[Patient consent for the TraumaRegistry DGU based on the GDPR-A challenge for the hospitals: status quo and solution strategies]. / Patienteneinwilligungen für das TraumaRegister DGU® aufgrund der EU-Datenschutz-Grundverordnung (EU-DSGVO) ­ Eine Herausforderung für die Kliniken: Status quo und Lösungsstrategien.

According to the General Data Protection Regulation (GDPR 05/2018), anonymized data sets with a sufficiently high data density are classified as traceable and require a declaration of consent if they are evaluated centrally for research or quality control purposes. Quality assurance and further increases in the quality of care are, however, only possible with a nearly complete survey of seriously injured persons in the sense of health services research. The more than 600 German clinics that take part in the TraumaRegistry DGU® try to obtain the declarations of consent from this special patient population. The study clinic evaluated the rate of consent and the reasons for rejection or failure to obtain consent over a 12-month period. While using a resource-intensive workflow especially for patient education and obtaining the consent, a patient consent rate of 64.5% and an error rate of 35.5% were recorded. Of the 276 potential TraumaRegistry DGU® data records 98 could not be entered and were therefore neither available for quality control nor for multiple trauma research. In order to guarantee the quality control and the further improvement of the quality of care, an approximate total recording of the patient population is necessary; however, this cannot be achieved by requiring a declaration of consent. We therefore advocate creating the possibility of collecting the TraumaRegistry data set without consent, as this ultimately represents a standard data set, comparable to the Hospital Remuneration Act (§21-KHEntgG) data set but pseudonymised.

Rehabilitation of Achilles tendon ruptures: is early functional rehabilitation daily routine?

INTRODUCTION: Ruptures of the Achilles tendon are the most common tendon injuries of the lower extremities. Besides the initial operative or non-operative treatment, rehabilitation of patients plays a crucial role for tendon healing and long-term outcome. As only limited evidence is available for optimized rehabilitation regimen and guidelines for the initial (e.g., first 6 weeks) rehabilitation are limited, this study investigated the current rehabilitation concepts after Achilles tendon rupture. MATERIALS AND METHODS: We analyzed 213 written rehabilitation protocols that are provided by orthopedic and trauma surgery institutions throughout Germany in terms of recommendations for weight-bearing, range of motion (ROM), physiotherapy, and choice of orthosis. All protocols for operatively and non-operatively treated Achilles tendon ruptures were included. Descriptive analysis was carried out and statistical analysis applied where appropriate. RESULTS: Of 213 institutions, 204 offered rehabilitation protocols for Achilles tendon rupture and, therefore, 243 protocols for operative and non-operative treatment could be analyzed. While the majority of protocols allowed increased weight-bearing over time, significant differences were found for durations of fixed plantar flexion between operative (o) and non-operative (n) treatments [fixed 30° (or 20)° to 15° (or 10)°: 3.6 weeks (±0.1; o) vs 4.7 weeks (±0.3; n) (p ≤ 0.0001) and fixed 15° (or 10)° to 0°: 5.8 weeks (±0.1; o) vs 6.6 weeks (±0.2; n) (p ≤ 0.001)]. The mean time of the recommended start of physiotherapy is at 2.9 weeks (±0.2; o) vs 3.3 weeks (±0.4; n), respectively. CONCLUSION: Our study shows that a huge variability in rehabilitation after Achilles tendon rupture exists. This study shows different strategies in rehabilitation of Achilles tendon ruptures using a convertible vacuum brace system. To improve patient care, further clinical as well as biomechanical studies need to be conducted. This study might serve as basis for prospective randomized controlled trials to optimize rehabilitation for Achilles tendon ruptures.

[While Others are Sleeping - Performance of Major Trauma Care at Night]. / Wenn andere schlafen ­ Leistungsfähigkeit der Patientenversorgung in der Nacht am Beispiel der Schwerverletztenversorgung.

