Safer paediatric surgical teams: A 5-year evaluation of crew resource management implementation and outcomes.

OBJECTIVE: Evaluate longitudinal changes in technical and non-technical skills (teamwork, situation monitoring, communication and leadership), safety culture, and clinical outcomes before and after implementation of a crew resource management (CRM) safety program. DESIGN: A multi-level prospective single case study in accordance with the SQUIRE-guidelines for reporting quality improvement efforts. SETTING: Large university paediatric surgical service. PARTICIPANT(S): All 153 managers and staff. INTERVENTIONS: Training of staff in CRM, systematic risk assessments, and the redesign of work practices captured and reinforced through the development, implementation and refinement of SOPs. MAIN OUTCOME MEASURE(S): Data were collected related to: 1) Relevance of CRM training (survey), 2) Safety culture (survey), 3) Team behaviours in clinical practice (non-participatory observations with MedPACT protocol) and 4) Effects on perioperative care for laparoscopic appendectomies-a representative and frequently performed surgical procedure (electronic medical records and administrative data for length of stay, unplanned readmissions and returns to the Operating Room). RESULTS: Non-technical skills, the use of safety tools, as well as adherence to guidelines for appendectomies all improved significantly over time. Significant safety culture improvements were found in teamwork across and within units, supervisors' expectations and actions, non-punitive response to adverse events, and perceptions of overall patient safety. Unplanned readmissions following appendectomy declined significantly. CONCLUSIONS: Implementation of a comprehensive CRM program including associated safety tools created sustained adherence to new work practices and improved non-technical and technical skills, surgical outcomes and safety culture.

Contextual adaptation of the Personnel Evaluation Standards for assessing faculty evaluation systems in developing countries: the case of Iran.

BACKGROUND: Faculty evaluations can identify needs to be addressed in effective development programs. Generic evaluation models exist, but these require adaptation to a particular context of interest. We report on one approach to such adaptation in the context of medical education in Iran, which is integrated into the delivery and management of healthcare services nationwide. METHODS: Using a triangulation design, interviews with senior faculty leaders were conducted to identify relevant areas for faculty evaluation. We then adapted the published checklist of the Personnel Evaluation Standards to fit the Iranian medical universities' context by considering faculty members' diverse roles. Then the adapted instrument was administered to faculty at twelve medical schools in Iran. RESULTS: The interviews revealed poor linkages between existing forms of development and evaluation, imbalance between the faculty work components and evaluated areas, inappropriate feedback and use of information in decision making. The principles of Personnel Evaluation Standards addressed almost all of these concerns and were used to assess the existing faculty evaluation system and also adapted to evaluate the core faculty roles. The survey response rate was 74%. Responses showed that the four principles in all faculty members' roles were met occasionally to frequently. Evaluation of teaching and research had the highest mean scores, while clinical and healthcare services, institutional administration, and self-development had the lowest mean scores. There were statistically significant differences between small medium and large medical schools (p < 0.000). CONCLUSION: The adapted Personnel Evaluation Standards appears to be valid and applicable for monitoring and continuous improvement of a faculty evaluation system in the context of medical universities in Iran. The approach developed here provides a more balanced assessment of multiple faculty roles, including educational, clinical and healthcare services. In order to address identified deficiencies, the evaluation system should recognize, document, and uniformly reward those activities that are vital to the academic mission. Inclusion of personal developmental concerns in the evaluation discussion is essential for evaluation systems.

Military aviators with mitral valve prolapse: long-term follow-up and aeromedical endpoints.

INTRODUCTION: Mitral valve prolapse (MVP) is a disqualifying condition for USAF aviators. Trained USAF aviators, and in recent years flying training applicants, may be granted waiver for initial or continued flying duties following extensive, periodic evaluation. This study examines the usefulness of the various tests performed in that evaluation process and provides long-term follow-up from 404 USAF flyers with MVP. METHODS: We retrospectively reviewed 2-dimensional echocardiography, Holter monitoring, treadmill exercise, thallium imaging, coronary fluoroscopy, cardiac catheterization, and centrifuge testing results from 404 military aviators evaluated at the Aeromedical Consultation Service between 1 January 1972 and 31 October 1993. Follow-up was achieved through questionnaires (91%) and death certificates, etc. RESULTS: Mean follow-up was 8.6 yr (range 1-21 yr). Age at study entry was 21 to 64 yr (mean = 36 yr). The occurrence rate for suddenly incapacitating events (sudden cardiac death, syncope, pre-syncope, and cerebral ischemic episodes) was 0.32%/yr. CONCLUSIONS: Echocardiographic MVP in military aviators is associated with a low but statistically increased prevalence of "incapacitating" aeromedical events. Univariate predictors of adverse outcome included study entry with an enlarged left ventricle or left atrium, cardiovascular symptoms or findings, or MVP with thickened leaflets. Evaluation of coronary artery disease (CAD) in this population, absent specific indicators of CAD risk, is not indicated.

