Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study

BACKGROUND

In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals.

OBJECTIVE

This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals.

MATERIAL AND METHODS

This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation.

RESULTS

The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources.

CONCLUSION

In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

[Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study]

BACKGROUND

In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals.

OBJECTIVE

This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals.

MATERIAL AND METHODS

This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation.

RESULTS

The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources.

CONCLUSION

In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

Course of psychiatric comorbidity and utilization of mental health care after laryngeal cancer: a prospective cohort study

In a German multi-center prospective cohort study, we wanted to assess the course of psychiatric comorbidity, utilization of mental health care and psychosocial care needs in laryngeal cancer patients during the first year after partial laryngectomy (PRL). Structured interviews with patients were conducted before surgery, 1 week (1 w), 3 months (3 m) and 1 year (12 m) after PRL. Psychiatric comorbidity was assessed using the Structured Clinical Interview for DSM-IV (SCID). Psychosocial care needs and utilization of mental health care were evaluated with standardized face-to-face interviews. In 176 patients, psychiatric disorders were prevalent in 11 % (1 w), 15 % (3 m) and 14 % (12 m), respectively, of which 4 % (12 m) underwent psychiatric treatment or psychotherapy. Two percent had acute, 15 % emerging and 6 % chronic psychiatric comorbidity. Chronically mental ill patients were more frequently younger than 65 years (p = 0.026), female (p = 0.045) and experienced more often a need for psychological counseling (p ≤ 0.001). One year after surgery, 27 % of the comorbid psychiatric patients expressed a need for additional psychological counseling. Alcohol-related disorders were diagnosed in 3 % (1 w), 3 % (3 m) and 8 % (12 m), respectively. Only one of these patients received psychological treatment, while 14 % expressed a need for psychological counseling and 7 % for additional medical consultations. The non-treatment of alcohol-related disorders measured in our sample indicates a major problem since continued alcohol consumption in laryngeal cancer patients is associated with reduced global quality of life, increased functional impairments and reduced overall survival. Screening instruments integrated into acute care are necessary to detect harmful drinking behavior.

[Progress of Rehabilitation for Cardiac Patients Depending on the Degree of Self-Sufficiency at Admission]

INTRODUCTION

There are hardly any publications about the outcome of cardiac rehabilitation considering patients with an increased need for medical, nursing and therapeutic care. The aim of this study, which consecutively included n=387 statutory health insurance inpatients over a period of 2 years, was to find out differences in outcome in self-care patients (Barthel index>70) as compared to patients with a need for complex care (Barthel index≤70).

METHODS

Rehabilitation outcomes concerning physical capacity, emotional status and activities of daily living as measured by Barthel index, FIM index, HADS, clinical complications, exercise test, duration of rehabilitation and form of dismission were analyzed and compared between both groups.

RESULTS

The inpatients with a Barthel index ≤70 at admission were older, had a longer stay in hospital and in rehabilitation, developed more complications and more often suffered from concomitant diseases. They were readmitted to hospital more often. They showed a comparatively higher increase in indices of self-care and a significant increase in physical performance tests.

CONCLUSION

Higher medical care expenses of multimorbid cardiac inpatients are no contraindication against rehabilitation, because even in this group the specific rehabilitation aims of the healthcare payers can be reached.

Mental disorders and psychosocial support during the first year after total laryngectomy: a prospective cohort study

OBJECTIVES

To assess the frequency of mental disorders and the use of psychosocial services in laryngectomised patients during the first year after surgery.

DESIGN

Multicentre prospective study including six interviews. Data regarding psychiatric comorbidity 3 months (3 m) and 1 year (12 m) after total laryngectomy (TLE) are reported in this study.

SETTING

Structured interviews were conducted at nine hospitals and three rehabilitation centres in Germany.

PARTICIPANTS

One hundred and seventy-one patients were interviewed at both time-points.

MAIN OUTCOME MEASURES

Structured clinical interview for DSM-IV (SCID).

RESULTS

Mental disorders were diagnosed in 25% of the patients (3 m) and in 22% of the patients (12 m), respectively. Six per cent of the patients developed a mental disorder during the first year after total laryngectomy. In general, male and female patients suffered from mental disorders with equal frequency (3 m: 23% versus 37%; P = 0.26; 12 m: 22% versus 21%; P = 1.00). Women suffered more often than men from post-traumatic stress disorder (3 m) (P = 0.01) and generalised anxiety disorder (12 m) (P = 0.01).Of the patients who had acquired no voice, 20% suffered from alcohol dependence (P = 0.01) [corrected]. There were no differences between men and women in receiving any kind of counselling (P = 0.79) or psychotherapy/psychiatric treatment (P = 0.47). Of those patients diagnosed with any mental disorder 3 months after total laryngectomy, 7% had received psychotherapy 1 year after total laryngectomy. None of the patients diagnosed with alcohol dependence received psychotherapy or psychiatric treatment.