Introduction: The literature indicates that medical staff suffer from a decline in cognitive and physical performance at night. This study evaluates the process quality and outcomes of emergency care during night-time and daytime. Method: Out of 1,226 prospectively registered patients, 420 were included into this study (observation period: 76 months). Inclusion criteria were an ISS ≥ 16 and admission to trauma room during "DAY" (8 am to 4 : 49 pm) or "NIGHT" (9 pm to 5 : 59 am). The fundamental part was the 130 items of the TraumaRegister DGU. The additional 350 items contain data about prehospital treatment, trauma room management and intensive care. Data were collected by a research assistant over a 24-h period. Results: The study sample contained 268 DAY-patients and 152 NIGHT-patients. Patients admitted during night were injured more severely: ISS 34.9 (± 16.4) vs. 31.1 (± 14.2), p = 0.015 and younger: 33.3 (± 16.6) vs. 43.6 (± 22.3) years old, p < 0.001. However, this had no impact on outcome prediction scores like RISC, RISC2 or TRISS, p ≥ 0.775. Furthermore, no difference in process quality was observed like the time to gain an arterial access: NIGHT 4.5 (± 3.7) vs. DAY 5.0 (± 3.7) min, p = 0.116, time for splinting 3.8 (± 3.7) vs. 3.4 (± 3.1) min, p = 0.922, or other parameters, like time to CT: 26.9 (± 11.2) vs. 26.6 (± 14.5) min, p = 0.520. Nor was there any difference in outcome: 17.8 % of the NIGHT-patients (RISC-prognosis: 23.8 %, SMR 0.74) died in hospital, and 18.3 % of the DAY-patients (RISC-prognosis: 24.0 %, SMR 0.77), p = 0.894. As well the comparison of the Glasgow Outcome Scale revealed no difference: NIGHT 3.8 (± 1.5) vs. DAY 3.8 (± 1.6), p = 0.491. Discussion: Although evidence suggests a drop of performance by medical staff at night, this effect could not be demonstrated. Considering this, the level of process quality and outcome - regardless of the time of arrival - remained constant on a high level. These results might be attributable to the quality management and the standardisation of the treatment.

Association of high volumes of hydroxyethyl starch with acute kidney injury in elderly trauma patients.

INTRODUCTION: Initial fluid resuscitation in trauma is still controversial. Hydroxyethyl starch (HES), a commonly used fluid for resuscitation in trauma patients, has potential nephrotoxic effects. Advancing age is a known risk factor for acute kidney injury (AKI) in trauma patients. Therefore, the objective of this study was to evaluate the impact of large volumes of HES 130/0.4 on renal function in trauma patients, with a particular focus on the significance of age. METHODS: A retrospective review of all patients admitted to the Trauma Centre of the University Hospital Regensburg from September 1, 2007 to December 31, 2012 was performed. This investigation used data from the TraumaRegister of the German Trauma Society (DGU®), including preclinical data from the prehospital emergency physician's protocol, the patient data management system of the intensive care units and the anaesthesia protocols of the emergency room and the operating room. AKI was evaluated according to the risk, injury, failure, loss, or end-stage kidney disease (RIFLE) criteria. The rate of AKI and the rate of renal replacement therapy (RRT) were compared between patients who received<2000ml HES 130/0.4 during the first 24h (L-HES) after trauma and patients who received≥2000ml HES 130/0.4 during the first 24h (H-HES) after trauma. An additional sub analysis of patients older than 59 years of age was performed. RESULTS: A total of 260 patients were included. Although patients in the H-HES group showed a higher injury severity score, the incidence of AKI and RRT were comparable. Furthermore, the sub analysis of patients older than 59 years of age also demonstrated similar results regarding incidence of AKI and the rate of RRT. CONCLUSIONS: Fluid resuscitation with more than 2000ml HES (130kD/0.4) during the first twenty four hours after trauma was not associated with an increased incidence of AKI or need for RRT in trauma patients compared to patients who were administered<2000ml HES (130kD/0.4). The analysis of patients older than 59 years of age did not demonstrate any difference in the incidence of AKI or the need for RRT.

[Prevention of road accidents involving non-motorized traffic participants (pedestrians and cyclists) in Germany]. / Prävention von Verkehrsunfällen äußerer Verkehrsteilnehmer (Fußgänger und Fahrradfahrer) in Deutschland.

During a 1-day workshop organized by the German Society of Orthopaedics and Traumatology (DGOU) 15 German accident researchers used different approaches to improve the effectiveness of accident prevention for pedestrians and bicyclists on German roads. The main results of this analysis show: Fatal injuries of pedestrians have been significantly reduced by 82% between 1970 (n=6.056) and 2007 (n=695). Similarly, fatalities of bicyclists have been reduced during the same time period from 1,835 to 425 which amount to almost 80%. However, the total number of injured cyclists increased almost twice, i.e. from 40,531 (in 1979) to 78,579 (in 2007) a fact that needs to be analyzed in more detail. Although scientifically proven to provide protection against severe head injuries, helmets are worn less frequently by adolescents and women as compared to younger children and men. Fatalities of bicyclists might be reduced by using Dobli mirrors which allow the truck driver to see the bicyclist when turning right. Recently developed sensors are able to detect pedestrians walking closely (<2.5 m) and warn the truck driver acoustically. Bicycle lanes should be planned for one direction only, separated from the pedestrian way and large enough (2.0 m are safer than 1.6 m). Traffic education for school beginners and younger children should be repeated to be effective. Training for elderly bicyclists in cities with heavy traffic would also be reasonable. Active security systems in cars like ESP (electronic stability program), BAS (brake assist system), special light systems for curves, and night vision utilities are most effective to prevent collision with pedestrians and bicyclists. TV spots for bicyclists could help to point out dangerous situations and the proven benefits of wearing a helmet in the same way as previous campaigns, e.g."The 7th Sense" for car drivers.

