G.G. Hanekop

Notärztliche Betreuung von Tumorpatienten in der finalen Krankheitsphase

ZusammenfassungHintergrundDie Versorgung von Patienten mit Tumorerkrankungen im finalen Krankheitsstadium erfolgt zunehmend im außerklinischen Umfeld. Aus diesem Grund wird auch der Rettungsdienst mit der Betreuung dieser Patienten bei akut exazerbierendem progredienten Krankheitsverlauf konfrontiert. Bisher fehlt allerdings ein entsprechender Ausbildungsinhalt in der Musterweiterbildungsordnung im Bereich Notfallmedizin. Ebenso ist die mögliche Integration ambulanter „palliative care teams“ (PCT) in die ambulante Notfallbehandlung noch nicht ausreichend umgesetzt.MethodenIn einem Zeitraum von 12xa0Monaten wurden retrospektiv alle Einsätze an 2xa0Notarztstützpunkten (Hubschrauber und Notarzteinsatzfahrzeug) untersucht, die als „Tumorerkrankung/Finalstadium“ kategorisiert waren. Entsprechend wurden alle Notarztprotokolle im Untersuchungszeitraum ausgewertet. Die Einsatzindikation, die durchgeführte Therapie und der Einfluss vorhandener PCT auf die Therapie wurden ermittelt.ErgebnisseIm definierten Zeitraum wurden 2765xa0Patienten notärztlich betreut. Primär palliativmedizinisch begründet waren 2,5% der Notarzteinsätze. Überwiegend erfolgten die Einsätze außerhalb der regulären Sprechzeiten der die Patienten versorgenden Hausärzte. Die häufigste Einsatzindikation war die akute Dyspnoe (42,7%). Eine stationäre Einweisung fand bei 61,8% der Patienten statt. Eine Einbindung eines ambulanten PCT war in den meisten Fällen nicht vorhanden (92,7%).SchlussfolgerungAnhand der Einsatzhäufigkeiten konnte verdeutlicht werden, dass palliativmedizinische Fragestellungen auch in der Notfallmedizin relevant sind. Bei Tumorpatienten im finalen Krankheitsstadium ist trotz notärztlicher Alarmierung häufig ein palliativmedizinischer Therapieansatz notwendig und sinnvoll. Aus diesem Grund erscheint eine strukturierte Kooperation der involvierten medizinischen Fachgebiete (Notfall- und Palliativmedizin) dringend geboten. Durch die Integration palliativmedizinischer Expertise in die notärztliche Versorgung im Rettungsdienst kann eine zielgerichtete Therapie im Sinne des Patientenwunsches auch im Notfall gewährleistet werden. Dieses wäre z.xa0B. über eine Integration ambulanter PCT in die Versorgung von Tumorpatienten in finalen Krankheitsstadien möglich.AbstractBackgroundPresently and even more in the near future more cancer patients will be treated at home especially in the final stage of their disease. For this reason the prehospital emergency system will be confronted with the specific needs of these patients. Palliative care is not part of the German model of post-graduate training regulations for emergency medicine and palliative care teams (PCT) are only involved in the treatment of cancer patients in emergency situations.MethodsOver a 12-month period we retrospectively analysed all emergency cases that had been categorised as final cancer stage at 2 emergency sites (one air-based, the other ground-based) involving physicians in an out-of-hospital setting. We analysed all cases for indications of emergency call, prehospital treatment and involvement of a PCT in the treatment of symptoms.ResultsFor this period we analysed 2,765 emergency documents and identified more than 2.5% as emergency calls by cancer patients or their relatives (the majority of patients had been in the final stage of the disease). Most emergency calls occurred at times when no general practitioner was on duty and acute dyspnoea (42.7%) was the prominent diagnosis. After emergency treatment 61.8% patients had been admitted to hospital. In most settings a PCT was not involved in the treatment of palliative care patients or their relatives (92.7%).ConclusionsOur data demonstrate that care of cancer patients in the final stage of the disease is relevant in emergency medicine. These patients are in need of help based on principles of palliative care. Under these circumstances cooperation of the medical disciplines (emergency and palliative medicine) concerned seems to be necessary. This may increase the possibility for patients to stay at home for the last days of their life. Because of this we are convinced that basic knowledge of palliative care should be integrated into the German model of post-graduate training regulations for emergency care. Combining parts of the curricula (palliative and emergency medicine) it would be possible for emergency physicians to guide their treatment by the ideas and strategies of palliative care. But we are also convinced that the system of PCT should increase and become more involved in prehospital care in emergency cases of palliative care patients.