CONCLUSIONS

Mental disorders occur in laryngectomees as frequently in men as they do in women. Total laryngectomised patients who were mentally ill did not receive enough psychotherapeutic or psychiatric support. As mental health seems to be related to successful voice restoration, future research should develop and evaluate special psychosocial supportive programmes for patients with laryngeal cancer, especially regarding alcohol dependence treatment.

[Diseases of the peripheral vestibular system: contribution of ENT medical diagnostics and therapy]

The most common types of vertigo caused by diseases of the peripheral vestibular system are benign paroxysmal positional vertigo (BPPV), Meniere's disease and vestibular neuritis. A thorough examination of the medical history and clinical examination are usually sufficient for the differential diagnostics. Treatment includes differentiated repositioning maneuvers, medicinal treatment and physiotherapy.

[Vocational rehabilitation after total laryngectomy]

BACKGROUND

Aim of this study was to find out how many patients after a total laryngectomy (TLE) return to work successfully and what factors support vocational rehabilitation.

PATIENTS AND METHODS

Laryngectomees (n=231) aged up to 60 years completed questionnaires and structured interviews before TLE (t1), before rehabilitation (t2), at the end of rehabilitation (t3), 1 year after TLE (t4), 2 years after TLE (t5), and 3 years after TLE (t6).

RESULTS

Prior to TLE, 38% of all respondents were employed, 34% were unemployed, 23% received disability-related and 3% age-related pension retirement. One year after TLE, 13% were employed, 15% 2 years and 14% 3 years after TLE. Unemployed were 10% (t4), 5% (t5), and 7% (t6) of the patients. For 59% of all respondents it was very important to have a job. Predictors of successful vocational rehabilitation were employment prior to TLE, age <50 years, being self-employed or clerical employee, good physical functioning, good speech intelligibility, high motivation to go back to work, and support from colleagues.

CONCLUSION

Only few laryngectomees return to work. However, even before TLE only a third of the patients was employed, another third was unemployed. Most of the patients receive pension retirement after TLE. As return to work is important for many patients, patient consultations should consider possibilities to support vocational rehabilitation before offering to apply for retirement.

[Use of cancer support groups by laryngectomees in central Germany]

BACKGROUND

Cancer support groups provide information and coping resources as well as represent patients' interests. To date it is unknown how often cancer patients post-laryngectomy use support groups and in which parameters users of support groups differ from non-users.

MATERIAL AND METHODS

In a multicentre study, 224 laryngectomees were asked about their support group membership. Further, possible predictors for membership one year post-surgery were assessed. Data were collected with a semi-structured interview and standardized instruments.

RESULTS

Overall, 23% of the laryngectomized patients are actively involved in cancer support groups. The probability of a membership increases if patients are well-educated, are living in good economic conditions and in a partnership, if they perceive low family support and wish additional counselling with a physician.

CONCLUSION

A cancer support group seems to "buffer" family support perceived to be insufficient. However, support group users are living more frequently in a partnership and in good economic conditions compared to non-users. Physicians and speech therapists are important mediators to cancer support groups. They particularly should inform laryngectomees who are living in bad economic conditions and who are not living in a partnership about the availability of cancer support groups.

[The role of sex in voice restoration and emotional functioning after laryngectomy]

BACKGROUND

Data on psychosocial factors of laryngectomized women is rare. All means of alaryngeal voice production sound male due to low fundamental frequency and roughness, which makes postlaryngectomy voice rehabilitation especially challenging to women. Aim of this study was to investigate whether women use alaryngeal speech more seldomly and therefore are more emotionally distressed.

MATERIAL AND METHODS

In a cross-sectional multi-centred study 12 female and 138 male laryngectomees were interviewed. To identify risc factors on seldom use of alaryngeal speech and emotional functioning, logistic regression was used and odds ratios were adjusted to age, time since laryngectomy, physical functioning, social activity and feelings of stigmatization.

RESULTS

Esophageal speech was used by 83% of the female and 57% of the male patients, prosthetic speech was used by 17% of the female and 20% of the male patients and electrolaryngeal speech was used by 17% of the female and 29% of the male patients. There was a higher risk for laryngectomees to be more emotionally distressed when feeling physically bad (OR=2,48; p=0,02) or having feelings of stigmatization (OR=3,94; p≤0,00). Besides more women tended to be socially active than men (83% vs. 54%; p=0,05).

