The situation of older Emergency Department patients. Results from a participatory observation study

Background

Elderly patients make up a substantial share of Emergency Department (ED) populations which will increase steadily in the coming decades. This poses a challenge for EDs that are not designed to care for multimorbid, frail, and care-dependent older patients. However, too little is known about the current situation of older ED patients and their specific needs. This study seeks to explore ED stays of older and geriatric patients from a patient-centered perspective.

Methods

Participatory observations of older patients’ ED stays were conducted in five different EDs in a central district of Berlin. This included the passive company of ED patients aged 65 years and older, as possible from admission to discharge or referral. The sampling strategy followed the logic of theoretical sampling. Observation notes were captured in a semi-structured protocol and subjected to systematic, comparative analysis based on the Grounded Theory approach.

Results

N = 71 cases of older ED patients were included. Patients’ mean age was 80 years and 52% were female. The total observation time amounted to 332 hours, the mean observation time was 4 hours and 40 minutes. Long waiting hours and uncertainty about the further course turned out to be burdensome for the patients. Other problems were the dependency of patients in their ability to satisfy basic needs such as toileting and hydration. Personnel mostly tried to address these needs but did not always have the capacities.

Conclusions

Like most health care institutions, EDs need to prepare for the consequences of aging societies. Older patients are more vulnerable to stressful situations such as ED stays and depend on more attention and nursing support. ED staff often lack the resources for this. Strategies are needed to adjust ED structures and processes to the specific needs of older patients. This includes the prevention of ED stays.

Key messages

Dealing with staff diversity in German hospitals: A comparative analysis of doctors and nurses

Background

Germany is increasingly recruiting foreign healthcare staff due to the shortage of skilled workers. This diversity of professional and cultural backgrounds poses a challenge to everyday life in inpatient care. Previous studies have focused on the renegotiation of professional identities and competencies in nursing or medicine. In contrast, this study sheds light on group-specific mechanisms through a comparative analysis: How do doctors and nurses deal with diversity in the workplace? Where do profession-specific differences emerge and what does this mean for future interventions?

Methods

Eight group discussions (June 2019 to October 2020) were conducted with groups of doctors and nurses with and without a migration background in four hospitals in two federal states in Germany; including 22 nurses and 10 doctors (n = 32). The data were analysed using the documentary method to examine professional meaning-making processes. The results were validated intersubjectively.

Results

The respective handling of diversity in the workplace is influenced by different professional group identities. The situation is precarious for nurses with a migration background - especially for those with an academic degree, as nursing is still an apprenticeship profession in Germany. In the medical profession, on the other hand, diversity does not lead to significant controversies, even if cultural differences are discussed.

Conclusions

Dealing with diversity is negotiated within professional groups. As nursing or medical ‘communities of practice’ (E. Wenger), these have a mediating role through which they can mitigate institutional and individual barriers to the integration of migrants in the workplace.

Key messages

Integration of migrant healthcare workforce from the perspective of leading hospital staff in Germany

Background

The German healthcare system is facing a serious shortage of healthcare professionals and is therefore dependent of foreign staff to ensure adequate healthcare. 14 % of the physicians and 17 % of the nurses working in Germany have foreign citizenship. The variety of cultural backgrounds and language skills raises the question for advantages and challenges when it comes to human resource policies in hospitals and outpatient care services.

Methods

The findings are based on 16 expert interviews with physicians, nurses, and managers in leading positions of two hospitals and two outpatient care services. These institutions differ in the extent to which they treat migrant patients and hire foreign healthcare workers.

Results

From the experts' perspective, the biggest advantage in foreign health workers are their language skills. Foreign language skills are a huge advantage provided that their knowledge matches the patients' languages and their German skills are adequate as well. Additionally, their knowledge about other medical cultures are very much appreciated. The experts see challenges in different qualifications that the professionals have gained in their home countries as well as diverse working cultures, which often leads to frustration among the teams. Therefore, too much ethnic diversity is difficult for everyday working life. Ethnic discrimination is the case in hospitals with less migrant staff and patients.

Conclusions

To ensure adequate healthcare, healthcare professionals should get a special training, which enables them to work in diverse teams with colleagues from other countries. Meanwhile, foreign staff need time to get used to new hospital structures and should feel strengthened to bring their skills in. This is a process, which the institutions must moderate and accompany constructively.

Key messages

Immigration of foreign healthcare professionals leads to multicultural teams in healthcare, which are characterized by differences in cultures and qualifications. Therefore, leading professionals should support and encourage multicultural teams to learn how to deal with this diversity in everyday working life.

