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ABSTRACT Fragestellung: Ziel der Studie war, Langzeitberlebensrate, funktionelles Outcome und Lebensqualitt 2Jahre nach schwerem Trauma zu analysieren. Methodik: Im Rahmen einer prospektiven Studie wurden Daten schwerverletzter Patienten... more
ABSTRACT Fragestellung: Ziel der Studie war, Langzeitberlebensrate, funktionelles Outcome und Lebensqualitt 2Jahre nach schwerem Trauma zu analysieren. Methodik: Im Rahmen einer prospektiven Studie wurden Daten schwerverletzter Patienten ausgewertet, welche zwischen 8/1998 und 8/2000 ber den Schockraum aufgenommen wurden; die Patienten wurden 2Jahre nach dem Trauma standardisiert nachuntersucht (GOS: Glasgow Outcome Score, SF-36, EuroQuol). Die poststationre Sterblichkeitsrate wurde ber Hausrzte und Meldemter ermittelt. Ergebnisse:482 Patienten (mittlerer ISS von 24) konnten dokumentiert werden (Durchschnittsalter 39Jahre). 2Jahre nach Unfall waren 26% verstorben. Von den berlebenden waren 68% nach GOS voll rehabilitiert, die brigen schwerbehindert, 13% davon andauernd pflegebedrftig. EuroQuol und SF-36 offenbaren bei >50% chronische Schmerzprobleme und Angstzustnde. Bei Alltagsaktivitten und Mobilitt zeigen 40–50% der Patienten andauernde Einschrnkungen. Die soziale Situation umfasst einen Anstieg der Arbeitslosigkeit (5% 13,5%) und Arbeitsunfhigkeit (0% 15,3%) mit Umschulungen (9,9%) und Arbeitsplatzwechsel (15,8%) und bei 30% aller Patienten begleitende finanzielle Verluste. Die familire Situation erscheint unbeeinflusst. Schlussfolgerungen: 2Jahre nach Polytrauma resultieren medizinische und soziale Probleme mit einem erheblichen Behandlungs- und Versorgungsaufwand. Anstrengungen zur Verbesserung sollten ber Frhrehabilitation und Wiedereingliederungsmanahmen hinausgehen.Objective:The present study analyses long-term survival, functional outcome and quality of live 2years after trauma. Patients and methods: The complete consecutive data sets of patients admitted through the ER from 8/1998 until 8/2000 was documented and analyzed by a standardized protocol (GOS: Glasgow Outcome Score, SF-36, EuroQuol) precisely 2 years after trauma. 2-year mortality was based on the information provided by family physicians and community officials. Results:A total of 482 patients (mean ISS 24) was prospectively included (mean age 39years). 2 years after trauma 26% had died. 68% were fully rehabilitated according to GOS, the rest remained severely disabled whereof 13% needed permanent care. EuroQuol and SF-36 revealed chronic pain and anxiety states in >50% of the patients. Everyday activities and mobility were permanently impaired in 40–50%. The social situation after trauma included increased unemployment (5% to 13,5%), disablement (0% to 15,3%), retraining (9,9%) and job changes (15,8%). Very often (30%) patients had to tolerate significant financial losses. Private live and family situation was seemingly unchanged. Conclusions:Patients after severe multiple trauma often suffer from significant psychophysical and socioeconomic impairment requiring adequate treatment and care from both health system and family resources. Based on structured early rehabilitation and occupational reintegration a coherent, long-term restructuring effort is needed for these patients.
The aim of this study was to evaluate the costs involved in treating severely injured patients at the clinic differentiated by several characteristics (injury, age), sectors (emergency room, surgery, intensive and normal care), and kinds... more
The aim of this study was to evaluate the costs involved in treating severely injured patients at the clinic differentiated by several characteristics (injury, age), sectors (emergency room, surgery, intensive and normal care), and kinds of costs (fixed costs, variable costs) and to determine influencing factors regarding costs based on the register of the DGU (Deutsche Gesellschaft für Unfallchirurgie). All patients were taken into account who had an injury severity score (ISS) of at least 16. On this basis costs of 3702 patients were analyzed. They were compared by using analysis of variance for different groups of patients classified according to kind of injury, severity of injury, and age. Moreover, multiple regression was performed to control the common influence of demographic factors and the type of injury on costs. The average ISS of the analyzed patients was 30.6 (+/-11.6) points. The average costs of the clinic were 32,166 (+/-25,404) EUR per patient. More than half of the...