[Quality circle in a trauma network of the German Association for Trauma Surgery. Upgrading patient care]. / Qualitätszirkel im TraumaNetzwerkD der DGU. Ein Instrument zur kontinuierlichen Verbesserung der Schwerverletztenversorgung.

In industry, especially in the automobile industry, improvements in efficiency could be demonstrated by quality management and quality circles. There is no doubt that in medicine, major trauma is also a very complex challenge.The German Association for Trauma Surgery published the White Paper on the Management of the Seriously Injured in 2006. The White Paper specifies the demand for quality of care, sets the level of structural requirements for trauma care and postulates the cooperation of regional hospitals within a network of dedicated trauma centres. The Trauma Network Eastern Bavaria (TNO) was the first certified trauma network in Germany. One of the reasons for this success is the fact that cooperation between trauma surgeons has already had a long tradition in this geographic area. The key factor is communication which is supported by all technical and organisational means. The formal installation of quality circles on each level of trauma care, e.g. within and across institutions, was accepted by all partners within the network. The goal is the improvement of patient care in trauma above and beyond the guidelines of the White Paper. This paper shows the instruments used to enhance the quality of trauma care within a network.

[The Abbreviated Injury Scale (AIS). Options and problems in application]. / Die Abbreviated Injury Scale (AIS). Potenzial und Probleme bei der Anwendung.

The new AIS (Abbreviated Injury Scale) was released with an update by the AAAM (Association for the Advancement of Automotive Medicine) in 2008. It is a universal scoring system in the field of trauma applicable in clinic and research. In engineering it is used as a classification system for vehicle safety. The AIS can therefore be considered as an international, interdisciplinary and universal code of injury severity. This review focuses on a historical overview, potential applications and new coding options in the current version and also outlines the associated problems.

[Realization and implementation of a trauma network of the German Association of Trauma Surgery (DGU) exemplified by the Trauma Network of eastern Bavaria]. / Umsetzung und Implementierung eines TraumaNetzwerksD der DGU am Beispiel des TraumaNetzwerks Ostbayern.

The quality of care of seriously injured persons in Germany is nationally and internationally recognized to be at a high level. However, there are local discrepancies. In 2006 the German Association of Trauma Surgery published the White Paper for the Management of the Seriously Injured. The goal of the paper is a further increase in the quality of care of seriously injured persons. A crucial point of the publication is the call to establish regional trauma networks in Germany. Work on this project has been carried out in eastern Bavaria since spring 2007. The first meeting of the Trauma Network of eastern Bavaria took place in July 2007. On 3rd September 2008 the university hospital of Regensburg was the first clinic audited in Germany. To date nearly 75% of all hospitals in the trauma network of eastern Bavaria have been audited. The establishment of a regional trauma network is a multifactorial event. Essential factors in the development of the trauma network were found to be the communication between the head physicians and the nomination of an appointee of the regional trauma network. For the head physicians the 9 meetings of the trauma network since July 2007 functioned as the communication platform. These exchanges of the head physicians are necessary to animate a trauma network. The appointee of the regional trauma network--most suitably a member of staff of the speaker of the trauma network--is essential to guarantee communication between meetings and to manage prompt responses to questions from the network. This article describes the experiences gained during the implementation of the trauma network in eastern Bavaria.

The influence of cyclic compression and distraction on the healing of experimental tibial fractures.

Interfragmentary displacement has a main effect on callus formation in fracture healing. To test whether compressive or distractive displacements have a more pronounced effect on new bone formation, a sheep osteotomy model was created whereby the gap tissue was subjected to constant bending displacement. A diaphyseal osteotomy with a gap of 2 mm was created in 18 sheep tibiae and stabilized with a special unilateral actuator-driven external fixator. Two experimental groups with six sheep each received either 10 or 1000 cycles evenly distributed over 24 h. The third group of six sheep served as a control group without actively induced displacement. The amount and direction of cyclic displacement was kept constant throughout the observation period, resulting in 50% compressive and 50% distractive displacement within the osteotomy gap. At sacrifice, six weeks after surgery, bending stiffness was measured and new bone formation was assessed radiologically and microradiographically. In all cycled groups, the amount of periosteal callus formation was up to 25 times greater on the compression compared to the distraction side (p < 0.001). The application of the higher number of daily cycles resulted in an up to 10-fold greater amount of periosteal new bone formation on the compression side (p < 0.012), while the difference on the distraction side was not significant. Ten cycles applied a day were sufficient to create an abundant periosteal callus on the compression side. In the 1000 cycle group, bending stiffness revealed slightly lower values but the difference was not significant. Solid periosteal bridging of the gap was observed in two sheep in the control group, whereas bridging in the cycled groups was observed exclusively at the medullary side. In conclusion, cyclic compressive displacements were found to be superior over distractive displacements. A higher number of enforced and maintained compressive displacements enhanced periosteal callus formation but did not allow bony bridging of the gap.