Implementation and adoption of SOAP-M and SBAR at a German anesthesiology department - a single-center survey study.

BACKGROUND: Checklists are a common tool used in order to mitigate risks caused by human factors and can facilitate the safe induction of anesthesia as well as handovers. SBAR (Situation, Background, Assessment, Recommendation) is a checklist recommended by the WHO and DGAI for handovers, while SOAP-M (Suction, Oxygen, Airway, Pharmaceuticals, Monitoring) is a checklist for the induction of anesthesia. This study investigates the implementation and adoption of these two checklists. METHODS: We conducted a single-center online survey one year after the implementation of SOAP-M and SBAR at a university hospital's anesthesiology department, using scales from three validated questionnaires to assess safety attitudes as well as the behavior of staff and the perceived usefulness of the checklists. RESULTS: Staff with a high score in general attitude towards patient safety, as determined by the safety attitudes questionnaire, considered both checklists useful additions to their work environment. Nurses and physicians (p = 0.102) as well as groups divided according to work experience (p = 0.077) showed no significant differences in using SOAP-M and SBAR. Perceived usefulness was significantly higher (p < 0.001) among users of the checklists, and the same goes for positive reinforcement (p < 0.001), social cues (p = 0.0215) and goal cues (p = 0.0252). CONCLUSION: SOAP-M and SBAR are perceived as useful checklists for patient handovers and anesthesia induction by tertiary referral hospital's employees with high score in general safety attitude and were therefore commonly used one year after their introduction. No significant difference in checklist adoption between occupations as well as groups divided according to work experience could be found. Perceived usefulness is significantly higher among users of the checklist, who feel using the checklists provides more support.

Impact of Introducing PROMPT on Permanent Brachial Plexus Injury and Tears III°/IV° in Shoulder Dystocia: The Hanover Cohort Study.

Objective: To test the hypothesis that PROMPT reduces permanent brachial plexus palsy and perineal tears. Design: A prospective/retrospective cohort study. Setting. Hanover Medical School, Germany. Population/Sample. A self-selected population. Methods: The training period is from November 9th, 2017, until December 31st, 2019; control: January 1st, 2004, until November 8th, 2017. Main Outcome Measures. Shoulder dystocia, nonpermanent and permanent brachial plexus injuries (BPIs), perineal tears III°/IV°, manual manoeuvres, and asphyxia. Results: There was a total of 22,640 births, and shoulder dystocia increased from 48/18,031 (0.27%) to 23/4,609 (0.50%) ((p=0.017), OR: 1.88, 95% CI: (1.14; 3.09)), whereas BPIs decreased from 7/48 (14.6%) to 1/23 (4.3%) (p=0.261). There was 1/7 (14.2%) of permanent BPI before and 0/1 (0%) case after. Perinatal asphyxia increased from 3/48 (6.3%) to 4/23 (17.4%) (p=0.23). However, adverse outcomes after one year were zero. McRoberts' manoeuvre increased from 37/48 (77.1%) to 23/23 (100%) ((p=0.013), OR: 1.62, 95% CI: (1.33; 1.98)), and internal rotation manoeuvres and manual extraction of the posterior arm from 6/48 (12.5%) to 5/23 (21.7%) (p=0.319). Episiotomies decreased from 5,267/18,031 (29.2%) to 836/4,609 (18.1%) ((p < 0.001), OR: 0.54, 95% CI: (0.49, 0.58)), whereas perineal tears III°/IV° associated with shoulder dystocia increased from 1/48 (2.1%) to 1/23 (4.8%) (p=0.546). Vaginal operative deliveries remained constant (6.5% vs. 7%). Conclusions: PROMPT significantly improves the management of shoulder dystocia and decreases permanent brachial plexus injuries but not perineal tears III°/IV°.

[Development of a competence catalogue for physicians in training for curriculum creation with respect to delivery room training]. / Entwicklung eines Kompetenzkatalogs für Ärzt:Innen in Weiterbildung zur Curriculumerstellung für die Kreißsaaleinarbeitung.