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The introduction of diagnosis related groups (DRG) will radically change the payment system for German hospitals. In 2002 the values for most DRG's were published for the german system (G-DRG). The polytrauma working group of the... more
The introduction of diagnosis related groups (DRG) will radically change the payment system for German hospitals. In 2002 the values for most DRG's were published for the german system (G-DRG). The polytrauma working group of the German Trauma Society developed a calculating algorithm to estimate the comprehensive hospital costs for every patient in the German trauma registry. The aim of this study was to compare these costs with the reimbursement according the the G-DRG's for a standardized population of polytrauma patients. For polytrauma patients treated at Hannover Medical School in 2000 and 2001 the reimbursement according to the G-DRG's was calculated using a base value of 2900 euro. In the same patients the total cost of inpatient treatment was calculated according to the algorithm developed by the polytrauma working group of the German Trauma Society. The difference between these values represents the economic result. This was calculated as an overall result, but...
Research Interests: Algorithms, Germany, Humans, Hospital costs, Female, and 6 moreMale, Registries, Length of Stay, Clinical Sciences, Middle Aged, and Adult
The availability of newer, faster computed tomography (CT) technology has engendered discussion about whole-body CT-scanning for primary radiological diagnostics of seriously injured patients. Within a quality management system, the... more
The availability of newer, faster computed tomography (CT) technology has engendered discussion about whole-body CT-scanning for primary radiological diagnostics of seriously injured patients. Within a quality management system, the scaled, priority-oriented scheme of conventional radiological and CT-diagnostics used in each institution was analysed and compared with the possible benefit of whole-body CT-scanning. Every patient with severe trauma admitted directly from the scene of an accident, underwent basic radiological and sonographic diagnostics in the emergency room (ER). According to the findings, patients in a stable vital condition had CT-scans when indicated by the guidelines of the particular institution. From 5/1998 until 12/2000, a total of 832 patients were treated in the ER. Of those, 480 patients (average ISS 20) were admitted directly from the scene of the accident. Basic radiological - sonographic diagnostics (radiographs of cervical spine, chest, and abdomen, as w...
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The aim of this study was to investigate perioperative morbidity in operative interventions in distal radiusfractures, comparing the operative approach from volar and dorsal. Only problems, resulting from the operative approach towards... more
The aim of this study was to investigate perioperative morbidity in operative interventions in distal radiusfractures, comparing the operative approach from volar and dorsal. Only problems, resulting from the operative approach towards the distal aspect of the radius, were examined. In a Case-Control-Study, we investigated patients with operative by plate-osteosynthesis treated distal radius-extensions-fractures. During 3 years we investigated 92 patients. 49 were operated with a volar approach, and after changing the operative management, consecutive 43 patients with a dorsal approach to the distal radius. Indications for operative treatment were not changed. The approach to the distal aspect of the radius corresponded to the recent guidelines. Further perioperative procedures were identical, including procedures in anesthesiology. Datas of patients have been investigated for epidemiology, kind of operations, point of time in treatment, duration of operation, X-Ray, immobilisation ...
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From May 1996 until April 1997 percutaneous CT-controlled ventriculostomy (PCV) was performed in 19 patients with severe traumatic brain injury and no indication for decompressive craniotomy. There was a significant reduction in the... more
From May 1996 until April 1997 percutaneous CT-controlled ventriculostomy (PCV) was performed in 19 patients with severe traumatic brain injury and no indication for decompressive craniotomy. There was a significant reduction in the duration of the procedure compared to burr-hole ventriculostomy with no complications. Because of further advantage of PCV CT-controlling is the possibility of puncturing even very narrow ventricles.
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This study was conducted to investigate the effects of intermittent prone positioning of patients with post-traumatic respiratory failure (paO2/FiO2 < 280 mm Hg) in comparison with conventional therapy in a supine position. Although... more
This study was conducted to investigate the effects of intermittent prone positioning of patients with post-traumatic respiratory failure (paO2/FiO2 < 280 mm Hg) in comparison with conventional therapy in a supine position. Although the severity of injury of the prone-positioned patients was much higher (ISS 35.8 vs 24.5), the ventilation time (32 vs 31 days) and ICU stay (39 vs 36 days) were similar to patients treated in the supine position. Besides the beneficial effect of prone positioning on oxygenation, for the first time we have evidence that prone positioning improves the outcome of patients with post-traumatic respiratory failure.
