Change of collective orientation through an interprofessional training with medical students and student nurses depending on presence and professional group.

BACKGROUND: Teamwork is an important success factors for patient treatment. The willingness of a healthcare provider to work in a team can be descripted with the construct of "Collective Orientation" (CO). The level of CO can be trained and is related to team performance. In this study, we investigated the effect of a simulator-based interprofessional training on the subject of patient fall in a hospital setting upon participations CO. To evaluate whether the course could be integrated into a longitudinal education concept, the participants were medical students and student nurses. Since effects of simulations can be influenced by the perceived reality, the results were measured as a function of Presence. METHOD: In this observation study, 62 medical students and student nurses took part in six one-day interprofessional simulation trainings with the topic patient fall. The primary outcome was the mean difference between the CO measured immediately before (T1) and after the training (T2). The Presence of the participants was measured by questionnaire immediately after the course (T2). RESULTS: Cronbach´s alpha for all scales and measurement points was higher than 0.69. CO increases over all professional groups from M = 3.42 (SD = 0.39) to M = 3.68 (SD = 0.54) significantly (p < .00; r = .5). Only the subscale "Dominance" in the professional group of the student nurses did not increase significantly. There was no correlation between Presence and the change in CO. CONCLUSION: The questionnaires of CO and Presence can be applied to medical students and student nurses. The simulation course with the topic patient fall influences the CO and can be integrated in a longitudinal curriculum of teamwork training. The subscale "Dominance" of student nurses did not change. Preparatory learning units may increase the effects. The perceived reality of the scenario is not a main success factor.

Complete heart block in lupus.

Conduction abnormalities are uncommon in adult patients with lupus. We present a young woman with recurrent syncope caused by third-degree atrio-ventricular block as the initial manifestation of lupus and review 31 additional cases of systemic lupus erythematosus patients that have been described previously with complete heart block. Heart blocks occurred almost exclusively in females. The median age was 37 years. In 24 cases heart blocks were diagnosed in patients with established lupus. In only five patients, including the patient presented here, heart blocks were diagnosed before the lupus diagnosis. Syncope was the most common presenting symptom of heart block. Electrocardiographic findings prior to heart block episodes were reported in 17 cases: eight had normal findings, but nine had already variant forms of atrioventricular or intraventricular conduction defects. Anti-nuclear antibody tests were reported in 25 cases and were all positive. Anti-DNA antibodies were also common and were positive in 16 of 19 cases (84%). Anti-La and anti-Ro antibodies were less common (13% and 35%, respectively). Three patients died, all prior to 1975. Heart block resolved in 10 cases. Follow-up was reported in four of these cases and heart block recurred in three of them. A permanent pacemaker was the eventual treatment in 22 cases. The etiology of lupus-associated complete heart block is not clear. It is probably variable, possibly related to effects of autoantibodies reacting with the conduction system, myocardial disease and adverse effects of antimalarials. Insertion of a permanent pacemaker seems to be the preferable method of treatment.

Closing the gap - detection of clinically relevant von Willebrand disease in emergency settings through an improved algorithm based on rotational Thromboelastometry.

BACKGROUND: Hemorrhage and blood loss are still among the main causes of preventable death. Global hemostatic assays are useful point-of-care test (POCT) devices to rapidly detect cumulative effects of plasma factors and platelets on coagulation. Thromboelastography (TEG) and Thromboelastometry (ROTEM) are established methods in many anesthesiological departments for guided hemostatic treatment. However, von Willebrand disease remains undetected by standard ROTEM, especially during emergency care, despite being the most prevalent congenital hemostatic disorder. METHODS: In our monocentric cohort pilot study we focused on hemostatic challenges associated with von Willebrand disease. Twenty-seven patients with suspected von Willebrand disease were included. We modified the routine ROTEM assay by adding a preincubation with ristocetin and commercially available plasma-derived von Willebrand factor to identify clinically relevant von Willebrand disease (VWD). RESULTS: Addition of von Willebrand factor to the ristocetin assay of a VWD type 3 patient restored the reaction of the whole blood probe to match the response of a healthy person. Our modified ROTEM assay with ristocetin (Ricotem) showed that all high responders (n = 7) had VWD. In the low responder group (n = 16) - 10 of 16 had VWD and in the normal responder group (n = 5), 2 of 5 had mild type 1 VWD. CONCLUSIONS: This new modification of the standard ROTEM assay enables the detection of otherwise unnoticed critical von Willebrand disease based on alterations in clot formation and might serve as a novel approach to reliably assess severe VWD patients by platelet-mediated blood clotting in an emergency setting. We recommend incorporating this new VWD-focused screening tool into the current ROTEM-based management algorithm of acute microvascular bleeding.

