Evaluation des Entlassungsmanagements aus der PatientInnenperspektive : Subjektives Erleben von PatientInnen mit Schlaganfallkomplexbehandlung bei der Überleitung aus dem Setting der Stroke Unit in den nachsorgenden Sektor

Das strukturierte Entlassungsmanagement soll eine hohe Versorgungsqualität bei der Überleitung von Patient:innen mit dem Krankheitsbild „Schlaganfall“ mit einem nachstationären Pflege- und Versorgungsbedarf gewährleisten. Seit dem 01.07.2015 haben alle Patient:innen nach § 39 Abs.1a SGB V einen gesetzlichen Anspruch auf ein „Krankenhaus Entlassungsmanagement“. Ziel ist die Optimierung der sektorenübergreifenden Versorgung. Diese Forschungsarbeit evaluiert den Prozess und die Ergebnisse des Entlassungsmanagements aus der Patient:innenperspektive. Um Versorgungsdefizite im Entlassungsmanagement zu erkennen, ist es unerlässlich, die Patient:innenperspektive zu erheben. Grundlage für die Evaluation sind die Empfehlungen des aktuellen Expertenstandards „Entlassungsmanagement in der Pflege“ (DQNP ,2019: 25-51). Patient:innen mit zu erwartenden Versorgungsproblemen nach der stationären Entlassung erhalten ein individuelles Entlassungsmanagement. Damit soll der Pflege- und Unterstützungsbedarf in der poststationären Versorgung sichergestellt werden. Durch die systematische Einschätzung des individuellen Pflegebedarfs, Beratung, Schulung und der Evaluation der Pflegeinterventionen sollen Pflegefachkräfte eine qualitativ hochwertige Versorgungssituation gewährleisten und die Patient:innen bei der Überleitung in den nachsorgenden Sektor unterstützen. Der Expertenstandard „Entlassungsmanagement in der Pflege“ beinhaltet sechs Kategorien, die jeweils in Struktur,- Prozess,- und Ergebniskriterien unterteilt sind. (DQNP, 2019: 25). Die Untersuchungen wurden vom 01.11.2019 bis 31.01.2020 an 35 Patient:innen mit einer Schlaganfall-Komplexbehandlung auf einer Stroke Unit durchgeführt. Eine Komplexbehandlung in der Medizin umfasst unterschiedliche, sich ergänzende Therapieansätze bei speziellen Krankheitsbildern. Eine Stroke Unit ist eine abgeschlossene Behandlungseinheit, die für Schlaganfall-Patient:innen vorgehalten wird. Die Patient:innen mit Schlaganfall werden von einem speziell ausgebildeten multiprofessionellen Team versorgt. Die Behandlung auf einer Stroke Unit stellt eine der wichtigsten und auf höchstem Evidenzniveau abgesicherten Maßnahmen in der Akuttherapie des Schlaganfalls dar (DGN, 2012). Die Gelegenheitsstichprobe umfasste 195 Patient:innen. Es konnten für 35 Patientenakten die Einwilligung zu der strukturierten Inhaltsanalyse (Dokumentenanalyse) eingeholt werden. Aus dieser Gruppe wurden parallel 14 leitfadengestützte Interviews durchgeführt, transkribiert und analysiert. Die Untersuchung wurde mittels quantitativer und qualitativer Methoden (Mixed-Methods-Design) durchgeführt. Die Untersuchung besteht aus einer quantitativen und einer qualitativen Teilstudie (Parallel-Design), um mit den unterschiedlichen Erhebungsmethoden die Qualität der Ergebnisse zu erhöhen (Triangulation). Die beiden Teilstudien verlaufen unabhängig voneinander. Die Auswertung erfolgte für beide Studien nach den spezifischen Standards quantitativer und qualitativer Forschung. Die Ergebnisse der Teilstudien wurden in getrennten Forschungsberichten dargestellt. Die Ergebnisse wurden im Anschluss an die Auswertung auf der Metaebene zusammengeführt. Die Untersucherin setzt in der qualitativen Untersuchung leitfadengestützte Interviews ein, um eine möglichst hohe Ausprägung von Informationen, Erlebnissen, Meinungen und Haltungen zu generieren. In der quantitativen Untersuchung, der strukturierten Inhaltsanalyse (nach Häufigkeiten), wurden Patientenakten nach definierten Kategorien in Bezug auf die Qualität des Entlassungsmanagements und den Bezug zum nachgeordneten Versorgungssektor analysiert. Die Ergebnisse