Reflections on the OECD guidelines for in vitro skin absorption studies

At the 8th conference of Occupational and Environmental Exposure of the Skin to Chemicals (OEESC) (16-18 September 2019) in Dublin, Ireland, several researchers performing skin permeation assays convened to discuss in vitro skin permeability experiments. We, along with other colleagues, all of us hands-on skin permeation researchers, present here the results from our discussions on the available OECD guidelines. The discussions were especially focused on three OECD skin absorption documents, including a recent revision of one: i) OECD Guidance Document 28 (GD28) for the conduct of skin absorption studies (OECD, 2004), ii) Test Guideline 428 (TGD428) for measuring skin absorption of chemical in vitro (OECD, 2004), and iii) OECD Guidance Notes 156 (GN156) on dermal absorption issued in 2011 (OECD, 2011). GN156 (OECD, 2019) is currently under review but not finalized. A mutual concern was that these guidance documents do not comprehensively address methodological issues or the performance of the test, which might be partially due to the years needed to finalize and update OECD documents with new skin research evidence. Here, we summarize the numerous factors that can influence skin permeation and its measurement, and where guidance on several of these are omitted and often not discussed in published articles. We propose several improvements of these guidelines, which would contribute in harmonizing future in vitro skin permeation experiments.

Ongoing MRI remodeling 3-7 years after collagen meniscus implantation in stable knees

PURPOSE

The purpose of the present study was to evaluate the clinical and radiological 3-7 years outcomes of patients who underwent collagen meniscus implantation in stable or stabilized knees. It was the hypothesis that using the collagen meniscus (CMI) good clinical 3-7 years outcomes with low pain levels are achieved.

METHODS

Thirty-nine patients (male:female = 30:9, mean age 34 ± 10 years) underwent arthroscopic CMI after subtotal medial (n = 32) or lateral meniscectomy (n = 7). A 7-mm CMI was performed due to prophylactic (n = 25) or therapeutic indication (n = 14). IKDC score, Tegner score preinjury, preoperatively and at follow-up, Lysholm score and visual analogue scale for pain and satisfaction (follow-up rate 90%) were assessed. MRI scans were analyzed according to the Genovese criteria (n = 19). Implant failure was defined as infection or mechanical failure of the device. The minimum follow-up time was 36 months (range 36-84 months).

RESULTS

The mean VAS satisfaction preoperatively and at follow-up was 4.0 ± 0 and 1.6 ± 1.0. The mean VAS pain was 4.3 ± 3.2 preoperatively and at last follow-up 2.1 ± 1.7. The median Tegner score preinjury was 7 (range 3-10), it decreased preoperatively to median 3.5 (range 1-8) and nearly reached the preinjury level at last follow-up 6 (range 3-10). The mean Lysholm score before surgery was 66 ± 20 and 91 ± 8 at last follow-up. Seven patients (38.9%) had a normal total IKDC score (A), 10 patients were nearly normal (B) and 1 patient slightly abnormal (C). In MRI the CMI was entirely resorbed in 4 patients (21%) and partially resorbed in 15 (79%). In 4 patients (21%) the CMI was isointense, in 14 (74%) slightly hyperintense and in 1 (5%) highly hyperintense. Ten patients (53%) showed marked signs of bone marrow edema. In 13 patients (68%) an extrusion of the meniscus > 3 mm at last follow-up was found.

CONCLUSIONS

Meniscal substitution with the CMI showed good to excellent clinical 3-7 results. The CMI shows an ongoing remodelling with decreased signal intensity and decreased size. However, as meniscus extrusion remained at the same level and bone marrow edema decreased from 1 year to longer term follow-up, it appears that the remodeling comes to an end at about 5 years after CMI.

LEVEL OF EVIDENCE

IV.

Intercultural opening: participant observation in two hospitals and two outpatient care services

Background

The German healthcare system is facing intercultural diversity, since numerous migrant patients, nurses, and doctors are involved. This raises the question as to what extent everyday processes, working cultures and institutional framework conditions change because of this and how intercultural healthcare can be improved.

Methods

The participant observation took place on 22 days during summer 2018 in two outpatient care services and two hospitals, which show different degrees of intercultural opening (e.g. more or less migrant employees and patients). The aim was to reconstruct the daily work routine of health staff as well as the patients’ daily routine. The anonymized records include meetings, care tours, handovers and visits. The observation protocols were analyzed by documentary method and compared on two levels: degree of intercultural opening and sector affiliation.

