The Effects of Displaying the Time Targets of the Manchester Triage System to Emergency Department Personnel: Prospective Crossover Study.

BACKGROUND: The use of triage systems such as the Manchester Triage System (MTS) is a standard procedure to determine the sequence of treatment in emergency departments (EDs). When using the MTS, time targets for treatment are determined. These are commonly displayed in the ED information system (EDIS) to ED staff. Using measurements as targets has been associated with a decline in meeting those targets. OBJECTIVE: This study investigated the impact of displaying time targets for treatment to physicians on processing times in the ED. METHODS: We analyzed the effects of displaying time targets to ED staff on waiting times in a prospective crossover study, during the introduction of a new EDIS in a large regional hospital in Germany. The old information system version used a module that showed the time target determined by the MTS, while the new system version used a priority list instead. Evaluation was based on 35,167 routinely collected electronic health records from the preintervention period and 10,655 records from the postintervention period. Electronic health records were extracted from the EDIS, and data were analyzed using descriptive statistics and generalized additive models. We evaluated the effects of the intervention on waiting times and the odds of achieving timely treatment according to the time targets set by the MTS. RESULTS: The average ED length of stay and waiting times increased when the EDIS that did not display time targets was used (average time from admission to treatment: preintervention phase=median 15, IQR 6-39 min; postintervention phase=median 11, IQR 5-23 min). However, severe cases with high acuity (as indicated by the triage score) benefited from lower waiting times (0.15 times as high as in the preintervention period for MTS1, only 0.49 as high for MTS2). Furthermore, these patients were less likely to receive delayed treatment, and we observed reduced odds of late treatment when crowding occurred. CONCLUSIONS: Our results suggest that it is beneficial to use a priority list instead of displaying time targets to ED personnel. These time targets may lead to false incentives. Our work highlights that working better is not the same as working faster.

[Reasons for non-participation in a patient survey in the context of prehospital emergency medical care by community emergency paramedics - A retrospective observational study]. / Gründe für die Nichtteilnahme an einer Patientenbefragung im Kontext der prähospitalen Notfallversorgung durch Gemeindenotfallsanitäter - eine retrospektive Beobachtungsstudie.

BACKGROUND: In order to evaluate whether the new rescue means "community emergency paramedics" (Gemeindenotfallsanitäter [G-NFS]) relieves the emergency medical service (EMS) in the care of low-priority emergencies, the perspective of general practitioners and patients was also surveyed in a written questionnaire as part of an innovation fund project. Recruitment for participation in the study proved to be difficult. The aim of this study is to evaluate why the G-NFS decided against providing information on study participation and what measures would be necessary to include more emergency patients in surveys in the future. METHODS: Retrospective analysis of the assignment protocols from April 1, 2021 to June 30, 2022. In addition to patient characteristics, data on treatments, interventions and recommendations to patients as well as reasons for non-participation in the patient survey were collected. RESULTS: 5,395 G-NFS protocols that contained information on non-participation were included in the analysis. The average age of the patients was 62.4 years (SD 22.7), and 50.2% were female. 57.4% of the cases were categorised as non-urgent, and 35.2% of the cases required an additional ambulance to be alerted. 404 (7.5%) patients used the EMS more than once, 1,120 (20.8%) did not have sufficient language skills, 1,012 (18.8%) patients declined study participation, and 2,975 (55.1%) patients were not able to participate according to the G-NFS assessment. Dementia/neurocognitive impairment (35%), acute/emergency situation (26.5%), mental health impairment (10.3%), and substance abuse (6.5%) were given as reasons for non-participation from the G-NFS perspective. DISCUSSION: The results show that more than half of the patients were unable to take part in a written survey for various reasons, even though there was no need for urgent care. This could be due to a high demand for care and the complex consent procedure. In addition, further resources are required to provide needs-based care for these patients in order to relieve the burden on emergency medical care. Over half of the patients were unable to take part in a written survey for various reasons. Further research is needed to determine what consent procedures are appropriate to facilitate patients' study participation.

Local Approval Processes in a Federated and Distributed Research Infrastructure - Lessons Learned from the AKTIN-Project.

The AKTIN-Emergency Department Registry is a federated and distributed health data network which uses a two-step process for local approval of received data queries and result transmission. For currently establishing distributed research infrastructures, we present our lessons learned from 5 years of established operations.

Changes in emergency department utilisation in Germany before and during different phases of the COVID-19 pandemic, using data from a national surveillance system up to June 2021.