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The data of 1037 severely injured patients (mean ISS = 20) from 15 clinics were centrally and prospectively collected in the Trauma Registry of the German Society of Trauma Surgery and analyzed anonymously. Significant differences in... more
The data of 1037 severely injured patients (mean ISS = 20) from 15 clinics were centrally and prospectively collected in the Trauma Registry of the German Society of Trauma Surgery and analyzed anonymously. Significant differences in respect to the treatment criteria (i.e., duration of basic diagnostics in severe trauma) and quality of outcome (TRISS method and Z statistic) were revealed for some clinics. The feedback of their data offers the associated clinics the possibility of identification of treatment phases that are worth being optimized.
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In order to assess the costs arising from the treatment of polytraumatized patients we analysed the data of 100 prospectively studied multiple trauma patients (ISS 38) calculating all medical expenses during their clinical stay. The... more
In order to assess the costs arising from the treatment of polytraumatized patients we analysed the data of 100 prospectively studied multiple trauma patients (ISS 38) calculating all medical expenses during their clinical stay. The average cost per patient in the studied group (n = 100) amounted to 63989.- DM. About 65% of this sum derived from the costs of intensive care, while the expenses for operations covered 19%. The group of primarily deceased patients (n = 25) generated the lowest costs of 8468.- DM (per pat.). The highest costs of 95626.- DM were caused by the treatment of patients (n = 32) that developed one or more complications (organ failure) during their stay in the intensive care unit or died (n = 10) during this therapy (101940.- DM). Since the data concerning medical equipment (i.e. surgical devices, radiological equipment) were not centrally registered in the administration department of our clinic, it was not possible to include these costs into this calculation....
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To present a novel two-incision minimally invasive (TIMI) method for the treatment of anterior acetabular fractures. The first TIMI incision is performed using a pararectal approach at the level of the proximal third of the arcuate line... more
To present a novel two-incision minimally invasive (TIMI) method for the treatment of anterior acetabular fractures. The first TIMI incision is performed using a pararectal approach at the level of the proximal third of the arcuate line of the ilium. After transection of the abdominal wall the iliac vessels are mobilized medially and the neuromuscular bundle laterally. The second approach lies above the medial pubic bone. The soft tissue is held back using a retraction system. After fracture reduction and fixation by isolated screws a conventional reconstruction plate is inserted for fracture neutralization. Since January 2008 we have performed the TIMI method in 88 cases with good results. Recently we have published the data of a first series with 26 patients that were seen at least 12 months after surgery. The mean operative time was 109 ± 30 min and all incisions showed primary healing. Postoperative radiological examination revealed an anatomic reduction in 20 fractures and a satisfactory reduction in 6. There were no local soft tissue complications and no revisions were needed. Follow-up examinations were performed after a minimum of 12 months in 19 patients (73%). The average Harris hip score (HHS) was 86.6 ± 8. Quality of life was comparable to control persons in the same age group. The TIMI approach represents a viable alternative to the ilioinguinal approach. Despite the limited number of incisions a comparable quality of fracture reduction is achieved. The authors believe this technique would be most useful in patients with a higher risk for postoperative soft tissue complications.
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Summary Quality management in early clinical care of patients with multiple injuries (description of actual process, identification of problems, implementation of quality improvement) is not possible without sufficient baseline data... more
Summary Quality management in early clinical care of patients with multiple injuries (description of actual process, identification of problems, implementation of quality improvement) is not possible without sufficient baseline data about the present situation of medical treatment. This study investigates whether the current documentation of treatment in the emergency room is appropriate to judge upon the quality of the process
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The aim of the study was to examine the predictive value of CT for severe intracranial lesions of mild (GCS 15-13) and moderate (12-9) head injuries. Further,we examined the possibility of predicting these lesions by various... more
The aim of the study was to examine the predictive value of CT for severe intracranial lesions of mild (GCS 15-13) and moderate (12-9) head injuries. Further,we examined the possibility of predicting these lesions by various variables/factors. Data were collected prospectively from the trauma registry of the DGU (Deutsche Gesellschaft für Unfallchirurgie). Patients with a GCS score from 15-13 and from 12-9 were included in this study and examined for intracranial lesions (AIS(head) 3-6). Over a time period from 1993 to 1999, 1778 patients with mild head injury and 235 patients with moderate head injury were analyzed. Severe intracranial lesions were suffered by 18.6% of the patients with mild head injury and 50.4% of the patients with moderate head injuries. Of the predictive variables, heart rate,patients' age,and primary assessment by the emergency physician showed a strong correlation with the later observed intracranial lesions. In conclusion: (1) independently of the initia...
