A survey and analysis of peri-operative quality indicators promoted by National Societies of Anaesthesiologists in Europe: The EQUIP project.

BACKGROUND: To capture preventable peri-operative patient harm and guide improvement initiatives, many quality indicators (QIs) have been developed. Several National Anaesthesiologist Societies (NAS) in Europe have implemented quality indicators. To date, the definitions, validity and dissemination of such quality indicators, and their comparability with validated published indicators are unknown. OBJECTIVES: The aim of this study was to identify all quality indicators promoted by NAS in Europe, to assess their characteristics and to compare them with published validated quality indicators. DESIGN: A cross-sectional study with mixed methods analysis. Using a survey questionnaire, representatives of 37 NAS were asked if their society provided quality indicators to their members and, if so, to provide the list, definitions and details of quality indicators. Characteristics of reported quality indicators were analysed. SETTING: The 37 NAS affiliated with the European Society of Anaesthesiology and Intensive Care (ESAIC) at the time. Data collection, translations: March 2018 to February 2020. PARTICIPANTS: Representatives of all 37 NAS completed the survey. MAIN OUTCOME MEASURES: QIs reported by NAS. RESULTS: Only 12 (32%) of the 37 NAS had made a set of quality indicators available to their members. Data collection was mandatory in six (16.2%) of the 37 countries. We identified 163 individual quality indicators, which were most commonly descriptive (60.1%), anaesthesia-specific (50.3%) and related to intra-operative care (21.5%). They often measured structures (41.7%) and aspects of safety (35.6%), appropriateness (20.9%) and prevention (16.6%). Patient-centred care (3.7%) was not well covered. Only 11.7% of QIs corresponded to published validated or well established quality indicator sets. CONCLUSIONS: Few NAS in Europe promoted peri-operative quality indicators. Most of them differed from published sets of validated indicators and were often related to the structural dimension of quality. There is a need to establish a European-wide comprehensive core set of usable and validated quality indicators to monitor the quality of peri-operative care. TRIAL REGISTRATION: No registration.

Patient safety practices in European anaesthesiology: Expert evaluation and ranking.

BACKGROUND: Patient safety is a key concern of anaesthesiology practice. However, good practices are often not widely shared between departments and hospitals, whether within or between countries. OBJECTIVE: We aimed to collect and analyse safety practices and tips from anaesthesiology departments around Europe in order to facilitate successful transfer of safety knowledge. DESIGN: Review of previously collected safety practices; allocation of numerical scores in order to rank them on 0-5 scales in terms of anticipated impact, and speed, cost, and ease of implementation; free text comment on any possible difficulties or unintended harms which might arise from adopting any of the collected practices. SETTING: Collaborative remote working of expert group. PARTICIPANTS: Nineteen experts in patient safety in anaesthesiology from nine European countries. MAIN OUTCOME MEASURES: Rankings of safety practices for anticipated practice impact, cost, speed, and ease of implementation. RESULTS: We collected 117 practices. The highest-ranked items for potential beneficial impact were: standardising the layout of drug trolleys (4.82); involving all staff in new safety initiatives in the operating theatre (4.73); ensuring patients' medical records are available at the time of surgery (4.71); running regular simulation training sessions in departments of anaesthesia (4.67); and creating a difficult airway management trolley (4.65). A major theme to emerge from the qualitative analysis of the experts' free text comments was the risk that practices aimed at enhancing patient safety might not achieve the effect intended, as introducing new safety activities can cause more mistakes during the implementation phase. CONCLUSION: Many useful practices to promote patient safety were identified, but as some practices appear to be context-dependent, we recommend that a proper, prospective risk assessment is carried out before they are introduced in a new setting. The full list of items is available online as Supplementary Digital Content, http://links.lww.com/EJA/A785 . TRIAL REGISTRATION: Not applicable.

Quality indicators for anesthesia and perioperative medicine.