Treatment of oncology patients in the final stadium of disease by prehospital emergency physicians

ZusammenfassungHintergrundDie Versorgung von Patienten mit Tumorerkrankungen im finalen Krankheitsstadium erfolgt zunehmend im außerklinischen Umfeld. Aus diesem Grund wird auch der Rettungsdienst mit der Betreuung dieser Patienten bei akut exazerbierendem progredienten Krankheitsverlauf konfrontiert. Bisher fehlt allerdings ein entsprechender Ausbildungsinhalt in der Musterweiterbildungsordnung im Bereich Notfallmedizin. Ebenso ist die mögliche Integration ambulanter „palliative care teams“ (PCT) in die ambulante Notfallbehandlung noch nicht ausreichend umgesetzt.MethodenIn einem Zeitraum von 12xa0Monaten wurden retrospektiv alle Einsätze an 2xa0Notarztstützpunkten (Hubschrauber und Notarzteinsatzfahrzeug) untersucht, die als „Tumorerkrankung/Finalstadium“ kategorisiert waren. Entsprechend wurden alle Notarztprotokolle im Untersuchungszeitraum ausgewertet. Die Einsatzindikation, die durchgeführte Therapie und der Einfluss vorhandener PCT auf die Therapie wurden ermittelt.ErgebnisseIm definierten Zeitraum wurden 2765xa0Patienten notärztlich betreut. Primär palliativmedizinisch begründet waren 2,5% der Notarzteinsätze. Überwiegend erfolgten die Einsätze außerhalb der regulären Sprechzeiten der die Patienten versorgenden Hausärzte. Die häufigste Einsatzindikation war die akute Dyspnoe (42,7%). Eine stationäre Einweisung fand bei 61,8% der Patienten statt. Eine Einbindung eines ambulanten PCT war in den meisten Fällen nicht vorhanden (92,7%).SchlussfolgerungAnhand der Einsatzhäufigkeiten konnte verdeutlicht werden, dass palliativmedizinische Fragestellungen auch in der Notfallmedizin relevant sind. Bei Tumorpatienten im finalen Krankheitsstadium ist trotz notärztlicher Alarmierung häufig ein palliativmedizinischer Therapieansatz notwendig und sinnvoll. Aus diesem Grund erscheint eine strukturierte Kooperation der involvierten medizinischen Fachgebiete (Notfall- und Palliativmedizin) dringend geboten. Durch die Integration palliativmedizinischer Expertise in die notärztliche Versorgung im Rettungsdienst kann eine zielgerichtete Therapie im Sinne des Patientenwunsches auch im Notfall gewährleistet werden. Dieses wäre z.xa0B. über eine Integration ambulanter PCT in die Versorgung von Tumorpatienten in finalen Krankheitsstadien möglich.AbstractBackgroundPresently and even more in the near future more cancer patients will be treated at home especially in the final stage of their disease. For this reason the prehospital emergency system will be confronted with the specific needs of these patients. Palliative care is not part of the German model of post-graduate training regulations for emergency medicine and palliative care teams (PCT) are only involved in the treatment of cancer patients in emergency situations.MethodsOver a 12-month period we retrospectively analysed all emergency cases that had been categorised as final cancer stage at 2 emergency sites (one air-based, the other ground-based) involving physicians in an out-of-hospital setting. We analysed all cases for indications of emergency call, prehospital treatment and involvement of a PCT in the treatment of symptoms.ResultsFor this period we analysed 2,765 emergency documents and identified more than 2.5% as emergency calls by cancer patients or their relatives (the majority of patients had been in the final stage of the disease). Most emergency calls occurred at times when no general practitioner was on duty and acute dyspnoea (42.7%) was the prominent diagnosis. After emergency treatment 61.8% patients had been admitted to hospital. In most settings a PCT was not involved in the treatment of palliative care patients or their relatives (92.7%).ConclusionsOur data demonstrate that care of cancer patients in the final stage of the disease is relevant in emergency medicine. These patients are in need of help based on principles of palliative care. Under these circumstances cooperation of the medical disciplines (emergency and palliative medicine) concerned seems to be necessary. This may increase the possibility for patients to stay at home for the last days of their life. Because of this we are convinced that basic knowledge of palliative care should be integrated into the German model of post-graduate training regulations for emergency care. Combining parts of the curricula (palliative and emergency medicine) it would be possible for emergency physicians to guide their treatment by the ideas and strategies of palliative care. But we are also convinced that the system of PCT should increase and become more involved in prehospital care in emergency cases of palliative care patients.