[Entrustable professional activities : Promising concept in postgraduate medical education]. / "Entrustable professional activities" : Zukunftsweisendes Konzept für die ärztliche Weiterbildung.

Entrustable professional activities (EPAs) are characterized as self-contained units of work in a given typical clinical context, which may be entrusted to a trainee for independent execution at a certain point of training. An example could be the intraoperative anesthesia management of an ASA 1 patient for an uncomplicated surgical intervention as an EPA in early postgraduate anesthesia training. The EPAs can be described as an evolution of a competency-based medical educational concept, applying the concept of the competencies of a person to specific workplace contexts. In this way the expected level of skills and supervision at a certain stage of training have a more practical meaning and the danger of fragmentation of individual competencies in the competence-based model is avoided. It is a more holistic view of a trainee. Experience with this new concept is so far limited, therefore, further studies are urgently needed to determine whether and how EPAs can contribute to improvements in further training.

[Learning how to learn for specialist further education]. / Für die Facharztweiterbildung Lernen lernen.

The world of medicine is becoming from year to year more complex. This necessitates efficient learning processes, which incorporate the principles of adult education but with unchanged periods of further education. The subject matter must be processed, organized, visualized, networked and comprehended. The learning process should be voluntary and self-driven with the aim of learning the profession and becoming an expert in a specialist field. Learning is an individual process. Despite this, the constantly cited learning styles are nowadays more controversial. An important factor is a healthy mixture of blended learning methods, which also use new technical possibilities. These include a multitude of e­learning options and simulations, which partly enable situative learning in a "shielded" environment. An exemplary role model of the teacher and feedback for the person in training also remain core and sustainable aspects in medical further education.

[Does annual simulation training influence the safety climate of a university hospital? : Prospective 5­year investigation using dimensions of the safety attitude questionnaire]. / Beeinflusst jährliches Simulationstraining das Sicherheitsklima einer universitären Klinik? : Prospektive Fünfjahresuntersuchung anhand Dimensionen des "Safety Attitudes Questionnaire".

BACKGROUND: Simulation-based training with a focus on non-technical skills can have a positive influence on safety relevant attitudes of participants. If an organization succeeds in training sufficient staff, it may experience a positive change in the safety climate. As the effects of a single training are of a transient nature, annual training sessions may lead to an incremental improvement of safety relevant attitudes of employees over time. In spring 2012 the Department of Anesthesia at the University Hospital of Erlangen established an annual simulation-based training for staff members (e.g. consultants, trainee anesthetists and nurse anesthetists). OBJECTIVE: The study aimed to test whether an annual simulation-based training would result in an incremental longitudinal improvement in attitudes towards teamwork, safety and stress recognition. METHODS: A survey comprising three domains (teamwork climate, safety climate and stress recognition) of the safety attitudes questionnaire (SAQ) and items addressing briefing and speaking up was distributed to all participants in an annual in-house simulation training. Participants filled out the questionnaire in the morning of each training day. The attitudes were measured before the first training series in 2012, 6 months after the first training and then every year (2013-2016). Participants generated a personalized identification code which allowed individuals to be anonymously tracked over time. Results of the 5­point Likert scale were transformed to a 100-point scale. Results were calculated at the group level and at the individual level. Univariable linear regression was used to calculate mean changes per year. RESULTS: Over a period of 5 years (2012-2016) a total of 255 individuals completed the questionnaire. Each year, 14-20% of all nurse anesthetists and 81-90% of all anesthetists participated in the simulation-based training. As a result of annual staff turnover 16-24% of participants were new staff members. A personalized code allowed the before and after comparison of 99 staff members who had participated twice or more. Physicians had a higher mean score for teamwork climate before the first training (+8.7 p < 0.001). Mean teamwork climate and safety climate scores before the first training increased over a period of 5 years (3.11 for teamwork climate, p < 0.001 and 2.73 for safety climate, p < 0.001). Repeat participation led to a bigger mean change of individual attitudes in nurse anesthetists: teamwork climate 5.2 (nurses) vs. 1.4 (physicians) and safety climate 5.3 (nurses) vs. 2.8 (physicians) without reaching significance. Participants acknowledged the importance of briefings but confirmed their existence in less than half of the cases. The frequency of briefings increased over the 5­year period. There were no changes in attitude towards speaking up. CONCLUSION: Over a 5-year period, small positive changes in attitudes towards teamwork and safety occurred. Low participation of nurse anesthetists as well as personnel turnover may have weakened the impact of simulation-based training on the safety climate.

