[Importance of trauma and emergency surgery for German metropolitan emergency departments-an analysis of 524,716 emergency patients]

[Head injuries and their wound treatment]

Head injuries are frequent occurrences in emergency departments worldwide and are notable for the fact that attention must be paid to the sequelae of intracranial and extracranial trauma. It is crucial to assess potential intracranial injuries and to strive for both medically sound and esthetically pleasing extracranial outcomes. The aim of this continuing education article is to provide a refresher on knowledge of head injuries and the associated nuances for wound care.

Regional Anesthesia for Acute Pain Treatment in Pre-Hospital and In-Hospital Emergency Medicine

BACKGROUND

More than half of all emergency department patients seek help for acute pain, which is usually of musculoskeletal origin. Acute pain is often inadequately treated even today, particularly in children and in older patients. In this study, we assess the potential role of regional anesthetic methods in improving the treatment of pain in the preclinical and clinical emergency setting.

METHODS

Pain-related reasons for admission were identified and quantified from emergency admission data. A structured literature search was carried out for clinical studies on the treatment of pain in the emergency setting, and a before-and-after comparison of the pain relief achieved with established vs. newer regional anesthetic methods was performed.

RESULTS

43% of emergency patients presented with acute musculoskeletal pain. The literature search yielded 3732 hits for screening; data on entity-specific pain therapy spectra were extracted from 153 studies and presented for the main pain regions. The degree of pain relief obtained through regional anesthetic procedures, on a nominal rating scale from 0 to 10, was 4 to 7 points for acute back and chest wall pain, >6 for shoulder pain, 5 to 7 for hand and forearm injuries, and >4 for hip fractures. These results were as good as, or better than, those obtained by analgesia/sedation with strong opioids.

CONCLUSION

Modern regional anesthetic techniques can improve acute pain management in the emergency department and, to some extent, in the pre-hospital setting as well. Pain relief with these techniques is quantifiably better than with strong opioids in some clinical situations; moreover, there is evidence of further advantages including process optimization and fewer complications. Data for comparative study remain scarce because of a lack of standardization.

Who, When, Why?-Traumatological Patients in the Emergency Department of a Maximum Care Provider

Nationwide, there is an annual increase in the number of patients in German emergency departments resulting in a growing workload for the entire emergency department staff. Several studies have investigated the situation in emergency departments, most of which were interdisciplinary, but there are no data on a solely traumatological patient population. The present study therefore aims to investigate the situation in a university-based trauma surgery emergency department. A total of 8582 traumatological patients attending a university hospital from 1 January 2019 to 31 December 2019 were studied. Various variables, such as reason for presentation, time of accident, diagnosis, and diagnostic as well as therapeutic measures performed were analyzed from the admission records created. The mean age was 36.2 years, 60.1% were male, 63.3% presented on their own to the emergency department, and 41.2% presented during regular working hours between 8:00 a.m. and 6:00 p.m., Monday through Friday. The most common reason for presentation was outdoor falls at 17.4%, and 63.3% presented to the emergency department within the first 12 h after the sustained trauma. The most common diagnosis was bruise (27.6%), and 14.2% of patients were admitted as inpatients. Many of the emergency room patients suffered no relevant trauma sequelae. In order to reduce the number of patients in emergency rooms in the future, existing institutions in the outpatient emergency sector must be further expanded and effectively advertised to the public. In this way, the emergency medical resources of clinics, including staff, can be relieved to provide the best possible care for actual emergency patients.

Die Neustrukturierung der Notaufnahme gemäß dem G-BA-Beschluss zu einem gestuften System von Notfallstrukturen

BACKGROUND

There is no assessment of the effects regarding the decision of the Federal Joint Committee from April 19th, 2018 which demands a central and interdisciplinary emergency room system under the control of a professionally and organizationally independent administration. The aim of this study was to solicit the current opinion of leading orthopedic surgeons regarding the above-mentioned decision.

MATERIAL AND METHODS

An online questionnaire was sent to all 731 members of the Verband Leitender Orthopäden und Unfallchirurgen (www.vlou.de) to compare the opinion of these leading physicians on their current and future emergency room system.