BACKGROUND: Anesthesiologic expertise is used at various points in the delivery room. The natural turnover of professionals requires continuous education and training for patient care. In a first survey among consultants and trainees, the desire for a delivery room-specific anesthesiologic curriculum has emerged. In order to enable a curriculum with decreasing supervision, a competence-oriented catalogue is used in many medical fields. The gain in competence develops gradually. The participation of practitioners should be obligatory to avoid a differentiation between theory and practice. The structural framework of curriculum development by Kern et al. provides the learning objective analysis after further evaluation. In the sense of specific learning objective definition, the present study aims to describe the competences for anesthetists in the delivery room. METHODS: An expert group (active in the anesthesiology delivery room environment) developed a set of items via a two-step online Delphi survey. The experts were recruited from the German Society for Anesthesiology and Intensive Care Medicine (DGAI). We evaluated the resulting parameters for relevance and validity in a larger collective. Lastly, we used factorial analyses to identify factors that could be used to group items into relevant scales. In total, 201 participants took part in the final validation survey. RESULTS: During the prioritization process of Delphi analyses, competencies such as neonatal care were not followed up. Not all items developed are exclusively delivery room-related, such as managing a difficult airway. Other items are specific to the environment of obstetrics. One example is integration of spinal anesthesia into the obstetric context. Some items are exclusively related to the delivery room, such as in-house standards of care in obstetrics as a basic skill. After validation, a competence catalogue with 8 scales with a total of 44 competence items resulted (Kayser-Meyer-Olkin criterion 0.88). CONCLUSION: A catalogue of relevant learning objectives for anesthetists in training could be developed. It specifies the generally required content of anesthesiologic training in Germany. Specific patient groups, such as patients with congenital heart defects, are not mapped. Competencies that could also be learned outside the delivery room, should be learned before the rotation. This enables the focus on the delivery room items, especially for those to be trained who do not work in a hospital with obstetrics. The catalogue needs to be revised for completeness for its own working environment. Particularly in hospitals that do not have a pediatrician available, neonatal care becomes significant. Didactic methods, such as entrustable professional activities, have to be tested and evaluated. These enable competence-based learning with decreasing supervision and reflect the reality in hospitals. As not every clinic can provide the necessary resources for this a nationwide provision of documents would be helpful.

Further development of crew resource management training : Needs assessment by means of teamwork-context analysis in anesthesia and intensive care teams.

BACKGROUND: Teams in anesthesia and intensive care work as high responsibility teams (HRT). Success in this environment partly depends on the use of nontechnical skills which can be learned through simulation-based training. A teamwork context analysis could help to identify training requirements for crew resource management training. MATERIAL AND METHODS: We used a multicentric observational cross-sectional study design utilizing survey methodology to evaluate the teamwork context of different work environments, using the 62-item TAKAI inventory. We surveyed anesthesia and intensive care staff from nine hospitals in Germany which provide varying levels of care. RESULTS: In total, 128 people (44.5% male, 53.9% female) from 9 German hospitals participated in the study. The topics "interconnectedness: departments", "interconnectedness: information flow", "dynamics", "polytely", "velocity of the team's movement", "velocity of system changes", "hierarchy" and "hierarchy: leadership", "shared task mental model", "shared team mental model" and all aspects of the scale "adaptive behaviors" were identified as focal aspects to be implemented into Crew-Resource-Management (CRM) training for the evaluated work environments. CONCLUSION: The TAKAI scales meet quality criteria (Cronbach's alpha > 0.6) and are appropriate for use in the analysis of the teamwork environment. The results indicate many similarities between the work contexts surveyed but also slight differences. TAKAI can be an additional method to design an appropriate simulation training program for HRT in anesthesia and intensive care medicine as there does not seem to be a one-size-fits-all simulation concept. For a special focus on the needs of a work context, the easy to perform TAKAI analysis in the needs analysis step is worthwhile.

[Analyses of requirements for curriculum development for the training of anesthesiologists in the delivery room-A nationwide survey]. / Bedarfsanalyse zur Curriculumsentwicklung für die anästhesiologische Kreißsaalversorgung ­ eine deutschlandweite Umfrage.

BACKGROUND: Anesthesiologic activity in the delivery room environment implies the specifics of a 200% lethality, which describes that emergency situations can affect mother and child. A circumstance that impressively underlines the need for special care in employee training and selection. The training situation in the delivery room is characterized by several difficulties. Technical procedures are often performed on the awake patient, who is herself in an exciting situation during childbirth. A detailed description of the necessary competences in this working environment does not exist at the present. The present study aims to describe the further education situation in anesthesiology. The results can represent the first step of a curriculum development according to the concept of Kern et al. in the sense of a needs assessment. MATERIAL AND METHODS: In a multicenter observational study, doctors in further training (AiW) and consultants (FÄ) were asked about methods of familiarization, feedback, activities taken on and the need for a curriculum. The level of supervision and confidence in action during procedures was also elicited. Participants were contacted via the membership database of the German Society of Anesthesia and Intensive Care and could answer the 11-item questionnaire online. RESULTS: A total of 495 questionnaires (329 FÄ; 166 AiW;) were completed. The FÄ and AiW gave different information on the conduct of exit interviews (59.6% vs. 10%) and curriculum support (76.3% vs.17.5%). Independent of the year of training, AiWs perform cesarean sections under on-demand (reactive) supervision. Peridural anesthesia (PDA) is the least frequently performed procedure in the context of the familiarization situation with obstetric anesthesia. The groups have a different confidence of security in the successful implementation of procedures, when AiW are proceeding without direct supervision (FÄ = MD 61; AiW = MD 77; p < 0.001; scale 0 = unsecure-100 = very secure). Practical and technical support is mostly provided immediately by FÄ (> MW 91; scale 0 = never-100 = immediately). Individual values deviate significantly from the average values (outliers). Both groups rate the usefulness or value of describing learning objectives and the availability of a curriculum as high. DISCUSSION: The support of familiarization and continuing support is partly answered differently by consultants and doctors in further training. Individual procedures that are rarely performed, such as administration of a PDA, require special attention in the future. Curricula with workplace-based assessments could provide feedback and assurance to increase confidence in the successful implementation of procedures by AiW. The AiW usually receive immediate professional support. Individual institutions do not seem to have any concepts here and must rethink their processes. This fact is particularly important against the background of the medicolegal significance of the subject. The description of learning objectives and curriculum development is desired both by FÄ and AiW.