[Full-scale simulation in German medical schools and anesthesia residency programs : Status quo]. / Full-Scale-Simulation in der anästhesiologischen Lehre und Weiterbildung in Deutschland : Gegenwärtiger Stand.

BACKGROUND: Simulation has been increasingly used in medicine. In 2003 German university departments of anesthesiology were provided with a full-scale patient simulator, designated for use with medical students. Meanwhile simulation courses are also offered to physicians and nurses. Currently, the national model curriculum for residency programs in anesthesiology is being revised, possibly to include mandatory simulation training. OBJECTIVES: To assess the status quo of full-scale simulation training for medical school, residency and continuing medical education in German anesthesiology. METHODS: All 38 German university chairs for anesthesiology as well as five arbitrarily chosen non-university facilities were invited to complete an online questionnaire regarding their centers' infrastructure and courses held between 2010 and 2012. RESULTS: The overall return rate was 86 %. In university simulation centers seven non-student staff members, mainly physicians, were involved, adding up to a full-time equivalent of 1.2. All hours of work were paid by 61 % of the centers. The median center size was 100 m2 (range 20-500 m2), equipped with three patient simulators (1-32). Simulators of high or very high fidelity are available at 80 % of the centers. Scripted scenarios were used by 91 %, video debriefing by 69 %. Of the participating university centers, 97 % offered courses for medical students, 81 % for the department's employees, 43 % for other departments of their hospital, and 61 % for external participants. In 2012 the median center reached 46 % of eligible students (0-100), 39 % of the department's physicians (8-96) and 16 % of its nurses (0-56) once. For physicians and nurses from these departments that equals one simulation-based training every 2.6 and 6 years, respectively. 31 % made simulation training mandatory for their residents, 29 % for their nurses and 24 % for their attending physicians. The overall rates of staff ever exposed to simulation were 45 % of residents (8-90), and 30 % each of nurses (10-80) and attendings (0-100). Including external courses the average center trained 59 (4-271) professionals overall in 2012. No clear trend could be observed over the three years polled. The results for the non-university centers were comparable. CONCLUSIONS: Important first steps have been taken to implement full-scale simulation in Germany. In addition to programs for medical students courses for physicians and nurses are available today. To reach everyone clinically involved in German anesthesiology on a regular basis the current capacities need to be dramatically increased. The basis for that to happen will be new concepts for funding, possibly supported by external requirements such as the national model curriculum for residency in anesthesiology.

[Briefing improves the management of a difficult mask ventilation in infants : Simulator study using Web-based decision support]. / Briefing verbessert das Management einer schwierigen Maskenbeatmung beim Säugling : Simulatorstudie unter Verwendung einer webbasierten Entscheidungshilfe.

