Dokumentation

RTH

Oligoanalgesie im Luftrettungsdienst?

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BACKGROUND: Oligoanalgesia, as well as adverse events related to the initiated pain therapy, are prevalent in out-of-hospital emergency medicine, even when a physician is present. We sought to identify factors involved in insufficient pain therapy of patients presenting with an initial Glasgow Coma Scale (GCS) >= 8 in the out-of-hospital phase, when therapy is provided by a physician-staffed helicopter emergency medical service (p-HEMS).

METHODS: This was a multicenter, secondary data analysis of conscious patients treated in primary p-HEMS missions between January 1, 2005, and December 31, 2017. Patients with a numeric rating scale (NRS) pain score >= 4, GCS >= 8 on the scene, without cardiopulmonary resuscitation, and a < VI were included. Multivariable logistic binary regression analyses were used to identify characteristics of oligoanalgesia (NRS >= 4 at handover or pain reduction < 3). Linear regression analysis was used to identify changes in pain treatment within the study period.

RESULTS: We analyzed data from 106,730 patients (3.6% missing data at variable level). Of these patients, 82.9% received some type of analgesic therapy on scene; 79.1% of all patients received analgesic drugs, and 38.6% received non-pharmacological interventions, while 37.4% received both types of intervention. Oligoanalgesia was identified in 18.4% (95% confidence interval [CI], 18.1–18.6) of patients. Factors associated with oligoanalgesia were a low National Advisory Committee for Aeronautics (NACA) score and a low NRS score, as well as central nervous system or gynecological/obstetric complaints. The use of weak opioids (odds ratio 1.05, 95% CI 0.68–1.57) had no clinically relevant association with oligoanalgesia, in contrast to the use of strong or moderate opioids, non-opioid analgesics, or ketamine. We observed changes in the analgesic drugs used over the 12-year study period, particularly in the use of strong opioids (fentanyl or sufentanil), from 30.3% to 42.3% (p value < 0.001). Of all patients, 17.1% (95% CI, 16.9–17.3) did not receive any type of pain therapy. 

CONCLUSIONS: In the studied p-HEMS cohort, oligoanalgesia was present in 18.4% of all cases. Special presenting complaints, low NACA scores, and low pain scores were associated with the occurrence of oligoanalgesia. However, 17.1% of patients received no type of pain therapy, which suggests scope for further improvement in prehospital pain therapy. Pharmacological and non-pharmaceutical pain relief should be initiated whenever indicated.

Helm M, Hossfeld B, Braun B, Werner D, Peter L, Kulla M: Oligoanalgesia in Patients With an Initial Glasgow Coma Scale Score ≥8 in a Physician-Staffed Helicopter Emergency Medical Service: A Multicentric Secondary Data Analysis of >100,000 Out-of-Hospital Emergency Missions. Anesth Analg130: 176-186 (2020)
Entwurf Datensatz Notaufnahmeprotokoll der DIVI 2020

Entwurf Datensatz Notaufnahmeprotokoll der DIVI 2020

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Die Datenelemente für Notaufnahmedokumentationssysteme sind die Weiterentwicklung des Notaufnahmeprotokoll Datensatzes V2015.1. Diese Datendefinition definiert die Datenelemente, die während der innerklinischen Versorgung eines notfallmedizinischen Patienten in einer Notaufnahme / Notfallambulanz / Notfallzentrum erfolgt. Dabei werden externe Datenquellen wie präklinisches (prähospitales) Notfallprotokoll (z.B. Notarztprotokoll) oder Voranmeldungsdaten aus IVENA integriert. Primäres Ziel ist die medizinische Dokumentation zur Informationsweitergabe im Behandlungsverlauf. Sekundäres Ziel ist die Datenerhebung und Datenweiterleitung für Sekundärnutzer wie medizinische Register (TraumaRegister DGU, Reanimationsregister, Schlaganfallregister, Herzinfarktregister; AKTIN-NotaufnahmeRegister). Auf Basis der Datenelemente für Notalldokumentationssysteme sollen technische Artefakte wie Leitfäden für HL7 CDA oder HL7 FHIR entwickelt werden. Die Datenelemente sollen ebenfalls die Basis für Minimaldokumentationsdefinitionen (Minimaldatensätze) für spezifisch klinische Situationen in der innerklinischen Notfallmedizin darstellen, die noch entwickelt werden müssen.