aus der Dokumentenanalyse lassen den Rückschluss zu, dass die im klinikinternen Standard „Entlassungsmanagement“ geforderten Kriterien weitgehend erfüllt sind. Des Weiteren lässt sich ableiten, dass das soziale Umfeld und das bestehende Setting bei der Aufnahme einen Einfluss auf den Entlassungsort des nachsorgenden Versorgungssektors haben können. Die Ergebnisse aus den leitfadengestützten Interviews zeigen, dass die Überleitung in den nachsorgenden Sektor mit Versorgungseinbrüchen einhergehen kann. Die Befragten erleben diese Versorgungseinbrüche als schwer belastende Ereignisse. Neben den Herausforderungen und Stressoren konnten jedoch auch unterschiedliche Ressourcen und Potentiale der Patient:innen identifiziert werden, auf welche die Betroffenen zurückgreifen, um Belastungssituationen zu bewältigen. Alle befragten Patient:innen zeigen eine hohe Motivation, in das häusliche Umfeld zurückzukehren. Sie beschreiben detailliert ihre Bereitschaft zur Verbesserung ihres individuellen Selbstkonzepts. Sie vertrauen ihren eigenen Fähigkeiten und nutzen die Ressourcen vor der Beeinträchtigung und verfügen über die Fähigkeit zur Anwendung von Problembewältigungsstrategien aus früheren, erfolgreich bewältigten Krisen. Die Ergebnisse aus den beiden Untersuchungen wurden im Kontext des Expertenstandards „Entlassungsmanagement in der Pflege“ und im Hinblick auf den Einsatz von Managed Care Modellen in Deutschland diskutiert. Insgesamt ist festzustellen, dass die Konzepte für innovative Versorgungskonzepte im deutschen Gesundheitswesen vorliegen und in unterschiedlicher Ausprägung genutzt werden. Für die Überleitung der Patient:innen aus der akutstationären Krankenversorgung im Bereich der Stroke Unit zeigen sich Defizite im Entlassungsmanagement. Die identifizierten Defizite wären vermeidbar, wenn die Kriterienebenen 5 und 6 im Expertenstandard konsequent umgesetzt würden. Der Verbesserungsansatz bedeutet zum einen, die Identifikation von Widerständen und Hemmnissen bei der Umsetzung der Kriterienebene 5 (Evaluation des Entlassungsplans 24 h vor Entlassung). Zum anderen, die Anpassung und Erweiterung des klinikinternen Standards Entlassungsmanagement um die erweiterten Inhalte der Kriterienebene 6 (Evaluation des Entlassungsmanagements 48 bis 72 h nach der Entlassung) aus der aktualisierten Form des Expertenstandards „Entlassungsmanagement in der Pflege“ von 2019.Structured discharge management is intended to ensure a high quality of care in the transfer of patients with the clinical picture "stroke" with a need for post-discharge care. Since July 1, 2015, all patients have a legal right to "hospital discharge management" in accordance with § 39 Para. 1a SGB V (German Social Code). The aim is to optimize cross-sectoral care. This research evaluates the process and the results of discharge management from the patient's perspective. In order to identify deficits in discharge management, it is essential to assess the patient's perspective. The recommendations of the current expert standard "Discharge management in nursing care" (DQNP, 2019: 25-51) form the basis for the evaluation. Patients with expected care problems after inpatient discharge receive individual discharge management. This is intended to ensure the care and support needs in post-inpatient care. Through systematic assessment of individual care needs, counseling, training and evaluation of care interventions, nurses should ensure a high-quality care situation and support patients in the transition to the post-discharge care sector. The expert standard "Discharge management in nursing" contains six categories, each of which is divided into structure, process, and outcome criteria. (DQNP, 2019: 25). The examinations were carried out from 01.11.2019 to 31.01.2020 on 35 patients with a stroke complex treatment on a stroke unit. Complex treatment