Palliativmedizinische Betreuung von Tumorschmerzpatienten in Niedersachsen

ZusammenfassungFragestellung. Bereits 1995 hat die Ärztekammer Niedersachsen ihr palliativmedizinisches Modellprojekt SUPPORT initiiert. Vor Beginn von Interventionsmaßnahmen wurde die aktuelle Strukturqualität untersucht.nMethodik. Ein standardisierter Fragebogen fokussierte u. a. die Verfügbarkeitsrate von BtM-Rezeptvordrucken sowie die schmerztherapeutische Kompetenz unter 1200 Ärzten einer repräsentativen Stichprobe.nErgebnisse. 865 Fragebögen wurden retourniert (Rücklaufquote 72,1%). Von den Respondenten verfügten nur 36,9% über BtM-Rezeptvordrucke und nur 33,1% kannten das WHO-Stufenschema. Für beide Items zeigte sich unter Berücksichtigung bestimmter Stratifizierungskriterien bei einigen Arztgruppen ein etwas positiveres Bild; insgesamt belegt die Untersuchung aber eine unzureichende Strukturqualität.nSchlussfolgerungen. Um die palliativmedizinische Betreuung terminal Kranker nachhaltig zu verbessern, erscheint eine “Doppelstrategie” erforderlich.AbstractIntroduction. Palliative care in Germany fails to reach established standards. To improve this situation the Chamber of Physicians of Lower-Saxony initiated SUPPORT in 1995. Prior to interventions structural quality of care was evaluated, specifically the rate of availability of opioid-prescription-forms and the ability to treat chronic pain (defined as a construct of knowledge, attitudes and skills) were examined.nMethods. The survey was carried out using a standardized questionnaire mailed to a representative stratified sample of 1200 physicians.nResults. Out of 865 answering physicians (response rate 72.1%) only 36.9% had their own opioid-prescription-forms. Differentiations regarding to speciality, working place (clinic vs. private practice) and treatment of cancer pain patients during the last three months shows a better result for GPs (84.6%), internists (48.6%), gynecologists (51%) and pain specialists (66.7%). Only 33.1% of respondents claimed knowledge of the WHO-3-step-analgesic-ladder. Again the aforementioned differentiations yield somewhat better results for GPs (49.2%), internists (51.5%), gynecologists (34.7%) and pain specialists (55.6%), however only two thirds of these physicians were able to identify the correct number of steps of the WHO-algorithm.nConclusions. These results verify an insufficient structural quality in palliative care in Lower-Saxony. In the authors opinion effective improvements can only be achieved by implementing a parallel strategy:improvement of basic knowledge in pain management with sufficient transfer of this knowledge into practice as well as raising the rate of availability of opioid-prescription-forms,and, on the other hand, establishing local palliative-care-teams with nursing and medical expertise with 24/7 on-demand availability to optimize palliative care.

Heart team approach for transcatheter aortic valve implantation procedures complicated by coronary artery occlusion.

We report on three out of 270 consecutive patients (1.1%) suffering from coronary artery obstruction or occlusion at the end of transcatheter aortic valve implantation (TAVI). The partial or total obstruction of the coronary artery seen in the post-implantation aortography was accompanied by haemodynamic instability and electrocardiographic changes typical for myocardial ischaemia. Immediate percutaneous coronary intervention with stent implantation was successful in two cases, while in the third case it was not possible to cross the occluded right coronary artery. Emergency coronary artery bypass grafting was performed resulting in uneventful myocardial recovery. All patients were discharged home. These cases highlight the awareness of this rare, life-threatening complication of TAVI, which is in need of a dedicated heart team involved not only in decision-making, but also in the procedure itself.

Der finale Tumorpatient in der notfallmedizinischen Versorgung

We report about an emergency case of a female patient with terminal carcinoma of the ovary. On the basis of this case it becomes evident that palliative care questions are also important in emergency medicine. In this situation cooperation of the medical disciplines involved appears urgently necessary. This may allow the possibility for terminally ill patients to stay at home in the last days of life.ZusammenfassungBerichtet wird über die notärztliche Versorgung einer Patientin mit einem multipel metastasierten Ovarialkarzinom im finalen Krankheitsstadium. Anhand dieses Einsatzes soll verdeutlicht werden, dass palliativmedizinische Fragestellungen auch in der Notfallmedizin relevant sind. Eine strukturierte Kooperation der in dieser Situation involvierten medizinischen Fachgebiete erscheint dringend geboten.AbstractWe report about an emergency case of a female patient with terminal carcinoma of the ovary. On the basis of this case it becomes evident that palliative care questions are also important in emergency medicine. In this situation cooperation of the medical disciplines involved appears urgently necessary. This may allow the possibility for terminally ill patients to stay at home in the last days of life.