[Stocked medications in emergency medical service vehicles staffed by physicians-is prehospital treatment according to current guidelines possible?] / Medikamentöse Ausstattung arztbesetzter Rettungsmittel ­ ist eine präklinische Therapie nach aktuellen Leitlinien möglich?

Background: High quality of care in prehospital emergency medicine is characterized by guideline-based therapy. The basic prerequisite for this therapy is the availability of the required drugs in accordance with the current guideline recommendations. It is currently unclear whether this is guaranteed nationwide. There is no uniform standard regarding which drugs must be stocked in emergency medical services (EMS) vehicles staffed by physicians in Germany. The aim of the present study is to identify important diagnoses and the drugs required for their therapy. In a second step, medical directors throughout Germany were interviewed about current drugs available in their physician-staffed EMS vehicles and these were compared with the previously defined diagnosis-dependent drug lists. Materials and methods: After a structured guideline search, tracer diagnoses were defined and relevant drugs were assigned to them. The levels of evidence and recommendations were also considered. In a second step, this was compared with the current drugs available in physician-staffed EMS vehicles. Results: A total of 156 different medications were identified. The median number of medications stocked was 58; the minimum number of medications stocked was 35 at one site, while multiple sites stocked a maximum of 77 medications . Discussion: The present study investigated stocked medications in physician-staffed EMS vehicles. Overall, compared to a 2011 study, drug availability has improved. Most of the recommended medications are available in physician-staffed vehicles in Germany. The data from this study can be used by EMS throughout Germany to evaluate their preparedness.

Effect of mannitol on platelet function during elective craniotomy in adult patients with brain tumor.

BACKGROUND: Mannitol is used in the treatment of raised intracranial pressure (ICP). The aim of this study was to investigate whether mannitol (MAN) leads to a relevant deterioration in platelet function in routine neurosurgical procedures. METHODS: Thirty-eight patients undergoing elective craniotomy due to a brain tumor with elevated ICP were included. After induction of anaesthesia a blood sample was taken (T1). The patients then received 1 g-kg-1 MAN within 30 minutes. The second blood sample (T2) was obtained 60 minutes after T1. Blood samples were examined by means of aggregometry (Multiplate®) and PFA-100® tests. RESULTS: No patient had clinical signs of increased bleeding. We could not find any deterioration in the aggregometry using Multiplate®, neither in the adenosinediphosphate (ADP), the arachidonic acid (ASPI), or the thrombin receptor activating protein (TRAP) test. PFA-100® closing times (cT) showed a significant prolongation between T1 and T2: collagen/adenosindiphosphate (COL/ADP) test 79s [70/99] and 91s [81/109]; p=0.002); collagen/epinephrine (COL/EPI) test 109s [92/129] and 122s [94/159]; p=0.0004). A subgroup analysis showed that the patients who received isotonic balanced infusions only, had no prolongation of cT, whereas the patients who received additionally gelatine solution had a significant prolongation. COL/ADP: 78s [70/98] and 91s [82/133]; p=0.0004). COL/EPI: test 111s [92/128] and 127s [103/146]; p=0.0026). Except for individual outliers, the measured values were in the normal range. CONCLUSIONS: In this study, we found no clinically relevant deterioration of platelet function in neurosurgical patients with increased ICP after administration of MAN. Changes that occurred were all within normal ranges.

Influence of presence in an inter-professional simulation training of the emergency caesarean section: a cross-sectional questionnaire study.

