Patient outcomes and preventive measures

National als auch international wird das Auftreten von Dekubitus als ernstzunehmendes Problem der Versorgung von Patienten und Bewohnern in stationären Einrichtungen des Gesundheitswesens betrachtet. Die Dekubitusprävalenz in europäischen Kliniken variiert von 23% bis 8,3% (Vanderwee et al. 2007), in Deutschland liegt sie bei 7,1% in den Kliniken (Dassen et al. 2009). In Pflegeheimen in Deutschland liegt die Prävalenz bei 4,3% (Dassen et al. 2009). Internationale Projekte wie die des European Pressure Ulcer Advisory Panel (EPUAP) oder auf nationaler Ebene die des Deutschen Netzwerks für Qualitätsentwicklung in der Pflege (DNQP) zeichnen sich durch das Bereitstellen evidenz-basierter Leitlinien oder Standards aus. In Deutschland entwickelte das DNQP den Expertenstandard Dekubitusprophylaxe in der Pflege mit dem Ziel, die pflegerische Versorgung von gefährdeten Patienten und Bewohnern zu verbessern und langfristig die Dekubitushäufigkeit zu senken. Leitlinien und Expertenstandards dienen als Evidenzgrundlage zur Entwicklung der hauseigenen Pflegestandards (Duff et al. 1998, Field, Lohr 1992, DNQP 2007). Aus jährlich stattfindenden bundesweiten Prävalenzerhebungen in Pflegeheimen und Kliniken der Jahre 2001 bis 2007 wurden Patientendaten der Kliniken zum Verlauf der Dekubitusprävalenz ausgewertet. Struktur- und Ergebnisdaten aus 2002 dienten zur Analyse, welcher Zusammenhang zwischen der Verwendung der hauseigenen Standards und der Dekubitusprävalenz vorliegt. Daten zu Dekubituspräventionsmaßnahmen aus 2004 und 2005 wurden hinsichtlich der Unterschiede zwischen den Einrichtungen untersucht, die den Expertenstandard zur Entwicklung der hauseigenen Standards nutzten oder nicht. Diese Daten dienten ebenfalls zur Berechnung des Zusammenhangs zwischen der Nutzung des Expertenstandards und der Dekubitusprävalenz. Der Verlauf der risikoadjustierten Dekubitusprävalenz ohne Grad 1 in den Kliniken von 2001 bis 2007 zeigte einen Rückgang der Prävalenz von 14,8% auf 9,3%. Im Vergleich der Einrichtungen mit und ohne hauseigenen Dekubituspräventionsstandard gab es keinen Unterschied hinsichtlich der Dekubitusprävalenz. Die Analyse der pflegerischen Versorgung zeigte einen hohen Anteil von dekubitusgefährdeten Patienten und Bewohnern, die mit empfohlenen Maßnahmen versorgt wurden. Nicht mehr empfohlene Maßnahmen wurden häufiger in Kliniken als in Pflegeheimen durchgeführt. Die Dekubitusprävalenz war in Pflegeheimen niedriger als in Kliniken, jedoch völlig unabhängig davon, ob hauseigene Präventionsstandards gemäß Expertenstandard entwickelt wurden. Die vom DNQP angestrebte Qualitätsverbesserung der Dekubitusversorgung durch die Implementierung des Expertenstandards kann anhand der vorliegenden Daten nicht eindeutig nachgewiesen werden.National as well as international, the occurrence of pressure ulcers is regarded as a serious problem of the health service of patients and residents in health care facilities. The prevalence of pressure ulcers in European hospitals varies from 23% to 8.3% (Vanderwee et al. 2007); in Germany the prevalence of pressure ulcers in hospitals is about 7.1% (Dassen et al. 2009). In German nursing homes the prevalence is about 4.3% (Dassen et al. 2009). International projects like the European Pressure Ulcer Advisory Panel (EPUAP) or on German national level the German Network of Quality Development in Nursing (DNQP) stand out due to providing evidence based guidelines or standards. In Germany, the DNQP developed the Expert Standard/specialist guideline „Pressure Ulcer Prevention in Nursing“. Aim of this Expert Standard is to improve the health service in nursing of patients and residents at risk and to reduce the amount of pressure ulcers long-ranging. Guidelines and Expert Standards serve as basis of evidence for developing internal nursing protocols (Duff et al. 1998, Field, Lohr 1992, DNQP 2007). Hospital patient data from 2001 to 2007 of annually nation wide pressure ulcer prevalence surveys in nursing homes and hospitals were analysed regarding progression of pressure ulcer prevalence. Further, data of facility structures and patient outcomes from 2002 were analysed to show the relation between the use of internal protocols and pressure ulcer prevalence. To examine differences between health care institutions, which used the Expert Standard for developing their internal protocols, data from 2004 and 2005 about pressure ulcer preventing interventions were analysed. Additionally, these data were used to calculate the relation between use of the Expert Standard and pressure ulcer prevalence. The progress of risk adjusted pressure ulcer prevalence without grade-one pressure ulcers in hospitals from 2001 to 2007 showed a prevalence reduction from 14.8% to 9.3%. By comparing the health care institutions with and without internal protocols of pressure ulcer prevention, there was no difference regarding pressure ulcer prevalence. Analysis of the nursing health service showed a high part of patients and residents at risk for pressure ulcer, who received recommended measures. Not recommended nursing measures were provided more often in hospitals than in nursing homes. Pressure ulcer prevalence was lower in nursing homes than in hospitals, however, regardless of protocols development according to the Expert Standard. Quality improvement of pressure ulcers health service, aimed at the DNQP by implementing the Expert Standard, cannot be confirmed by the present data definitely

