Case delay in the OR morning start in hospitals of different size and academic status : Results from a German multicenter study to identify incidence and causes of delayed anesthesia ready time.

BACKGROUND: Delays in the start of morning operations cause a loss of expensive OR capacity as well as frustration and potential conflicts among the different professions involved. There are a lot of reasons which can lead to delayed anesthesia ready time (ART). This is the first large multicenter study to identify incidence, extent and reasons of delay in ART. METHODS: First case delays in ART were studied in all regular ORs in 36 hospitals of different sizes (smaller community hospitals, larger community hospitals and university hospitals) over a period of 2 weeks. We analyzed the results comparing the 3 hospital types regarding incidence, extent and reasons for delay. RESULTS: A total of 3628 first of day cases were included in the study. Incidences of delayed ART (delay >5 min) ranged from 26.5% in university hospitals to 40.8% in larger community hospitals. However, university hospitals had higher incidences than smaller community hospitals of delays greater than 15 and 30 min. The main reasons for delays were prolonged induction of anesthesia, patient in-hospital logistics and delayed patient arrival at the hospitals. The highest mean delay of delayed cases was found in university hospitals with 21.7 min ± 14.7 min (SD). CONCLUSIONS: Delays in anesthesia ready time have a high prevalence in most hospitals, however the reasons for delay are manifold, making interventions to reduce delay complex.

[Delayed incision time of the first case : Analysis of incidences and causes and the effect of list planning instability]. / Verzögerungen der Schnittzeit des ersten Falles : Analyse von Inzidenzen und Ursachen sowie des Effektes von Planinstabilität.

BACKGROUND: Delays in beginning operations in the morning lead to a loss of valuable operating time and can cause frustration among the medical personnel involved. OBJECTIVE: So far there are no prospective, multicentric investigations of the incidence and reasons for delayed first incision times in the morning. The effect of planning list instability of first cases on late operating room starts has not yet been evaluated. MATERIAL AND METHODS: In this multicenter prospective study delays in surgical incision time in all first cases of the day were investigated in 36 German and Swiss hospitals (14 surgical specialties) over a period of 2 weeks. RESULTS: A total of 3628 first of the day cases were included in the study. Looking at all subspecialties combined 50.8% of the first cases of the day were delayed by more than 5 min and in 30.2% of cases longer than 15 min. Incidences of delayed surgical incision time >5 min ranged from 40.0% (gynecology) to 66.8% (neurosurgery). The main reasons for delays in ascending order were prolonged induction of anesthesia compared to the planned time, the delayed appearance of the surgeon and prolonged preparation for surgery. The incidence of delays in incision times for planning list instability was increased by 10% and the average delay increased by 7 min. CONCLUSION: Delays in surgical incision times of the first operation of the day have a high incidence in most surgical specialties; however, the reasons for delays are manifold. Plan instability of operating room lists with respect to the first cases has a negative effect on the punctuality of the incision time and should therefore be avoided.

[Algorithm for flexible decision-making in the intra-hospital management of patients with the changing requirements of the SARS-CoV-2 pandemic]. / Flexibler Entscheidungsalgorithmus zum innerklinischen stationären Patient*innen-Management unter wechselnden Anforderungen der SARS-CoV-2-Pandemie.

After the initial fulminant outbreak, the SARS-CoV­2 pandemic has now taken a more protracted course which, nevertheless, challenges hospitals in returning to a "normal" mode and in preparing for a worst-case scenario of a second wave. Not only the organization of the first contact with the patient and the admission in the emergency department but also the admission as an in-patient and the subsequent management requires both flexibility and clear directions of action for the medical personnel involved. The aim of the algorithm was to develop a structured, easy to implement and easy to follow guideline while simultaneously preserving resources. The algorithm covers some key points of decision making such as clinical signs, first contact, admission for in-patient treatment, consequences of swab and computed tomography (CT) results, and allocation and isolation measures within the hospital. The algorithm is not intended to guide diagnostics, decisions and treatment in the narrower medical sense but to provide more general instructions for the management of in-patients considering specific aspects of SARS-CoV­2.

