Entrustable professional activities (EPAs) for undergraduate medical education - development and exploration of social validity.

BACKGROUND: The development of entrustable professional activities (EPAs) as a framework for work-based training and assessment in undergraduate medical education has become popular. EPAs are defined as units of a professional activity requiring adequate knowledge, skills, and attitudes, with a recognized output of professional labor, independently executable within a time frame, observable and measurable in its process and outcome, and reflecting one or more competencies. Before a new framework is implemented in a specific context, it is valuable to explore social validity, that is, the acceptability by relevant stakeholders. AIM: The aim of our work was to define Core EPAs for undergraduate medical education and further explore the social validity of the constructs. METHOD AND MATERIAL: In a nationwide collaboration, EPAs were developed using a modified Delphi procedure and validated according to EQual by a group consisting of teachers nominated from each of the seven Swedish medical schools, two student representatives, and an educational developer (n = 16). In the next step, social validity was explored in a nationwide survey. The survey introduced the suggested EPAs. For each EPA, the importance of the EPA was rated, as was the rater's perception of the present graduates' required level of supervision when performing the activity. Free-text comments were also included and analyzed. RESULTS: Ten Core EPAs were defined and validated. The validation scores for EQual ranged from 4.1 to 4.9. The nationwide survey had 473 responders. All activities were rated as "important" by most responders, ranging from 54 to 96%. When asked how independent current graduates were in performing the ten activities, 6 to 35% reported "independent". The three themes of the free text comments were: 'relevant target areas and content'; 'definition of the activities'; and 'clinical practice and learning'. CONCLUSION: Ten Core EPAs were defined and assessed as relevant for Swedish undergraduate medical education. There was a consistent gap between the perceived importance and the certainty that the students could perform these professional activities independently at the time of graduation. These results indicate that the ten EPAs may have a role in undergraduate education by creating clarity for all stakeholders.

Postoperative recovery in preschool-aged children: A secondary analysis of a randomized controlled trial comparing premedication with midazolam, clonidine, and dexmedetomidine.

BACKGROUND: Preoperative anxiety in pediatric patients can worsen postoperative outcomes and delay discharge. Drugs aimed at reducing preoperative anxiety and facilitating postoperative recovery are available; however, their effects on postoperative recovery from propofol-remifentanil anesthesia have not been studied in preschool-aged children. Thus, we aimed to investigate the effects of three sedative premedications on postoperative recovery from total intravenous anesthesia in children aged 2-6 years. METHODS: In this prespecified secondary analysis of a double-blinded randomized trial, 90 children scheduled for ear, nose, and throat surgery were randomized (1:1:1) to receive sedative premedication: oral midazolam 0.5 mg/kg, oral clonidine 4 µg/kg, or intranasal dexmedetomidine 2 µg/kg. Using validated instruments, outcome measures including time for readiness to discharge from the postoperative care unit, postoperative sedation, emergence delirium, anxiety, pain, and nausea/vomiting were measured. RESULTS: After excluding eight children due to drug refusal or deviation from the protocol, 82 children were included in this study. No differences were found between the groups in terms of median time [interquartile range] to readiness for discharge (midazolam, 90 min [48]; clonidine, 80 min [46]; dexmedetomidine 100.5 min [42]). Compared to the midazolam group, logistic regression with a mixed model and repeated measures approach found no differences in sedation, less emergence delirium, and less pain in the dexmedetomidine group, and less anxiety in both clonidine and dexmedetomidine groups. CONCLUSIONS: No statistical difference was observed in the postoperative recovery times between the premedication regimens. Compared with midazolam, dexmedetomidine was favorable in reducing both emergence delirium and pain in the postoperative care unit, and both clonidine and dexmedetomidine reduced anxiety in the postoperative care unit. Our results indicated that premedication with α2 -agonists had a better recovery profile than short-acting benzodiazepines; although the overall recovery time in the postoperative care unit was not affected.

Reliability and validity testing of team emergency assessment measure in a distributed team context.