PURPOSE: Emergency training using simulation is a method to increase patient safety in the delivery room. The effect of individual training concepts is critically discussed and requires evaluation. A possible influence factor of success can be the perceived reality of the participants. The objective of this study was to investigate whether the presence in a simulated emergency caesarean section improves subjective effect of the training and evaluation. METHODS: In this observation study, professionals took part in simulated emergency caesarean sections to improve workflow and non-technical skills. Presence was measured by means of a validated questionnaire, effects and evaluation by means of a newly created questionnaire directly after the training. Primary outcome was a correlation between presence and assumed effect of training and evaluation. RESULTS: 106 participants (70% of course participants) answered the questionnaires. Reliability of the presence scale was good (Cronbach's alpha 0.72). The presence correlated significantly with all evaluated items of non-technical skills and evaluation of the course. The factor "mutual support" showed a high effect size (0.639), the overall evaluation of the course (0.395) and the willingness to participate again (0.350) a medium effect. There were no differences between the professional groups. CONCLUSION: The presence correlates with the assumed training objectives and evaluation of the course. If training is not successful, it is one factor that needs to be improved.

Structured evaluation of stress triggers in prehospital emergency medical care : An analysis by questionnaire regarding the professional groups.

BACKGROUND: Emergency medical services work in the environment of high responsibility teams and have to act under unpredictable working conditions. Stress occurs and has potential of negative effects on tasks, teamwork, prioritization processes and cognitive control. Stress is not exclusively dictated by the situation-the individuals rate the situation of having the necessary skills that a particular situation demands. There are different occupational groups in the emergency medical services in Germany. Training, tasks and legal framework of these groups vary. OBJECTIVE: The aim of this study was to identify professional group-specific stressors for emergency medical services. These stress situations can be used to design skills building tools to enable individuals to cope with these stressors. MATERIAL AND METHODS: The participants were invited to the study via posters and social media. An expert group (minimum 6 months of experience) developed a set of items via a two-step online Delphi survey. The experts were recruited from all professional groups represented in the German emergency medical service. We evaluated the resulting parameters for relevance and validity in a larger collective. Lastly, we identified stress factors that could be grouped in relevant scales. In total 1017 participants (paramedics, physicians) took part in the final validation survey. RESULTS: After validation, we identified a catalogue of stressors with 7 scales and 25 items for EMT (Emergency Medical Technician) paramedics (KMO [Kayser-Meyer-Olkin criterion] 0.81), 6 scales and 24 items for advanced paramedics (KMO 0.82) and 6 scales and 24 items for EMS (Emergency Medical Service) physicians (KMO 0.82). For the professional group of EMT basic, the quality parameters did not allow further processing of the items. Professional group-specific scales for EMT paramedics are "professional limitations", "organizational framework", "expectations" and "questions of meaning". For advanced paramedics "appreciation", "exceptional circumstances" and "legal certainty" were identified. The EMT physicians named "handling third parties", "tolerance to ambiguity", "task management" and "pressure to act". A scale that is representative for all professional groups is "teamwork". Organizational circumstances occur in all groups. The item "unnecessary missions" for EMT paramedics and "legal concerns with the application of methods" for advanced paramedics are examples. DISCUSSION: Different stressors are relevant for the individual professional groups in the German emergency medical service. The developed catalogue can be used in the future to evaluate the subjective stress load of emergency service professionals. There are stressors that are inherent in the working environment (e.g. pressure to act) and others that can be improved through training (teamwork). We recommend training of general resistance as well as training of specific items (e.g., technical, nontechnical skills). All professionals mentioned items with respect to organizational factors. The responsible persons can identify potential for improvement based on the legal and organizational items. The EMT basic requires further subdivision according to task areas due to its variable applicability.

Usage of power by different types of trainers in the education of paramedics - evaluation by means of a validated questionnaire.

Objective: Emergency medical services are characterized by a high pressure to act. Dealing with trainees is a challenge. It is known, that the use of power in education subsists: power can be applied in a participative and restrictive way. We investigated the transferability of existing scales to the education system of Emergency medical service trainees. We hypothesized: a restrictive (a) and participative (b) use of power, can be demonstrated in Emergency medical service training, (c) the use of power by educators, who are responsible for theoretical learning, and instructors, who accompany trainees in real-life emergencies, are different and (d) the assessed participatory and restrictive use of power by trainers is negatively correlated. Methods: In a cross-sectional study, 206 trainees of Emergency medical service schools completed a questionnaire. The survey consists of 35 power related items regarding medical educators and practical instructors. Differences in the dimensions of power application were tested. The effect size and the correlation between power dimension were calculated. Results: The reliability of the scales was .92 (practical instructor) and .89 (medical educator) by removing one item. All subscales showed values with higher Cronbach's alpha than .68. Application of participative power differs (p<.00) between practical instructors (mean 64.7; SD 20.3) and medical educators (mean 55.3; SD 17.8). The participatory and the restrictive use of power correlated for medical educators significant negatively (r=-.48; p<.01). Conclusion: In both educator and instructor groups the use of participative power had a greater agreement that the use of restrictive techniques. The practical instructors used participative power slightly more often that did educators due to the dependency on the trainee as a team member. The context of the scales partially overlaps with other descriptions such as leadership and instructor quality.

