Dokumentation im Rettungsdienst

Zusammenfassung.

Einsatzdokumentation des Notarztdienstes als Instrument der Qualitätssicherung oder als Basis für notfallmedizinische Forschung sind nur an wenigen Rettungszentren in der Bundesrepublik Deutschland realisiert. Das im Auftrag der Deutschen Inderdisziplinären Vereinigung für Intensiv- und Notfallmedizin entwickelte Bundeseinheitliche Notarzteinsatzprotokoll ermöglicht aufgrund des Dokumentationskonzepts und der -inhalte die Möglichkeit, Analysen zur Struktur und Prozeßqualität bundesweit durchzuführen. Damit kann die Diskussion über Effektivität, Effizienz und Akzeptanz des Notarztdienstes auf eine objektive Datenbasis zurückgreifen.

Abstract.

Documentation of physician-staffed ambulance runs traditionally focuses on information transfer between the prehospital care provider and the receiving hospital. To use this information as a tool for research and quality assurance programs, the German Interdisciplinary Association of Critical Care Medicine developed in a consensus process a protocol for nationwide use. Protocol development was based on the question of what information can be obtained reliably in the emergency medical service (EMS) environment and what questions should be answered by data analysis. The protocol content was evaluated in several pilot studies and focuses on incidents and interventions that occur with reasonable frequency. It was taken into account that due to this approach, not all information that can possibly be obtained during the ambulance run can be documented. For data collection, the concepts of manual processing versus optical scanning are evaluated. The data analysis can serve as a basic tool for screening structure and process quality of EMS systems on a local as well as a nationwide level. During this process, areas for improvement as well as for clinical research are identified.