RESULTS

The majority of the 179 responding surgeons consider emergency room systems with primary treatment of orthopedic patients by orthopedic surgeons in certain aspects to be more appropriate suitable than systems without such primary treatment. It is also not yet clear how work-related accidents should be treated according to the specifications of the German statutory accident insurance (DGUV®). The provision of training content could become more difficult if the ER rotation of orthopedic surgeons is not any longer part of these new ER concepts.

CONCLUSION

The consequences of the decision of the Federal Joint Committee from April 19th, 2018 need to be reevaluated continuously and, if necessary, optimised accordingly, taking into account competing requirements, such as training regulations and the SGB VII.

[Position of trauma surgery in emergency medicine]

BACKGROUND

The decision of the Federal Joint Committee has resulted in the further development of in-hospital emergency medicine through the establishment of central emergency departments and staged emergency care. In addition, the additional training in clinical acute and emergency medicine was established.

AIM

The aim of this work is on the one hand to make trauma surgeons aware of these structural changes. On the other hand, we would like to evaluate an opinion and discuss the position of trauma surgery in emergency medicine.

METHODS

A web-based online survey was conducted at the Trauma Network and Trauma Registry Congress to collect participants' opinions on the position of trauma surgery in emergency medicine.

RESULTS

Of 143 congress participants, 98 (67%) responded to the survey. The majority of participants were male (n = 78, 80%), over 40 years of age (n = 62, 63%), and in a professional position with staff responsibility (n = 73, 75%). Emergency medicine (mean: 84.8; SD: 18.7) and intensive care medicine (mean: 78.3; SD: 20.4) training appears important. On the other hand, subsequent work in these areas appears less important (prehospital emergency medicine: mean: 65.1; SD: 28.0; ICU: mean: 53.7, SD: 30.3); however, activity in an emergency department is rated higher (MW: 87.0; SD: 18.7). There is high agreement that the trauma leader should be a trauma surgeon (mean 87.9; SD: 19.7).

DISCUSSION

A high volume of emergency trauma surgery patients and the care of severely injured patients in designated trauma centers show that trauma surgery expertise is mandatory in a central emergency department. Senior positions should also be sought to ensure high quality standards.

Saturday Night Fever: Interpersonal Violence as a Reason for Presentation in a University Emergency Department

(1) Presentations to a trauma emergency department following a violent confrontation account for a relevant proportion of the overall population. To date, violence (against women) in the domestic setting has been studied in particular. However, representative demographic and preclinical/clinical data outside of this specific subgroup on interpersonal violence are limited; (2) Patient admission records were searched for the occurrence of violent acts between 1 January and 31 December 2019. A total of 290 patients out of over 9000 patients were retrospectively included in the "violence group" (VG). A "typical" traumatologic cohort (presentation due to, among other things, sport-related trauma, falls, or traffic accidents) who had presented during the same period served as comparison group. Then, differences in the type of presentation (pedestrian, ambulance, or trauma room), time of presentation (day of week, time of day), diagnostic (imaging) and therapeutic (wound care, surgery, inpatient admission) measures performed, and discharge diagnosis were examined; (3) A large proportion of the VG were male, and half of the patients were under the influence of alcohol. Significantly more patients in the VG presented via the ambulance service or trauma room and during the weekend and the night. Computed tomography was performed significantly more often in the VG. Surgical wound care in the VG was required significantly more often, with injuries to the head being the most common; (4) The VG represents a relevant cost factor for the healthcare system. Because of the frequent head injuries with concomitant alcohol intoxication, all mental status abnormalities should be attributed to brain injury rather than alcohol intoxication until proven otherwise, to ensure the best possible clinical outcome.

Analysis of severe hand trauma injury frequency during "Munich's Oktoberfest" within the last 9 years in comparison to years with absence due to the COVID-19 pandemic

INTRODUCTION

Within its 2 week period, the Oktoberfest attracts around 6 million visitors yearly to Munich, Germany. Due to alcohol intake, congested halls, and disorderly activities, numerous accidents occur. Although many hand injuries are observed, the impact of Oktoberfest on severe hand trauma injury frequency is under investigated.