[Does hospital volume correlate with surgical process time? : Retrospective analysis of the five most common procedures for visceral surgery, trauma and orthopedic surgery and gynecology/obstetrics from the benchmarking program of the Berufsverband Deutscher Anästhesisten (BDA), Berufsverband Deutscher Chirurgen (BDC) and Verband für OP-Management (VOPM)]. / Korreliert die Leistungsmenge eines Krankenhauses mit der chirurgischen Prozesszeit? : Retrospektive Analyse der jeweils fünf häufigsten Prozeduren aus den Bereichen Viszeralchirurgie, Unfall­/orthopädische Chirurgie und Gynäkologie/Geburtshilfe aus dem Benchmarking-Programm von BDA, BDC und VOPM.

BACKGROUND: Minimum volume thresholds for specific surgical procedures in German hospitals were established in 2004 but remain controversial. For the first time, this study investigated the relationship between hospital performance volume and surgical procedure duration in a multicenter approach. The question here was whether a concentration on frequently performed procedures leads to a reduction in surgical process times. METHODS: In a retrospective analysis, the 5 most common procedures from visceral, trauma/orthopedic and gynecological/obstetrics surgery were examined in hospitals participating in a benchmarking program. For each procedure performed between 2013 and 2015, hospitals were divided into 4 groups depending on the hospital volume provided. The average surgical duration of incision to suture time was calculated between the group with "very low" hospital volume and the other three groups ("low", "high" and "very high"). RESULTS: OR cases from 75 hospitals were analyzed. The number of included cases per procedure ranged from 31,940 to 2705. The average number of operations performed in a specific procedure was 3-4 times higher in high-volume hospitals compared to very low-volume hospitals. A linear relationship between hospital volume and surgical process time only appeared to be clearly seen in laparoscopic cholecystectomy, appendectomy and arthroscopic meniscus surgery: a higher case load led to a reduction in incision to suture time. For the other procedures, the surgical process times were inconsistent between the hospital groups. CONCLUSION: The case volume only appeared to have a direct but limited influence on incision to suture times in laparoscopic and arthroscopic procedures. Overall, the hospital performance volume appeared to be of subordinate importance in terms of OR-economics.

[Cost estimation for hospital mass casualty exercises]. / Kostenabschätzung für MANV-Übungen im Krankenhaus.

A mass casualty event (MCE) poses an enormous challenge for rescue services and hospitals. In addition to a hospital emergency plan, employee training and practice exercises are essential to be prepared for such an event. The organizational and financial burden of MCE exercises in a hospital is extraordinarily high. In a retrospective analysis of several large hospital exercises, the magnitude of the necessary financial means for the preparation and execution of such drills is outlined. Depending on the size (number of patients) and scope (extent of departments involved) of the MCE exercise in a hospital, a full-size MCE drill may entail costs between 10,000 and 100,000€. Since the execution of such exercises is essential in the sense of preparedness and considering quality management aspects, possibilities of refinancing and more cost-efficient training must be developed.

[Reorientation of Medical Procedures Covered by Statutory Accident Insurance]. / Neuausrichtung der Heilverfahren der Gesetzlichen Unfallversicherung.

As of 01/01/2014, the German Statutory Accident Insurance (DGUV) has reorganized inpatient medical procedures. The central element of reorientation is the reorganization of the catalogue of types of accidents and type of medical procedures of hospitalized injured patients in 3 care stages. In addition, the reorientation also concentrates on hospitals with the highest performance and the best qualification and also focuses on severe and most severe injuries.This reorientation is also based on the White Paper of the German Society for Trauma Surgery (DGU), especially on the Trauma Network DGU. The new regulations will be implemented by the state associations of the German Statutory Accident Insurance.The hierarchy of care depends on established admission criteria and the severity of injury. This structuring also refers to special competence in the field of rehabilitation and will lead to the strengthening of multidisciplinary rehabilitation management and workplace-related modules of the healthcare. Overall, the accident insurance institution will place increased demands on their network partners.