Training of airway management for anesthesia teams - Measurement of transfer into daily work routine by questionnaire.

THEORY: Problems in airway management are rare in anesthesia but when they occur, they have serious consequences for the patient. For this reason, training is recommended for professionals involved in anesthetic care. Here we investigated, if a newly developed technical/ non-technical hybrid airway training would be relevant for daily practice in a tertiary referral hospital. HYPOTHESES: We hypothesized that: (a) both parts of the validated questionnaires meet the quality criteria for the application in anesthesia teams, (b) even though the team regularly deals with airway management, airway management training is relevant to all professions and (c) contents of the developed training can be integrated into the behaviour of the teams. METHOD: In this observational study, 104 professionals took part in a one-day technical/non-technical hybrid airway training programme. Participants received a questionnaire six months after training, based on selected scales of the validated tools; "Training Evaluation Inventory" and "Transfer Climate Questionnaire". RESULTS: The scales of "perceived usefulness", "task cues" and "positive reinforcement" showed good internal consistency and all were rated higher than 3.9 on a 5-point Likert scale (1=complete rejection; 5=fullest approval). The scale "negative reinforcement and punishment" showed satisfactory internal consistency for physicians (rated 2.75 ± 0.8). By removing an item in each case, the scales "attitude towards training" (rated 4.93 ± 0.2) and "extinction" (rated 3.02 ± 0.8) showed satisfactory internal consistency for nurses and anesthetic technicians. "Social Cues" did not meet qualitative criteria. There was no difference in the assessment by the professional groups. CONCLUSIONS: The presented training course was perceived as useful by both professional groups equally, which supported the interprofessional concept. The content was positively reinforced in practice six months after training and is relevant for professionals who are regularly confronted with the topic "airway management". Scales which meet qualitative criteria for only one profession and the scale "social cues" should be reconsidered in the context of an interprofessional team.

Albumin combined with Mannitol impairs whole blood coagulation and platelet function in vitro.

BACKGROUND: The indication of hydroxyethyl starch is currently under critical discussion and albumin 5% (ALB) has an increasing use in the operating theatre. Therefore, ALB is routinely used in neurosurgical procedures and often combined with mannitol 20% (MAN). Purpose of this in-vitro study was to determine the influence of the combination of MAN and ALB on blood coagulation and platelet function. METHODS: Twenty-two healthy volunteers were included into this study and 21 analyzed. Blood was obtained and diluted into five groups: 1) 7% dilution with MAN; 2) 10% dilution with ALB; 3) 17% dilution with isotonic balanced electrolyte solution; 4) 17% dilution with MAN+ALB; and 5) undiluted blood as control group (CON). Rotational thrombelastometry via ROTEM® (EXTEM™/FIBTEM™ Test; SABIC, Riyad, Saudi Arabia) and thrombocyte aggregometry via Multiplate® (Roche Diagnostics, Grenzach-Wyhlen, Germany) (ASPI, ADP and TRAP-test) were used to detect differences within the intervention groups and compared to the control group. RESULTS: The maximum clot firmness in the FIBTEM™ Test (SABIC) decreased under the normal range with the combination of MAN+ALB: 8 mm (5.5-11) compared to CON: 15 mm (12.5-20), P<0.05. Platelet function (ADP test) showed significant decreases for ALB: 51 AUC (40-84) and MAN+ALB: 54 AUC (41-68) compared to CON: 92 AUC (75-101), P<0.05. Except in clotting time all other EXTEM™ tests (SABIC) of MAN+ALB subgroup showed significant impairment on blood coagulation compared to the control group. CONCLUSIONS: In this in-vitro study clinically relevant dilutions of MAN+ALB showed a significant inhibition of blood coagulation and platelet function. Further in-vivo studies are necessary to confirm these results.

[Complications and success rates of subclavian vein catheterization depending on experience]. / Komplikationen und Erfolgsraten des Vena-subclavia-Katheters in Abhängigkeit der Erfahrung.