in medicine comprises various complementary therapeutic approaches for specific clinical pictures. A stroke unit is a selfcontained treatment unit for stroke patients. Stroke patients are cared for by a specially trained multiprofessional team. Treatment in a stroke unit is one of the most important measures in the acute treatment of stroke and has been validated at the highest level of evidence. (DGN, 2012). The opportunity sample consisted of 195 patients. Consent for the structured content analysis (document analysis) could be obtained for 35 patient files. From this group, 14 guided interviews were conducted in parallel, transcribed and analyzed. The study was conducted using quantitative and qualitative methods (mixed-methods design). The study consists of a quantitative and a qualitative sub-study (parallel design) in order to increase the quality of the results with the different survey methods (triangulation). The two sub-studies run independently of each other. The evaluation of both studies was carried out according to the specific standards of quantitative and qualitative research. The results of the sub-studies were presented in separate research reports. The results were combined on the meta-level following the evaluation. In the qualitative research, the investigator used guided interviews to generate as much information, experiences, opinions and attitudes as possible. In the quantitative study, structured content analysis (by frequencies), patient records were analyzed according to defined categories related to the quality of discharge management and the relationship to the downstream care sector. The results from the document analysis allow the conclusion that the criteria required in the hospital's internal standard "Discharge Management" are largely fulfilled. Furthermore, it can be deduced that the social environment and the existing setting at admission can have an influence on the discharge location of the downstream care sector. The results from the guideline-based interviews show that the transition to the aftercare sector can be accompanied by interruptions in care. Interviewees experience these disruptions in care as severely stressful events. In addition to the challenges and stressors, however, it was also possible to identify different resources and potentials of the patients, which they draw on to cope with stressful situations. All patients interviewed showed a high level of motivation to return to their home environment. They describe in detail their willingness to improve their individual self-concept. They trust their own abilities and use resources prior to the impairment and have the ability to apply problem coping strategies from previous crises that they have successfully managed. The results from the two studies were discussed in the context of the expert standard "Discharge Management in Nursing Care" and with regard to the use of managed care models in Germany. Overall, it can be stated that the concepts for innovative care concepts are available in the German healthcare system and are used to varying degrees. For the transfer of patients from acute inpatient care in the stroke unit, deficits in discharge management are evident. The deficits identified could be avoided if criteria levels 5 and 6 in the expert standard were consistently implemented. The improvement approach means, on the one hand, the identification of resistance and obstacles in the implementation of criteria level 5 (evaluation of the discharge plan 24 h before discharge). On the other hand, the adaptation and expansion of the hospital's internal standard for discharge management to include the expanded content of criteria level 6 (evaluation of discharge management 48 to 72 hours after discharge) from the updated form of the 2019 expert standard "Discharge management in nursing care"