Results

The results show that intercultural opening has a sector-specific impact on organization and daily work processes. The health staff of the hospital with high intercultural opening showed routine handling and relaxed reactions to communication difficulties due to the regular care of migrant patients, whereas that of the hospital with low intercultural opening showed stress-related defensive stance due to rare cases. The situation in the outpatient sector is different: The care of migrant patients was perceived to be more costly in the institution with high intercultural opening, because the migrant employees repeatedly perform additional socio-educational work that is not covered by insurance.

Conclusions

The migration-specific knowledge of employees has a positive effect on patient care in both inpatient and outpatient sector. However, this may be financially disadvantageous for nursing services under the conditions of outpatient care.

Key messages

Synergy effects arise from the involvement of migrant health workers and the care of migrant patients. Framework conditions must support these synergy effects in order to improve cultural sensitive healthcare.

Older Patients in Emergency Departments. Challenges from the health care providers’ perspective

Background

Patients aged 65 and above are the fastest growing patient population in Europe. This is one of greatest challenges for almost all health services providers, including acute hospitals and their Emergency Departments (ED). As of today, older patients represent up to 30% of all ED patients, it is estimated. However, it is largely unclear to what degree EDs are currently prepared for older patients and how they need to adjust. This study analyses the present situation from the perspective of health care professionals caring for older ED patients.

Methods

The study was embedded in a mixed methods design using qualitative expert interviews. N = 25 semi-structured, guided interviews were conducted with professional health care providers from 7 Berlin EDs (physicians, nurses), and adjacent health care sectors such as nursing homes, rehabilitation clinics, and medical practices. Interviewees were asked about their daily experiences with older ED patients and their ideas of health care deficits and potentials. Data was analyzed using content analysis and hermeneutics.

Results

Health care providers assess the ED care situation for older patients and the necessity of adjustments in different ways but mostly as deficient. EDs are described as not elderly-friendly and partly as hazardous: older patients are at risk of adverse events such as developing a delirium. Risk factors are prolonged length of stay, the busy and noisy ED setting, and falls hazards. In general, ED staffing is not adequate to care for older patients with complex needs.

Conclusions

Considering demographic change, German Eds need to concentrate on the growing number of oder patients and their specific needs. Further research and development of specific care concepts for older ED patients is strongly needed. Potential adjustments of ED structures and care concepts also need to involve patients’ experiences and subjective needs. However, data on the patient perspective is still missing.

Key messages

Older patients and demographic change represent great challenges for EDs. Care concepts need to be developed to meet older patients needs and to avoid risks of adverse events.

[Empirical health services research in emergency and acute medicine : Preliminary results of concomitant monitoring of patient recruitment and sample quality]

BACKGROUND

Up until now, research data on the implementation of empirical health services research in emergency departments in Germany are scarce.

STUDY AIM

A monitoring instrument applied in a multicenter prospective cohort study in emergency departments (EDs) is described and discussed regarding requirements for the control and supervision of data collection.

MATERIALS AND METHODS

Patients with cardiac diseases, respiratory tract infections, and hip fractures were recruited in eight EDs located in a central district of Berlin. Enrolment figures and nonresponder reasons were analyzed through descriptive statistics. Potential sample bias was examined in terms of response rates as well as the distribution of age and sex in the group of participants and nonresponders. Qualitative content analysis was applied to data from routine supervisory and feedback meetings with study nurses.

RESULTS

Within the first 8 months of data collection, 61.1% of the aimed 1104 patients were recruited. Most frequently stated nonresponder reasons were the dense work and care processes in EDs (41.9%) and patients' disease burden (24.7%). Moreover, qualitative results revealed problems with identifying potentially eligible participants and difficulties because of missing research infrastructure in study centers. The response rate of 50.7% and approximately equal distribution of age and sex in participants and nonresponders do not indicate sample biases.

DISCUSSION

The monitoring instrument has proven to be suited for empirical research in EDs and revealed optimization potential. We recommend using qualitative and quantitative data systematically.

The Genovese grading scale is not reliable for MR assessment of collagen meniscus implants

BACKGROUND

The purpose of the study was to evaluate the intra- and inter-observer reliabilities of the Genovese grading on MRI in patients after collagen meniscus substitution.

METHODS

84 MRI images of 74 consecutive patients who underwent partial meniscus substitution using collagen meniscus implant (CMI) were assessed. MRIs were evaluated using the Genovese grading system. Furthermore, meniscal extrusion was assessed. Two observers performed the grading twice, blinded to each other and to the previous results, with a six weeks interval. The inter- and intra-observer reliabilities were assessed using kappa and weighted kappa values.