[Indicators of structural quality in palliative care for cancer pain patients in Lower-Saxony].

ZusammenfassungFragestellung. Bereits 1995 hat die Ärztekammer Niedersachsen ihr palliativmedizinisches Modellprojekt SUPPORT initiiert. Vor Beginn von Interventionsmaßnahmen wurde die aktuelle Strukturqualität untersucht.nMethodik. Ein standardisierter Fragebogen fokussierte u. a. die Verfügbarkeitsrate von BtM-Rezeptvordrucken sowie die schmerztherapeutische Kompetenz unter 1200 Ärzten einer repräsentativen Stichprobe.nErgebnisse. 865 Fragebögen wurden retourniert (Rücklaufquote 72,1%). Von den Respondenten verfügten nur 36,9% über BtM-Rezeptvordrucke und nur 33,1% kannten das WHO-Stufenschema. Für beide Items zeigte sich unter Berücksichtigung bestimmter Stratifizierungskriterien bei einigen Arztgruppen ein etwas positiveres Bild; insgesamt belegt die Untersuchung aber eine unzureichende Strukturqualität.nSchlussfolgerungen. Um die palliativmedizinische Betreuung terminal Kranker nachhaltig zu verbessern, erscheint eine “Doppelstrategie” erforderlich.AbstractIntroduction. Palliative care in Germany fails to reach established standards. To improve this situation the Chamber of Physicians of Lower-Saxony initiated SUPPORT in 1995. Prior to interventions structural quality of care was evaluated, specifically the rate of availability of opioid-prescription-forms and the ability to treat chronic pain (defined as a construct of knowledge, attitudes and skills) were examined.nMethods. The survey was carried out using a standardized questionnaire mailed to a representative stratified sample of 1200 physicians.nResults. Out of 865 answering physicians (response rate 72.1%) only 36.9% had their own opioid-prescription-forms. Differentiations regarding to speciality, working place (clinic vs. private practice) and treatment of cancer pain patients during the last three months shows a better result for GPs (84.6%), internists (48.6%), gynecologists (51%) and pain specialists (66.7%). Only 33.1% of respondents claimed knowledge of the WHO-3-step-analgesic-ladder. Again the aforementioned differentiations yield somewhat better results for GPs (49.2%), internists (51.5%), gynecologists (34.7%) and pain specialists (55.6%), however only two thirds of these physicians were able to identify the correct number of steps of the WHO-algorithm.nConclusions. These results verify an insufficient structural quality in palliative care in Lower-Saxony. In the authors opinion effective improvements can only be achieved by implementing a parallel strategy:improvement of basic knowledge in pain management with sufficient transfer of this knowledge into practice as well as raising the rate of availability of opioid-prescription-forms,and, on the other hand, establishing local palliative-care-teams with nursing and medical expertise with 24/7 on-demand availability to optimize palliative care.

Kenntnisse angehender Notfallmediziner über die Tumorschmerztherapie bei Palliativpatienten

