Enhancing patient safety: detection of in-hospital hazards and effect of training on detection (by training in a low-fidelity simulation Room of Improvement based on hospital-specific CIRS cases).

IMPORTANCE: Adequate situational awareness in patient care increases patient safety and quality of care. To improve situational awareness, an innovative, low-fidelity simulation method referred to as Room of Improvement, has proven effective in various clinical settings. OBJECTIVE: To investigate the impact after 3 months of Room of Improvement training on the ability to detect patient safety hazards during an intensive care unit shift handover, based on critical incident reporting system (CIRS) cases reported in the same hospital. METHODS: In this educational intervention, 130 healthcare professionals observed safety hazards in a Room of Improvement in a 2 (time 1 vs time 2)×2 (alone vs in a team) factorial design. The hazards were divided into immediately critical and non-critical. RESULTS: The results of 130 participants were included in the analysis. At time 1, no statistically significant differences were found between individuals and teams, either overall or for non-critical errors. At time 2, there was an increase in the detection rate of all implemented errors for teams compared with time 1, but not for individuals. The detection rate for critical errors was higher than for non-critical errors at both time points, with individual and group results at time 2 not significantly different from those at time 1. An increase in the perception of safety culture was found in the pre-post test for the questions whether the handling of errors is open and professional and whether errors are discussed in the team. DISCUSSION: Our results indicate a sustained learning effect after 12 weeks, with collaboration in teams leading to a significantly better outcome. The training improved the actual error detection rates, and participants reported improved handling and discussion of errors in their daily work. This indicates a subjectively improved safety culture among healthcare workers as a result of the situational awareness training in the Room of Improvement. As this method promotes a culture of safety, it is a promising tool for a well-functioning CIRS that closes the loop.

Accuracy between prehospital and hospital diagnosis in helicopter emergency medical services and its consequences for trauma care.

PURPOSE: For optimal prehospital trauma care, it is essential to adequately recognize potential life-threatening injuries in order to correctly triage patients and to initiate life-saving measures. The aim of the present study was to determine the accuracy of prehospital diagnoses suspected by helicopter emergency medical services (HEMS). METHODS: This retrospective multicenter study included patients from the Swiss Trauma Registry with ISS ≥ 16 or AIS head ≥ 3 transported by Switzerland's largest HEMS and subsequently admitted to one of twelve Swiss trauma centers from 01/2020 to 12/2020. The primary outcome was the comparison of injuries suspected prehospital with the final diagnoses obtained at the hospital using the abbreviated injury scale (AIS) per body region. As secondary outcomes, prehospital interventions were compared to corresponding relevant diagnoses. RESULTS: Relevant head trauma was the most commonly injured body region and was identified in 96.3% (95% CI: 92.1%; 98.6%) of the cases prehospital. Relevant injuries to the chest, abdomen, and pelvis were also common but less often identified prehospital [62.7% (95% CI: 54.2%; 70.6%), 45.5% (95% CI: 30.4%; 61.2%), and 61.5% (95% CI: 44.6%; 76.6%)]. Overall, 7 of 95 (7.4%) patients with pneumothorax received a chest decompression and in 22 of 39 (56.4%) patients with an instable pelvic fracture a pelvic binder was applied prehospital. CONCLUSION: Approximately half of severe chest, abdominal, and pelvic diagnoses made in hospital went undetected in the challenging prehospital environment. This underlines the difficult circumstances faced by the rescue teams. Potentially life-saving interventions such as prehospital chest decompression and increased use of a pelvic binder were identified as potential improvements to prehospital care.

Autoreactive T cells targeting type II pneumocyte antigens in COVID-19 convalescent patients.

BACKGROUND: The role of autoreactive T cells on the course of Coronavirus disease-19 (COVID-19) remains elusive. Type II pneumocytes represent the main target cells of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Autoimmune responses against antigens highly expressed in type II pneumocytes may influence the severity of COVID-19 disease. OBJECTIVE: The aim of this study was to investigate autoreactive T cell responses against self-antigens highly expressed in type II pneumocytes in the blood of COVID-19 patients with severe and non-severe disease. METHODS: We collected blood samples of COVID-19 patients with varying degrees of disease severity and of pre-pandemic controls. T cell stimulation assays with peptide pools of type II pneumocyte antigens were performed in two independent cohorts to analyze the autoimmune T cell responses in patients with non-severe and severe COVID-19 disease. Target cell lysis assays were performed with lung cancer cell lines to determine the extent of cell killing by type II PAA-specific T cells. RESULTS: We identified autoreactive T cell responses against four recently described self-antigens highly expressed in type II pneumocytes, known as surfactant protein A, surfactant protein B, surfactant protein C and napsin A, in the blood of COVID-19 patients. These antigens were termed type II pneumocyte-associated antigens (type II PAAs). We found that patients with non-severe COVID-19 disease showed a significantly higher frequency of type II PAA-specific autoreactive T cells in the blood when compared to severely ill patients. The presence of high frequencies of type II PAA-specific T cells in the blood of non-severe COVID-19 patients was independent of their age. We also found that napsin A-specific T cells from convalescent COVID-19 patients could kill lung cancer cells, demonstrating the functional and cytotoxic role of these T cells. CONCLUSIONS: Our data suggest that autoreactive type II PAA-specific T cells have a protective role in SARS-CoV-2 infections and the presence of high frequencies of these autoreactive T cells indicates effective viral control in COVID-19 patients. Type II-PAA-specific T cells may therefore promote the killing of infected type II pneumocytes and viral clearance.