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The aim of this study is the presentation of the polyaxial locking NCB-plate in the treatment of femoral fractures, especially in elderly patients and in proximity of a prosthetic implant. The reduction and fixation of these fractures is... more
The aim of this study is the presentation of the polyaxial locking NCB-plate in the treatment of femoral fractures, especially in elderly patients and in proximity of a prosthetic implant. The reduction and fixation of these fractures is a challenging surgical procedure with high complication rates reported up to 40%. A total of 72 patients with femoral fractures had polyaxial locking plate osteosynthesis. Indications included fractures of the shaft and around an implant. Concerning surgical procedures, three different standardized techniques were performed: (1) minimally invasive with percutaneous distal insertion using a targeting device; (2) mini-open with additional cerclage wire via the same approach and (3) a conventional open reduction and internal fixation. Data collection included intraoperative data and early complications at 6, 24 and 52 weeks. Fifty-two patients had an implant or prosthesis in situ. Thirty-three patients were treated by technique (1), 32 patients had min...
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Geriatric fractures are an increasing challenge for the German health-care system. While the acute care for patients with proximal femoral fractures is already standardised, differences remain in the further treatment and rehabilitation.... more
Geriatric fractures are an increasing challenge for the German health-care system. While the acute care for patients with proximal femoral fractures is already standardised, differences remain in the further treatment and rehabilitation. A survey was conducted in cooperation with the section of geriatric trauma (AG Alterstraumatologie) of the German Association of Trauma Surgery (DGU) to point out existing problems in this group of patients. In October/November 2010 an electronic questionnaire, assessing the medical care for patients after proximal femoral fracture, was sent to 1080 medical directors of trauma and orthopaedic surgery departments in Germany. 339 (31.4 %) departments participated. The analysis revealed that 57 % of the hospitals had cooperation agreements with aftercare hospitals. 37 % of all hospitals had problems in finding a rehabilitation hospital. The initiation of a rehabilitation procedure is almost exclusively based on the doctors' decision. Influence of e...
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Thorax trauma (TT) is associated with a high rate of pulmonary failure and increased mortality. To prevent these complications, the German trauma system recommends intubation and chest tube insertion at the scene of the accident, even in... more
Thorax trauma (TT) is associated with a high rate of pulmonary failure and increased mortality. To prevent these complications, the German trauma system recommends intubation and chest tube insertion at the scene of the accident, even in cases without acute respiratory dysfunction. Due to the possible life threatening complications of the therapy, the emergency surgeon should be able to correctly identify a TT at the scene. Therefore, we retrospectively compared the evaluation of chest trauma by the emergency surgeon with objective injury severity according to the Abbreviated Injury Scale (AIS). Data from 2,392 patients (aged 39+/-1 years, Injury Severity Score 27+/-0.3) were taken from the multiple trauma database of the German Trauma Society. The evaluation of TT (absent, light, medium, severe) by the emergency surgeon was compared with objective injury severity (AIS=0: absent, 0>AIS<3: light, AIS=3: medium, AIS>3: severe). If the difference between the subjective and obj...
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Algorithms represent a graphical display of decision-making by giving clearly defined and formalized guidelines. The systematic order of decisions and consequent actions is guided by medical priority and regulates the time frame and... more
Algorithms represent a graphical display of decision-making by giving clearly defined and formalized guidelines. The systematic order of decisions and consequent actions is guided by medical priority and regulates the time frame and sequence of each single step in a logical manner. With the help of clinical algorithms highly complex processes such as the management of the severely injured patient can be translated into a clearly structured, logical pathway. They delineate a consistent and valid guideline but require aberrations in proven exceptions. The use of algorithms allows a systematic search for errors in the process of quality management. In emergency situations they suggest a structured way of problem-solving to the less experienced user. Algorithms are useful instruments in teaching medical decision-making.