Strategieoptionen zur Realisierung einer 100%igen Biofütterung bei Monogastriern im ökologischen Landbau

Die Umstellung auf 100%ige Biofütterung innerhalb der nächsten drei Jahre stellt eine große Herausforderung in der Monogastrierfütterung dar. Die in diesem Dossier vorgestellten Lösungsoptionen sind hinsichtlich ihrer Implementierungsmöglichkeit sehr unterschiedlich zu bewerten: Manche Optionen, wie beispielsweise die bakterielle Aminosäureherstellung, setzen noch erhebliche Forschungsarbeiten voraus, andere, wie die Verfütterung von bestimmten Silagen, sind bereits bewerte Praxis bei der Fütterung von Wiederkäuern, müssen allerdings erst noch auf Monogastrier angepasst werden. Während für die bakterielle Aminosäureherstellung entsprechende Bakterienstämme in ihrer Leistungsfähigkeit optimiert und geeignete Biosubstrate gefunden werden müssen, müssen bei der Silagebereitung und -verfütterung vor allem noch verbesserte technische Lösungen gefunden und installiert werden, damit das darin vorhandene Potenzial zur Entfaltung kommt

Abiotic and Biotic Soil Characteristics in Old Growth Forests and Thinned or Unthinned Mature Stands in Three Regions of Oregon

We compared forest floor depth, soil organic matter, soil moisture, anaerobic mineralizable nitrogen (a measure of microbial biomass), denitrification potential, and soil/litter arthropod communities among old growth, unthinned mature stands, and thinned mature stands at nine sites (each with all three stand types) distributed among three regions of Oregon. Mineral soil measurements were restricted to the top 10 cm. Data were analyzed with both multivariate and univariate analyses of variance. Multivariate analyses were conducted with and without soil mesofauna or forest floor mesofauna, as data for those taxa were not collected on some sites. In multivariate analysis with soil mesofauna, the model giving the strongest separation among stand types (P = 0.019) included abundance and richness of soil mesofauna and anaerobic mineralizable nitrogen. The best model with forest floor mesofauna (P = 0.010) included anaerobic mineralizable nitrogen, soil moisture content, and richness of forest floor mesofauna. Old growth had the highest mean values for all variables, and in both models differed significantly from mature stands, while the latter did not differ. Old growth also averaged higher percent soil organic matter, and analysis including that variable was significant but not as strong as without it. Results of the multivariate analyses were mostly supported by univariate analyses, but there were some differences. In univariate analysis, the difference in percent soil organic matter between old growth and thinned mature was due to a single site in which the old growth had exceptionally high soil organic matter; without that site, percent soil organic matter did not differ between old growth and thinned mature, and a multivariate model containing soil organic matter was not statistically significant. In univariate analyses soil mesofauna had to be compared nonparametrically (because of heavy left-tails) and differed only in the Siskiyou Mountains, where they were most abundant and species rich in old growth forests. Species richness of mineral soil mesofauna correlated significantly (+) with percent soil organic matter and soil moisture, while richness of forest floor mesofauna correlated (+) with depth of the forest floor. Composition of forest floor and soil mesofauna suggest the two groups represent a single community. Soil moisture correlated highly with percent soil organic matter, with no evidence for drying in sites that were sampled relatively late in the summer drought, suggesting losses of surface soil moisture were at least partially replaced by hydraulic lift (which has been demonstrated in other forests of the region)

Complementation of a pathogenic IFNGR2 misfolding mutation with modifiers of N-glycosylation

Germline mutations may cause human disease by various mechanisms. Missense and other in-frame mutations may be deleterious because the mutant proteins are not correctly targeted, do not function correctly, or both. We studied a child with mycobacterial disease caused by homozygosity for a novel in-frame microinsertion in IFNGR2. In cells transfected with the mutant allele, most of the interferon γ receptor 2 (IFN-γR2) protein was retained within the cell, and that expressed on the cell surface had an abnormally high molecular weight (MW). The misfolding mutation was not gain-of-glycosylation, as it created no new N-glycosylation site. The mutant IFNGR2 allele was null, as the patient's cells did not respond to IFN-γ. Based on the well-established relationship between protein N-glycosylation and protein quality control processes, we tested 29 compounds affecting maturation by N-glycosylation in the secretory pathway. Remarkably, up to 13 of these compounds reduced the MW of surface-expressed mutant IFN-γR2 molecules and restored cellular responsiveness to IFN-γ. Modifiers of N-glycosylation may therefore complement human cells carrying in-frame and misfolding, but not necessarily gain-of-glycosylation, mutations in genes encoding proteins subject to trafficking via the secretory pathway. Some of these compounds are available for clinical use, paving the way for clinical trials of chemical complementation for various human genetic traits

The aged lymphoid tissue environment fails to support naive T cell homeostasis.