Characteristics and neurological survival following intraoperative cardiac arrest in a Swiss University Hospital: a 7-year retrospective observational cohort study.

Introduction: Little is known about intraoperative cardiac arrest during anesthesia care. In particular, data on characteristics of cardiac arrest and neurological survival are scarce. Methods: We conducted a single-center retrospective observational study evaluating anesthetic procedures from January 2015 until December 2021. We included patients with an intraoperative cardiac arrest and excluded cardiac arrest outside of the operating room. The primary outcome was the return of spontaneous circulation (ROSC). Secondary outcomes were sustained ROSC over 20 min, 30-day survival, and favorable neurological outcome according to Clinical Performance Category (CPC) 1 and 2. Results: We screened 228,712 anesthetic procedures, 195 of which met inclusion criteria and were analyzed. The incidence of intraoperative cardiac arrest was 90 (CI 95% 78-103) in 100,000 procedures. The median age was 70.5 [60.0; 79.4] years, and two-thirds of patients (n = 135; 69.2%) were male. Most of these patients with cardiac arrest had ASA physical status IV (n = 83; 42.6%) or V (n = 47; 24.1%). Cardiac arrest occurred more frequently (n = 104; 53.1%) during emergency procedures than elective ones (n = 92; 46.9%). Initial rhythm was pre-dominantly non-shockable with pulseless electrical activity mostly. Most patients (n = 163/195, 83.6%; CI 95 77.6-88.5%) had at least one instance of ROSC. Sustained ROSC over 20 min was achieved in most patients with ROSC (n = 147/163; 90.2%). Of the 163 patients with ROSC, 111 (68.1%, CI 95 60.4-75.2%) remained alive after 30 days, and most (n = 90/111; 84.9%) had favorable neurological survival (CPC 1 and 2). Conclusion: Intraoperative cardiac arrest is rare but is more likely in older patients, patients with ASA physical status ≥IV, cardiac and vascular surgery, and emergency procedures. Patients often present with pulseless electrical activity as the initial rhythm. ROSC can be achieved in most patients. Over half of the patients are alive after 30 days, most with favorable neurological outcomes, if treated immediately.

Risk factors and outcomes of postoperative aspiration pneumonia in abdominal surgery patients: An exact matching and weighting analysis.

BACKGROUND: Postoperative aspiration pneumonia is a feared complication contributing significantly to postoperative morbidity and mortality. Over decades, there has been little progress in reducing incidence and mortality of postoperative aspiration pneumonia. Here, we assessed risk factors for postoperative aspiration pneumonia in general and abdominal surgery patients. METHODS: Patients undergoing surgery between January 2012 and December 2018 were included in this exact matched and weighted case-control study. Data from a prospectively acquired clinical database were retrospectively analyzed. RESULTS: Among 23,647 patients undergoing 32,901 operations, 144 (0.44%, 95% Confidence Interval: 0.37%-0.52%) cases of postoperative aspiration pneumonia were identified. Ninety-day mortality was 27.8% (n = 40). Major risk factors for postoperative aspiration pneumonia were emergency surgery in patients with prolonged preoperative fasting (>6 hours; odds ratio: 3.25, 95% confidence interval: 1.46-7.26; P < .001), older age with increasing risk in octogenarians compared to seniors (65-80 years: n = 69; odds ratio 5.23, 95% confidence interval: 2.18-12.51; >80 years: n = 50; odds ratio 13.72, 95% confidence interval: 4.94-38.09; P < .001), American Society of Anesthesiologists scores >II (American Society of Anesthesiologists III: n = 90; odds ratio 3.38, 95% confidence interval: 1.08-16.01; American Society of Anesthesiologists IV/V: n = 18; odds ratio 5.20, 95% confidence interval: 1.48-27.61; P < .001), and body mass index <18 kg/m2 (n = 9; odds ratio: 2.53; 95% confidence interval: 1.04-6.11; P = .029). Laparoscopies (odds ratio 0.45, 95% confidence interval: 0.23-0.88; <0.001) and female sex were associated with a decreased risk for postoperative aspiration pneumonia (odds ratio 0.40, 95% confidence interval: 0.23-0.69; P < .001). CONCLUSION: Preventive measures to reduce postoperative aspiration pneumonia should focus on older patients with American Society of Anesthesiologists scores ≥III undergoing open surgery. Cachectic patients and patients undergoing emergency surgery with prolonged preoperative fasting require increased attention. Laparoscopy was associated with a lower risk for postoperative aspiration pneumonia and should be preferred whenever appropriate.