Targeted deletion of angiotensin II type 2 receptor caused cardiac rupture after acute myocardial infarction.

BACKGROUND: Accumulating evidence has suggested that the cardiac renin-angiotensin system is activated during the remodeling process after myocardial infarction (MI). Although 2 types of angiotensin II receptors (AT(1) and AT(2)) are upregulated in the infarcted tissue, the contribution of AT(2) to the subsequent fibrogenetic phase of wound healing is less certain. This study was conducted to evaluate the role of AT(2) in wound healing after MI using an in vivo intervention study in mice with MI. METHODS AND RESULTS: We examined myocardial hypertrophy, cardiac fibrosis, and morphological evidence of fibrillar collagen accumulation at the infarcted and noninfarcted regions in male mice lacking the AT(2) receptor (Agtr2-/Y) and age-matched wild-type (WT) animals. Of the Agtr2-/Y mice, 63.6% died of cardiac rupture, whereas 23.5% of the WT mice died of the same cause within 1 week. The extent of fibrosis and that of collagen gene expression in Agtr2-/Y mice were significantly reduced compared with WT mice at 1 week after coronary ligation. Furthermore, MI resulted in a marked increase in the prostaglandin E(2) (PGE(2)) level at 4 days after surgery in Agtr2-/Y mice. In WT mice, the PGE(2) level was also elevated after MI but to a significantly lesser extent than in Agtr2-/Y mice. CONCLUSIONS: A chronic loss of AT(2) by gene targeting prevented the collagen deposition and caused cardiac rupture. The markedly elevated PGE(2) may be a mechanism that inhibits collagen synthesis in the infarcted region of Agtr2-/Y mice.

The impact of aviation-based teamwork training on the attitudes of health-care professionals.

BACKGROUND: Both the Institute of Medicine and the Agency for Healthcare Research and Quality suggest patient safety can be enhanced by implementing aviation Crew Resource Management (CRM) in health care. CRM emphasizes six key areas: managing fatigue, creating and managing teams, recognizing adverse situations (red flags), cross-checking and communication, decision making, and performance feedback. This study evaluates participant reactions and attitudes to CRM training. STUDY DESIGN: From April 22, 2003, to December 11, 2003, clinical teams from the trauma unit, emergency department, operative services, cardiac catheterization laboratory, and administration underwent an 8-hour training course. Participants completed an 11-question End-of-Course Critique (ECC), designed to assess the perceived need for training and usefulness of CRM skill sets. The Human Factors Attitude Survey contains 23 items and is administered on the same day both pre- and posttraining. It measures attitudinal shifts toward the six training modules and CRM. RESULTS: Of the 489 participants undergoing CRM training during the study period, 463 (95%) completed the ECC and 338 (69%) completed the Human Factors Attitude Survey. The demographics of the group included 288 (59%) nurses and technicians, 104 (21%) physicians, and 97 (20%) administrative personnel. Responses to the ECC were very positive for all questions, and 95% of respondents agreed or strongly agreed CRM training would reduce errors in their practice. Responses to the Human Factors Attitude Survey indicated that the training had a positive impact on 20 of the 23 items (p < 0.01). CONCLUSIONS: CRM training improves attitudes toward fatigue management, team building, communication, recognizing adverse events, team decision making, and performance feedback. Participants agreed that CRM training will reduce errors and improve patient safety.

Do women simply complain more? National patient injury claims data show gender and age differences.