Aging is associated with a gradual loss of naive T cells and a reciprocal increase in the proportion of memory T cells. While reduced thymic output is important, age-dependent changes in factors supporting naive T cells homeostasis may also be involved. Indeed, we noted a dramatic decrease in the ability of aged mice to support survival and homeostatic proliferation of naive T cells. The defect was not due to a reduction in IL-7 expression, but from a combination of changes in the secondary lymphoid environment that impaired naive T cell entry and access to key survival factors. We observed an age-related shift in the expression of homing chemokines and structural deterioration of the stromal network in T cell zones. Treatment with IL-7/mAb complexes can restore naive T cell homeostatic proliferation in aged mice. Our data suggests that homeostatic mechanisms that support the naive T cell pool deteriorate with age.11128Ysciescopu

The EGS Grading Scale For Skin And Soft Tissue Infections Is Predictive Of Poor Outcomes : A Multicenter Validation Study

Introduction: Over the last five years, the American Association for the Surgery of Trauma (AAST) has developed grading scales for Emergency General Surgery (EGS) diseases. In a prior validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay and mortality in skin and soft tissue infections (STI). Methods: This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics and outcomes such as mortality, overall complications, hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability. Results: 1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher LRINEC scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status and hospital-level volume. Grade V disease was significantly associated with mortality as well. Conclusion: This validation effort demonstrates that Grade IV and V STI are significantly predictive of complications, hospital length of stay and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process, in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes

The Eighth Data Release of the Sloan Digital Sky Survey: First Data from SDSS-III

The Sloan Digital Sky Survey (SDSS) started a new phase in August 2008, with new instrumentation and new surveys focused on Galactic structure and chemical evolution, measurements of the baryon oscillation feature in the clustering of galaxies and the quasar Ly alpha forest, and a radial velocity search for planets around ~8000 stars. This paper describes the first data release of SDSS-III (and the eighth counting from the beginning of the SDSS). The release includes five-band imaging of roughly 5200 deg^2 in the Southern Galactic Cap, bringing the total footprint of the SDSS imaging to 14,555 deg^2, or over a third of the Celestial Sphere. All the imaging data have been reprocessed with an improved sky-subtraction algorithm and a final, self-consistent photometric recalibration and flat-field determination. This release also includes all data from the second phase of the Sloan Extension for Galactic Understanding and Evolution (SEGUE-2), consisting of spectroscopy of approximately 118,000 stars at both high and low Galactic latitudes. All the more than half a million stellar spectra obtained with the SDSS spectrograph have been reprocessed through an improved stellar parameters pipeline, which has better determination of metallicity for high metallicity stars.Comment: Astrophysical Journal Supplements, in press (minor updates from submitted version

The detection and prevention of adverse drug events in nursing home and home care patients: Study protocol of a quasi-experimental study

Aim: To estimate the cost-effectiveness of an intervention facilitating the early detection of adverse drug events through the means of health professional training and the application of a digital screening tool. Design: Multi-centred non-randomized controlled trial from August 2018 to March 2020 including 65 nursing homes or home care providers. Methods: We aim to estimate the effect of the intervention on the rate of adverse drug events as primary outcome through a quasi-experimental empirical study design. As secondary outcomes, we use hospital admissions and falls. All outcomes will be measured on patient-month level. Once the causal effect of the intervention is estimated, cost-effectiveness will be calculated. For cost-effectiveness, we include all patient costs observed by the German statutory health insurance. Results: The results of this study will inform about the cost-effectiveness of the optimized drug supply intervention and provide evidence for potential reimbursement within the German statutory health insurance system.TU Berlin, Open-Access-Mittel – 202