PURPOSE OF REVIEW: Routine monitoring of care quality is fundamental considering the high reported rates of preventable perioperative morbidity and mortality. However, no set of valid and feasible quality indicators is available as the gold standard for comprehensive routine monitoring of the overall quality of perioperative care. The purpose of this review is to describe underlying difficulties, to summarize current trends and initiatives and to outline the perspectives in support of suitable perioperative quality indicators. RECENT FINDINGS: Most perioperative quality indicators used in the clinical setting are based on low or no evidence. Evidence-based perioperative quality indicators validated for research purposes are not always applicable in routine care. Developing a core set of perioperative quality indicators for clinical practice may benefit from matching feasible routine indicators with evidence-based indicators validated for research, from evaluating additional new indicators, and from including patients' views. SUMMARY: A core set of valid and feasible quality indicators is essential for monitoring perioperative care quality. The development of such a set may benefit from matching evidence-based indicators with feasible standard indicators and from including patients' views.

Ten years of the Helsinki Declaration on patient safety in anaesthesiology: An expert opinion on peri-operative safety aspects.

: Patient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the 'Helsinki Declaration on Patient Safety in Anaesthesiology'. In May/June 2020, ESA and EBA are celebrating the 10th anniversary of the Helsinki Declaration on Patient Safety in Anaesthesiology; a good opportunity to look back and forward evaluating what was achieved in the recent 10 years, and what needs to be done in the upcoming years. The Patient Safety and Quality Committee (PSQC) of ESA invited experts in their fields to contribute, and these experts addressed their topic in different ways; there are classical, narrative reviews, more systematic reviews, political statements, personal opinions and also original data presentation. With this publication we hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.

Measuring and monitoring perioperative patient safety: a basic approach for clinicians.

PURPOSE OF REVIEW: Recent research points to considerable rates of preventable perioperative patient harm and anaesthesiologists' concerns about eroding patient safety. Anaesthesia has always been at the forefront of patient safety improvement initiatives. However, factual local safety improvement requires local measurement, which may be afflicted by barriers to data collection and improvement activities. Because many of these barriers are related to mandatory reporting, the focus of this review is on measurement methods that can be used by practicing anaesthesiologists as self-improvement tools, even independently from mandatory reporting, and using basic techniques widely available in most institutions. RECENT FINDINGS: Four mutually complementary measurement approaches may be suited for local patient safety learning: incident and rate-based measurements, staff surveys and patient surveys. Reportedly, individual methods have helped to tailor problem solutions and to reduce patient harm, morbidity, and mortality. SUMMARY: Considering the potential for perioperative patient safety measurements to improve patient outcomes, the absence of a generally accepted measurement standard and manifold barriers to reporting, a pragmatic approach to locally measuring patient safety appears advisable.

Patient safety and the role of the Helsinki Declaration on Patient Safety in Anaesthesiology: A European survey.

BACKGROUND: The Helsinki Declaration on Patient Safety was launched in 2010 by the European Society of Anaesthesiology and the European Board of Anaesthesiology. It is not clear how widely its vision and standards have been adopted. OBJECTIVE: To explore the role of the Helsinki Declaration in promoting and maintaining patient safety in European anaesthesiology. DESIGN: Online survey. SETTING: A total of 38 countries within Europe. PARTICIPANTS: Members of the European Society of Anaesthesiology who responded to an invitation to take part by electronic mail. MAIN OUTCOME MEASURES: Responses from a 16-item online survey to explore each member anaesthesiologist's understanding of the Declaration and compliance with its standards. RESULTS: We received 1589 responses (33.4% response rate), with members from all countries responding. The median [IQR] response rate of members was 20.5% [11.7 to 37.0] per country. There were many commonalities across Europe. There were very high levels of use of monitoring (pulse oximetry: 99.6%, blood pressure: 99.4%; ECG: 98.1% and capnography: 96.0%). Protocols and guidelines were also widely used, with those for pre-operative assessment, and difficult and failed intubation being particularly popular (mentioned by 93.4% and 88.9% of respondents, respectively). There was evidence of widespread use of the WHO Safe Surgery checklist, with only 93 respondents (6.0%) suggesting that they never used it. Annual reports of measures taken to improve patient safety, and of morbidity and mortality, were produced in the hospitals of 588 (37.3%) and 876 (55.7%) respondents, respectively. Around three-quarters of respondents, 1216, (78.7%) stated that their hospital used a critical incident reporting system. Respondents suggested that measures to promote implementation of the Declaration, such as a formal set of checklist items for day-to-day practice, publicity, translation and simulation training, would currently be more important than possible changes to its content. CONCLUSION: Many patient safety practices encouraged by the Declaration are well embedded in many European countries. The data have highlighted areas where there is still room for improvement.