BACKGROUND: During the COVID-19 pandemic and associated public health and social measures, decreasing patient numbers have been described in various healthcare settings in Germany, including emergency care. This could be explained by changes in disease burden, e.g. due to contact restrictions, but could also be a result of changes in utilisation behaviour of the population. To better understand those dynamics, we analysed routine data from emergency departments to quantify changes in consultation numbers, age distribution, disease acuity and day and hour of the day during different phases of the COVID-19 pandemic. METHODS: We used interrupted time series analyses to estimate relative changes for consultation numbers of 20 emergency departments spread throughout Germany. For the pandemic period (16-03-2020 - 13-06-2021) four different phases of the COVID-19 pandemic were defined as interruption points, the pre-pandemic period (06-03-2017 - 09-03-2020) was used as the reference. RESULTS: The most pronounced decreases were visible in the first and second wave of the pandemic, with changes of - 30.0% (95%CI: - 32.2%; - 27.7%) and - 25.7% (95%CI: - 27.4%; - 23.9%) for overall consultations, respectively. The decrease was even stronger for the age group of 0-19 years, with - 39.4% in the first and - 35.0% in the second wave. Regarding acuity levels, consultations assessed as urgent, standard, and non-urgent showed the largest decrease, while the most severe cases showed the smallest decrease. CONCLUSIONS: The number of emergency department consultations decreased rapidly during the COVID-19 pandemic, without extensive variation in the distribution of patient characteristics. Smallest changes were observed for the most severe consultations and older age groups, which is especially reassuring regarding concerns of possible long-term complications due to patients avoiding urgent emergency care during the pandemic.

Optimal@NRW: optimized acute care of nursing home residents using an intersectoral telemedical cooperation network - study protocol for a stepped-wedge trial.

BACKGROUND: Increasing life expectancy is associated with a growing number of people living in nursing homes, while the availability of outpatient medical care, especially from family doctors, is stagnating in this sector. Consequently, numerous and often avoidable, low-threshold hospitalizations of nursing home residents are observed. This results in unnecessary use of resources such as emergency services and emergency rooms as well as in potential health risks to the nursing home residents related to hospitalization. This study aims to improve this healthcare gap by implementing an intersectoral telemedicine approach. METHODS: Twenty-five nursing homes are participating and provided with telemedical equipment to perform teleconsultations. Additionally, an early warning system and a digital patient record system are implemented. Telephysicians based at RWTH Aachen University Hospital are ready to support the nursing homes around the clock if the family doctor or an emergency service practice is not available in time. Mobile non-physician practice assistants from the telemedicine centre can be dispatched to perform delegable medical activities. General practitioners and the medical emergency practices also have access to the telemedical infrastructure and the non-physician practice assistants. DISCUSSION: Optimal@NRW adds a telemedicine component to standard care - combining elements of outpatient and inpatient health care as well as emergency service practices - to enable timely medical consultation for nursing home residents in case of the development of an acute medical condition. In addition to optimized medical care, the goal is to reduce unnecessary hospital admissions. The intersectoral approach allows for the appropriate use of resources to match the individually needed medical treatment. TRIAL REGISTRATION: ClinicalTrials.gov NCT04879537 . Registered on May 10, 2021.

Medical and cardio-vascular emergency department visits during the COVID-19 pandemic in 2020: is there a collateral damage? A retrospective routine data analysis.

BACKGROUND: In this retrospective routine data analysis, we investigate the number of emergency department (ED) consultations during the COVID-19 pandemic of 2020 in Germany compared to the previous year with a special focus on numbers of myocardial infarction and acute heart failure. METHODS: Aggregated case numbers for the two consecutive years 2019 and 2020 were obtained from 24 university hospitals and 9 non-university hospitals in Germany and assessed by age, gender, triage scores, disposition, care level and by ICD-10 codes including the tracer diagnoses myocardial infarction (I21) and heart failure (I50). RESULTS: A total of 2,216,627 ED consultations were analyzed, of which 1,178,470 occurred in 2019 and 1,038,157 in 2020. The median deviation in case numbers between 2019 and 2020 was - 14% [CI (- 11)-(- 16)]. After a marked drop in all cases in the first COVID-19 wave in spring 2020, case numbers normalized during the summer. Thereafter starting in calendar week 39 case numbers constantly declined until the end of the year 2020. The decline in case numbers predominantly concerned younger [- 16%; CI (- 13)-(- 19)], less urgent [- 18%; CI (- 12)-(- 22)] and non-admitted cases [- 17%; CI (- 13)-(- 20)] in particular during the second wave. During the entire observation period admissions for chest pain [- 13%; CI (- 21)-2], myocardial infarction [- 2%; CI (- 9)-11] and heart failure [- 2%; CI (- 10)-6] were less affected and remained comparable to the previous year. CONCLUSIONS: ED visits were noticeably reduced during both SARS-CoV-2 pandemic waves in Germany but cardiovascular diagnoses were less affected and no refractory increase was noted. However, long-term effects cannot be ruled out and need to be analysed in future studies.

ToolPool Gesundheitsforschung - A Repository for Software and Services Focused on Supporting Clinical and Epidemiological Research.