CONCLUSIONS

There was no influence of sex neither on use of alaryngeal speech nor on emotional functioning. Since there is evidence for a different psychosocial adjustment in laryngectomized men and women, more investigation including bigger sample sizes will be needed on this special issue.

[The use of resorbable osteosynthesis materials]

INTRODUCTION

Different materials can be used for fixation of fractures or for osteoplastic operations in head and neck surgery. Especially metallic and resorbable implants are at the market now. Advantages and disadvantages of the different implants should be considered as decisive for different indications.

PATIENTS AND METHODS

We retrospectively analyzed the patients since 1999 which we operated using such resorbable materials. From 1999 until 2006 we used LactoSorb(®). 2007 we introduced the Resorb X(®) plates and -meshs and the SonicWeld Rx-System(®). Here the plates or meshs will be fixed by an ultrasonically welded pin.

RESULTS

In 52 cases we implanted LactoSorb(®) and Resorb X(®) with the SonicWeld Rx-System(®). In 2 cases we saw a foreign body reaction that resulted in a fistula. In one case a plate broke after fixing.

CONCLUSION

The use of resorbable materials with ultrasonically welded pin osteosynthesis resulted in a stable mechanical connection, an easy intraoperative handling and a low rate of complications. Those materials can be used for traumatologic and osteoplastic reconstructions in head and neck surgery.

Side-effects of topical androgenic and anabolic substances and steroids. A short review

There is an increasing interest, including androgenic and anabolic substances (AAS). The uncritical use may be associated with severe adverse effects. We observed five patients with different patterns of adverse reaction to AAS: two females and three males, they were identified when seeking medical help and advice. The following adverse effects from of AAS have been observed: deepening of the voice due to topical use of AAS in an anti-cellulite cream; circumscribed hypertrichosis and late onset acneiform eruptions due to testosterone replacement therapy after ovariectomy; homolateral gynecomastia and infertility, acne and striae distensae in males using injectable AAS.

CONCLUSIONS

ASS can trigger significant adverse effects. An interdisciplinary approach may be necessary for evaluation. The dermatologists should be familiar with the adverse effects.

[Vaccination project for vocational students]

As part of a North-Rhine-Westphalian state project the district of Unna developed a vaccination programme for continuation schools in 1996. The reason for this programme realized for the first time in a vocational school, was a considerable lack of protection by vaccination in ninth year classes. The present results from the first vocational school show a significant lack of standard vaccination as well as boosters. To improve the current situation it will be necessary to authorize and enable the Public Health Services to carry out even more standard and indication vaccinations at secondary and vocational schools as well as at institutions for the handicapped.

[Differences in auditory frequency discrimination ability in musicians of different specialties]

The frequency discrimination capacity of 63 musicians of different specialties (singers, string players, wood and brass players, pianists and rhythm teachers) was investigated using a binaural frequency discrimination test. Statistically significant differences between the groups of musicians were found. The string players revealed the highest tuning reproducibility. The results show that frequency discrimination capacity is influenced by specific phenomena of the instrumental education.

[Receptive musical aptitude using a binaural frequency discrimination test]

Musical aptitude is the most important precondition for any applicant taking up studies at a music conservatory. Thus, the applicants are tested and assessed very thoroughly by experienced music teachers. To support these subjective results by objective data a procedure was developed allowing to test both the examinee's frequency and octave discrimination capacity in a simple way. In a 1-Hz cycle the frequencies f1 and f2 are directed mutually to the right and left ear, respectively, at a defined sound level. Then the examinee is asked to syntonize e.g. frequency equality f1 = f2 (or f1 = 2 x f2). It can be shown that there is a direct correlation between the amount of deviation from nominal frequency and subjective assessment of musicality.

The significance of coronary topography for operative technique and tactics in multiple myocardial revascularization with jump-grafts

Aortocoronary bypass procedures for proximal lesions are accepted with widely documented excellent results, but are still controversial in their application for diffuse disease. However, failures of the single graft technique to small coronary branches with marginal flows are markedly reduced by the jump technique. In our experience with 447 angiographic controls from April 1978 to December 1980, the jump-graft patency rate was 87.8% versus 84.9% for single grafts, and as high as 96.3% in the subgroup of multiple jumps (sequential grafts). The sequence of the anastomoses as far as the individual flow is concerned significantly influences the results of the jump-graft technique.