Perceived barriers to computerised quality documentation during anaesthesia: a survey of anaesthesia staff.

BACKGROUND: Underreporting of intraoperative events in anaesthesia is well-known and compromises quality documentation. The reasons for such omissions remain unclear. We conducted a questionnaire-based survey of anaesthesia staff to explore perceived barriers to reliable documentation during anaesthesia. METHODS: Participants anonymously completed a paper-based questionnaire. Predefined answers referred to potential barriers. Additional written comments were encouraged. Differences between physician and nurse anaesthetists were tested with t-tests and chi-square tests. RESULTS: Twenty-five physician and 30 nurse anaesthetists (81% of total staff) completed the survey. The reported problems referred to three main categories: (I) potential influences related to working conditions and practices of data collection, such as premature entry of the data (indicated by 85% of the respondents), competing duties (87%), and interfering interruptions or noise (67%); (II) problems referring to institutional management of the data, for example lacking feedback on the results (95%) and lacking knowledge about what the data are used for (75%); (III) problems related to specific attitudes, e.g., considering these data not useful for quality improvement (47%). Physicians were more sceptical than nurses regarding the relevance of these data for quality and patient safety. CONCLUSIONS: The common perceived difficulties reported by physician and nurse anaesthetists resemble established barriers to incident reporting and may similarly act as barriers to quality documentation during anaesthesia. Further studies should investigate if these perceived obstacles have a causal impact on quality reporting in anaesthesia. TRIAL REGISTRATION: ClinicalTrials.gov identifier is NCT01524484. Registration date: January 21, 2012.

The role of the anesthesiologist in perioperative patient safety.

PURPOSE OF REVIEW: Despite the benefits of rapidly advancing therapeutic and diagnostic possibilities, the perioperative setting still exposes patients to significant risks of adverse events and harm. Anesthesiologists are in midstream of perioperative care and can make significant contributions to patient safety and patient outcomes. This article reviews recent research results outlining the current trends of perioperative patient harm and summarizes the evidence in favor of patient safety practices. RECENT FINDINGS: Adverse events and patient harm continue to be frequent in the perioperative period. Adverse events occur in about 30% of hospital admissions, are associated with higher mortality, and may be preventable in more than 50%. Evidence-based recommendations are available for many patient safety issues. No magic bullet practices exist, but promising targets include the prevention and limitation of perioperative infections and of complications of airway and respiratory management, the maintenance of achieved safety standards, the use of checklists, and others. SUMMARY: Current research provides growing evidence for the effectiveness of several patient safety practices designed to prevent or diminish perioperative adverse events and patient harm. Future investigations will hopefully fill the numerous persisting knowledge gaps.

Speaking up is related to better team performance in simulated anesthesia inductions: an observational study.