Medical multi-professional teams are increasingly collaborating via telemedicine. In distributed team settings, members are geographically separated and collaborate through technology. Developing improved training strategies for distributed teams and finding appropriate instruments to assess team performance is necessary. The Team Emergency Assessment Measure (TEAM), an instrument validated in traditional collocated acute-care settings, was tested for validity and reliability in this study when used for distributed teams. Three raters assessed video recordings of simulated team training scenarios (n = 18) among teams with varying levels of proficiency working with a remotely located physician via telemedicine. Inter-rater reliability, determined by intraclass correlation, was 0.74-0.92 on the TEAM instrument's three domains of leadership, teamwork, and task management. Internal consistency (Cronbach's alpha) ranged between 0.89-0.97 for the various domains. Predictive validity was established by comparing scores with proficiency levels. Finally, concurrent validity was established by high correlations, >0.92, between scores in the three TEAM domains and the teams' overall performance. Our results indicate that TEAM can be used in distributed acute-care team settings and consequently applied in future-directed learning and research on distributed healthcare teams.

Palonosetron as prophylaxis for post-discharge nausea and vomiting: a prospective, randomised, double-blind, placebo-controlled trial in ambulatory surgery.

BACKGROUND: Approximately 25% of ambulatory surgery patients experience post-discharge nausea and vomiting (PDNV). We aimed to investigate whether palonosetron, a long-acting anti-emetic, decreases the incidence of PDNV in high-risk patients. METHODS: In this prospective, randomised, double-blind, placebo-controlled trial, 170 male and female patients undergoing ambulatory surgery under general anaesthesia, with a high predicted risk for PDNV, were randomised to receive either palonosetron 75 µg i.v. (n=84) or normal saline (n=86) before discharge. During the first 3 postoperative days (PODs), we measured outcomes using a patient questionnaire. The primary outcome was the incidence of a complete response (no nausea, vomiting, or use of rescue medication) until POD 2. Secondary outcomes included the incidence of PDNV each day until POD 3. RESULTS: The incidence of a complete response until POD 2 was 48% (n=32) in the palonosetron group and 36% (n=25) in the placebo group (odds ratio 1.69 [95% confidence interval: 0.85-3.37]; P=0.131). No significant difference in the incidence of PDNV was observed between the two groups on the day of surgery (47% vs 56%; P=0.31). Significant differences in the incidence of PDNV were found on POD 1 (18% vs 34%; P=0.033) and POD 2 (9% vs 27%; P=0.007). No differences were observed on POD 3 (15% vs 13%; P=0.700). CONCLUSIONS: Compared with placebo, palonosetron did not reduce the overall incidence of post-discharge nausea and vomiting up to postoperative day 2. The lower incidence of post-discharge nausea and vomiting on poatoperative days 1 and 2 in the palonosetron group requires further investigation. CLINICAL TRIAL REGISTRATION: EudraCT 2015-003956-32.

Preoperative anxiety level is not associated with postoperative negative behavioral changes in premedicated children.

BACKGROUND: Anesthesia preinduction anxiety in children can according to some studies lead to long-term anxiety and negative behavioral changes (NBC), while other studies have not found this effect. This secondary analysis from a recent premedication trial comparing clonidine and midazolam aimed to test the relation between preoperative anxiety assessed with modified Yale Preoperative Anxiety Scale (mYPAS) and postoperative NBCs assessed with Post Hospital Behavior Questionnaire (PHBQ), regardless of premedication type. METHODS: This is a planned secondary analysis from a published premedication comparison trial in an outpatient surgery cohort, children aged 2-7 years. Participant and preoperative factors, particularly preoperative anxiety as mYPAS scores, were assessed for association with development of postoperative NBCs. RESULTS: Fifty-four of the 115 participants had high preinduction anxiety (mYPAS >30), and 19 of 115 developed >3 postoperative NBCs 1 week after surgery. There was no association between preinduction anxiety level as mYPAS scores and the development of postoperative NBCs at 1 week after surgery (10 of 19 had both, p = .62) nor after 4- or 26-weeks post-surgery. Only lower age was associated with development of NBCs postoperatively. CONCLUSIONS: Based on the findings from this cohort, high preinduction anxiety does not appear to be associated with NBCs postoperatively in children premedicated with clonidine or midazolam.