The Swedish Counties Mutual Insurance (LOF) owns and operates the Swedish Patient Insurance Company, (PSR) a no-blame insurance system that compensates patients for injuries that result from errors in medical practice. We combined malpractice claims data (from PSR) with national hospital discharge registry data (National Board of Health and Welfare-Socialstyrelsen) and determined Swedish inpatient malpractice claims rates for the years 1996-2000. Women have higher claims rates than men, but their claims are adjudicated as valid more often than men's claims. The data are consistent with other lines of evidence suggesting poorer quality of care for women, e.g., heart disease, kidney disease, and cancer. Middle-aged (40- to 59-year-old) patients file malpractice claims at almost twice the national rate, whereas patients younger than 19 years and older than 80 years of age file at significantly below the average rate. Differences in claims rates have major financial and quality of care implications. Further studies are needed.

An intravenous medication safety system: preventing high-risk medication errors at the point of care.

Improving medication safety at the point of care--particularly for high-risk drugs--is a major concern of nursing administrators. The medication errors most likely to cause harm are administration errors related to infusion of high-risk medications. An intravenous medication safety system is designed to prevent high-risk infusion medication errors and to capture continuous quality improvement data for best practice improvement. Initial testing with 50 systems in 2 units at Vanderbilt University Medical Center revealed that, even in the presence of a fully mature computerized prescriber order-entry system, the new safety system averted 99 potential infusion errors in 8 months.

A novel angiotensin II type 2 receptor signaling pathway: possible role in cardiac hypertrophy.

We describe a novel signaling mechanism mediated by the G-protein-coupled receptor (GPCR) angiotensin II (Ang II) type 2 receptor (AT(2)). Yeast two-hybrid studies and affinity column binding assay show that the isolated AT(2) C-terminus binds to the transcription factor promyelocytic zinc finger protein (PLZF). Cellular studies employing confocal microscopy show that Ang II stimulation induces cytosolic PLZF to co-localize with AT(2) at the plasma membrane, then drives AT(2) and PLZF to internalize. PLZF slowly emerges in the nucleus whereas AT(2) accumulates in the perinuclear region. Nuclear PLZF binds to a consensus sequence of the phosphatidylinositol-3 kinase p85 alpha subunit (p85 alpha PI3K) gene. AT(2) enhances expression of p85 alpha PI3K followed by enhanced p70(S6) kinase, essential to protein synthesis. An inactive mutant of PLZF abolishes this effect. PLZF is expressed robustly in the heart in contrast to many other tissues. This cardiac selective pathway involving AT(2), PLZF and p85 alpha PI3K may explain the absence of a cardiac hypertrophic response in AT(2) gene-deleted mice.

Human muscle sympathetic nerve activity and plasma noradrenaline kinetics in space.

Astronauts returning from space have reduced red blood cell masses, hypovolaemia and orthostatic intolerance, marked by greater cardio-acceleration during standing than before spaceflight, and in some, orthostatic hypotension and presyncope. Adaptation of the sympathetic nervous system occurring during spaceflight may be responsible for these postflight alterations. We tested the hypotheses that exposure to microgravity reduces sympathetic neural outflow and impairs sympathetic neural responses to orthostatic stress. We measured heart rate, photoplethysmographic finger arterial pressure, peroneal nerve muscle sympathetic activity and plasma noradrenaline spillover and clearance, in male astronauts before, during (flight day 12 or 13) and after the 16 day Neurolab space shuttle mission. Measurements were made during supine rest and orthostatic stress, as simulated on Earth and in space by 7 min periods of 15 and 30 mmHg lower body suction. Mean (+/- S.E.M.) heart rates before lower body suction were similar pre-flight and in flight. Heart rate responses to -30 mmHg were greater in flight (from 56 +/- 4 to 72 +/- 4 beats min(-1)) than pre-flight (from 56 +/- 4 at rest to 62 +/- 4 beats min(-1), P < 0.05). Noradrenaline spillover and clearance were increased from pre-flight levels during baseline periods and during lower body suction, both in flight (n = 3) and on post-flight days 1 or 2 (n = 5, P < 0.05). In-flight baseline sympathetic nerve activity was increased above pre-flight levels (by 10-33 %) in the same three subjects in whom noradrenaline spillover and clearance were increased. The sympathetic response to 30 mmHg lower body suction was at pre-flight levels or higher in each subject (35 pre-flight vs. 40 bursts min(-1) in flight). No astronaut experienced presyncope during lower body suction in space (or during upright tilt following the Neurolab mission). We conclude that in space, baseline sympathetic neural outflow is increased moderately and sympathetic responses to lower body suction are exaggerated. Therefore, notwithstanding hypovolaemia, astronauts respond normally to simulated orthostatic stress and are able to maintain their arterial pressures at normal levels.