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To enhance the quality of treatment of patients with multiple injuries (blunt trauma), guidelines for the acute clinical management (trauma-algorithm) were implemented at our clinic in 1994. The impact of these guidelines was analysed,... more
To enhance the quality of treatment of patients with multiple injuries (blunt trauma), guidelines for the acute clinical management (trauma-algorithm) were implemented at our clinic in 1994. The impact of these guidelines was analysed, comparing two prospectively recorded collectives of polytraumatized patients 4/1988-12/1993 (A; n = 126) and 1/1994-6/1996 (B; n = 74). Nine specifically defined parameters were used to assess the therapeutic process of early clinical trauma management. All parameters showed an improvement after implementation of the algorithm (group B): (1) Complete radiological and sonographic basic diagnostics in 97% vs. 92% of patients; (2) time interval of 38 min vs. 55 min until cranial CT was done after severe head injury (GCS < 10); (3) reduction of delayed diagnosis of lesions to 5% vs. 24%; (4) duration of 16 min vs. 20 min until intubation; (5) period of 23 min to 30 min to pleural drainage; (6) duration of 18 min vs. 32 min until transfusion in shock; (...
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ABSTRACT Das TraumaNetzwerkD DGU (Deutsche Gesellschaft für Unfallchirurgie) hat die Verbesserung der Schwerverletztenversorgung durch Bildung von regionalen Netzwerken und Sicherstellung von organisatorischen, personellen und... more
ABSTRACT Das TraumaNetzwerkD DGU (Deutsche Gesellschaft für Unfallchirurgie) hat die Verbesserung der Schwerverletztenversorgung durch Bildung von regionalen Netzwerken und Sicherstellung von organisatorischen, personellen und strukturellen Mindestanforderungen, basierend auf dem Weißbuch zur Schwerverletztenversorgung der DGU, zum Ziel. In den 4 Jahren seit seiner Entstehung vollzog es eine rasante Entwicklung. Der größte Teil der an der Schwerverletztenversorgung teilnehmenden Kliniken Deutschlands ist nun in 53 regionalen Traumanetzwerken organisiert. Davon sind bereits 5 Netzwerke zertifiziert, 322 Kliniken erfolgreich auditiert und 56 Audits geplant. Eine strukturierte Befragung aller Kliniken im Rahmen des Zertifizierungsprozesses ergab, dass von vielen Häusern nicht unerhebliche organisatorische, personelle und auch strukturelle Änderungen durchgeführt wurden, wobei die organisatorischen (53,2%) gegenüber den personellen (26,7%) und strukturellen Neuerungen (15,5%) überwogen. Diese Änderungen und der durch die Gründung des TraumaNetzwerkD DGU belebte Dialog haben bereits zu maßgeblichen Veränderungen in der Schwerverletztenversorgung geführt. Abstract The main objective of the TraumaNetzwerkD DGU (German Society for Trauma Surgery) is the improvement of care for severely injured patients by establishing regional networks and ensuring minimum organizational, personnel and structural requirements based on the White Book of severely injured care of the DGU. Since its foundation 4 years ago it has made great progress. Most of the German trauma centres which take part in the care for severely injured patients are now organized in 53 regional trauma networks of which 5 networks have been certified, 322 hospitals audited and another 56 audits are being planned. A structured survey of all hospitals going through the audit process showed that most clinics made many organizational, personnel and even structural changes. Organizational changes were predominant (53.2%) but there were many personnel (26.7%) and structural (15.5%) changes as well. These modifications and the revived discussion on the topic following the foundation of the TraumaNetzwerkD DGU have already led to major changes in the care for severely injured patients.
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Zusammenfassung Im Rahmen des Traumaregisters der DGU wurde ein Qualitätsmanagementsystem (QM) für die Behandlung Schwerverletzter entwickelt, seit 1998 erfolgen jährliche QM-Rückmeldungen an die beteiligten Kliniken. Anhand der Daten... more
Zusammenfassung Im Rahmen des Traumaregisters der DGU wurde ein Qualitätsmanagementsystem (QM) für die Behandlung Schwerverletzter entwickelt, seit 1998 erfolgen jährliche QM-Rückmeldungen an die beteiligten Kliniken. Anhand der Daten von 2005 wurde die Versorgungsqualität aller Kliniken, die von 1999–2005 Patientendaten übermittelt hatten, analysiert. Die Prozessqualität wurde anhand einzelner an die Kliniken zurückgemeldeter Parameter aus Diagnostik und Therapie ermittelt. Die Ergebnisqualität wurde unter Berücksichtigung von Letalität und Prognose erhoben. Bei gleich bleibender Verletzungsschwere und Prognose ging die Letalität von 22,8 auf 15,1% zurück. Die initiale radiologisch-sonographische Diagnostik wurde von 25 auf 12 min verkürzt, die Inzidenz der Ganzkörper-CT bei schwerverletzten Patienten stieg von 10 auf 46%. Die Zeitdauer bis zur Operation im Blutungsschock sank um 6 min. Die Verwendung des Fixateur externe zur inititalen Stabilisierung von Femurfrakturen stieg von ...