MATERIALS AND METHODS

Data from the regional emergency medical service (EMS) was analyzed over a 9 year period regarding the frequency of severe hand injuries during the world's largest fair and compared to the corresponding period in the years 2020 and 2021 where the event was cancelled due to the world-wide COVID-19 pandemic. Additionally, we compared the patient numbers during the same period in one Emergency Department of a level-1-trauma and hand trauma center located close to the venue.

RESULTS

An exploratory description is made from data collected over a 9 year period (2013-2021) with focus on hand injuries before, during and after the "Oktoberfest". A total of 4017 hand injuries were allocated to hospitals by EMS. There was an increase in severe hand injuries by 66% during the 2-weeks-Oktoberfest-period compared to years where the Oktoberfest did not take place. Pre-pandemic statistics show an increasing severe hand trauma frequency of 57.5% in September, compared to EMS-referrals during the remanding year.

CONCLUSION

The risk of injuring relevant structures of the hand during Oktoberfest is extremely high as compared to other parts of the body due to beer stein and fall-associated injuries. These injuries can lead to lifelong impairments. Our data are the first that quantifies and pinpoints the risk of severe injury to the hand during Oktoberfest and therefore, it is of great interest for visitors, hand surgeons, paramedics and emergency department healthcare workers.

[Analysis of 6851 foot and ankle injuries from 2010-2017 in an emergency department]

Hintergrund

Sprunggelenk- und Fußverletzungen gehören zu den häufigsten Krankheitsbildern in der Traumatologie. Ziel dieser Studie war es, die demografischen Veränderungen von Patienten mit Fuß- und Sprunggelenkverletzungen, das zeitliche Auftreten und die Entwicklung über die Jahre in einer Notaufnahme zu untersuchen.

Material und Methoden

Retrospektive Datenauswertung von Patienten, welche aufgrund einer Fuß- und Sprunggelenkverletzung in der Notaufnahme im Zeitraum von 2010 bis 2017 behandelt wurden. Die Patienten wurden mittels ICD-Codes identifiziert und die demografischen Veränderungen, das zeitliche Auftreten und die Entwicklung über die Jahre analysiert. Mittels Quantil-Quantil-Diagramm wurden kontinuierliche Variablen auf Normalverteilung getestet und, falls zutreffend, mittels t‑Test oder nichtparametrischem Mann-Whitney-U-Test auf Signifikanz überprüft.

Ergebnisse

Insgesamt wurden 6581 Fuß- und Sprunggelenkverletzungen in die Analyse eingeschlossen. Das mittlere Alter von Patienten mit einer Fußfraktur war 39 ± 17,4 Jahre und mit einer Sprunggelenkfraktur 47 ± 19,2 Jahre (p < 0,001). Ligamentäre Verletzungen des Sprunggelenks traten insbesondere bei jüngeren Patienten in den Sommermonaten auf. Die Altersverteilung bei Sprunggelenkfrakturen zeigte für Männer einen Häufigkeitsgipfel zwischen dem 30. und 39. Lebensjahr und bei Frauen ein vermehrtes Auftreten ab dem 50. Lebensjahr. In der Altersgruppe zwischen 65 und 75 Jahren stellten Trimalleolarfrakturen die zweithäufigste Sprunggelenkfraktur dar. Frakturen des Fußes betrafen am häufigsten Patienten im Alter von 20 bis 29 Jahren, wobei bei Frauen ein 2. Häufigkeitsgipfel zwischen dem 50. und 59. Lebensjahr zu beobachten war.

Schlussfolgerung

Ligamentäre Verletzungen des Sprunggelenks sind häufige Krankheitsbilder in der Notaufnahme und betreffen v. a. jüngere Patienten. Sprunggelenkfrakturen zeigten für Frauen eine bimodale Altersverteilung, und insbesondere Bi- und Trimalleolarfrakturen waren vermehrt bei Frauen ab dem 65. Lebensjahr zu beobachten. Aufgrund der erhöhten Prävalenz von Fuß- und Sprunggelenkfrakturen bei älteren Frauen sollte in diesem Patientenkollektiv eine weitere Osteoporoseabklärung veranlasst werden.