[Developing medical education with a research base: Swedish research output and conditions for its use in educational quality]. / Medicinpedagogisk forskning krävs för utveckling av läkarutbildningen.

To secure high-quality education for healthcare professionals, the teaching and learning processes-the "how" in education-should be informed by a research base. Although Swedish medical education research is growing, it lacks a national strategy. This study analysed and compared Swedish and Dutch production of medical education articles over ten years in nine core journals, including the number of editorial board members.  During the period 2012-2021, Swedish authors produced 217 articles, whereas Dutch authors published 1,441. The journals had 466 board members, of which 31 (7%) were Dutch and four (<1%) Swedish. The results show that medical education in Swedish medical faculties requires improvement. To ensure high-quality education opportunities, we propose a national effort to strengthen the educational research base, using the Dutch effort as inspiration.

Less use of rescue morphine when a combined PSP/IPP-block is used for postoperative analgesia in breast cancer surgery: A randomised controlled trial.

BACKGROUND: Surgery for breast cancer is common, and intravenous opioids are often used to control postoperative pain. Recently, pectoralis-2 (PECS-2) block has emerged as a promising regional anaesthetic alternative. With nomenclature recently proposed, this block is termed combined PSP/IPP-block (pectoserratus plane block/interpectoral plane block). OBJECTIVE: We aimed to compare the need for postoperative rescue morphine between the intervention group that received a pre-operative combined PSP/IPP-block and a control group that received peri-operative long-acting opioids for postoperative analgesia. DESIGN: A randomised controlled study. SETTING: Operating theatres of two Swedish hospitals. The patients were recruited between May 2017 and October 2020. PATIENTS: Among the 199 women scheduled to undergo breast cancer surgery (sector resection or radical mastectomy) who were enrolled in the study, 185 were available for follow up. INTERVENTION: All patients received general anaesthesia. The intervention group received a combined PSP/IPP-block before surgery. The control group received intravenous morphine 30 min before emergence from anaesthesia. MAIN OUTCOME MEASURE: The primary endpoint was the cumulative need for intravenous rescue morphine to reach a predefined level of pain control (visual analogue scale score <40 mm) during the first 48 h after surgery. RESULTS: Data from 92 and 93 patients in the intervention and control groups, respectively, were analysed. The amount of rescue morphine administered in the 48 h after surgery was significantly lower in the intervention group than in the control group (median: 2.25 vs 3.0 mg, P  = 0.021). The first measured pain score was lower in the intervention group than in the control group (35 vs. 40 mm, P  = 0.035). There was no significant difference in the incidence of nausea between the groups (8.7 vs. 12.9%, P  = 0.357). CONCLUSION: The use of a combined PSP/IPP-block block before breast cancer surgery reduces the need for postoperative rescue morphine, even when compared with the use of intra-operative morphine. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT03117894.

Cardiorespiratory Response to Sedative Premedication in Preschool Children: A Randomized Controlled Trial Comparing Midazolam, Clonidine, and Dexmedetomidine.