The academic research environment is characterized by self-developed, innovative, customized solutions, which are often free to use for third parties with open-source code and open licenses. On the other hand, they are maintained only to a very limited extent after the end of project funding. The ToolPool Gesundheitsforschung addresses the problem of finding ready to use solutions by building a registry of proven and supported tools, services, concepts and consulting offers. The goal is to provide an up-to-date selection of "relevant" solutions for a given domain that are immediately usable and that are actually used by third parties, rather than aiming at a complete list of all solutions which belong to that domain. Proof of relevance and usage must be provided, for example, by concrete application scenarios, experience reports by uninvolved third parties, references in publications or workshops held. Quality assurance is carried out for new entries by an agreed list of admission criteria, for existing entries at least once a year by a special task force. Currently, 79 solutions are represented, this number is to be significantly expanded by involving of new editors from current national funding initiatives in Germany.

A Federated and Distributed Data Management Infrastructure to Enable Public Health Surveillance from Intensive Care Unit Data.

The Robert Koch Institute (RKI) monitors the actual number of COVID-19 patients requiring intensive care from aggregated data reported by hospitals in Germany. So far, there is no infrastructure to make use of individual patient-level data from intensive care units for public health surveillance. Adopting concepts and components of the already established AKTIN Emergency Department Data registry, we implemented the prototype of a federated and distributed research infrastructure giving the RKI access to patient-level intensive care data.

ILEG - A Case of Recording Patient Journeys.

In 2019 the Gemeindenotfallsanitäter was introduced in the area of Oldenburg, and scientific monitoring starting 2021 with Inanspruchnahme, Leistungen und Effekte des Gemeindenotfallsanitäters. Since then, it is possible to track patient journeys, starting from the emergency call to the subsequent treatment. This short communication provides an overview of the necessary data-acquisition and dataflow from all participating institutions and its possibilities.

Establishing a Data Quality Baseline in the AKTIN Emergency Department Data Registry - A Secondary Use Perspective.

Secondary use of clinical data is an increasing application that is affected by the data quality (DQ) of its source systems. Techniques such as audits and risk-based monitoring for controlling DQ often rely on source data verification (SDV). SDV requires access to data generating systems. We present an approach to a targeted SDV based on manual input and synthetic data that is applicable in low resource settings with restricted system access. We deployed the protocol in the DQ management of the AKTIN Emergency Department Data Registry. Our targeted approach has shown to be feasible to form a DQ baseline that can be used for different DQ monitoring processes such as the identification of different error sources.

Evaluation of outcome relevance of quality indicators in the emergency department (ENQuIRE): study protocol for a prospective multicentre cohort study.

INTRODUCTION: Quality of emergency department (ED) care affects patient outcomes substantially. Quality indicators (QIs) for ED care are a major challenge due to the heterogeneity of patient populations, health care structures and processes in Germany. Although a number of quality measures are already in use, there is a paucity of data on the importance of these QIs on medium-term and long-term outcomes. The evaluation of outcome relevance of quality indicators in the emergency department study (ENQuIRE) aims to identify and investigate the relevance of QIs in the ED on patient outcomes in a 12-month follow-up. METHODS AND ANALYSIS: The study is a prospective non-interventional multicentre cohort study conducted in 15 EDs throughout Germany. Included are all patients in 2019, who were ≥18 years of age, insured at the Techniker Krankenkasse (statutory health insurance (SHI)) and gave their written informed consent to the study.The primary objective of the study is to assess the effect of selected quality measures on patient outcome. The data collected for this purpose comprise medical records from the ED treatment, discharge (claims) data from hospitalised patients, a patient questionnaire to be answered 6-8 weeks after emergency admission, and outcome measures in a 12-month follow-up obtained as claims data from the SHI.Descriptive and analytical statistics will be applied to provide summaries about the characteristics of QIs and associations between quality measures and patient outcomes. ETHICS AND DISSEMINATION: Approval of the leading ethics committee at the Medical Faculty of the University of Magdeburg (reference number 163/18 from 19 November 2018) has been obtained and adapted by responsible local ethics committees.The findings of this work will be disseminated by publication of peer-reviewed manuscripts and presentations as conference contributions (abstracts, poster or oral presentations).Moreover, results will be discussed with clinical experts and medical associations before being proposed for implementation into the quality management of EDs. TRIAL REGISTRATION NUMBER: German Clinical Trials Registry (DRKS00015203); Pre-results.

Human-Induced Errors in Networked Healthcare Research: Risk Management Under the GDPR.

Modern research projects in healthcare research and medical research are oftentimes multi-centered, multi-disciplinary, and conducted by a consortium of multiple collaborators. Increasingly, the resulting data emanating emerging from different primary and secondary sources is linked on a personal level. The General Data Protection Regulation regulates many fundamental processes in such research projects. Despite the regulatory framework given, it can happen that a collaborator does not handle data properly. We propose a systematic risk management for the handling of data as well as a systematic error management.