[Cost factor "outpatient wound care" in the emergency department : Cost-revenue deficit of outpatient wound treatment in a German university hospital]

BACKGROUND

In addition to highly specialized medicine, the initial treatment of wounds and minor surgical interventions are generally necessary basic services of emergency care in hospitals. The reimbursement of outpatient emergency services for persons with statutory insurance is currently based on the uniform assessment standard (EBM), where the recording of business expenses in the private practice sector serves as the basis for the calculation. Hospitals have considerably higher maintenance costs than medical practices.

OBJECTIVE

In this article the resulting cost-revenue ratio of outpatient wound care in an emergency department is analyzed through the reimbursement according to EBM.

MATERIAL AND METHODS

The data were collected in the emergency surgical department of the University Hospital Frankfurt am Main over 12 months. Included were all patients who received sutured wound care during this period. The costs incurred were compared to the remuneration according to EBM 01210 (or 01212) with the additional flat rate for small surgical procedures EBM 02301.

RESULTS

During the observation period 1548 patients were treated, i.e. 19.52% of all trauma surgery cases. The resulting costs of a standard wound care of 45.40 € are offset by a remuneration of 31.83 €. The calculation of the total revenue shows a deficit amount of 13.57 € per outpatient case, this corresponds to an annual deficit of 21,006.36 €.

CONCLUSION

It could be shown that even without consideration of the relevant holding costs, cost coverage cannot be achieved in any case. The previous reimbursement of outpatient wound care on the basis of the EBM appears to be inadequate. In the future, an adjustment or supplementary remuneration seems to be necessary in order to ensure sufficient quality of care.

Patientenaufkommen, Diagnosen und Verletzungsmechanismen eines überregionalen Traumazentrums mit Beginn der COVID-19-Pandemie im Vergleich zum Mittelwert der 3 Vorjahre

Hintergrund

Im Rahmen der COVID-19-Pandemie wurden zur Reduktion der Infektionszahlen politische Entscheidungen getroffen, die die soziale Interaktion reduzieren sollen. Ziel hierbei war das Schaffen von Kapazitäten zur innerhospitalen Versorgung der erkrankten Patienten.

Ziel der Arbeit

Ob seit Beginn der getroffenen Maßnahmen auch eine Reduktion des unfallchirurgischen Patientenaufkommens im Vergleich zum Mittelwert der 3 Vorjahre zu beobachten ist, sollte geprüft werden.

Material und Methoden

Es wurden retrospektiv alle Patienten, die sich in unserer unfallchirurgischen Notaufnahme im Zeitraum vom 01.03.2020 bis 15.04.2020 vorgestellt haben, mit dem Mittelwert der Patienten der 3 Vorjahre 2017–2019 verglichen. Es wurden Alter der Patienten, Vorstellungszeitpunkt, Diagnosen, Verbleib der Patienten, stationär oder ambulant, Anzahl und Dauer der operativen Versorgung und benötigte Kapazität auf Normal- und Intensivstation erhoben. Der Verletzungsmechanismus wurde ebenfalls untersucht.

Ergebnisse

Es wurden insgesamt 4967 Patienten im Beobachtungszeitraum vom 01.03.–15.04. eingeschlossen. Im Schnitt der 3 Vorjahre wurden insgesamt 1348 Patienten, d. h. pro Tag 29,3 Patienten vorstellig. Im Jahr 2020 wurden insgesamt 923, d. h. pro Tag 20 Patienten vorstellig (p < 0,01).

Im Schnitt der Vorjahre wurden 227 (24,6 %) im Vergleich zu 2020 311,5 (23,1 %) stationär aufgenommen. Im Schnitt der Vorjahre resultierten 143 im Vergleich zu 2020 mit 136 Operationen hieraus. Die stationären Tage waren von 2442 im Schnitt der Vorjahre, im Jahr 2020, mit 1172 Tagen um 52,1 % reduziert. Die Anzahl der Tage auf der ICU betrug im Mittel der Vorjahre 450 Tage und im Jahr 2020 303 Tage (−32,7 %).

Diskussion

Das Patientenaufkommen in der unfallchirurgischen Notaufnahme war im Beobachtungszeitraum im Jahr 2020 im Vergleich zum Mittelwert der 3 Vorjahre deutlich reduziert. Hierdurch sind direkt Ressourcen für die Betreuung von COVID-19-Patienten frei geworden.