BACKGROUNDnCancer diseases are often associated with acute and chronic pain. Therefore, cancer pain is a symptom frequently reported by palliative care patients with cancer diseases. Prehospital emergency physicians may be confronted with exacerbation of pain in cancer patients. The aim of this study was to evaluate the knowledge of prehospital emergency physicians in training concerning cancer pain therapy.nnnMETHODSnA total of 471 prehospital emergency physicians received a questionnaire (period of time: 2007-2009). The questionnaire was prepared for the study (mixed methods design). Twenty-four questions concerning cancer pain therapy (response options: scaling, open) were designed. The evaluation was done descriptively according to professional experience, field name and experience in treating patients with cancer as well.nnnRESULTSnA total of 469 participants completed the questionnaire (response rate 99%). On average, 10.8 (SD +5.7, range 2-24) questions were answered correctly. Resident physicians answered statistically significantly more questions correctly than consultants (p=0.02). Only physicians working in internal medicine achieved statistically significantly better results than other disciplines (e.g., surgery; p=0.01). Physicians with professional experience of less than 5 years answered statistically significantly more questions correctly (p=0.004).nnnCONCLUSIONSnThe results of this study verify that emergency physicians in training have insufficient knowledge of pain therapy and end-of-life decisions. The data of this investigation suggest that more attention should be paid to education on pain therapy and end-of-life care in medical curricula. Prehospital emergency physicians may thus be better prepared to provide quality care for palliative patients.ZusammenfassungHintergrundPatienten mit Tumorerkrankungen im palliativen Stadium können unter starken Schmerzexazerbationen leiden. Diese bedürfen einer schnellen, differenzierten und effektiven Therapie. Im Einsatz werden Notfallmediziner bei Patienten unter palliativer Therapie regelmäßig mit Tumorschmerzen konfrontiert. Ziel der vorliegenden Untersuchung war die Evaluation der Vorkenntnisse angehender Notärzte über die Tumorschmerztherapie.MethodenIm Untersuchungszeitraum 2007 bis 2009 wurden 471xa0Teilnehmer standardisierter Notarztausbildungskurse (nach den Empfehlungen der Bundesärztekammer) zu Kenntnissen der Tumorschmerztherapie befragt. Die Auswertung erfolgte bezogen auf die Gesamtgruppe deskriptiv sowie in Abhängigkeit von Berufserfahrung, Gebietsbezeichnung und Erfahrungen in der Therapie von Patienten mit Tumorerkrankungen. Insgesamt wurden 24xa0Wissensfragen zur Tumorschmerztherapie (Antwortmöglichkeiten: Skalierung, offen) anhand eines für die Untersuchung erstellten Fragebogens („mixed methods design“) erhoben.ErgebnisseAusgewertet wurden 469xa0Fragebögen aus 5xa0Kursen. Im Mittel wurden 10,8 der 24xa0Wissensfragen (SDxa0±5,7; Range 2–24) richtig beantwortet. Ärzte in Weiterbildung konnten unabhängig von der Gebietsausbildung signifikant mehr Wissensfragen korrekt beantworten als Ärzte mit Gebietsbezeichnung (p=0,02). Entsprechend den Gebietsausbildungen konnten lediglich Ärzte der inneren Medizin signifikant mehr Wissensfragen richtig beantworten als Ärzte sonstiger Gebietsbezeichnungen (p=0,01). Ärzte mit einer Berufserfahrung ≤5xa0Jahren beantworteten signifikant mehr Wissensfragen korrekt als Ärzte mit >5xa0Jahren Berufserfahrung (p=0,004).SchlussfolgerungDie vorliegende Untersuchung zeigt, dass angehende Notfallmediziner unzureichend in der differenzierten Tumorschmerztherapie ausgebildet sind. Änderungen in der Weiterbildung und frühzeitige Integration relevanter schmerztherapeutischer Themen in die medizinische Ausbildung sind daher weiter zu empfehlen und scheinen bereits erste positive Effekte zu zeigen. Die allgemeine notfallmedizinische Qualität der Versorgung von Patienten mit Tumorschmerzen und der Erfolg der Umsetzung der Empfehlungen müssen in folgenden klinischen Studien untersucht werden.AbstractBackgroundCancer diseases are often associated with acute and chronic pain. Therefore, cancer pain is a symptom frequently reported by palliative care patients with cancer diseases. Prehospital emergency physicians may be confronted with exacerbation of pain in cancer patients. The aim of this study was to evaluate the knowledge of prehospital emergency physicians in training concerning cancer pain therapy.MethodsA total of 471 prehospital emergency physicians received a questionnaire (period of time: 2007–2009). The questionnaire was prepared for the study (“mixed methods design”). Twenty-four questions concerning cancer pain therapy (response options: scaling, open) were designed. The evaluation was done descriptively according to professional experience, field name and experience in treating patients with cancer as well.ResultsA total of 469 participants completed the questionnaire (response rate 99%). On average, 10.8 (SD +5.7, range 2–24) questions were answered correctly. Resident physicians answered statistically significantly more questions correctly than consultants (p=0.02). Only physicians working in internal medicine achieved statistically significantly better results than other disciplines (e.g., surgery; p=0.01). Physicians with professional experience of less than 5xa0years answered statistically significantly more questions correctly (p=0.004).ConclusionsThe results of this study verify that emergency physicians in training have insufficient knowledge of pain therapy and end-of-life decisions. The data of this investigation suggest that more attention should be paid to education on pain therapy and end-of-life care in medical curricula. Prehospital emergency physicians may thus be better prepared to provide quality care for palliative patients.