BACKGROUND: The infraclavicular puncture of the subclavian vein is a standard procedure for anesthetists. Meanwhile the literature and recommendations are clear and the use of real-time ultrasound guidance is the standard procedure; however, anesthetists will always get into special circumstances were they have to use the landmark technique, so this competence must be preserved. Feared complications of infraclavicular subclavian vein puncture are pneumothorax and arterial puncture. Up to now there is no clear learning curve for the infraclavicular subclavian vein puncture in the landmark technique performed by anesthetists. OBJECTIVE: The aim of this study was to examine the influence of the puncture experience on the success rate and mechanical complications, such as pneumothorax and arterial puncture in patients who received an infraclavicular subclavian vein puncture with the landmark technique. Three levels of experience were defined for comparison: inexperienced 0-20 punctures, moderately experienced 21-50 and experienced over 50 punctures. MATERIAL AND METHODS: Post hoc analysis of a previously published noninferiority study to examine the influence of ventilation on the pneumothorax rate in the subclavian vein puncture using the landmark technique. This analysis included 1021 anesthetized patients who were included in the original study between August 2014 and October 2017. Demographic data as well as the number of puncture attempts, puncture success, the overall rate of mechanical complications, pneumothorax rate and arterial puncture rates were calculated. RESULTS: The overall rate of mechanical complications (pneumothorax + arterial puncture) was significantly higher in the inexperienced group (0-21) compared to the experienced group (>50, 15% vs. 8.5%, respectively, p = 0.023). This resulted in an odds ratio of 0.52 (confidence interval, CI: 0.32-0.85, p = 0.027). Likewise, the rate of puncture attempts in the group of inexperienced (0-20) with 1.85 ± 1.12 was significantly higher than in the group of experienced (>50, 1.58 ± 0.99, p = 0.004) and resulted in an odds ratio of 0.59 (CI: 0.31-0.96, p = 0.028). Although the puncture attempts of the moderately experienced (21-50) compared to the inexperienced (0-20) was not significant lower, we found an odds ratio of 0.69 (CI: 0.48-0.99, p = 0.042). The rate of successful puncture was 95.1% in the experienced group versus 89.3% in the inexperienced group (p = 0.001), which resulted in an odds ratio of 2.35 (CI: 1.28-4.31, p = 0.018). When viewed individually, no significant differences were found for pneumothorax and arterial puncture. CONCLUSION: In this post hoc analysis of the puncture of the subclavian vein using the landmark technique, we found a significant reduction of puncture attempts and overall mechanical complications. At least 50 punctures seem to be necessary to achieve the end of the learning curve; however, the landmark technique should only be used under special circumstances, when real-time ultrasound is not available. Anesthetists who want to complete their repertoire and learn the landmark technique should always perform a static ultrasound examination before starting the puncture in order to reduce complications due to anatomical variations or thrombosis.

Current Approach for External Cephalic Version in Germany.

Introduction Fetal breech presentation at terms occurs in 3 - 6% of pregnancies. External cephalic version can reduce the number of cesarean sections and vaginal breech deliveries. Different approaches are used to carry out external cephalic version. This study looked at the different approaches used in Germany and compared the approach used with the recommendations given in German and international guidelines. Material and Methods An anonymized online survey of 234 hospitals in Germany was carried out in 2018. In addition to asking about hospital structures, questions also focused on how external version was carried out in practice (preparations, tocolysis, anesthetics, etc.), on relative and absolute contraindications and on the success rate. Results 37.2% of the hospitals approached for the survey participated in the study. Of these, 98.8% performed external version procedures. The majority of participating hospitals were university hospitals (26.4%) and maximum care hospitals (35.6%) with an average number of more than 2000 births per year (60.9%). External cephalic version is the preferred (61.7%) obstetrical procedure to deal with breech presentation, rather than vaginal breech birth or primary cesarean section. 45.8% of respondents carry out external version procedures on an outpatient basis, and 42.1% of hospitals perform the procedure as an inpatient intervention, especially from the 37th week of gestation. Prior to performing an external version procedure, 21.6% of surveyed institutions carry out a vaginal examination to evaluate possible fixation of the fetal rump. 95.5% of institutions used fenoterol for tocolytic therapy; the majority using it for continuous tocolysis (70.2%). 1 - 3 attempts at external version (8.4%) were usually carried out by a specific senior physician. In most cases, no analgesics were administered. The reported rate of emergency cesarean sections was very low. The most common indication for emergency C-section was pathological CTG (56,7%). The assessment of relative and absolute contraindications varied, depending on the surveyed hospital. 67.5% asked patients to empty their bladders before carrying out external version, while 10.8% carried out external version when the bladder was filled. The reported success rate was more than 45%. After successful version, only 14.8% of hospitals arranged for patients to wear an abdominal binder. For 32.4%, the decision to apply an abdominal binder was taken on a case-by-case basis. Conclusion The approach used in Germany to carry out external cephalic version is based on the (expired) German guideline on breech presentation. Based on the evidence obtained, a number of individual recommendations should be re-evaluated. More recent international guidelines could be useful to update the standard procedure.

Sentinel lymph node biopsy in vulvar cancer: status, level of knowledge, and counseling in outpatient setting.

