in the individual ICU. (4) Actions to improve ICU staffing and qualification.

[Questionnaire for the utilization of the Emergency Department : Implications for the patient survey]

BACKGROUND

For several years, Emergency Departments (ED) in Germany have observed increasing patient numbers, resulting in ED crowding. This leads to the question of whether patients with nonurgent conditions could also receive adequate treatment in primary care. Our objective was to develop a quantitative questionnaire to investigate in a larger patient group the reasons for this and to describe the implications for a patient survey in the ED.

METHODS

The development of the questionnaire was based on a literature search and the results of the qualitative EPICS-2 study. Two pretest surveys were conducted in three EDs at the Charité - Universitätsmedizin Berlin. We included patients aged ≥ 18 years with outpatient treatment and the categories blue (nonurgent), green (standard), or yellow (urgent) according to the Manchester Triage System (MTS).

RESULTS

In total, 189 patients were recruited in two surveys (pretest 1: n = 89, pretest 2 n = 100). The final questionnaire includes 24 items, which were evaluated and adapted during both pretests. The items evaluate basic clinical characteristics, reasons for choosing the ED, prior contacts in primary care, utilization of primary care after-hours services as well as sociodemographic characteristics. Data from the hospital information system were used to link the survey data with clinical characteristics.

CONCLUSIONS

The questionnaire is based on reasons for ED utilization. We recommend the written, self-applied questionnaire for patient surveys with plausibility checks conducted by staff. It is necessary to consider the heterogenic study surroundings in the ED, which requires a lot of flexibility during data collection.

[Focal point emergency departments]

The number of patients treated in hospital emergency departments in Germany has risen in recent years to approximately 20 million. This escalation also applies to the increasing numbers of patients presenting with neurological symptoms and diseases, which occur in approximately 20 % of emergency patients. In addition to patients with stroke, inflammatory or degenerative central nervous system (CNS) and peripheral nervous system (PNS) disorders who need urgent treatment, more and more patients with nonspecific complaints or conditions attend emergency departments for elective treatment, not least because timely appointments with specialist neurologists in practices could not be obtained. Neurological expertise and presence in emergency departments at the level of specialist standard are therefore indispensable for providing a professional level of treatment, which also corresponds to current legal requirements. The implementation of a generalist emergency physician in Germany, as introduced in some European countries, would mean a retrograde step for neurological expertise in emergency admission management. The discipline of neurology must work together with other emergency disciplines to improve the financing of emergency departments and provide neurologists working there with a substantive curriculum of further and continuing education in emergency-related aspects of neurology. The discipline of neurology has a responsibility to emergency patients within its range of competencies and must, therefore, strengthen and improve its role in healthcare politics and concerning organizational and personnel aspects of neurological emergencies.

[Chest pain in the emergency department : Differential diagnosis and diagnostic strategy]

Chest pain as the leading symptom in emergency patients can have numerous causes and requires an immediate and targeted diagnostic and therapeutic strategy. Clinical scoring systems facilitate risk assessment for individual patients. In the emergency department, critical factors for success are defined professional qualification standards for physicians and nursing staff combined with a well-functioning organization of all technical procedures.