German hospitals face up to a tougher financial future

HANNOVER, Germany - Amid criticisms and not a little hostility, Horst Seehofer, Germany's federal minister of health, faced several thousand congress participants when he spoke at the recent 20th Congress of German Hospitals, held in conjunction with the annual Interhospital show.

Although the planned third phase of the Health Care Reform officially stalled in mid-September last year when it was rejected by the Bundesrat (upper house), the German Federal Government is still intending to reach its original objectives through legislative channels in three separate bills which do not require Bundesrat approval.

In addition, the new "Law on the Reduction of Contributions in the Statutory Healthcare System" already faces German hospitals. That law caps the base budget made available to hospitals for their own operating budget negotiations by 1% a year in the 1997-1999 period.

In his speech, Seehofer attempted to clarify for his audience the future role of hospitals from the perspective of the federal government. It was clear that although critical scrutiny of the status quo in hospital care is a step forward, it is one that needs to be accompanied by efforts to pinpoint solutions to help hospitals master the resultant difficulties.

Hermann Hoffmann, chairman of the administrative board of the German Hospital Federation, identified pressures from demographic changes (the "greying" of the population), medical advances, increased multimorbidity, increasing patient admittance figures and shorter hospital stays. He said that in this situation hospitals must critically analyze their ability to continue fulfilling the provisions of the Social Security Code requiring that medical care be humane, adequate, appropriate, demand-oriented, cost-efficient and in line with current medical standards. In this context, Hoffmann said the theme of the German Hospital Congress, "Hospital performance in the face of scarce resources," was a fitting objective.

Is outsourcing in?

The use of commercial outsourcing services is still comparatively new in German hospitals, which traditionally have provided most facilities themselves inhouse. Two service sectors where at least partial outside contracting is commonplace are catering and cleaning/janitorial services. Departmental outsourcing is not uncommon, with smaller German hospitals frequently contracting clinical diagnostic testing either to larger hospital groups or private laboratories. Bioscientia (Ingelheim, Germany) is probably the largest commercial diagnostic laboratory in Germany providing diagnostic testing services.

SmithKline Beecham (Greenford, England) recently opened a new $17 million clinical diagnostic testing laboratory in Watford, with the intention of providing contract diagnostic services throughout Europe. Its first contract with the West London Hospital is for all non-urgent clinical diagnostic testing, but its intention is to target hospital laboratory testing all over Europe.

The emphasis given in the congress program to the achievement of operating economies arising from greater use of external contract services indicates a much higher level of interest in widening the field of outsourcing to include radiology, hospital administration and home nursing care services.

Epidural injection simulation

The use of epidural analgesics, such as propafol from Zeneca (Macclesfield, England), is particularly widespread in ambulatory surgery and similar sectors. Alimitation on their wider use has been the necessity of one-to-one training on live patients, with inherent risks. Burrough House Associates (Middlezoy, England) demonstrated for the first time at Interhospital its new Epidural Injection Simulator system.

The simulator comprises of a self-contained operating module with needle/syringe assembly. The device is controlled through a specially developed user-friendly software program. By resistance variation during a simulated injection procedure, it communicates to the operator the "feel," or differentiation between the tissue types through which the needle travels.

Using any IBM-compatible PC, the software provides an on-screen inter-active graphical display for position of the needle insertion, tracking and final entry into the cere-bro-spinal fluid space and beyond. Variations in morphology can be set in by the instructing tutor, and the Simulator software can also provide hard copy results. Weighing less than 2 kilos, the simulator is fully portable and incorporates a closed-system reservoir which allows charging/discharging of saline using the syringe.

Douglas Bartys, director at Burrough House, told BBI that patent applications had already been registered for the operating system, and that discussions were under way with major epidural syringe suppliers and with pharmaceutical groups marketing epidural analgesics interested in expanding their training programs.

Operating theater developments

Heraeus Meal (Hanau, Germany) announced at Interhospital a strategic alliance with Medap Appartebau (Usingen, Germany), with the intention of jointly marketing Medap centralized gas supply and suction pump systems together with Heraeus Hanaulux surgical lights, Hanauport ceiling-mounted equipment columns and centralized medical gas supply systems.

Thomas Ihlenfeldt, managing director of Heraeus Med, said, "Both companies complement each other in an ideal way. Products and services are very compatible, with minimal overlapping." Ihlenfeldt said, "It is planned to leave both businesses a significant degree of independence also in the future, while implementing the synergic potential very swiftly." Medap reported 1996 revenues of around $18 million, while the Heraeus Group, which also has interests in precious metals, dental equipment and quartz glass, had much greater sales of $3.9 billion.

Dr. Mach (Ebersberg, Germany) has developed a new line of operating theater lights which are said to provide extremely high color rendition, especially in red and yellow sectors. The Mach processor-controlled Dual Focus System also enables pinpointing high intensity light on specific areas within the operating fields. In the more general hospital medical application sector, Guerra (Carmagnola, Italy) produces specialized halogen and incandescent lamps.

Berchtold (Tuttlingen, Germany) has developed the Chromophare D650 operating lamp, which is molded in impact-resistant plastic, making it extra light and readily adjustable.

TLV (Roubais, France) has developed a new ceiling suspended, multi-movement pendant system. The CMS 300 line can provide single or dual combinations with a variety of articulated arm sizes, electrical and gas connections and shelving with a load-bearing capacity of up to 484 pounds.

Among recently introduced operating tables were the Orthostar II from Maquet (Rastatt, Germany), designed to offer a wide range of applications in traumatology, orthopedics and spinal column surgery.