PURPOSE: Sedative premedication in children may negatively impact their cardiorespiratory status during the perioperative course, and no clear consensus exists on the optimal premedication treatment for pediatric patients. The objective was to compare the perioperative cardiorespiratory responses to sedation using three different sedative premedication regimens in preschool children scheduled for surgery with total intravenous anesthesia. DESIGN: A single-center randomized controlled trial. METHODS: This is a planned secondary analysis of a study conducted at a 200-bed tertiary referral hospital. Ninety children participated in the study. They were aged 2-6 years and scheduled for ear, nose, and throat surgery with propofol/remifentanil anesthesia. Participants were randomly assigned to receive oral midazolam 0.5 mg/kg-1 (MID), oral clonidine 4 mcg/kg-1 (CLO), or intranasal dexmedetomidine 2 mcg/kg-1 (DEX). The main outcome measures were the sedation level, based on the Ramsay Sedation Scale (RSS), and cardiorespiratory status, monitored during the perioperative period. FINDINGS: The final cohort had 83 children (MID, n=27; CLO, n=26; DEX, n=30), with similar intergroup patient characteristics. RSS scores were lower in the MID group than in the CLO and DEX groups before induction and within 30 min postsurgery (P<0.001 and P=0.006, respectively). A negative correlation existed between the RSS and heart rate (HR) (r=-0.570, P<0.001). Before anesthesia induction, the respiratory rate was lowest in the DEX group (MID 21.5±1.7 min-1, CLO 20.6±2.6 min-1, DEX 20.2±1.7 min-1; P=0.042). The HR was lower in the CLO and DEX groups than in the MID group (MID, 102.8±10.0 min-1; CLO, 87.4±9.6 min-1; DEX, 87.6±7.9 min-1; P<0.001). The HR was lower immediately after induction (P=0.009) and intraoperatively (P=0.025) in the CLO and DEX groups than in the MID group. CONCLUSIONS: When used as premedication before propofol/remifentanil anesthesia, clonidine and dexmedetomidine provided deeper preoperative sedation compared to midazolam. From a clinical perspective, all three study drugs provided essentially stable cardiovascular and respiratory conditions during the entire perioperative period.

Left atrial contraction strain during a Valsalva manoeuvre: A study in healthy humans.

BACKGROUND: Cardiac mechanics are influenced by loading conditions as well as sympathetic tone. Left atrial (LA) contractile function assessed by two-dimensional (2D) strain has been described in the setting of controlled preload alterations; however, studies show conflicting findings about change or direction of change. We hypothesized that the controlled preload reduction and the sympathetic nervous system activation that occurs during a standardized Valsalva manoeuvre would bring about a change in LA contraction strain. METHODS: Healthy young adults of both sexes were recruited. Transthoracic echocardiographic ultrasound images were collected before and during a Valsalva manoeuvre. Standard imaging windows for LA strain assessment were used and the images were copied and stored for later offline analysis. These were assessed for adequate atrial wall visualization in 2D strain assessment. Paired comparisons were carried out using Student's T test. RESULT: Thirty-eight participants were included and there were 22 complete studies with paired pre- and during Valsalva manoeuvre. LA contraction strain at baseline was 10.5 ± 2.8% (standard deviation) and during the Valsalva manoeuvre 10.6 ± 4.6%, p = 0.86. CONCLUSION: The Valsalva manoeuvre, a combination of preload reduction and sympathetic nervous system activation, seems not to be associated with a change in LA contraction strain in healthy young individuals. LA contraction strain should be interpreted in the context of both atrial loading conditions and prevailing autonomic nervous system activity.

Spinal anaesthesia with clonidine: pain relief and earlier mobilisation after open nephrectomy - a randomised clinical trial.

OBJECTIVES: Early mobilisation and effective pain management after open nephrectomy for renal cell carcinoma often include epidural analgesia (EDA), requiring an infusion pump and a urinary catheter, thus impeding mobilisation. Spinal anaesthesia (SpA) may be an alternative. This randomised clinical trial evaluated whether SpA improves analgesia and facilitates mobilisation over EDA and which factors influence mobilisation and length of stay (LOS). METHODS: Between 2012 and 2015, 135 patients were randomised and stratified by surgical method to either SpA with clonidine or EDA. Mobility index score (MobIs), pain scale, patient satisfaction questionnaire, and LOS were the main outcome measures. RESULTS: SpA patients exhibited an increase in MobIs significantly earlier than EDA patients. Among SpA patients >50% reached MobIs ≥13 by postoperative day 3, while 29% of EDA patients never reached MobIs ≥13 before discharge. SpA patients had higher maximum pain scores on postoperative days 1 and 2, but both groups had similar patient satisfaction. One day before discharge, 36/64 SpA versus 22/67 EDA patients (56% and 33%, respectively) were opioid-free. SpA patients were discharged significantly earlier than EDA patients. CONCLUSIONS: SpA facilitates postoperative pain management and is associated with faster mobilisation and shorter LOS.The trial was registered at ClinicalTrials.org (ID-NCT02030717).