Palliative medicine. Fifth pillar of anaesthesia departments

Palliative medicine has progressed during recent years to an independent medical faculty within the German health system. Despite this development palliative care systems for out-of-hospital and in-hospital palliative care are still insufficient in Germany so that the development of necessary resources must be considered as not yet completed. To support the further national development palliative medicine can be temporarily or permanently coupled to existing departments, which can be advantageous for all concerned and last but not least be profitable to patients and their relatives. Possibilities for participation of anaesthesiologists in this area of medical care are discussed in the study reported here. Anaesthesiologists have always historically been represented in palliative medical departments, e.g. as pain specialists. In the following investigation the special possibilities of anaesthesia departments for supporting the education and development of in-hospital and out-of hospital palliative medical care departments are reported. Previous experience of co-operation between these two departments is well established. Departments of palliative medicine depend on a well working interdisciplinary co-operation between different medical disciplines (e.g. anaesthesiology, radiotherapy, surgery and oncology) and several medical professions (e.g. physicians, nurses, psychologists). The aim of palliative care therapy is to be responsible for the best possible therapy for cancer patients and to give support to their care-giving relatives. Due to the increasing establishment of palliative care procedures in Germany, departments of anaesthesiology should actively take part in the further development. Part of the responsibility of most anaesthesia departments is to practice pain management and critical care medicine, which are reasons why anaesthesiologists are predestined to be part of the system for palliative care patients and their relatives. Anaesthesia departments can be responsible for the organization of in-hospital and out-of-hospital palliative medicine and palliative care. The integration of anaesthesiological expertise into palliative medicine departments and vice versa can be a great opportunity for both medical departments and therefore represents a worthwhile engagement.

Ambulante und stationäre palliativmedizinische Patientenversorgung in Deutschland