PURPOSE: Evaluating the counseling of patients with vulvar cancer in outpatient setting regarding the application of sentinel lymph node dissection (SLND), the selection of hospitals for further treatment, and level of knowledge. METHODS: A questionnaire containing 29 questions about SLND in vulvar cancer was sent to gynecologists in Lower Saxony. The questionnaire contained multiple choice questions and open questions. The study was approved by the local ethics committee. RESULTS: The median age of the 86 respondents was 54 (26-66) years. Most participants (83.1%) reported to only treat one to five patients with vulvar cancer per year. Interestingly, 70.5% of the gynecologists send their patients to university hospitals and 64.1% to hospitals offering maximum care, respectively. Of all, 32.7% replied that SLND was performed rarely or never in their patients. The gynecologists answered that only 36.7% of the patients are well informed about advantages and possible disadvantages of SLND. Most (84%) felt responsible to counsel patients on treatment decisions independently from or additionally to the hospital. Of all, 72% replied that they are not completely sure about the exact recurrence rates after SLND. Of notice, 66% believe that SLND for vulvar cancer is safe if applied in specialized centers and 92% stated that focusing treatment on specialized centers is required for best results. CONCLUSION: SLND for vulvar cancer is widely accepted and regularly recommended among gynecologists. Outpatient doctors report to send most patients to specialized centers. However, it appears that patients remain uninformed after counseling in the clinics and that there is a lack of detailed knowledge about risks and complication rates of groin treatment in the outpatient setting.

Impact of Simulator-Based Crisis Resource Management Training on Collective Orientation in Anaesthesia: Pre-Post Survey Study With Interprofessional Anaesthesia Teams.

THEORY: Individuals have different qualities, levels of willingness, and degrees of engagement for working in teams. This behaviour is termed 'Collective Orientation' (CO). Collective orientation can be trained and has a positive influence on team processes. Here, we investigated the effect of a simulator-based, Crisis Resource Management team training upon the participants' CO. HYPOTHESES: We hypothesized (1) the scales of CO and Presence for lab-based microworld research (PLBMR) are applicable to the German anaesthesia teams, (2) the CO can be influenced by means of simulation training, (3) the training effect is dependent on sex and/or profession, and (4) the change of CO depends on the perceived presence of the participants in the scenario. METHOD: In a pre-post study, 66 nurses and doctors from various anaesthetic departments took part in a 1-day training course to improve non-technical skills. The primary outcome was the mean difference between the CO measured (via questionnaires) immediately before (T1) and after (T2) training. The change was then tested for dependence upon other variables, such as sex, professional group, and immersion into the simulation scenarios. RESULTS: Collective orientation improved significantly after training (mean difference: 0.2; P < .001; dz = 0.53). Considering the subscales, affiliation increased significantly (P < .001; dz = 0.59), whereas dominance remained unchanged. Furthermore, no correlation was found regarding sex, professional group, or immersion into the simulation scenarios. CONCLUSIONS: Our study demonstrated that simulation-based training improves the participants' COs, primarily by increasing affiliation. Subjective scenario reality did not significantly influence this. Nonetheless, it remains unclear as to what factors categorically resulted in this benefit. The shared experience in the course by all team members might trigger the effects. However, further studies are needed to identify the modifiable factors that can improve teamwork attitudes.

Transfer of an interprofessional emergency caesarean section training program: using questionnaire combined with outcome data of newborn.

PUPROSE: An emergency caesarean section is a potentially life-threatening situation both for the mother and the newborn. Non-technical skills can be improved by simulation training and are necessary to manage this urgent situation successfully. The objective of this study was to investigate, if training of emergency caesarean section can be transferred into daily work to improve the outcome parameters pH an APGAR of the newborn. METHODS: In this pre-post study, 141 professionals took part in a training for emergency caesarean section. Participants received a questionnaire, based on the tools "Training Evaluation Inventory" and "Transfer Climate Questionnaire" 1 year after training. Outcome data of the newborn were collected from the hospitals information system. RESULTS: Except the scale "extinction", Cronbach's alpha was higher than 0.62. All scales were rated lower than 2.02 on a 5-point Likert Scale (1 = fullest approval; 5 = complete rejection). "Negative reinforcement" was rated with 2.87 (SD 0.73). There were no significant differences in outcome data prior. The questionnaire fulfils criteria for application except the scale "extinction". CONCLUSION: The presented training course was perceived as useful by the professionals and attitudes toward training were positive; the content was positively reinforced in practice 1 year after training. Parameters of the newborn did not change. It is conceivable that other outcome parameters (e.g. posttraumatic stress disorder) are addressed by the training. The development of relevant outcome parameters for the quality of emergency sections needs further investigation.

Expectations, training and evaluation of intensive care staff to an interprofessional simulation course in Germany - Development of a relevant training concept.