BACKGROUND: Our goal in this study was to test the relationship between speaking up--i.e., questioning, correcting, or clarifying a current procedure--and technical team performance in anesthesia. Hypothesis 1: team members' higher levels of speaking up are related to higher levels of technical team performance. Hypothesis 2: team members will react to speaking up by either clarifying their procedure or initiating a procedural change. Hypothesis 3: higher levels of speaking up during an earlier phase of teamwork will be related to higher levels of speaking up during a later phase. METHODS: This prospective observational study involved 2-person ad hoc anesthesia teams performing simulated inductions of general anesthesia with minor nonroutine events (e.g., bradycardia) in a large teaching hospital. Subjects were registered anesthesia nurses and residents. Each team consisted of 1 nurse and 1 resident. Synchronized video and vital parameter recordings were obtained. Two trained observers blinded to the hypotheses coded speaking up and further team communication and coordination behavior on the basis of 12 distinct categories. All teamwork measures were quantified as percentage of total time spent on the respective teamwork category. Two experienced staff anesthesiologists blinded to the hypotheses evaluated technical team performance using a Delphi-validated rating checklist. Hypotheses 1 and 3 were tested using linear regression with residents' and nurses' levels of speaking up as 2 separate predictor variables. Hypothesis 2 was analyzed using lag sequential analysis, resulting in Z values representing the extent to which the observed value for a conditional transition significantly differs from its unconditional value. RESULTS: Thirty-one nurses and 31 residents participated. Technical team performance could be predicted by the level of speaking up from nurses (R(2) = 0.18, P = 0.017) but not from residents (R(2) = 0.19, P = 0.053); this result supports Hypothesis 1 for nurses. Supporting Hypothesis 2, residents reacted to speaking up with clarifying the procedure by providing information (Z = 18.08, P < 0.001), initiating procedural change by giving instructions (Z = 4.74, P < 0.001) and team member monitoring (Z = 3, P = 0.0013). Likewise, nurses reacted with clarifying the procedure by providing or evaluating information (Z = 16.09, P < 0.001; Z = 3.72, P < 0.001) and initiating procedural change by providing assistance (Z = 0.57, P < 0.001). Indicating a trend for Hypothesis 3, nurses' level of speaking up before intubation predicted their level of speaking up during intubation (R(2) = 0.15, P = 0.034), although this did not reach the Bonferroni-corrected significance level of P = 0.025. No respective relationship was found for residents (R(2) = 0.15, P = 0.096). CONCLUSIONS: This study provides empirical evidence and shows mechanisms for the positive relationship between speaking-up behavior and technical team performance.

Helium breathing provides modest antiinflammatory, but no endothelial protection against ischemia-reperfusion injury in humans in vivo.

BACKGROUND: The noble gas helium is devoid of anesthetic effects, and it elicits cardiac preconditioning. We hypothesized that inhalation of helium provides protection against postocclusive endothelial dysfunction after ischemia-reperfusion of the forearm in humans. METHODS: Eight healthy male subjects were enrolled in this study with a crossover design. Each volunteer was randomly exposed to 15 min of forearm ischemia in the presence or absence of helium inhalation. Helium was inhaled at an end-tidal concentration of 50 vol% from 15 min before ischemia until 5 min after the onset of reperfusion ("helium conditioning"). Hyperemic reaction, a marker of nitric oxide bioavailability and endothelial function, was determined at 15 and 30 min of reperfusion on the forearm using venous occlusion plethysmography. Expression of the proinflammatory markers CD11b, ICAM-1, PSGL-1, and L-selectin (CD62L) on leukocytes and P-selectin (CD62P), PSGL-1, and CD42b on platelets were measured by flow cytometry during reperfusion. RESULTS: Ischemia-reperfusion consistently reduced the postocclusive endothelium-dependent hyperemic reaction at 15 and 30 min of reperfusion. Periischemic inhalation of helium at 50 vol% did not improve postocclusive hyperemic reaction. Helium decreased expression of the proinflammatory marker CD11b and ICAM-1 on leukocytes and attenuated the expression of the procoagulant markers CD42b and PSGL-1 on platelets. CONCLUSIONS: Although inhalation of helium diminished the postischemic inflammatory reaction, our data indicate that human endothelium, which is a component of all vital organs, is not amenable to protection by helium at 50 vol% in vivo. This is in contrast to sevoflurane, which protects human endothelium at low subanesthetic concentrations.