BACKGROUNDnIn Germany, specialized out-patient palliative care systems (SPCS) are still structurally and organizationally under construction. Palliative care patients need an easy access to a qualified SPCS. The purpose of the present investigation was to show the nationwide distribution of all SPCS teams in comparison to the distribution of emergency medical systems. Possibilities for an effective structure of palliative medical care systems will be discussed in order to optimize patient care..nnnMETHODSnAll SPCS teams in Germany (according to the Guide to hospices and palliative medicine of the German Association for Palliative Care 2008/2009) were documented. A cartographic representation of the structural distribution of palliative care systems was made taking a catchment area diameter of 50 km for each SPCS team and an accessibility diameter of 20 km for every palliative ward into account. These data were compared with the nationwide distribution of emergency institutions.nnnRESULTSnIn Germany 25 SPCS teams and 198 palliative wards could be identified. In contrast there are 1,109 emergency physician locations (1,051 ground based, 58 air based). The nationwide distribution of the existing SPCS teams does not at present give exhaustive coverage in comparison to emergency medical structures. No structure which might potentially result in an exhaustive implementation of SPCS teams and palliative stations is recognizable in the analysis or distribution.nnnCONCLUSIONSnThe coverage of SPCS and in-hospital palliative care is still a theoretical construct in many regions of Germany. The number of existing SPCS teams and in-patient palliative institutions is insufficient to guarantee an exhaustive coverage of patient care as in emergency medical services. In order to achieve a higher quality of results the quality of the structure and processes must first be ensured. The distribution of palliative care should be centrally coordinated along the same lines as the emergency institutions in order to achieve a need-oriented exhaustive coverage. A surplus of care in some regions at the expense of an undersupply in other regions must be avoided. In the next step a further development and adaption of existing structures to the requirements would be a logical approach.ZusammenfassungHintergrundIn Deutschland befinden sich sowohl die ambulante als auch die stationäre Palliativversorgung strukturell und organisatorisch im Aufbau. Palliativpatienten benötigen einen einfachen und schnellen Zugang zu palliativmedizinischen Strukturen. Ziel der Untersuchung ist es, die bundesweite Palliativversorgung im Vergleich mit der Verteilung notärztlicher Rettungsmittel kartografisch darzustellen. Es werden Möglichkeiten einer effektiven Struktur palliativmedizinischer Versorgungssysteme diskutiert, um die Patientenversorgung zu optimieren.MethodeAlle im Wegweiser Hospiz- und Palliativmedizin Deutschland 2008/2009 genannten spezialisierten ambulanten Palliativdienste (SAPD) und alle Palliativstationen wurden ermittelt. Es erfolgte eine kartografische Darstellung der strukturellen Verteilung der Palliativversorgungssysteme unter Berücksichtigung eines Tätigkeitsdurchmessers von 50xa0km für SAPD und eines Erreichbarkeitsdurchmessers von 20xa0km für Palliativstationen. Diese Daten wurden mit der bundesweiten Verteilung notärztlicher Institutionen verglichen.ErgebnisseInsgesamt konnten 25xa0SAPD und 198xa0Palliativstationen identifiziert werden. Demgegenüber gibt es derzeit 1109xa0Notarztstandorte (1051 bodengebundene Notarztstandorte, 58xa0Primärrettungshubschrauber). Die Verteilung der Palliativversorgung ist im Vergleich zu notfallmedizinischen Strukturen nicht flächendeckend. Bei der Analyse bezüglich der Verteilung wird auch keine Struktur erkennbar, die eine flächendeckende Implementierung der SAPD und Palliativstationen erwarten lässt.SchlussfolgerungDie flächendeckende Palliativversorgung ist zurzeit in weiten Bereichen Deutschlands ein theoretisches Konstrukt. Die Anzahl der vorhandenen SAPD und der stationären Palliativeinrichtungen ist nicht ausreichend, um eine, wie in der Notfallrettung bestehende, flächendeckende Patientenversorgung zu gewährleisten. Um eine hohe Ergebnisqualität zu ermöglichen, müssen zuerst die Struktur- und Prozessqualität gesichert werden. Die Verteilung der Palliativversorgung sollte entsprechend den notfallmedizinischen Institutionen zentral koordiniert werden, um eine bedarfsadaptierte, flächendeckende Aufteilung zu erreichen. Es muss ein Überangebot in einzelnen Bereichen zulasten einer Unterversorgung anderer Bereiche vermieden werden. In einem weiteren Schritt sind ein Ausbau und eine Bedarfsanpassung der bestehenden Strukturen sinnvoll.AbstractBackgroundIn Germany, specialized out-patient palliative care systems (SPCS) are still structurally and organizationally under construction. Palliative care patients need an easy access to a qualified SPCS. The purpose of the present investigation was to show the nationwide distribution of all SPCS teams in comparison to the distribution of emergency medical systems. Possibilities for an effective structure of palliative medical care systems will be discussed in order to optimize patient care..MethodsAll SPCS teams in Germany (according to the Guide to hospices and palliative medicine of the German Association for Palliative Care 2008/2009) were documented. A cartographic representation of the structural distribution of palliative care systems was made taking a catchment area diameter of 50xa0km for each SPCS team and an accessibility diameter of 20xa0km for every palliative ward into account. These data were compared with the nationwide distribution of emergency institutions.ResultsIn Germany 25 SPCS teams and 198 palliative wards could be identified. In contrast there are 1,109 emergency physician locations (1,051 ground based, 58 air based). The nationwide distribution of the existing SPCS teams does not at present give exhaustive coverage in comparison to emergency medical structures. No structure which might potentially result in an exhaustive implementation of SPCS teams and palliative stations is recognizable in the analysis or distribution.ConclusionsThe coverage of SPCS and in-hospital palliative care is still a theoretical construct in many regions of Germany. The number of existing SPCS teams and in-patient palliative institutions is insufficient to guarantee an exhaustive coverage of patient care as in emergency medical services. In order to achieve a higher quality of results the quality of the structure and processes must first be ensured. The distribution of palliative care should be centrally coordinated along the same lines as the emergency institutions in order to achieve a need-oriented exhaustive coverage. A surplus of care in some regions at the expense of an undersupply in other regions must be avoided. In the next step a further development and adaption of existing structures to the requirements would be a logical approach.

[Cancer pain therapy in palliative care patients: knowledge of prehospital emergency physicians in training. Prospective questionnaire-based investigation].