Management of Germ Cell Tumours of the Testis in Adult Patients. German Clinical Practice Guideline Part I: Epidemiology, Classification, Diagnosis, Prognosis, Fertility Preservation, and Treatment Recommendations for Localized Stages

INTRODUCTION This is the first German evidence- and consensus-based clinical guideline on diagnosis, treatment, and follow-up on germ cell tumours (GCTs) of the testis in adult patients. We present the guideline content in two publications. Part I covers the topic's background, methods, epidemiology, classification systems, diagnostics, prognosis, and treatment recommendations for the localized stages. METHODS An interdisciplinary panel of 42 experts including 1 patient representative developed the guideline content. Clinical recommendations and statements were based on scientific evidence and expert consensus. For this purpose, evidence tables for several review questions, which were based on systematic literature searches (last search was in March 2018) were provided. Thirty-one experts entitled to vote, rated the final clinical recommendations and statements. RESULTS We provide 161 clinical recommendations and statements. We present information on the quality of cancer care and epidemiology and give recommendations for staging and classification as well as for diagnostic procedures. The diagnostic recommendations encompass measures for assessing the primary tumour as well as procedures for the detection of metastases. One chapter addresses prognostic factors. In part I, we separately present the treatment recommendations for germ cell neoplasia in situ, and the organ-confined stages (clinical stage I) of both seminoma and nonseminoma. CONCLUSION Although GCT is a rare tumour entity with excellent survival rates for the localized stages, its management requires an interdisciplinary approach, including several clinical experts. Quality of care is highly related to institutional expertise and can be reassured by established online-based second-opinion boards. There are very few studies on diagnostics with good level of evidence. Treatment of metastatic GCTs must be tailored to the risk according to the International Germ Cell Cancer Collaboration Group classification after careful diagnostic evaluation. An interdisciplinary approach as well as the referral of selected patients to centres with proven experience can help achieve favourable clinical outcomes

Management of Germ Cell Tumours of the Testes in Adult Patients: German Clinical Practice Guideline, PART II - Recommendations for the Treatment of Advanced, Recurrent, and Refractory Disease and Extragonadal and Sex Cord/Stromal Tumours and for the Management of Follow-Up, Toxicity, Quality of Life, Palliative Care, and Supportive Therapy

OBJECTIVES We developed the first German evidence- and consensus-based clinical guideline on diagnosis, treatment, and follow-up of germ cell tumours (GCT) of the testes in adult patients. We present the guideline content in 2 separate publications. The present second part summarizes therecommendations for the treatment of advanced disease stages and for the management of follow-up and late effects. MATERIALS AND METHODS An interdisciplinary panel of 42 experts including 1 patient representative developed the guideline content. Clinical recommendations and statements were based on scientific evidence and expert consensus. For this purpose, evidence tables for several review questions, which were based on systematic literature searches (last search in March 2018), were provided. Thirty-one experts, who were entitled to vote, rated the final clinical recommendations and statements. RESULTS Here we present the treatment recommendations separately for patients with metastatic seminoma and non-seminomatous GCT (stages IIA/B and IIC/III), for restaging and treatment of residual masses, and for relapsed and refractory disease stages. The recommendations also cover extragonadal and sex cord/stromal tumours, the management of follow-up and toxicity, quality-of-life aspects, palliative care, and supportive therapy. CONCLUSION Physicians and other medical service providers who are involved in the diagnostics, treatment, and follow-up of GCT (all stages, outpatient and inpatient care as well as rehabilitation) are the users of the present guideline. The guideline also comprises quality indicators for measuring the implementation of the guideline recommendations in routine clinical care; these data will be presented in a future publication