Stem cell-like human endothelial progenitors show enhanced colony-forming capacity after brief sevoflurane exposure: preconditioning of angiogenic cells by volatile anesthetics.

BACKGROUND: Endothelial progenitor cells play a pivotal role in tissue repair, and thus are used for cell replacement therapies in "regenerative medicine." We tested whether the anesthetic sevoflurane would modulate growth or mobilization of these angiogenic cells. METHODS: In an in vitro model, mononuclear cells isolated from peripheral blood of healthy donors were preconditioned with sevoflurane (3 times 30 min at 2 vol% interspersed by 30 min of air). Colony-forming units were determined after 9 days in culture and compared with time-matched untreated control. Using magnetic cell sorting, CD133+/CD34+ endothelial progenitors were enriched from human umbilical cord blood, and vascular endothelial growth factor (VEGF), VEGFR2 (KDR), granulocyte colony-stimulating factor (G-CSF), STAT3, c-kit, and CXCR4 expressions were determined in sevoflurane-treated and untreated cells by real-time reverse transcriptase polymerase chain reaction. In a volunteer study with crossover design, we tested whether sevoflurane inhalation (<1 vol% end-tidal concentration) would mobilize endothelial progenitor cells from the bone marrow niche into the circulation using flow cytometry of peripheral blood samples. VEGF and G-CSF plasma levels were also measured. RESULTS: In vitro sevoflurane exposure of mononuclear cells enhanced colony-forming capacity and increased VEGF mRNA levels in CD133+/CD34+ cord blood cells (P = 0.017). Sevoflurane inhalation in healthy volunteers did not alter the number of CD133+/CD34+ or KDR+/CD34+ endothelial progenitors in the circulation, but increased the number of colony-forming units (P = 0.034), whereas VEGF and G-CSF plasma levels remained unchanged. CONCLUSIONS: Sevoflurane preconditioning promotes growth and proliferation of stem cell-like human endothelial progenitors. Hence, it may be used to promote perioperative vascular healing and to support cell replacement therapies.

Uncertain progress in Swiss perioperative mortality 1998-2014 for 22 operation groups.

BACKGROUND: The perioperative mortality rate (POMR) is used as a quality indicator to monitor health care system performance at regional and national levels. The Swiss Federal Office of Public Health publishes national in-hospital mortality rates for several indicator conditions and indicator operation types (IORs). We investigated long-term time trends of POMRs from 1998-2014. In view of continual advances in perioperative care, we expected to find decreasing trends. METHODS: Non-cardiosurgical IORs containing aggregated age- and sex-specific data (number of operations and deaths) for all years of the study period were included to calculate age-standardised POMRs using the 2013 European Standard Population. We assessed calendar time trends of POMRs using multivariable Poisson regression. We categorised IORs according to the type of time trend (decreasing, unchanged, or increasing incident rate ratio) and mean risk levels (age-adjusted POMR). RESULTS: A total of 22 IORs were included, comprising 1,561,012 operations and 22,140 deaths (overall crude POMR 1.42%). POMR trends decreased for 6 IORs representing 26.8% of operations, remained unchanged for 13 IORs (56.9% of operations), and increased for 3 IORs (16.4% of operations). IOR categorisation according to POMR trends and to risk levels yielded four groups. (1) Decreasing POMR trends, low- to intermediate-risk IORs (age-adjusted POMR 0.2-2.2%): cholecystectomy; arterial pelvic/leg aneurysm or dissection operation; femoral neck fracture; trochanteric fractures; gastric, duodenal or jejunal ulcer resection; major pulmonary or bronchial resection. (2) Unchanged POMR trends, low-risk IORs (0.1-0.9%): transurethral resection of the prostate (TUR prostate); hernia repair without intestinal operation; hysterectomy; extracranial vascular operation; nephrectomy; amputation foot, non-traumatic. (3) Unchanged POMR trends, intermediate-risk IORs (1.7-3.8%): hernia repair with intestinal operation; gastric carcinoma resection; non-ruptured abdominal aortic aneurysm (open operation); arterial pelvic/leg thromboembolic operation; colorectal resection, pancreatic resection; complex oesophageal procedure. (4) Increasing POMR trends, low- to high-risk IORs (0.1-5.2%): hip endoprosthesis; cystectomy; amputation lower limb. Impact of sex on POMR: hysterectomy and TUR prostate comprised 19.7% of all operations; among the remaining operations, 68.5% showed significantly lower and 27.1% significantly higher POMRs in females. 4.4% showed no sex difference. CONCLUSIONS: In Switzerland, in-hospital POMR trends from 1998-2014 were unchanged or even increasing for the majority of IORs (73% of included operations). Our analysis used age-standardisation but cannot account for changes in coding practices and organisation of healthcare delivery. POMR trends should be systematically monitored at the national level and used to guide priorities in national quality improvement strategies.