RESULTS

The criterion "morphology/size" showed a weighted kappa value inter-observer reliability of 0.069 (rater 1)/0.352 (rater 2) and intra-observer reliability of 0.170 (1st rating)/0.582 (2nd rating). The criterion "signal intensity" showed a weighted kappa value inter-observer reliability of 0.175/0.284 and intra-observer reliability of 0.294/0.458. The criterion "cartilage lesions" showed a kappa value inter-observer reliability of 0.091/0.525 and intra-observer reliability of 0.409/0.413. The criterion "bone marrow edema" showed a kappa value inter-observer reliability of 0.667/0.808 and intra-observer reliability of 0.702/0.715. The criterion "cartilage lesions" showed a kappa value inter-observer reliability of 0.091/0.525 and intra-observer reliability of 0.409/0.413. Regarding meniscal extrusion kappa values for the inter-observer reliability were 0.625/0.940 and 0.625/0.889 for intra-observer reliability.

CONCLUSIONS

Three of the four Genovese grading items showed only slight to moderate inter- and intra-observer reliabilities in evaluating CMI on MRI. Hence, such grading results need to be considered with all due care. Only the criteria "bone marrow edema" and "meniscal extrusion" showed a good agreement for both inter- and intra-observer reliabilities.

Early intervention of patients at risk for acute respiratory failure and prolonged mechanical ventilation with a checklist aimed at the prevention of organ failure: protocol for a pragmatic stepped-wedged cluster trial of PROOFCheck

INTRODUCTION

Acute respiratory failure (ARF) often presents and progresses outside of the intensive care unit. However, recognition and treatment of acute critical illness is often delayed with inconsistent adherence to evidence-based care known to decrease the duration of mechanical ventilation (MV) and complications of critical illness. The goal of this trial is to determine whether the implementation of an electronic medical record-based early alert for progressive respiratory failure coupled with a checklist to promote early compliance to best practice in respiratory failure can improve the outcomes of patients at risk for prolonged respiratory failure and death.

METHODS AND ANALYSIS

A pragmatic stepped-wedged cluster clinical trial involving 6 hospitals is planned. The study will include adult hospitalised patients identified as high risk for MV >48 hours or death because they were mechanically ventilated outside of the operating room or they were identified as high risk for ARF on the Accurate Prediction of PROlonged VEntilation (APPROVE) score. Patients with advanced directives limiting intubation will be excluded. The intervention will consist of (1) automated identification and notification of clinician of high-risk patients by APPROVE or by invasive MV and (2) checklist of evidence-based practices in ARF (Prevention of Organ Failure Checklist-PROOFCheck). APPROVE and PROOFCheck will be developed in the pretrial period. Primary outcome is hospital mortality. Secondary outcomes include length of stay, ventilator and organ failure-free days and 6-month and 12-month mortality. Predefined subgroup analysis of patients with limitation of aggressive care after study entry is planned. Generalised estimating equations will be used to compare patients in the intervention phase with the control phase, adjusting for clustering within hospitals and time.

ETHICS AND DISSEMINATION

The study was approved by the institutional review boards. Results will be published in peer-reviewed journals and presented at international meetings.

TRIAL REGISTRATION NUMBER

NCT02488174.

[Stroke occurence in Germany - on the comparability of insurance data and registry-based data]

PURPOSE

This article presents epidemiological data regarding stroke frequency in Germany based on nationwide statutory health insurance data (Deutsche BKK) and aims to analyse them in the context of current research. The comparability of the most important resources of stroke frequency data - stroke registers, DRG data and insurance data - is initially discussed in order to assess the presented data adequately.

METHODS

The study cohort comes from a population of about 1 000 000 people insured with BKK and consists of all persons who were treated for a stroke in an acute care hospital in 2007 (n = 4,843). Data were subjected to statistical secondary analysis including uni- and bivariate statistics and t tests. Reference studies for the observation period include data from GEK and AOK health insurances, from quality assurances Hessen and Bayern, from the ADSR, and hospital DRG data. The different study types are compared regarding their inclusion/exclusion criteria and the resulting effects on reported prevalences.

RESULTS

Different inclusion criteria and accordingly different operationalisations of "stroke" impede the comparability of existing German data resources regarding stroke. The inclusion of TIA, non-traumatic subdural haemorrhage (I62), and the frequency of unspecified strokes (I64) is especially inconsistent. In addition, recurrent strokes and the definition of first-ever strokes are treated differently. The study cohort reveals no major discrepancies regarding aetiological subgroups compared to previous results, only the percentage of women (60.3 %) seems exceptionally high.

