[Implementation of a standardized perioperative pain management concept in three hospitals of a consortium]

BACKGROUND

Provision of sufficient perioperative pain therapy is an obligation in the clinical management of patients suffering from pain. The implementation of a standardized pain management concept was planned to be introduced in the clinical routine. The results of three hospitals are shown.

MATERIAL AND METHODS

The concept included tools which gave information about legal aspects and basic fundamentals of pain relief, management modules regarding agreements on the implementation of perioperative pain therapy, instruments to measure pain intensity, assigning accountability and documentation modules. Questionnaires were carried out according to Picker.

RESULTS

The project revealed that, according to the Picker questionnaire, about 50% of the patients treated in the hospitals had pain, 30-40% still had intensive pain during the stay in hospital and 90% of the patients received pain relief medication within 10 min of the request. More than 78% of the patients thought the hospital staff did their best to relieve the pain and over 92% found the pain treatment adequate.

CONCLUSION

It was possible to implement a standardized perioperative pain therapy concept in three hospitals of a consortium. Whether an adequate pain relief can be improved with the help of standard measurements and documentation, could not be evaluated in this study.

[Formulation of reference ranges within the scope of quality assurance from case account totals and special reimbursement. Are results of clinical studies helpful?]

Normal ranges, which were set up for quality control, serve to define an acceptable qualitative niveau of treatment. To establish such criteria, it is important to consider group-specific characteristics during investigations. Results of clinical trials are the basics to determine the normal range of parameters of quality control. For external evaluation of data, which were not obtained in clinical studies, but in daily routine, normal ranges of the regional hospitals, which participated in the trial, are recommended to be included. However, an adequate total number of data is the prerequisite to allow statistically relevant evaluation.

[Male subfertility and conventional in vitro fertilization in Germany 1990 to 1993]

A retrospective study was carried out to compare the results of in vitro fertilisation (IVF) in 20936 patients with different sperm parameters who underwent IVF in Germany between 1990 and 1993. The study was designed to evaluate prognostic factors for IVF outcome, such as sperm parameters and pre-treatment diagnosis. The percentage of subfertile sperm parameters ( < 10 millions sperm per ml and/or < 30% progressive mobility and/or < 30% normal morphology) increased from 31.4% in 1990 to 51.1% in 1993. The fertilisation rate per puncture varied between 87.9% in patients with normozoospermia and 38.7% in patients with severe oligo-astheno-teratozoospermia (OAT). The fertilisation rate in patients with tubal indication was significantly higher than in patients with male indication and comparable spermatozoa. The pregnancy rate per embryo transfer was 23% in patients with normozoospermia and 13.8% in patients with "severe OAT syndrome" in the IVF semen parameters. On the other hand, patients with male sterility as pre-treatment diagnosis showed significantly higher chances of pregnancy than patients with a tubal factor (24% versus 20%, p < 0.05). Comparing percoll and swim-up preparation techniques, we found significantly higher fertilisation rates in normozoospermia and significantly higher pregnancy rates in subfertile patients after percoll sperm preparation. The results of the study demonstrated that patients with moderate subfertile sperm parameters have good chances of fertilisation and pregnancy following conventional IVE. It seems reasonable to set the boundary at a sperm count of 10 millions sperm/ml with 30% progressive motility and 30% normal morphology. Below these limits intracytoplasmic sperm injection shows better IVF outcome.

[Does quality assurance modify clinical research, medical progress and medical graduate education in surgery?]

For years, external safeguard of quality has been continuously practised in the field of surgery by several local medical societies. Beside its original task of comparing and reviewing given standards of all surgical departments, other clinically or scientifically relevant questions can be answered on the basis of the enormous numerical data, too. The patient data, available to the chamber of physicians of Westphalia-Lippe, German, are showing that the experiences of clinical research rapidly and almost ubiquitously find their expression in the daily routine work of surgeons. Examples like the introduction of routine thrombosis prophylactics of changes in the surgical techniques for inguinal rupture and gallstone show how progress in medicine by postgraduate medical education is realized in the daily clinical workday routine.

[Polytrauma and femoral fracture]

From 1976 to 1986 1.003 polytraumatized patients were treated at our institution. 88% had suffered fractures of spine, pelvis and limbs. Of particular relevance are the femoral fractures (36% of all cases) in the management of those patients. In not adequately immobilized femoral fractures the rate of general and local complications in this group is elevated. Impaired microcirculation and the required high doses of analgesics can lead to an increased risk of eventually lethal ARDS. From 1976 to 1983 we used the conventional approach and stabilized femoral fractures using plates and IM nails. Due to the time required for the operation, the eventual blood loss and the invasiveness of the operation, we could operate only on 44% of the femoral fractures within the first 24 hours. In 1984 we introduced the DAF device in our service and used it in compound femurs and unstable patients with femoral fractures. In the other cases the locking nail (GK Nail) was used. With this concept we managed to increase the rate of surgery of femoral fractures in polytrauma victims within the first 24 hours to 80%. Further assessment of the date showed a significant drop of 27.3% in mortality, mainly due to a decreased rate in late ARDS-related deaths. The advantage of the DAF concept in the stabilization of these fractures in polytrauma victims we see in the less time consuming fixation, the minimal blood loss, easier ICU care and fewer local complications. The DAF device is used as a definitive management tool and does not generally require a change to another method of fixation.