Zentrale Notaufnahme Universitätsklinikum Leipzig

Transcription

15. Kongress der Deutschen Interdisziplinären Vereinigung
für Intensiv- und Notfallmedizin (DIVI)
Leipzig, 02. – 04. Dezember 2015
Organisationsformen von Notaufnahmen
in Deutschland –
Emergency Departments in Germany
André Gries
Zentrale Notaufnahme, Universitätsklinikum Leipzig
Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)
Sektion Zusatzweiterbildung Interdisziplinäre Notaufnahme DIVI
© Gries / Zentrale Notaufnahme / Universitätsklinikum Leipzig AöR (2015)
chain of survival…
prehospital
care
ED
in hospital
care
mod. nach Koch (2008) Notfall Rettungsmed 11: 491-499
2
www.zna.uniklinikum-leipzig.de
• University Hospital of Leipzig
• 1.400 beds
• patient care, science, education
• EMS (prehospital physician staffed)
• large catchment area (trauma, stroke, MI,…)
• HBO-chamber
• Emergency department 2014: 34.060 patients
3
ED in Germany…
• • function
&?
tasks
Warum
• • patients
Was ?
• • staff
Wie&? organization
Wer ?challenges
• • future
4
ED in Germany…
• • function
&?
tasks
Warum
• • patients
Was ?
• • staff
Wie&? organization
Wer ?challenges
• • future
5
ED-targets…
•
best medical care
- standard emergency care (guidelines)
- waiting time , lenght of stay , in-hopital transports 
- patient satisfaction !
•
economical aspects
- saving costs (centralization, personel, ressources)
- coordination of hospital admission (bed occupancy rate)
- lenght of in hospital stay  (DRG)
- increasing number of patients (competition)
•
other targets
- image of hospital
- reliable partner
- satisfaction of patients and personel
6
Management…
•
•
•
•
•
triage
stabilization of vital functions
diagnostic and treatment „bundles“
organization and initiation of (further) therapy
hospital admission or ambulatory treatment
Bernhard M et al., AINS 2009; 44: 454-459
7
State of Hessen: planning emergency care…
Metzner (2007) Notfall Rettungsmed 8: 436-439
“…hospitals should
establish emergency
departments“.
8
ED in Germany…
• • function
tasks
Warum& ?
• • patients
Was ?
• • staff
Wie&? organization
Wer ?challenges
• • future
9
Emergency medicine in all its facets…
10
...for all patients*
*sometimes also those better visiting their family doctor!
11
Different structures…
pediatrics
elective admissions
special outpatient clinic
primary care physician
other sepcialists
Zentrale Notaufnahme
ED
ICU
Chest pain unit
stroke unit
12
Different structures…
pediatrics
elective admissions
special outpatient clinic
primary care physician
other sepcialists
ICU
ED
Chest pain unit
stroke unit
13
Where do the patients come from…
•
inidividual initiative („Walking Emergencies“)
•
primary care (and other) physicians (ambulatory systems)
•
other hospitals
•
emergency medical services
14
Triage first: „Leipziger Triage System (LeiTS)“…
15
EMS 50%…
LeiTS-Klassifizierung
(01.10.2014 - 31.12.2014, n= 8309)
LeiTS 5
7%
NA
14%
LeiTS 4
26%
EMS
RD
33%
LeiTS 3
11%
RTH
36
0%
LEER
5%
LeiTS 1
1%
LeiTS 2
3%
16
Multimorbidity…
 cardiovascular system
 respiratory tract
 neurological diseases
„Severe accident due to
myocardial infarction“
 trauma
 obesity
 diabetes
 side effects of medication (eg anticoagulation)
 …
17
Increasing age…
…chronical diseases
and lack of ambulatory care!
18
(misleading) symptoms – no diagnosis !
19
…cooperation with all other disciplines
for best definite care!
stationäre Aufnahmen (01.01. - 01.06.2011, n=4213)
psych. Psyth.
Psychosm.
psy tageskl.
UCH
TX-Gefäß-CH
IOI
Neuro
Ortho
18%
5%
6%
URO
Nuklearmed.
MKG
HNO
13%
9%
6%
10%
12%
…65% leaving ED!
Augen
Neurologie
III
Kardio/Angio
Gastro
Endo/Neph
RHEU
PNEU
DERM
HÄM
PALL
Kogn. Neurolo.
20
Increasing number of patients…
- Patientenzahlen 2005-2014 -
40000
35000
32.872
29804
30000
Patientenzahl
30982
31507
31437
31339
34058patients
all
 + 3,4 % per year
33672
27820
25226
25000
ZNA gesamt
20000
stationär gesamt
15000
10000
7439
8001
8405
8626
8802
9193
9839
10770
5000
2005
2006
2007
2008
2009
2010
Jahr
2011
2012
10816
11707
Hospital admissions
2013
2014
 + 5,2
% per year
Universitätsklinikum Leipzig
Prof. Dr. A. Gries
21
ED in Germany…
• • function
&?
tasks
Warum
• • patients
Was ?
• • staff
Wie&? organization
Wer ?challenges
• • future
22
Skills dependent on management…
seperate treatment rooms
Triage / coordination
EMS announcements
ambulatory care
(isolation in case of infection)
Resuscitation room
ED
Fast-track
IMC/ICU
EMS
admission
unit 24 h
23
Comparable fields ?
24
Standard operating procedures…
25
Most important: good staff members!
26
Different concepts…
Personnel of
departments
ED personnel