[Medical controlling as medical economical service center. Successful concept for orthopedics and trauma surgery centers?]. / Medizincontrolling als medizinökonomisches Dienstleistungszentrum. Erfolgskonzept für Orthopädie und Unfallchirurgie?

The management of patients from administrative admission through the orthopedic-surgical treatment to completion of the billing is complex. Additional challenges originate from the necessity to treat patients in both outpatient and inpatient departments and in more than one medical sector. A superior coordination is essential for a successful cooperation of the various procedures of controlling. The model of a medical controlling department as a service center with effective competence in the management of service and cost, functions as a successful solution to the problem. Central elements of a successful medical economical case management are a well-defined assignment of tasks and definitions of intersections, the integration of health professionals and administrative employees, the utilization of software for process control and the implementation of inlier controlling.

[Quality of case allocation of orthopedics and trauma surgery in the 2004 and 2014 versions of the German DRG system. An interim assessment of the development process]. / Abbildung orthopädisch-unfallchirurgischer Leistungen in den G-DRG-Systemversionen 2004 und 2014. Eine Zwischenbilanz des Weiterentwicklungsprozesses.

BACKGROUND: Since 2004 the German diagnosis-related groups (DRG) system has been applied nationwide in all German somatic hospitals. The G-DRG system is updated annually in order to increase the quality of case allocation. What developments have occurred since 2004 from the perspective of orthopedics and trauma surgery? This article takes stock of the developments between 2004 and 2014. METHODS: Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2004 and 2014 based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS: The number of G-DRGs in the whole system increased by 45.1 % between 2004 and 2014. The number of G-DRGs in the major diagnostic category (MDC) 08 that contains the majority of orthopedic and trauma surgery categories increased in the same period by 61.6 %. The reduction of variance of inlier costs in the MDC 08 category, a statistical measure of the performance of the G-DRG system, was below the corresponding value of the total system in 2004 as well in 2014. However, the reduction of variance of inlier costs in MDC 08 (+ 30.0 %) rose more from 2004 to 2014 than the corresponding value of the overall system (+ 21.5 %). CONCLUSION: Many modifications of the classification systems of diagnoses (ICD-10-GM) and medical procedures (OPS) and the structures of the G-DRG system could significantly improve the quality of case allocation from the perspective of orthopedics and trauma surgery between 2004 and 2014. Th assignment of cases could be differentiated so that complex cases with more utilization of resources were allocated to higher rated G-DRGs and vice versa. However, further improvements of the G-DRG system are necessary. Only correct and complete documentation and coding can provide a high quality of calculation of costs as a basis for a correct case allocation in future G-DRG systems.

[Implementation of the laryngeal tube for prehospital airway management: training of 1,069 emergency physicians and paramedics]. / Implementierung des Larynxtubus im präklinischen Atemwegsmanagement: Ausbildung von 1069 Notärzten und Rettungsassistenten.

OBJECTIVE: The European Resuscitation Council recommends that only rescuers experienced and well-trained in airway management should perform endotracheal intubation. Less trained rescuers should use alternative airway devices instead. Therefore, a concept to train almost 1,100 emergency physicians (EP) and emergency medical technicians (EMT) in prehospital airway management using the disposable laryngeal tube suction (LTS-D) is presented. METHODS: In five operational areas of emergency medicine services in Germany and Switzerland all EPs and EMTs were trained in the use of the LTS-D by means of a standardized curriculum in the years 2006 and 2007. The main focus of the training was on different insertion techniques and LTS-D use in children and infants. Subsequently, all prehospital LTS-D applications from 2008 to 2010'were prospectively recorded. RESULTS: None of the 762 participating EMTs and less than 20% of the EPs had previous clinical experience with the LTS-D. After the theoretical (practical) part of the training, the participants self-assessed their personal familiarity in using the LTS-D with a median value of 8 (8) and a range of 2-10 (range 1-10) of 10 points (1: worst, 10: best). Within the 3-year follow-up period the LTS-D was used in 303 prehospital cases of which 296 were successfully managed with the device. During the first year the LTS-D was used as primary airway in more than half of the cases, i.e. without previous attempts of endotracheal intubation. In the following years such cases decreased to 40% without reaching statistical significance. However, the mean number of intubation attempts which failed before the LTS-D was used as a rescue device decreased significantly during the study period (2008: 2.2 ± 0.3; 2009: 1.6 ± 0.4; 2010: 1.7 ± 0.3). CONCLUSION: A standardized training concept enabled almost 1,100 rescuers to be trained in the use of an alternative airway device and to successfully implement the LTS-D into the prehospital airway management algorithm. Because the LTS-D recently became an accepted alternative to endotracheal intubation in difficult airway scenarios, the number of intubation attempts before considering an alternative airway device is steadily decreasing.