External compression of superior vena cava after the replacement of ascending aorta.

We present a rare complication after open-heart surgery resulting in compression of the superior vena cava (SVC) with the concurrent findings of the hypertrophic obstructive cardiomyopathy physiology. A 59-year-old woman developed a low cardiac output syndrome, persistent hypotension, and increasing filling pressures after emergency replacement of the ascending aorta and resuspension of the aortic valve due to a type A aortic dissection. Transesophageal echocardiography (TEE) evaluation revealed partial SVC obstruction, under-filled left ventricle (LV), and a persistent mitral systolic anterior motion with increasing pressure gradient in the left ventricular outflow tract (LVOT). Surgical exposure uncovered an intrapericardial thrombus around the aortic graft compressing the SVC. Removal of the thrombus resulted in immediate haemodynamic improvement and elimination of both SVC and LVOT obstructions. A comprehensive TEE exam should always be performed, and all the structures should be visualized for the proper diagnosis and management of patients after cardiac surgery.

Delayed inhibition of agonist-induced granulocyte-platelet aggregation after low-dose sevoflurane inhalation in humans.

BACKGROUND: Sevoflurane can be used as sedative-analgesic drug with endothelial protective properties. We tested whether low-dose sevoflurane inhalation provides sustained inhibition of detrimental granulocyte-platelet aggregation in humans. METHODS: Ten healthy male volunteers were enrolled in this crossover study. Each subject inhaled sevoflurane for 1 h at 0.5-1 vol % end-tidal concentration in oxygen (50 vol %). Inhaling oxygen (50 vol %) alone served as control. Venous blood samples were collected at baseline before inhalation, immediately after inhalation, and 24 h thereafter, and were used for flow cytometry to determine platelet surface marker (CD41, CD42b, CD62P/P-selectin, and PAC-1) on platelets and granulocytes and for kaolin-induced clot formation, as assessed by thromboelastography. In flow cytometry experiments, platelets were stimulated with arachidonic acid (AA, 30 microM), adenosine diphosphate (ADP, 1 microM), and thrombin receptor agonist peptide-6 (TRAP-6, 6 microM). RESULTS: AA, ADP, and TRAP-6 markedly increased the expression of CD62P on platelets, whereas CD42b (shedding) and PAC-1 (heterotypic conjugates) expression decreased. The amount of granulocyte-platelet aggregates increased upon agonist stimulation. Low-dose sevoflurane inhalation reduced ADP-induced CD62P expression on platelets 24 h after inhalation, and inhibited the formation of granulocyte-platelet aggregates under stimulation with AA and ADP after 1 and 24 h, and with TRAP-6 after 24 h compared with control. Inhibition of granulocyte-platelet aggregates was accompanied by reduced clot firmness 24 h after sevoflurane inhalation compared with control. CONCLUSIONS: We demonstrated for the first time that inhaling low-dose sevoflurane (<1 vol % end-tidal) inhibits agonist-induced granulocyte-platelet interactions 24 h after administration and thus counteracts thromboinflammatory processes.