BACKGROUND: Unanticipated airway problems in infants can rapidly develop into severe hypoxemia. Team members can provide support and suggest steps of action if a shared mental model of the next steps exists. Briefing prior to induction of anaesthesia may create such a shared mental model among all team members. OBJECTIVES: The aim of the study was to assess whether a short briefing on the recommendations for an unexpected difficult airway, developed by the Working Group on Paediatric Anaesthesia of the German Society for Anaesthesiology and Intensive Care Medicine, would influence the management of an unexpected difficult mask ventilation in an infant. The study also aims to assess whether a shared mental model would encourage the anaesthesia nurse to speak up and foster implicit coordination. METHODS: Nineteen teams consisting of an anaesthesia resident and an anaesthesia nurse participated in a scenario of an urgent induction of anaesthesia in an infant. Teams were randomized to either conduct a briefing on the recommendations for an unexpected difficult airway prior to induction of anaesthesia or to have access to a Web-based cognitive aid with an emergency manual page containing the identical algorithm if needed. Induction of anaesthesia triggered upper airway obstruction and desaturation. The time course of desaturation followed published physiologic modelling. The time until the obstruction was relieved was recorded. Video recordings of the scenarios were analysed with respect to coordination patterns prior to induction as well as to coordination forms (implicit vs. explicit) during the emergency. At the end of the course, participants were asked to fill out a questionnaire. RESULTS: Teams of both groups checked on the availability of airway equipment, but teams in the briefing group talked more often about treatment steps to relieve airway obstruction (p < 0.005). The time until the obstruction was relieved was significantly shorter in the briefing group (median: 80 s vs. 126 s; p < 0.005). In 45 % of the intervention scenarios the nurse suggested the solution to the airway problem whereas only 10 % of the nurses in the control group proposed a measure to relieve the obstruction (n.s.). Both groups showed no difference in the frequency of implicit vs. explicit coordination patterns. Nurses from the intervention group found the situation to be less an emergency and felt better prepared than nurses from the control group (p < 0.05). CONCLUSION: Briefings prior to anaesthesia induction in paediatric anaesthesia should include management of unanticipated problems. In a simulation setting, a briefing on treatment steps for an unexpected difficult airway improves management of an upper airway obstruction. Explicit communication of intended actions by the anaesthesiologist may foster speaking up by team members.

["Jump in at the deep end" : simulator-based learning in acute care]. / "Sprung ins kalte Wasser" : Simulatorbasiertes Lernen in akutmedizinischen Bereichen.

BACKGROUND: With high-fidelity simulators in a modern blended learning setting, students are able to acquire knowledge and practical skills in acute medicine in realistic scenarios. However, it has not yet been clarified if the sequence of linking between knowledge and simulator-based training of practical skills plays an important role for increasing knowledge, for the self-concept and learning emotions of trainees. AIM: In a pilot study the influence of the type of knowledge acquisition under two independent conditions was investigated in which the order of presenting the learning material (firstly theory and then simulation vs. simulation elements before the theory) was reversed. In addition the influence of individual attributes of personality on the construction of situated knowledge was correlated with these conditions in two groups. MATERIAL AND METHODS: To investigate the outcome of simulator-based learning 20 students were randomly allocated to one of the two conditions and undertook two scenarios (anaphylactic shock and myocardial infarction), whereby the theoretical lessons were given either before or after the scenarios. Using standardized questionnaires and problem-centered semi-standardized interviews, the following variables of the participants were assessed: personality traits, current positive and negative feelings, professional self-concept, general self-efficacy and coping strategies for stress. Theoretical knowledge and practical skills were assessed using a knowledge test and standardized assessment questionnaires which also focused on performance and patient safety. RESULTS: All together the results showed a slight advantage for the condition of theory before simulation which was not determined by the acquisition of knowledge but by a better performance of trainees as assessed by the trainers. Regarding knowledge acquisition, no statistically significant differences could be shown. Significant differences (p < 0.05) were found for negative feelings (very intense negative emotional state) and for the professional self-concept (perception of own professional skills) in favor of the theory then simulation condition. More extrovert participants showed poorer results which could not be attributed to one of the conditions. However, the participants always assessed the allocated learning condition as the best premise for effective learning outcome. Reaction to stress has been described as "jumping in at the deep end" as well as the lasting effect on learning from errors. CONCLUSION: In the context of simulation-based teaching, the learning outcome not only depends on knowledge, practical skills and motivational variables but also on the presence of negative feelings, ability self-concepts and various personality traits. There was a trend which showed that simulation in the field of anesthesiology and emergency medicine should be set up with the theoretical basis first in order to avoid negative feelings.

Vulnerable in the end - Longitudinal study among medical students on mental health and personal and work-related resources over a 5.5-year-period.