Pre-operative point-of-care assessment of left ventricular diastolic dysfunction, an observational study.

BACKGROUND: Left ventricular (LV) diastolic dysfunction is an acknowledged peri-operative risk factor that should be identified before surgery. This study aimed to evaluate a simplified echocardiographic method using e' and E/e' for identification and grading of diastolic dysfunction pre-operatively. METHODS: Ninety six ambulatory surgical patients were consecutively included to this prospective observational study. Pre-operative transthoracic echocardiography was conducted prior to surgery, and diagnosis of LV diastolic dysfunction was established by comprehensive and simplified assessment, and the results were compared. The accuracy of e'-velocities in order to discriminate patients with diastolic dysfunction was established by calculating accuracy, efficiency, positive (PPV) and negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC). RESULTS: Comprehensive assessment established diastolic dysfunction in 77% (74/96) of patients. Of these, 22/74 was categorized as mild dysfunction, 43/74 as moderate dysfunction and 9/74 as severe dysfunction. Using the simplified method with e' and E/e', diastolic dysfunction was established in 70.8% (68/96) of patients. Of these, 8/68 was categorized as mild dysfunction, 36/68 as moderate dysfunction and 24/68 as severe dysfunction. To discriminate diastolic dysfunction of any grade, e'-velocities (mean < 9 cm s- 1) had an AUROC of 0.901 (95%CI 0.840-0.962), with a PPV of 55.2%, a NPV of 90.9% and a test efficiency of 0.78. CONCLUSIONS: The results of this study indicate that a simplified approach with tissue Doppler e'-velocities may be used to rule out patients with diastolic dysfunction pre-operatively, but together with E/e' ratio the severity of diastolic dysfunction may be overestimated. TRIAL REGISTRATION: Clinicaltrials.gov, Identifier: NCT03349593 . Date of registration 21/11/2017. https://clinicaltrials.gov .

Left atrial contraction strain and controlled preload alterations, a study in healthy individuals.

BACKGROUND: In order to assess left atrial contractile function in disturbed circulatory conditions, it is necessary to have a clear understanding of how it behaves in a normal resting state with changes in loading conditions. However, currently the understanding of this relationship is incomplete. We hypothesize that in healthy individuals, left atrial contraction strain and its peak strain rate are increased or decreased by increasing or decreasing preload, respectively. METHODS: Controlled maneuvers used to change preload included continuous positive airway pressure by mask (CPAP 20 cmH2O) for preload decrease, and passive leg raise (15 degrees angle) for preload increase. Cardiac ultrasound 4-chamber views of the left atria and left ventricle were acquired at baseline and during maneuver. Acquired images were post processed and analyzed offline. Comparisons were made using paired t-test and means with 95% confidence interval. RESULTS: There were 38 participants, complete results were obtained from 23 in the CPAP maneuver and 27 in the passive leg raise maneuver. For the CPAP group, left atrial contraction strain was 11.6% (10.1 to 13.1) at baseline and 12.8% (11.0 to 14.6) during the maneuver (p = 0.16). Left atrial contraction peak strain rate was - 1.7 s- 1 (- 1.8 to - 1.5) at baseline and - 1.8 s- 1 (- 2.0 to - 1.6) during the maneuver (p = 0.29). For the passive leg raise-group, left atrial contraction strain was 10.1% (9.0 to 11.2) at baseline and 10.8% (9.4 to 12.3) during the maneuver (p = 0.28). Left atrial contraction peak strain rate was - 1.5 s- 1 (- 1.6 to - 1.4) at baseline and - 1.6 s- 1 (- 1.8 to - 1.5) during the maneuver (p = 0.29). Left atrial area, an indicator of preload, increased significantly during passive leg raise and decreased during CPAP. CONCLUSION: In healthy individuals, left atrial contraction strain and its peak strain rate seem to be preload-independent. TRIAL REGISTRATION: The study was 2018-02-19 registered at clinicaltrials.gov ( NCT03436030 ).

Routine use of LMWH prophylaxis is associated with a lower incidence of venous thromboembolic events following an ankle fracture.