Monitoring and talking to the room: autochthonous coordination patterns in team interaction and performance.

This paper builds on and extends theory on team functioning in high-risk environments. We examined 2 implicit coordination behaviors that tend to emerge autochthonously within high-risk teams: team member monitoring and talking to the room. Focusing on nonrandom patterns of behavior, we examined sequential patterns of team member monitoring and talking to the room in higher- and lower-performing action teams working in a high-risk health care environment. Using behavior observation methods, we coded verbal and nonverbal behaviors of 27 anesthesia teams performing an induction of general anesthesia in a natural setting and assessed team performance with a Delphi-validated checklist-based performance measure. Lag sequential analyses revealed that higher-performing teams were characterized by patterns in which team member monitoring was followed by speaking up, providing assistance, and giving instructions and by patterns in which talking to the room was followed by further talking to the room and not followed by instructions. Higher- and lower-performing teams did not differ with respect to the frequency of team member monitoring and talking to the room occurrence. The results illustrate the importance of patterns of autochthonous coordination behaviors and demonstrate that the interaction patterns, as opposed to the behavior frequencies, discriminated higher- from lower-performing teams. Implications for future research and for team training are included. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Interactions of team mental models and monitoring behaviors predict team performance in simulated anesthesia inductions.

In the present study, we investigated how two team mental model properties (similarity vs. accuracy) and two forms of monitoring behavior (team vs. systems) interacted to predict team performance in anesthesia. In particular, we were interested in whether the relationship between monitoring behavior and team performance was moderated by team mental model properties. Thirty-one two-person teams consisting of anesthesia resident and anesthesia nurse were videotaped during a simulated anesthesia induction of general anesthesia. Team mental models were assessed with a newly developed measurement tool based on the concept-mapping technique. Monitoring behavior was coded by two organizational psychologists using a structured observation system. Team performance was rated by two expert anesthetists using a performance-checklist. Moderated multiple regression analysis revealed that team mental model similarity moderated the relationship between team monitoring and performance; a higher level of team monitoring in the absence of a similar team mental model had a negative effect on performance. Furthermore, team mental model similarity and accuracy interacted to predict team performance. Our findings provide new insights on factors influencing the relationship between team processes and team performance in health care. When investigating the effectiveness of a specific team coordination behavior, team cognition has to be taken into account. This represents a necessary and compelling extension of the popular process-outcome relationship on which previous teamwork research in health care has focused. Moreover, the current study adds further external validity to the concept of team mental models by highlighting its usefulness in health care.

Managing nonroutine events in anesthesia: the role of adaptive coordination.

OBJECTIVE: This field study aimed at examining the role of anesthesia teams' adaptive coordination in managing changing situational demands, such as in nonroutine events (NREs). BACKGROUND: Medical teams' ability to adapt their teamwork (e.g., their coordination activities) to changing situational demands is crucial to team performance and, thus, to patient safety. Whereas the majority of previous studies on the matter have focused on critical but rare events, it has recently been pointed out that the effective management of NREs is a key challenge to medical teams. Hence this study investigated the relationship between coordination activities, NRE occurrence, and team performance. METHOD: We videotaped 22 anesthesia teams during standard anesthesia induction and recorded data from the vital signs monitor and the ventilator. Coordination was coded by a trained observer using a structured observation system. NREs were recorded by an experienced staff anesthesiologist using all three video streams. Checklist-based team performance assessment was also performed by an experienced staff anesthesiologist. RESULTS: We found that anesthesia teams adapt their coordination activities to changing situational demands. In particular, the increased occurrence of NREs caused an increase in the time the teams spent on task management. A stronger increase in the teams' task management (i.e., more adaptive coordination) was related to their performance. CONCLUSION: Our results emphasize the importance of adaptive coordination in managing NREs effectively. APPLICATION: This study provides valuable information for developing novel team training programs in health care that focus on adaptation to changing task requirements, for example, when faced with NREs.