BACKGROUND: Mental health problems are common in medical professionals and their development already starts at the undergraduate level. Studies on medical students can replicate higher prevalence for depression and burnout in this group, but they normally compare semester cohorts in an anonymized, cross-sectional approach and without a preventive perspective. METHODS: We surveyed medical students at the beginning and end of their medical curriculum and collected data on burnout, depressivity, work related experience and salutogenesis parameters with validated self-administered questionnaires. Most remarkably we obtained the data from the same 58 individuals after 5.5 years, representing data of the highest quality in order to compare the mental health status at the beginning and the end of our students´ medical curriculum. RESULTS: Our results not only show a severe exacerbation of physical, mental and emotional burnout in the participants at the end of their studies. The students also do not seem to have sufficient personal (resilience) or social resources (e.g. experience of social support) for coping with their mental health problems around the time of their graduation. CONCLUSIONS: Our participants reflect a development of mental health during their medical studies at university that is paving the way to the devastating prevalence of mental disorders and suicide in health professionals. From our results we derive an urgent need to integrate self-care and active coping in the learning goals of medical curricula.

[Pain management in international curricula for undergraduate education in palliative medicine. A palliative education assessment tool (PEAT) analysis]. / Schmerztherapeutische Inhalte internationaler Curricula für die studentische Lehre in der Palliativmedizin. Eine PEAT-basierte Analyse.

BACKGROUND: In the context of undergraduate medical education, there is the question of overlap between palliative medicine and pain management. International curricula for palliative medicine were analyzed with regard to the content concerning pain management. METHODS: Available international curricula were sought through general search engines (Google, Medline/Pubmed) in the German and English languages. The palliative care education assessment tool (PEAT), a validated instrument for curricula mapping, was used for detection of pain management content. The PEAT comprises 7 domains and 83 objectives. Domain II (pain) contains 12 items (15%). Additional pain management content was analyzed qualitatively. RESULTS: Between 1993 and 2011 16 international curricula for undergraduate education in palliative medicine were identified and every curriculum contained PEAT-domain II (pain). Altogether, 2-65 out of 83 PEAT objectives and 0-11 specific pain-related PEAT objectives were included as learning content. Hence, the latter define 0-21% of the contents of the analyzed curricula. The only additional topic was "breakthrough pain" which was mentioned in 4 out of 16 curricula. CONCLUSIONS: Pain-related objectives are regularly mentioned in international undergraduate palliative medicine curricula. The extent is limited and therefore the concordance to general pain management is low.

[Do residents and nurses communicate safety relevant concerns? : simulation study on the influence of the authority gradient]. / Äußern assistenzärzte und pflegekräfte sicherheitsrelevante bedenken? : simulatorstudie zum einfluss des "autoritätsgradienten"

BACKGROUND: Due to the negative impact on decision-making too steep authority gradients in teams represent a risk factor for patient safety. As residents and nursing staff may fear sanctions they may be reluctant to forward critical information to or challenge planned actions of attending physicians. In the setting of a simulation course it was investigated whether and to what extent team members would challenge decisions of familiar attending physicians. In each case where participants did not voice an opinion the underlying motives for the behavior were investigated. METHODS: A total of 59 physicians and 18 nursing staff participated in the scenario. During a rapid sequence induction they were confronted with 7 critical situations created by the attending physician who had been instructed by the simulation team. Recommendations of the German Society of Anaesthesiology were ignored as well as clinical standard operating procedures (SOPs) and two potentially fatal drug administrations were ordered. An attempt was made to determine whether team members were aware of the safety threat at all and if so how they would solve the resulting conflicts. The level of verbal challenge was scored. During debriefing participants were asked to verbalize the motives which they thought might account for their silence or level of challenge. RESULTS: In situations where non-verbal conflict resolution was possible 65% of the participants pursued that strategy whereas 35% voiced an opinion. Situations necessitating verbal intervention were identified in 66% but 72% of the participants chose to remain silent. Team members decided to challenge the attending physician in only 28% of the situations. In 35% their statement was oblique, in 25% the problem was addressed but not further pursued and only in 40% did participants show crisp advocacy and assertiveness and initiated discussion. Asked why they had refrained from challenging the attending physician 37% had no answer, in 35% of situations participants observed a discrepancy between their own knowledge and the intended course of action yet they decided not to address the problem, 12% explained their behavior with the perceived authority of the attending physician and 8% stated that in their opinion attending physicians violated SOPs on a daily basis. None of the participants had the feeling that the simulation setting had provoked a response different to what they might have done in everyday life. CONCLUSIONS: The authority gradient can have a major negative impact on perioperative patient care. Residents and nursing staff are seldom able to challenge the attending physicians when patient safety is at risk. However, even attending physicians who normally accept feedback and criticism from team members can fail to receive support.