BACKGROUND: Venous thromboembolic events (VTE) are well-known and serious complications following a trauma to the lower extremities. There is an ongoing debate on the benefit of low-molecular-weight heparin (LMWH) as prophylaxis following ankle fracture treatment. We examined the association between the incidence of VTE and the use of LMWH-prophylaxis following an ankle fracture, as well as factors affecting the risk of VTE. METHODS: In this retrospective cohort study, data on ankle fractures and fracture treatment from the Swedish Fracture Register was linked to data from the Swedish National Patient Register and the Swedish Prescribed Drug Register. Patients with VTE and patients who received LMWH prophylaxis were identified. The treating orthopedic departments were sent a questionnaire about their guidelines regarding the use of LMWH prophylaxis. RESULTS: 222 cases of diagnosed VTE were identified among 14,954 ankle fractures. Orthopedic departments with higher-than-average use of LMWH prophylaxis among non-operatively treated ankle fractures had a lower incidence of VTE (OR 0.60, CI 0.39-0.92). Among operatively treated patients, departments with a guideline for the routine use of LMWH prophylaxis also had lower incidence of VTE (OR 0.56, CI 0.37-0.86). A later onset of VTE was seen among patients prescribed LMWH prophylaxis, with a mean of 56 days to onset (CI 44-67), compared to 39 days (CI 33-45) in patients without prescribed prophylaxis. During the first two weeks following injury, there was only one case of VTE in patients with prescribed LMWH, compared to 39 cases of VTE among patients without prescribed prophylaxis. CONCLUSIONS: Routine use of LMWH in patients with operatively treated ankle fractures was associated with a lower incidence of VTE. A more frequent use of LMWH among patients with non-operatively treated ankle fractures were associated with a lower incidence of VTE. The onset occurred later among patients with LMWH-prophylaxis who still suffered a VTE.

Preoperative anxiety in preschool children: A randomized clinical trial comparing midazolam, clonidine, and dexmedetomidine.

INTRODUCTION: Anxiety in pediatric patients may challenge perioperative anesthesiology management and worsen postoperative outcomes. Sedative drugs aimed to reducing anxiety are available with different pharmacologic profiles, and there is no consensus on their effect or the best option for preschool children. In this study, we aimed to compare the effect of three different premedications on anxiety before anesthesia induction in preschool children aged 2-6 years scheduled for elective surgery. The secondary outcomes comprised distress during peripheral catheter (PVC) insertion, compliance at anesthesia induction, and level of sedation. PATIENTS AND METHODS: In this double-blinded randomized clinical trial, we enrolled 90 participants aged 2-6 years, who were scheduled for elective ear-, nose-and-throat surgery. The participants were randomly assigned to three groups: those who were administered 0.5 mg/kg oral midazolam, 4 µg/kg oral clonidine, or 2 µg/kg intranasal dexmedetomidine. Anxiety, distress during PVC insertion, compliance with mask during preoxygenation, and sedation were measured using the modified Yale Preoperative Anxiety Scale, Behavioral Distress Scale, Induction Compliance Checklist, and Ramsay Sedation Scale, respectively. RESULTS: Six children who refused premedication were excluded, leaving 84 enrolled patients. At baseline, all groups had similar levels of preoperative anxiety and distress. During anesthesia preparation, anxiety was increased in the children who received clonidine and dexmedetomidine; however, it remained unaltered in the midazolam group. There were no differences in distress during PVC insertion or compliance at induction between the groups. The children in the clonidine and dexmedetomidine groups developed higher levels of sedation than those in the midazolam group. CONCLUSIONS: In preschool children, midazolam resulted in a more effective anxiolysis and less sedation compared to clonidine and dexmedetomidine.

Do team and task performance improve after training situation awareness? A randomized controlled study of interprofessional intensive care teams.