The Genupectum accessory from Merivara (Lathi, Finland) is used with its OPI900 operating table for disc and laminectomy surgery. Merivara also has developed an Orthopedic Extension Device for use in orthopedic and trauma procedures such as femur and tibia nailing.

Gasless laparoscopy

Laparoscopic procedures using pressurized C[O.sub.2] have been widely employed in thoracic procedures such as cholysytectomies using valved trocar ports, but the development of gasless laparoscopic procedures has made possible the development of extraperitoneal laparoscopic techniques in cardiovascular, pulmonary and orthopedic sectors. The first commercialized gasless system, the Laparolift and later the Laparafan from Origin MealSystems (Menlo Park, California), was followed by the LaparoTenser device made by L&T Lucini (Milan, Italy), which uses two curved Pluriplan needles inserted subcutaneously to provide retraction.

Aesculap (Tuttlingen, Germany) has launched the VarioLift Retraction System, which has been developed in cooperation with Dr. Gutt of the Universitatsklinik Hospital (Frankfurt/Main, Germany), who also has developed a special range of instruments adapted to the special requirements of gasless laparoscopy. Some instruments such as Metzenbaum scissors and Overholt clamps are insulated, permitting the safe use of coagulation techniques. An optional "hold-down" device can be used to hold organs and structures out of the way. It consists of two arms with transparent film between to provide a better overview.

Until now, the visualization in laparoscopic procedures of details such as suturing or cauterization has required moving and refocusing the endoscope. To overcome this problem, Karl Storz (Tuttlingen, Germany) has developed the Tricam SL/DX three-clip video camera with a parfocal zoom lensing system. This produces optimal image sizing for all endoscopes, removing the need to refocus when magnifying the image. Use of the zoom should replace the need for a range of fixed focal length adaptors and, additionally, use of an integrated camera head and adaptor will help significantly toward eliminating fogging.

New in anesthesia

Siemens-Elema (Solna, Sweden) has launched the KION anesthesia system, which has the screen and control panel mounted on a rotating arm so it can be positioned wherever is most convenient. Using electronic flow meters in the gas delivery system improves gas delivery accuracy with a wide range of ventilation modes. The KION system integrates with Siemens' Pick and Go continuous care monitoring concept and can also interface with the hospital mainframe recordkeeping system.

Blease (Chesham, England) has taken a different approach with the Frontline Plus modular anesthesia system. Blease has aimed to provide "a simpler answer in a complicated world" with a system termed ergonomically-designed and user-friendly, while the SAM (Smart Anesthesia Multigas) module from Marquette Hellige (Freiburg, Germany) uses infrared technology for general purpose anesthesia monitoring control.

Argon plasma coagulation

Erbe Elekromedizin (Tubingen, Germany) has developed a line of flexible argon plasma coagulation (APC) probes down to 1.5 mm diameter. Used with the Erbotom ICC 350 HF surgery unit and the APC 300 coagulation unit, these flexible APC probes make possible uniform but limited coagulation depth over wide areas, and without adhesions. Valleylab (Boulder, Colorado), with its Force Argon II electrosurgery system, has included a low-gas-flow mode for laparoscopic applications and a new over-pressure monitoring system to help avoid over-insufflation during laparoscopic procedures.

Blood cell separation

Fresenius (Bad Homburg, Germany) has added a new blood cell separator to its critical care product line. The AS.TEC 204 system is fully automated to combine both versatility and maximum donor/patient safety. In addition, Fresenius has developed an improved software revision 2.0 for its Continuous Autotransfusion System (CATS). New capabilities with the updated software include plasma sequestration (separation of hemodilution blood), cryopreservation of red blood cells and a low-volume wash program for pediatric surgery.

Bone densitometry

A new arrival in the DXA bone mineral densitometer measurement area is Aloka (Tokyo, Japan), with its DCS-600EX. The instrument is compact, with bone mineral content measurement calculated from scans of the patient's forearm, rather than traditional heel bone (calcaneum) measurements. Lunar (Madison, Wisconsin), McCue (Compton Winchester, England), CompuMed (Manhattan Beach, California), Hologic (Waltham, Massachusetts) and Norland (Fort Atkinson, Wisconsin) are other suppliers in the bone densitometry sector.

Bloodgas analyzers add lactate measurement

Both Chiron Diagnostics (Walpole, Massachusetts) and Radiometer (Copenhagen, Denmark) have added lactate measurement capabilities to their emergency analyzers.

Lactate monitoring can provide an early indicator of oxygen deficits, so providing a rapid warning of the gravity of trauma or shock in, for example, septic shock syndrome. The 800 series combined blood gas and electrolyte analyzers from Chiron Diagnostics have both glucose and lactate measurement capabilities, as have the ABL System 625 analyzers from Radiometer. The Radiometer lactate analysis module uses a lactate membrane device which needs to be replaced monthly using a "snap-on" rapid change system. Radiometer says its system lasts longer and is more cost effective than biosensor systems.

Solar-powered blood glucose testing

Card Imac (Schonberg, Germany) says its new Solarimac meter for rapid blood glucose home testing is the first to use solar power with battery back-up. Bjorn Nassat, president of Card Imac, said that the patented Solarimac test strip, which provides a white-to-green color change, is already reimbursed on the German market, with a cost of around 80 cents per strip. The Solarimac meter retails at $92.50 in Germany.

Lithotripters from Turkey

Turkey is an upcoming source of supply for a growing range of medical equipment. Two new suppliers of lithotripters are Elmed Lithotripsy Systems and PCK Company, both located in Ankara.

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