BACKGROUNDnCancer diseases are often associated with acute and chronic pain. Therefore, cancer pain is a symptom frequently reported by palliative care patients with cancer diseases. Prehospital emergency physicians may be confronted with exacerbation of pain in cancer patients. The aim of this study was to evaluate the knowledge of prehospital emergency physicians in training concerning cancer pain therapy.nnnMETHODSnA total of 471 prehospital emergency physicians received a questionnaire (period of time: 2007-2009). The questionnaire was prepared for the study (mixed methods design). Twenty-four questions concerning cancer pain therapy (response options: scaling, open) were designed. The evaluation was done descriptively according to professional experience, field name and experience in treating patients with cancer as well.nnnRESULTSnA total of 469 participants completed the questionnaire (response rate 99%). On average, 10.8 (SD +5.7, range 2-24) questions were answered correctly. Resident physicians answered statistically significantly more questions correctly than consultants (p=0.02). Only physicians working in internal medicine achieved statistically significantly better results than other disciplines (e.g., surgery; p=0.01). Physicians with professional experience of less than 5 years answered statistically significantly more questions correctly (p=0.004).nnnCONCLUSIONSnThe results of this study verify that emergency physicians in training have insufficient knowledge of pain therapy and end-of-life decisions. The data of this investigation suggest that more attention should be paid to education on pain therapy and end-of-life care in medical curricula. Prehospital emergency physicians may thus be better prepared to provide quality care for palliative patients.ZusammenfassungHintergrundPatienten mit Tumorerkrankungen im palliativen Stadium können unter starken Schmerzexazerbationen leiden. Diese bedürfen einer schnellen, differenzierten und effektiven Therapie. Im Einsatz werden Notfallmediziner bei Patienten unter palliativer Therapie regelmäßig mit Tumorschmerzen konfrontiert. Ziel der vorliegenden Untersuchung war die Evaluation der Vorkenntnisse angehender Notärzte über die Tumorschmerztherapie.MethodenIm Untersuchungszeitraum 2007 bis 2009 wurden 471xa0Teilnehmer standardisierter Notarztausbildungskurse (nach den Empfehlungen der Bundesärztekammer) zu Kenntnissen der Tumorschmerztherapie befragt. Die Auswertung erfolgte bezogen auf die Gesamtgruppe deskriptiv sowie in Abhängigkeit von Berufserfahrung, Gebietsbezeichnung und Erfahrungen in der Therapie von Patienten mit Tumorerkrankungen. Insgesamt wurden 24xa0Wissensfragen zur Tumorschmerztherapie (Antwortmöglichkeiten: Skalierung, offen) anhand eines für die Untersuchung erstellten Fragebogens („mixed methods design“) erhoben.ErgebnisseAusgewertet wurden 469xa0Fragebögen aus 5xa0Kursen. Im Mittel wurden 10,8 der 24xa0Wissensfragen (SDxa0±5,7; Range 2–24) richtig beantwortet. Ärzte in Weiterbildung konnten unabhängig von der Gebietsausbildung signifikant mehr Wissensfragen korrekt beantworten als Ärzte mit Gebietsbezeichnung (p=0,02). Entsprechend den Gebietsausbildungen konnten lediglich Ärzte der inneren Medizin signifikant mehr Wissensfragen richtig beantworten als Ärzte sonstiger Gebietsbezeichnungen (p=0,01). Ärzte mit einer Berufserfahrung ≤5xa0Jahren beantworteten signifikant mehr Wissensfragen korrekt als Ärzte mit >5xa0Jahren Berufserfahrung (p=0,004).SchlussfolgerungDie vorliegende Untersuchung zeigt, dass angehende Notfallmediziner unzureichend in der differenzierten Tumorschmerztherapie ausgebildet sind. Änderungen in der Weiterbildung und frühzeitige Integration relevanter schmerztherapeutischer Themen in die medizinische Ausbildung sind daher weiter zu empfehlen und scheinen bereits erste positive Effekte zu zeigen. Die allgemeine notfallmedizinische Qualität der Versorgung von Patienten mit Tumorschmerzen und der Erfolg der Umsetzung der Empfehlungen müssen in folgenden klinischen Studien untersucht werden.AbstractBackgroundCancer diseases are often associated with acute and chronic pain. Therefore, cancer pain is a symptom frequently reported by palliative care patients with cancer diseases. Prehospital emergency physicians may be confronted with exacerbation of pain in cancer patients. The aim of this study was to evaluate the knowledge of prehospital emergency physicians in training concerning cancer pain therapy.MethodsA total of 471 prehospital emergency physicians received a questionnaire (period of time: 2007–2009). The questionnaire was prepared for the study (“mixed methods design”). Twenty-four questions concerning cancer pain therapy (response options: scaling, open) were designed. The evaluation was done descriptively according to professional experience, field name and experience in treating patients with cancer as well.ResultsA total of 469 participants completed the questionnaire (response rate 99%). On average, 10.8 (SD +5.7, range 2–24) questions were answered correctly. Resident physicians answered statistically significantly more questions correctly than consultants (p=0.02). Only physicians working in internal medicine achieved statistically significantly better results than other disciplines (e.g., surgery; p=0.01). Physicians with professional experience of less than 5xa0years answered statistically significantly more questions correctly (p=0.004).ConclusionsThe results of this study verify that emergency physicians in training have insufficient knowledge of pain therapy and end-of-life decisions. The data of this investigation suggest that more attention should be paid to education on pain therapy and end-of-life care in medical curricula. Prehospital emergency physicians may thus be better prepared to provide quality care for palliative patients.