Leadership in anaesthesia teams: the most effective leadership is shared.

BACKGROUND: Leadership plays a crucial role in teams working in complex environments, and research has shown that shared leadership where all team members perform leadership functions is an effective strategy. The authors aimed to describe shared leadership patterns during anaesthesia induction and show how they are linked to team performance. METHODS: 12 anaesthesia teams consisting of one resident and one nurse during a simulated anaesthesia induction including a non-routine event (asystole) were videotaped, and two kinds of leadership behaviour (content-oriented and structuring) were coded. Team performance was operationalised as the reaction time to the non-routine event. The amount of leadership sharedness was compared between low- and high-performing teams by performing a univariate analysis of variance. Wilcoxon signed-rank tests were used to analyse the distribution of the two kinds of leadership behaviour among team members. RESULTS: Statistical analysis revealed that in high-performing teams, residents and nurses shared their leadership, while in low-performing teams, residents showed significantly higher levels of leadership behaviour than nurses. Further analyses revealed different distributions of leadership functions among team members. While residents of low-performing teams assumed both kinds of leadership behaviour, members of high-performing teams seemed to have distinct leadership roles: nurses mainly used content-oriented leadership behaviour, and residents tended to show structuring leadership behaviour. CONCLUSIONS: The study documents the effectiveness of shared leadership in situations with high task complexity and indicates that a clear distribution of content-oriented and structuring leadership among team members is an effective strategy. The findings have implications for training in shared leadership and also give rise to a number of recommendations for further research. ClinicalTrials (http://www.clinicaltrials.gov) registration number is NCT00706108.

Adrenergic receptor genotype but not perioperative bisoprolol therapy may determine cardiovascular outcome in at-risk patients undergoing surgery with spinal block: the Swiss Beta Blocker in Spinal Anesthesia (BBSA) study: a double-blinded, placebo-controlled, multicenter trial with 1-year follow-up.

BACKGROUND: Neuraxial blockade is used as primary anesthetic technique in one third of surgical procedures. The authors tested whether bisoprolol would protect patients at risk for cardiovascular complications undergoing surgery with spinal block. METHODS: The authors performed a double-blinded, placebo-controlled, multicenter trial to compare the effect of bisoprolol with that of placebo on 1-yr composite outcome including cardiovascular mortality, nonfatal myocardial infarction, unstable angina, congestive heart failure, and cerebrovascular insult. Bisoprolol was given orally before and after surgery for a maximum of 10 days. Adrenergic receptor polymorphisms and safety outcome measures of bisoprolol therapy were also determined. RESULTS: A total of 224 patients were enrolled. Spinal block could not be established in 5 patients. One hundred ten patients were assigned to the bisoprolol group, and 109 patients were assigned to the placebo group. The mean duration of treatment was 4.9 days in the bisoprolol group and 5.1 days in the placebo group. Bisoprolol therapy reduced mean heart rate by 10 beats/min. The primary outcome was identical between treatment groups and occurred in 25 patients (22.7%) in the bisoprolol group and 24 patients (22.0%) in the placebo group during the 1-yr follow-up (hazard ratio, 0.97; 95% confidence interval, 0.55-1.69; P = 0.90). However, carriers of at least one Gly allele of the beta1-adrenergic receptor polymorphism Arg389Gly showed a higher number of adverse events than Arg homozygous (32.4% vs. 18.7%; hazard ratio, 1.87; 95% confidence interval, 1.04-3.35; P = 0.04). CONCLUSIONS: Perioperative bisoprolol therapy did not affect cardiovascular outcome in these elderly at-risk patients undergoing surgery with spinal block.