BACKGROUND: When working in complex environments with critically ill patients, team performance is influenced by situation awareness in teams. Moreover, improved situation awareness in the teams will probably improve team and task performance. The aim of this study is to evaluate an educational programme on situation awareness for interprofessional teams at the intensive care units using team and task performance as outcomes. METHOD: Twenty interprofessional teams from the northern part of Sweden participated in this randomized controlled intervention study conducted in situ in two intensive care units. The study was based on three cases (cases 0, 1 and 2) with patients in a critical situation. The intervention group (n = 11) participated in a two-hour educational programme in situation awareness, including theory, practice, and reflection, while the control group (n = 9) performed the training without education in situation awareness. The outcomes were team performance (TEAM instrument), task performance (ABCDE checklist) and situation awareness (Situation Awareness Global Assessment Technique (SAGAT)). Generalized estimating equation were used to analyse the changes from case 0 to case 2, and from case 1 to case 2. RESULTS: Education in situation awareness in the intervention group improved TEAM leadership (p = 0.003), TEAM task management (p = 0.018) and TEAM total (p = 0.030) when comparing cases 1 and 2; these significant improvements were not found in the control group. No significant differences were observed in the SAGAT or the ABCDE checklist. CONCLUSIONS: This intervention study shows that a 2-h education in situation awareness improved parts of team performance in an acute care situation. Team leadership and task management improved in the intervention group, which may indicate that the one or several of the components in situation awareness (perception, comprehension and projection) were improved. However, in the present study this potential increase in situation awareness was not detected with SAGAT. Further research is needed to evaluate how educational programs can be used to increase situation awareness in interprofessional ICU teams and to establish which components that are essential in these programs. TRIAL REGISTRATION: This randomized controlled trial was not registered as it does not report the results of health outcomes after a health care intervention on human participants.

Early post-operative nausea and vomiting: A retrospective observational study of 2030 patients.

BACKGROUND: The overall risk of post-operative nausea and vomiting (PONV) after general anaesthesia is reportedly 20%-40%. The first episode of PONV may occur early in the post-anaesthesia care unit (PACU) or later at the ward or after discharge at home in an ambulatory setting. This study aimed to investigate and describe the risk of early PONV in a PACU, and we hypothesised that patients and perioperative factors were associated with early PONV. METHODS: This single-centre retrospective observational study was conducted in a Swedish county hospital from January to June 2017 and included adult patients who underwent surgical procedures under general anaesthesia. Perioperative data were obtained by reviewing the local registry for surgical procedures, medical records and anaesthesia and post-operative charts. Early PONV was defined as PONV occurring up to 4 hours post-operatively at the PACU. Any notification in the medical records, perioperative charts or the registry regarding nausea, vomiting or PONV treatment was regarded as PONV. Univariate and multivariate analyses were performed for factors associated with early PONV. RESULTS: A total of 2030 patients were included in the study, of which 9.6% (n = 194) experienced early PONV. Factors associated with a high risk of early PONV were suboptimal PONV prophylaxis, need for opioids, female sex, body mass index >35 kg m-2 and major surgery and anaesthesia time ≥60 minutes. CONCLUSION: We found that every 10th patient under general anaesthesia experienced early PONV. Suboptimal PONV prophylaxis and previously acknowledged risk factors for PONV were associated with early PONV.

Factors Influencing Team and Task Performance in Intensive Care Teams in a Simulated Scenario.

INTRODUCTION: Healthcare teams and their performance in a complex environment such as that of intensive care units (ICUs) are influenced by several factors. This study investigates the relationship between team background characteristics and team as well as task performance. METHODS: This study included 105 professionals (26 teams), working at the ICUs of 2 hospitals in Northern Sweden. The team-based simulation training sessions were video recorded, and thereafter, team performance and task performance were analyzed based on ratings of the TEAM instrument and the ABCDE checklist. RESULTS: The final analyses showed that a higher age was significantly associated with better total team performance (ß = 0.35, P = 0.04), teamwork (ß = 0.04, P = 0.04), and task management (ß = 0.04, P = 0.05) and with a higher overall rating for global team performance (ß = 0.09, P = 0.02). The same pattern was found for the association between age and task performance (ß = 0.02, P = 0.04). In addition, prior team training without video-facilitated reflection was significantly associated with better task performance (ß = 0.35, P = 0.04). On the other hand, prior team training in communication was significantly associated with worse (ß = -1.30, P = 0.02) leadership performance. CONCLUSIONS: This study reveals that a higher age is important for better team performance when caring for a severely ill patient in a simulation setting in the ICU. In addition, prior team training had a positive impact on task performance. Therefore, on a team level, this study indicates that age and, to some extent, prior team training without video-facilitated reflection have an impact on team performance in the care of critically ill patients.