Emergency Department
• Nurses
• (emergency) physicians
• others
Dept. of
Surgery
3
3
10
Dept. of
Internal
Medicine
ED physicians
Dept. of
Neurology
2
2
Other
Depts
-
Interdisciplinary ER team…
28
Working conditions…
• Professional development
• Job planning (clinical duties)
• Shift patterns
• Unsociable Hours
• …
International Federation For Emergency Medicine
April 2015
29
Crowding…
 20 „new“ patients / 2,5 h
30
Personnel adopted to patient number and
daytime…
31
Personnel concept…
• senior physicians ED*
}
*(surgeons, internists, anesthesiologists (CIA) with additional qualifications)
• specialists ED residents ED
• (residents) of Departments
„ED Team“
• Shift pattern reflects number of patients
• prehospital EMS
• experts from other departments on call
• standard operation procedures (SOP)
32
ED in Germany…
• • function
&?
tasks
Warum
• • patients
Was ?
• • staff
Wie&? organization
Wer ?challenges
• • future
33
...the personnel point of view ?
•
ED university hospital, Basel (CH)
•
ER-missions (n=171)
•
anonymized quesitionnaires by team members (n=884)
•
„conflicts between specialists (eg: surgeons – anesthesiologists)“
•
„poor time management“
•
„no or insufficient protocols (management)“
•
„use of technical ressources not adequate“
•
„lack of training / education“
Chirurg 2005; 76: 959-66
34
Emergency medicine is no speciality…
• Primary speciality:
UK, Ireland, Bulgaria, Czech Republic, Hungary,
Malta, Poland, Romania, Slovakia, Belgium,
Estonia, Italy, Latvia, Luxembourg, Slovenia
• Supra-speciality
Finland, France, Sweden, Belgium, Czech
Republic, Poland
• in progress in other countries
35
Controversial discussion…
Emergency medicine as a primary speciality
in Germany - Pro / Con
36
Milestone…
2010
…all medical societies considered an additional qualification necessary!
37
Supraspeciality for ED-medicine*
*(Interdisziplinäre Arbeitsgruppe der Deutschen Fachgesellschaften/DIVI 2012/2013)
preconditions
• specialist in surgery, anesthesiology, internal medicine,
neurology,…
• qualification in prehospital emergency medicine o
contents
• considering European curriculum for emergency medicine
• ED practise (24 months)
• Intensive care medicine 6 months
• Interdisciplinary curriculum (160 h - education)
...in process !
38
Berlin…
39
www.divi.de/veranstaltungen...
Curriculum (theoretical parts II/III):
Leipzig, 23.11.- 29.11.2015
40
Summary…
• Symptomes not diagnosis…
• triage…
• treatment areas…
• team members…
• coordination…
• cooperation EMS – ED…
• bundles and SOPs…
• ongoing education…
• supraspeciality in process
• …
41
Sektion…
Thank
you !
http://www.divi.de/wissenschaft/
wissenschaftliche-sektionen/notfallmedizin
[email protected]
[email protected]
42
Diagnosis and prediction of level of care
is difficult in the field…
• …keine oder nur teilweise
Übereinstimmung von Einweisungsund ZNA-Diagnose aus dem niedergelassenen Bereich in >40 %
Anaesthesist 2013; 62: 617-623
• …notwendiges Behandlungsniveau
(Normalstation, IMC, ICU) durch
Notärzte in < 50 % korrekt
vorhergesagt
Anaesthesist 2014; 63: 394-400
43
Different concepts…
Personnel of
ED personnel
departments


•
Identität
•
Kontinuität
•
Standards
•
Weiterentwicklung
•
„breiter“ Blick
•
interdisziplinär
•
kritische Menge
•
Emergency Department
• Nurses
• (emergency) physicians
• others
- ad hoc Überbelastung
zu kompensieren
•
„eigene“ Patienten
bereits in/ab ZNA
•
Weiterbildung im
originären Fach
Dept. of
Surgery
3
- Ausfallkonzept
- hohe Dienstbelastung
Ausfälle leichter
3
10
Dept. of
Internal
Medicine
ED physicians
Dept. of
Neurology
2
2
Other
Depts
•
Tunnelblick
•
“Turf-Mentalität“
•
Kein Kümmerer
•
Fluktuation
•
Weiterbildung
•
Motivation
•
Perspektive
•
Individualtherapie
ED admissions and time…
Patienteintreffen Woche
Zentrale Notaufnahme/ Notaufnahmestation
Universitätsklinikum Leipzig
(01.01.01.06.2012, n=13615)
14
13
12
montags
dienstags
mittwochs
donnerstags
freitags
samstags
sonntags
11
10
Patienten [n]
9
8
7
6
5
4
3
2
1
3:
59
22
:0
0
-2
1:
59
20
:0
0
-2
9:
59
18
:0
0
-1
7:
59
16
:0
0
-1
5:
59
14
:0
0
-1
3:
59
12
:0
0
-1
1:
59
10
:0
0
-1
9:
59
08
:0
0
-0
7:
59
06
:0
0
-0
5:
59
04
:0
0
-0
3:
59
-0
:0
0
02
00
:0
0
-0
1:
59
0
Zeit
45
„Fixation Error“…
https://www.pinterest.com/pin/481814860106197237/
46
Structures still confusing…
• DKI-Umfrage 2010*
*(260 aller 1467 allgemeinen Krankenhäuser > 50 Betten)
• 72% der KH mit „ZNA“
• 45% ausschließlich eine ZNA
• „72%
Hospital with ED“
• 27% zentrale sowie dezentrale Notaufnahmen
• „45%
Only one ED (centralized)“
• 28% nur dezentrale Strukturen
• „27 %
centralized and decentralized ED“
• keine Angaben:
• „28 %
only decentralized structures“
- Leistungsspektrum
- Organisationsform
- Fachabteilungen
- Interdisziplinarität Zahl
• „repräsentative Stichprobe“
Schöpke T, Plappert T (2011) Notfall Rettungsmed 14: 372-378
47

Zentrale Notaufnahme Universitätsklinikum Leipzig

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