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Hip fractures are associated with reduced health-related quality of life (HrQoL). We found pre-existing need of care or limited function, cognitive impairment, and depression to be independent factors associated with lower HrQoL during... more
Hip fractures are associated with reduced health-related quality of life (HrQoL). We found pre-existing need of care or limited function, cognitive impairment, and depression to be independent factors associated with lower HrQoL during the postsurgical period. In contrast, joint replacement was associated with better HrQoL compared to internal fixation. Patients&#39; treatment should be focused on functional recovery and treatment of depression. The aim of the study was to identify independent factors that were correlated with health-related quality of life (HrQoL) after hip fracture. A total of 402 patients with a mean age of 81 years suffering from a hip fracture were included in this prospective, observational cohort study. HrQoL (determined by the EuroQol instrument) was measured at admission and at discharge from an acute care hospital. Independent factors correlated with HrQoL at discharge and changes from pre-fracture to discharge were determined using multivariate analyses. The influence of antidepressants was evaluated by an ANOVA with repeated measurements. Need of care prior to fracture was the most important determinant of EQ-5D index at discharge (ß = -0.359, p = 0.003). Additionally, low Mini Mental Status Examination (MMSE) was associated with a lower EQ-5D index at discharge (MMSE 0-9: ß = -0.238, p &lt;0.001; MMSE 10-19: ß = -0.294, p &lt;0.001) and a greater decrease in EQ-5D during hospitalisation (MMSE 10-19: ß = 0.281, p &lt;0.001), while joint replacement (compared to internal fixation) was associated with a higher EQ-5D index (ß = 0.188, p = 0.002) and a lower decrease in the index (ß = -0.216, p = 0.003). EQ VAS values at discharge were correlated with pre-fracture Barthel Index (ß = 0.253, p &lt;0.001) and Geriatric Depression Scale scores (ß = -0.135, p = 0.026). Depressive patients on antidepressants demonstrated less of a decrease in the EQ-5D index compared to patients not receiving medication (F = 2.907, p = 0.090). Acute care of hip fracture patients should be focused on functional recovery and treatment of depression. When the preferred surgical strategy is unclear, joint replacement should be considered.
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Zusammenfassung Das Konzept TraumaNetzwerkD der Deutschen Gesellschaft für Unfallchirurgie (DGU) hat das Ziel, die Inhalte des Weissbuchs „Schwerverletztenversorgung“ der DGU flächendeckend in Deutschland umzusetzen und damit eine... more
Zusammenfassung Das Konzept TraumaNetzwerkD der Deutschen Gesellschaft für Unfallchirurgie (DGU) hat das Ziel, die Inhalte des Weissbuchs „Schwerverletztenversorgung“ der DGU flächendeckend in Deutschland umzusetzen und damit eine qualitativ hochwertige Versorgung schwerverletzter Patienten aufzubauen. Zur Sicherung der Versorgungsqualität werden die teilnehmenden Kliniken sowie das jeweilige Traumanetzwerk einem strukturierten Zertifizierungsprozess unterworfen. Dessen wissenschaftliche Begleitung und Konzeptgebung werden durch den Arbeitskreis zur Umsetzung des Weissbuchs/TraumaNetzwerkD (AKUT) sichergestellt. Im vorliegenden Beitrag werden die Organisationsstruktur der Zertifizierung (Organigramm) sowie aktuelle Fragen zur Umsetzung dargestellt. Dem Informationsaustausch zwischen den Teilnehmern kommt bei der Umsetzung von Traumanetzwerken in ganz Deutschland, die trotz der unterschiedlich begründeten Schwierigkeiten voranschreitet, eine entscheidende Rolle zu. Um die optimale f...