Preoperative Point-of-Care Assessment of Left Ventricular Systolic Dysfunction With Transthoracic Echocardiography.

BACKGROUND: Left ventricular (LV) systolic dysfunction is an acknowledged perioperative risk factor and should be identified before surgery. Conventional echocardiographic assessment of LV ejection fraction (LVEF) obtained by biplane LV volumes is the gold standard to detect LV systolic dysfunction. However, this modality needs extensive training and is time consuming. Hence, a feasible point-of-care screening method for this purpose is warranted. The aim of this study was to evaluate 3 point-of-care echocardiographic methods for identification of LV systolic dysfunction in comparison with biplane LVEF. METHODS: One hundred elective surgical patients, with a mean age of 63 ± 12 years and body mass index of 27 ± 4 kg/m2, were consecutively enrolled in this prospective observational study. Transthoracic echocardiography was conducted 1-2 hours before surgery. LVEF was obtained by automatic two-dimensional (2D) biplane ejection fraction (EF) software. We evaluated if Tissue Doppler Imaging peak systolic myocardial velocities (TDISm), anatomic M-mode E-point septal separation (EPSS), and conventional M-mode mitral annular plane systolic excursion (MAPSE) could discriminate LV systolic dysfunction (LVEF <50%) by calculating accuracy, efficiency, correlation, positive (PPV) respective negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC) for each point-of-care method. RESULTS: LVEF<50% was identified in 22% (21 of 94) of patients. To discriminate an LVEF <50%, AUROC for TDISm (mean <8 cm/s) was 0.73 (95% confidence interval [CI], 0.62-0.84; P < .001), with a PPV of 47% and an NPV of 90%. EPSS with a cutoff value of >6 mm had an AUROC 0.89 (95% CI, 0.80-0.98; P < .001), with a PPV of 67% and an NPV of 96%. MAPSE (mean <12 mm) had an AUROC 0.80 (95% CI, 0.70-0.90; P < 0.001) with a PPV of 57% and an NPV of 98%. CONCLUSIONS: All 3 point-of-care methods performed reasonably well to discriminate patients with LVEF <50%. The clinician may choose the most suitable method according to praxis and observer experience.

Preparedness for peer first response to mining emergencies resulting in injuries: a cross-sectional study.

OBJECTIVE: Identify factors of preparedness for peer first response to underground mining emergencies with injured victims. DESIGN: Cross-sectional questionnaire study of Swedish underground mineworkers. SETTING: Seven out of nine Swedish underground mines. PARTICIPANTS: A total of 741 mineworkers out of 1022 (73%) participated in this study. INTERVENTIONS: None. OUTCOME MEASURES: Level of preparedness for emergencies with injuries in underground mines. RESULTS: Three factors influenced the preparedness of mineworkers for a peer first response: (1) familiarity with rescue procedures during emergencies with injuries; (2) risk perception of emergencies with injuries and (3) experience of using self-protective and first aid equipment. Mineworkers who believed that they knew how to handle emergencies with injuries (OR 1.30, 95% CI 1.22 to 1.38) and those who were trained in the use of self-protective and first aid equipment (OR 1.19, 95% CI 1.07 to 1.32) considered themselves to be better prepared for a peer first response than those who were unfamiliar with the rescue procedures or who had not used self-protective and first aid equipment. However, mineworkers who rated the risk for emergencies with injuries as high considered themselves to be less prepared than those who rated the risk as low (OR 0.95, 95% CI 0.91 to 0.98). CONCLUSION: This study identified three factors that were important for the peer-support preparedness of underground mineworkers. More research is needed to adapt and contextualise first aid courses to the needs of underground peer responders.