Quellen:

Register in der Notfallmedizin

Register in der Notfallmedizin

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In der aktuellen Ausgabe der Zeitschrift DIVI fasst Wibke Schirrmeister aus der Sektion Notaufnahmeprotokoll der DIVI wissenswertes über Register in der Notfall- und Akutmedizin zusammen:

Zur Sicherung einer qualitativ hochwertigen Patientenversorgung durch interne oder externe Qualitätsmanagementverfahren sind aktuelle, standardisierte und somit vergleichbare Daten unerlässlich. In der Akut- und Notfallmedizin stellen dabei Register eine wichtige Datenquelle für das Qualitäts- management, die Versorgungsforschung und die evidenzbasierte Medizin dar. Akutmedizinische Register, die Patienten anhand von Tracer-Diagnosen, z.B. Herzinfarkt, Schlaganfall oder schweres Trau- ma und Prozeduren, die z.B. Reanimation einschließen, sind bereits etabliert. Es entstehen aber auch strukturbezogene Register, wie das AKTIN-NotaufnahmeRegister, welches alle Patienten einschließt, die in der Notaufnahme versorgt werden. Zunehmend wird die ressourcenschonende Datenerhebung für die Register durch Sekundärdatennutzung aus der medizinischen Dokumentation (Routinedaten) angestrebt. Durch die Harmonisierung der Datensätze zwischen den Registern kann die Datenerhe- bung optimiert, der Zeitaufwand reduziert und die Vergleichbarkeit der Ergebnisse verbessert werden.“

Quelle:

Schirrmeister W, Wehrle M, Lefering R, Walcher F, Kulla M, Brammen D, Greiner F: German registries in acute and emergency care. DIVI 10: 148-157 (2019) (https://dx.doi.org/10.3238/DIVI.2019.0148-0157)

Digital Pen and Paper Technology

Digital Pen and Paper Technology

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ABSTRACT

Background: The Syria crisis has forced more than 4 million people to leave their homeland. As a result, in 2016, an overwhelming number of refugees reached Germany. In response to this, it was of utmost importance to set up refugee camps and to provide humanitarian aid, but a health surveillance system was also implemented in order to obtain rapid information about emerging diseases.

Objective: The present study describes the effects of using digital paper and pen (DPP) technology on the speed, sequence, and behavior of epidemiological documentation in a refugee camp.

Methods: DPP technology was used to examine documentation speed, sequence, and behavior. The data log of the digital pens used to fill in the documentation was analyzed, and each pen stroke in a field was recorded using a timestamp. Documentation time was the difference between first and last stroke on the paper, which includes clinical examination and translation.

Results: For three months, 495 data sets were recorded. After corrections had been made, 421 data sets were considered valid and subjected to further analysis. The median documentation time was 41:41 min (interquartile range 29:54 min; mean 45:02 min; SD 22:28 min). The documentation of vital signs ended up having the strongest effect on the overall time of documentation. Furthermore, filling in the free-text field clinical findings or therapy or measures required the most time (mean 16:49 min; SD 20:32 min). Analysis of the documentation sequence revealed that the final step of coding the diagnosis was a time-consuming step that took place once the form had been completed.

Conclusions: We concluded that medical documentation using DPP technology leads to both an increase in documentation speed and data quality through the compliance of the data recorders who regard the tool to be convenient in everyday routine. Further analysis of more data sets will allow optimization of the documentation form used. Thus, DPP technology is an effective tool for the medical documentation process in refugee camps.

weiterführende Links

Digitale Dokumentation in der ZNA

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Background:

Some of the advantages of implementing electronic emergency department information systems (EDIS) are improvements in data availability and simplification of statistical evaluations of emergency department (ED) treatments. However, for multi-center evaluations, standardized documentation is necessary. The AKTIN project (“National Emergency Department Register: Improvement of Health Services Research in Acute Medicine in Germany”) has used the “German Emergency Department Medical Record” (GEDMR) published by the German Interdisciplinary Association of Intensive and Emergency Care as the documentation standard for its national data registry.

Methods

Until March 2016 the documentation standard in ED was the pen-and-paper version of the GEDMR. In April 2016 we implemented the GEDMR in a timeline-based EDIS. Related to this, we compared the availability of structured treatment information of traumatological patients between pen-and-paper-based and electronic documentation, with special focus on the treatment time.

Results

All 796 data fields of the 6 modules (basic data, severe trauma, patient surveillance, anesthesia, council, neurology) were adapted for use with the existing EDIS configuration by a physician working regularly in the ED. Electronic implementation increased availability of structured anamnesis and treatment information. However, treatment time was increased in electronic documentation both immediately (2:12±0:04h; n = 2907) and 6 months after implementation (2:18±0:03 h; n = 4778) compared to the pen-and-paper group (1:43±0:02 h; n = 2523; p < 0.001).

Conclusions

We successfully implemented standardized documentation in an EDIS. The availability of structured treatment information was improved, but treatment time was also increased. Thus, further work is necessary to improve input time.

Links:

https://rdcu.be/bOg5v

https://doi.org/10.1186/s12913-019-4400-y

Lucas B. Schlitz P, Schirrmeister W, Plissee G, Walcher F, Kulla M, Brammen D: The way from pen and paper to electronic documentation in a German emergency department. BMC Health Services Research 19:558 (2019)