[Web-based evidence of treatment capacity. An instrument for optimizing the interface between prehospital and hospital management]. / Web-basierter Versorgungskapazitätsnachweis. Ein Instrument zur Schnittstellenoptimierung zwischen Präklinik und Klinik.

BACKGROUND: The outcome of injured patients depends on intrastractural circumstances as well as on the time until clinical treatment begins. A rapid patient allocation can only be achieved occur if informations about the care capacity status of the medical centers are available. Considering this an improvement at the interface prehospital/clinical care seems possible. MATERIAL AND METHOD: In 2010 in Frankfurt am Main the announcement of free capacity (positive proof) was converted to a web-based negative proof of interdisciplinary care capacities. So-called closings are indicated in a web portal, recorded centrally and registered at the local health authority and the management of participating hospitals. RESULTS: Analyses of the allocations to hospitals of all professional disciplines from the years 2009 and 2010 showed an optimized use of the resources. A decline of the allocations by the order from 261 to 0 could be reached by the introduction of the clear care capacity proof system. The health authorities as the regulating body rarely had to intervene (decline from 400 to 7 cases). Surgical care in Frankfurt was guaranteed at any time by one of the large medical centers. CONCLUSION: The web-based care capacity proof system introduced in 2010 does justice to the demand for optimum resource use on-line. Integration of this allocation system into the developing trauma networks can optimize the process for a quick and high quality care of severely injured patients. It opens new approaches to improve allocation of high numbers of casualties in disaster medicine.

Measurements of the quadriceps femoris function after meniscus refixation at the stable athlete's knee.

INTRODUCTION: The purpose of this study was to monitor the muscular changes regarding the isokinetic strength and torque pattern of the quadriceps femoris at the stable athlete's knee after meniscus tear refixation. MATERIALS AND METHODS: Therefore 15 athletes (10 male, 5 female) performing recreational or competitional sports at least five times a week before injury were retrospectively examined in the average 2.5 years after isolated arthroscopic meniscus refixation using Inside Out technique. Next to function and sport activity focused scores the isokinetic peak torque (PT) and in the EMG have been analyzed compared to the uninjured knee. RESULTS: The mean age was 31.26 years. The time between injury and surgery was in the average 13.7 days. According to our first results the data suggest a complete recovery of functional and muscular pattern after meniscus refixation at the stable athlete's knee. No significant EMG changes for quadriceps femoris were detectable. The PT was fully recovered. The functional and sport activity score analysis (Lysholm and Tegner score) showed no changes in the postoperative long-term follow up compared to the preinjured status. CONCLUSION: Examining isokinetic PT and the EMG of the quadriceps femoris, these data show no side-to-side differences. Regarding the function and sports activity score system, the functionally high demand patients seem to profit by this procedure.

Quality criteria for electronic publications in medicine.

This paper defines "electronic publications in medicine (EPM)" as computer based training programs, databases, knowledge-based systems, multimedia applications and electronic books running on standard platforms and available by usual distribution channels. A detailed catalogue of quality criteria as a basis for development and evaluation of EPMs is presented. The necessity to raise the quality level of electronic publications is stressed considering aspects of domain knowledge, software engineering, media development, interface design and didactics.