Objective: Increasingly, intensive care units (ICU) are operated by teams of physicians and nurses with specialist training in anaesthesia and intensive care. The aims of our study were to evaluate any prior experience, expectations and the requisites for interprofessional ICU simulation-based training (SBT), and to evaluate a newly designed training course incorporating these findings. Methods: The study was laid out as a cross-sectional study and is projected in three steps. First, questionnaires were sent out to ICU nurses and physicians from 15 different hospitals in a greater metropolitan area (> million citizens). Based upon this survey a one-day ICU simulator course designed for 12 participants (6 nurses and 6 physicians) was developed, with evaluation data from four subsequent courses being analysed. Results: In the survey 40% of nurses and 57% of the physicians had had prior exposure to SBT. Various course formats were explored with respect to duration, day of the week, and group composition. After completing the course, the majority deemed a full working day in interprofessional setting to be most appropriate (p<0.001). The scenarios were considered relevant and had a positive impact on communication, workflow and coping with stress. Conclusion: Currently SBT is not a mainstream tool used by German ICU teams for further education, and this lack of familiarity must be taken into consideration when preparing SBT courses for them. We developed a nontechnical skills training course for ICU teams which was undertaken in the setting of simulated clinical scenarios (pertinent to their work environment). The participants found the course's content to be relevant for their daily work, rated the course's impact on their workplace practices as being good and advocated for longer training sessions.

Changes of collective orientation through a medical student's anaesthesia simulation course - simulation-based training study with non-technical skills debriefing versus medical debriefing.

BACKGROUND: Non-technical skills (NTS) are known to have a positive impact on quality of medical care. The team performance enhancing behaviour, as an example for NTS, is termed "Collective Orientation" (CO). In this study, we investigated the effect of a simulator-based anaesthesia training upon student's CO in relation to medical and TeamGAINS (guided team self-correction, advocacy-inquiry and systemic-constructivist techniques) debriefing. We hypothesized (a) the scale collective orientation, as demonstrated in other team setting, is applicable to fourth year German medical students, (b) collective orientation increases by a four-hour anaesthesia simulation course, (c) the change in collective orientation can be influenced by type of debriefing. METHOD: All classes of an anaesthesia module (4th year medical students) were randomized into two groups. Students took part in a four-hour simulation course with team scenarios, supported by a simulated nurse. In group one the trainer focused on a debriefing on medical problems and in group two, a debriefing according to the specifications of the TeamGAINS concept was conducted. The primary outcome was the mean difference between the collective orientation measured (via questionnaires) immediately before (T1) and after (T2) training. RESULTS: Cronbach's alpha for all scales and measurement points was higher than 0.72. The scale "affiliation" decreases in the group medical debriefing MD = 0.1 (p = 0.008; r = 0.31) and was unchanged in the group TeamGAINS. "Dominance" increases in both groups. The values were MD = 0.19 (p = 0.003; r = 0.25) for medical debriefing and MD = 0.22 (p = 0.01; r = 0.40) for TeamGAINS debriefing. CONCLUSION: The collective orientation questionnaire can be applied to fourth year medical students. Simulation courses influence the attitude towards teamwork. The influence is negatively to the subscale "affiliation" by a "medical debriefing" and independently regardless of the nature of the debriefing for the subscale "dominance". We recommend a debriefing for medical students using the TeamGAINS approach to clarify the connection between the individual performance and non-technical skills. Anaesthesia simulation courses have the potential being a part of a longitudinal education curriculum for teaching non-technical skills.

Instructors for on-the-job training of advanced paramedics - definition of competencies and development of a quality management tool for a "High Responsibility Organization".

Objective: The psychological demands placed upon the emergency medical services, assures them of their place amongst High Responsibility Organizations. A high pressure to act and an irreversibility of situations are integral features of their workplaces. After the emergency services' job profiles were restructured in Germany, the practical stage of paramedic training is now undertaken in these conditions. That is, they are trained by a supervising instructor whilst caring for critically ill patients. This paper aims to describe the requisite skills for such an instructor, formulate the associated competences as learning objectives, and develop a quality-measuring instrument for the description of training situations. Methods: The compilation of a competence catalogue was done via a two-step process: following a Delphi survey with an expert panel of practical trainers and trainees, a large cohort of parameters were validated in terms of their relevance. Those factors that formed scales together were identified. Results: After validating the results of the Delphi analysis, six scales (composed of 25 items in toto) were defined. They included the areas of "Training during times of action", "Training during periods of calm", "Background and practical relevance", "Character and personality traits", "Pedagogical competencies" and "Organizational behaviour". Conclusion: For the first time, a competency catalogue has been developed for instructors working in the emergency medical services from German-speaking countries. The catalogue focuses upon clinical training during the acute care of critically ill patients. The scales and items can be used for training-the-trainers, and also quality monitoring. Further research needs to focus on the application of the catalogue in clinical practice and evaluate the need for situational customization.