Analysis of tracheal intubation in out-of-hospital helicopter emergency medicine recorded by video laryngoscopy.

BACKGROUND: Tracheal intubation remains the gold standard of airway management in emergency medicine and maximizing safety, intubation success, and especially first-pass intubation success (FPS) in these situations is imperative. METHODS: We conducted a prospective observational study on all 12 helicopter emergency medical service (HEMS) bases of the Swiss Air Rescue, between February 15, 2018, and February 14, 2019. All 428 patients on whom out-of-hospital advanced airway management was performed by the HEMS crew were included. The C-MAC video laryngoscope was used as the primary device for tracheal intubation. Intubation procedures were recorded by the video laryngoscope and precise time points were recorded to verify the time necessary for each attempt and the overall procedure time until successful intubation. The videos were further analysed for problems and complications during airway management by an independent reviewer. Additionally, a questionnaire about the intubation procedure, basic characteristics of the patient, circumstances, environmental factors, and the provider's level of experience in airway management was filled out. Main outcome measures were FPS of tracheal intubation, overall success rate, overall intubation time, problems and complications of video laryngoscopy. RESULTS: FPS rate was 87.6% and overall success rate 98.6%. Success rates, overall time to intubation, and subjective difficulty were not associated to the providers' expertise in airway management. In patients undergoing CPR FPS was 84.8%, in trauma patients 86.4% and in non-trauma patients 93.3%. FPS in patients with difficult airway characteristics, facial trauma/burns or obesity ranges between 87 and 89%. Performing airway management indoors or inside an ambulance resulted in a significantly higher FPS of 91.1% compared to outdoor locations (p < 0.001). Direct solar irradiation on the screen, fogging of the lens, and blood on the camera significantly impaired FPS. Several issues for further improvements in the use of video laryngoscopy in the out-of-hospital setting and for quality control in airway management were identified. CONCLUSION: Airway management using the C-MAC video laryngoscope with Macintosh blade in a group of operators with mixed experience showed high FPS and overall rates of intubation success. Video recording emergency intubations may improve education and quality control.

Up-regulation of heme oxygenase-1 by sevoflurane is not dependent on Kupffer cells and associates with ERK1/2 and AP-1 activation in the rat liver.

Sevoflurane is a potent non-toxic inducer of the hepatoprotective enzyme heme oxygenase-1 (HO-1). So far, little is known about the underlying molecular mechanism. Therefore the aim of this study was to characterize the respective signal transduction pathway and in particular to elucidate the role of Kupffer cells in this context. Rats were treated with or without sevoflurane. The effects on hepatic HO-1 gene expression, mitogen-activated protein kinases and transcription factors were studied by Northern and Western blot analyses, immunostaining, electrophoretic mobility shift assays, and enzymatic activity assays. Kupffer cells were depleted by administration of clodronate liposomes in vivo to characterize their role in HO-1 signal transduction. In additional in vitro experiments, HO-1 mRNA expression in primary rat hepatocytes and HepG2 cells was assessed. Sevoflurane up-regulated HO-1 gene expression in pericentral hepatocytes and increased HO enzyme activity in vivo. This was associated with activation of ERK1/2 and activator protein-1. We identified c-jun/AP-1, JunD, c-fos, and Fra-1 as active subunits of the activator protein-1 complex. Administration of clodronate liposomes to rats led to depletion of Kupffer cells without affecting sevoflurane induced HO-1 expression. Moreover, sevoflurane up-regulated HO-1 mRNA in primary rat hepatocytes but not in HepG2 cells. Our results suggest that sevoflurane induced HO-1 gene expression in pericentral hepatocytes does not depend on Kupffer cells and is associated with activation of ERK1/2 and activator protein-1. Since we could recently demonstrate significant hepatoprotective effects of HO-1 induced by isoflurane, the present results may help to establish new concepts in hepatic organ protection.