CONCLUSIONS

The gender effect is attributed to the BKK member structure, and especially the high proportion of women in the older age groups. Discussion of stroke frequency in Germany needs to take structural differences between study types into account. There are two vulnerable groups that tend to be underrepresented: TIA patients with a high risk of recurrent strokes, and high-risk patients who have already had a stroke and are care-dependent, which are often unspecifically coded. In the future, study designs should include the whole range of stroke coding, thus enabling differentiated analyses.

[Physio- and occupational therapy pathways of stroke patients and stroke mortality]

AIMS

This study examines the relationship between adherence to clinical guidelines and survival time in the first year after stroke.

METHODS

The sample comprises all clients of the Deutsche BKK, a large German health insurance company, who received acute inpatient care for stroke in 2007, who survived the hospital stay by at least 14 days, and who had motor deficits at the end of their acute treatment (n=1 791). 3 types of treatment that differ in the degree of adherence to clinical guidelines are identified ("Frühreha-Plus">"Standard-Plus">"Nur Akut").

RESULTS

There is a positive relationship between adherence to clinical guidelines and survival time, even when relevant covariates are controlled. The hazard-ratios are 0.49 for "Frühreha-Plus" and 0.65 for "Standard-Plus" compared to "Nur Akut".

CONCLUSIONS

Healthcare processes should be organized on the basis of cross-sector collaboration and in line with the recommendations of the guidelines.

[A cross-sectorial analysis of physio and occupational therapy pathways after stroke]

PURPOSE

This article examines the provision of physiotherapy and occupational therapy for stroke patients from a cross-sectorial perspective, from acute to rehabilitative care to outpatient services.

METHODS

The sample comprises all clients of the Deutsche BKK, a large German health insurance company, who received acute care for stroke in 2007, who survived the initial hospital stay, and who had a secondary diagnosis of motor deficits (n = 1 929).

RESULTS

For 60.4% of these stroke patients, no further treatment was provided after acute care. The odds of receiving early rehabilitation treatment while in hospital stay decreased by 1% with each year of life. Only 18.8% of patients received a form of treatment that was largely in line with current recommendations for stroke care, beginning with early rehabilitation and including further treatment in the context of rehabilitation measures or outpatient care. Patients who were in long-term nursing care before stroke were at increased risk of not being placed on this treatment pathway, which has been positively evaluated. 20.7% of patients did not receive any early rehabilitation treatment, but received further rehabilitation treatment and/or outpatient services after hospital discharge.

CONCLUSIONS

We recommend that receipt of long-term nursing care should routinely be regarded as a risk factor for underprovision of treatment after stroke (yellow flag).

One-year clinical and MR imaging outcome after partial meniscal replacement in stabilized knees using a collagen meniscus implant

PURPOSE

The purpose of the study was to evaluate the clinical and radiological outcomes after medial/lateral collagen meniscus substitution (CMI) at 12 months postoperatively.

METHODS

Sixty-seven patients (m:f = 47:20, mean age 36 ± 10 years) underwent arthroscopic CMI after previous subtotal medial (n = 55) or lateral meniscectomy (n = 12) due to persistent joint line pain (n = 25) or to prophylactic reasons (n = 42). Clinical follow-up consisted of IKDC score, Tegner score, Lysholm score, and visual analog scale for pain and satisfaction (preinjury, preoperatively, and 12 months postoperatively; follow-up rate 90 %). MRI scans were analyzed according to the Genovese criteria.

RESULTS

Nineteen patients (29 %) showed a normal (A), 35 nearly normal (B), 5 abnormal (C), and 1 patient severely abnormal total IKDC score (D). The median Tegner preinjury score was 7 (range 2-10) and at follow-up 6 (range 2-10). The mean Lysholm score before surgery was 68 ± 20 and 93 ± 9 at follow-up. Preoperatively, the mean VAS pain was 4.4 ± 3.1 and 2.0 ± 1.0 at follow-up. Clinical failure of the CMI occurred in 3 patients (n = 1 infection, n = 1 failure of the implant, n = 1 chronic synovitis). On MRI, the CMI was completely resorbed in 3 patients (5 %), partially resorbed in 55 (92 %), and entirely preserved in 3 (5 %) patients. In 5 patients (8 %) the CMI was isointense, in 54 (90 %) slightly and 1 (2 %) highly hyperintense. 43 (72 %) patients showed an extrusion of the CMI implant of more than 3 mm.

CONCLUSIONS

Significant pain relief and functional improvement throughout all scores at 1 year was noted. The CMI undergoes significant remodeling, degradation, resorption, and extrusion in most of the patients. No difference in outcomes between the medial and lateral CMI was observed.

LEVEL OF EVIDENCE

Prospective therapeutic study, Level IV.