[Undergraduate teaching of anaesthesiology : a nationwide survey in Germany]. / Universitäre Lehre der Anästhesiologie : Bestandsaufnahme in Deutschland.

BACKGROUND: In 2003 anaesthesiology was implemented as a compulsory speciality of undergraduate teaching in Germany due to the revised regulations of medical education. Besides the preexisting subject of emergency medicine an obligatory course in anaesthesiology was introduced. Thus anaesthesiology has gained considerable importance in all medical faculties. To gain insight into the current status of undergraduate medical education in the university departments of anaesthesiology a nationwide survey at all university departments in Germany was initiated. METHODS: In cooperation with the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) a standardized questionnaire was developed and sent to 36 departments of anaesthesiology of all German medical faculties. Questions concerned the structure of the respective curriculum, learning goals, teaching, assessment and evaluation methods as well as facultative courses. RESULTS: Of the 36 university departments of anaesthesiology, 35 returned the questionnaire. In 66% undergraduate education in anaesthesiology is part of the fourth or fifth year of medical training. In 91% of the faculties lectures were accompanied by teaching in small student groups. A simulator-based training is integrated either in anaesthesiology and/or in emergency medicine in 91% of the departments of anaesthesiology. In 69% of the departments contents of anaesthesia, critical care medicine, emergency medicine and pain management are an integral part of undergraduate teaching in anaesthesiology. The primary learning goals are directed towards general anaesthesia and there is less focus on topics of preoperative or postoperative care, such as preoperative risk evaluation, postoperative pain management and regional anaesthesia. Besides a multiple choice test (91%) oral (63%) and/or practical examinations (71%) are used as assessment tools. In 71% of the medical faculties the respective departments of anaesthesiology are leading and organising skills laboratories. In student evaluations anaesthesiology achieved best ranking in 66% of the medical faculties compared to other specialties. The possibility to take an elective course in anaesthesiology exists in 74% of the faculties. Half of these faculties organize this elective as a longitudinal course for one complete semester, the other half as a full time course over mostly 1 or 2 weeks. At present E-learning plays a minor role. CONCLUSIONS: This survey provides detailed information about the current status of undergraduate teaching of the university departments of anaesthesiology in Germany. The study shows a remarkable consistency of structure, contents and methods of education in anaesthesiology throughout all university departments of anaesthesiology. This information is the basis for triggering synergistic effects, for improving educational standards in anaesthesiology and for introducing a platform for developing modern learning media, e.g. through the scientific society DGAI.

Effect of biopsy length on the rate of positive temporal artery biopsies.

OBJECTIVE: To investigate the relationship between temporal artery biopsy (TAB) length and the diagnostic sensitivity for giant cell arteritis (GCA). METHODS: TAB pathology reports were reviewed for histological findings and formalin-fixed TAB lengths. The patient's charts were reviewed for clinical data. TAB was considered positive if there was a mononuclear cell infiltrate in the vessel wall. Biopsy-negative GCA was diagnosed when patients fulfilled the American College of Rheumatology classification criteria, in addition to favorable rapid response to steroid therapy. Patients were divided into 3 groups according to the clinical and histological features: Biopsy-positive GCA, biopsy-negative GCA, and no GCA. RESULTS: 305 TAB reports of 173 individuals were reviewed. When only GCA patients TAB-positive and TAB-negative were considered, TAB in the biopsy-positive patients was significantly longer than in biopsy-negative cases (p=0.008). The rate of positive biopsies was only 19% with TAB length of 5 mm or less, but increased to 71-79% with TAB lengths of 6-20 mm, and to 89% when TAB length was longer than 20 mm. Only 3% of positive biopsies were 5 mm or shorter, compared to 27% of TAB in biopsy-negative GCA cases (p<0.001). CONCLUSION: TAB with post-fixation length shorter than 5 mm carries an increased biopsy-negative rate therefore longer TAB length is required for accurate diagnosis. Increasing post-fixation TAB length beyond 20 mm may further increase the rate of positive biopsies, although data were insufficient in that regard.