[Central induction area. Reduction of non-operative time without additional costs]. / Zentrale Einleitung. Personalneutrale Reduktion der Wechselzeiten.

BACKGROUND: Induction areas (IA) can lead to more efficient operating sessions through shortening the changeover time between patients. To date IAs have always required additional staff members, whose cost was only partly covered by improvements in productivity. The objective of this project was to demonstrate that a reduction in non-operative time through a newly introduced induction area can be achieved without a need for extra personnel. METHODS: Non-operative time in 5,963 ENT, orthopedic and cardiac surgical patients from 8 operating theatres were studied for 1 year before and 1 year after the introduction of an induction area. The non-operative time was defined as the time between the end of surgical procedures in one operation and the start of surgical procedures in the next, within regular working hours. Through reallocation of anesthetic nursing and medical staff it was possible to introduce the induction area without increasing staff numbers. RESULTS: Non-operative time was significantly reduced from 20 min (range 10-30 min) to 14 min (5-25 min). Subgroup analysis showed significant reductions in all specialities: from 10 min (2.5-20 min) to 5 min (0-20 min) in 1,240 cardiac surgical patients, 25 min (20-35 min) to 15 min (5-25 min) in 2,433 ENT patients and 20 min (10-30 min) to 10 min (0-20 min) in 2,290 orthopedic patients. There were no critical incidents attributable to patient handover. DISCUSSION AND CONCLUSIONS: An induction area can be established and can reduce non-operative time and improve operation theatre throughput without the need for extra personnel. The efficiency of these measures will be increased when the relevant surgical organizational measures are taken to adjust to the faster anesthesiology workflow. The induction area does not lead to a higher rate of critical incidents. To what extent the induction area can be used for structured training of doctors and nurses, remains to be investigated.

[Responsibility of the anaesthetist in preoperative risk management. Comments on the legal implications of medical publications in this field]. / Die Verantwortung des Anästhesisten in der präoperativen Risikoabklärung. Bemerkungen zu der rechtlichen Bedeutung von medizinischen Publikationen zu diesem Thema.

There is an increasing number of publications in the medical literature which address the medical and legal obligations of a specialist in a given field. These articles, mostly editorials, seek to delineate the optimal course of treatment based on the current state of the art and science of medicine. However, we believe that the unreflected adoption of these often highly theoretical ideas and suggestions carries its own dangers. For one thing, there is the threatening financial crisis in the public health system. In addition, the feasibility of implementing these suggestions in routine medical and surgical practice is questionable. Last but not least, suggestions and guidelines for preoperative risk management by, for instance, Lingnau and Strohmenger 2002 cross the well established boundaries of the various medical and surgical specialties, which obviously demands careful deliberations among the specialties involved. So far, few specialty boards have seen fit to act on these suggestions. Our article on the medical and legal responsibilities of the anaesthesiologist in perioperative risk management restates the aforementioned concerns. We attempt to point out medical and legal points of controversy. In particular, we caution against the ever present danger of a bona fide adoption of visionary guidelines as the "standard of care" by both medical and legal experts. We feel that it is imperative to carefully evaluate editorial comments and suggestions, however well meaning, in the light of established teaching and practice, lest these comments and suggestions become the basis of an unjustified determination of a physicians innocence or guilt in a court of law.

[Third-party funding and industrial sponsoring]. / Drittmittelfinanzierung und Industriesponsoring - Zulässigkeit und strafrechtliche Grenzen.

Due to sensational publications, media-effective proceedings and not least due to personal involvement in many cases the medical profession became aware of the potential criminal significance of third-party funding and industrial sponsoring in hospitals. It started with the so-called Heart-Valve-Affair ("Herzklappenskandal") in 1994. Since then, insecurity prevails which was further nourished by a new series of legal proceedings in spring 2002. Industrial sponsoring has been practised in hospitals for a long time. Research work at universities and colleges would hardly be possible without third-party funding, which is accepted de lege lata according to section sign 25 of the German Hochschulrahmengesetz (framework law on universities and colleges). In view of the course of action of the criminal prosecution authorities the question came up which precautions must be taken with regard to grants by the medical-pharmaceutical industry to avoid consequences from the point of view of criminal law.[nl]There are various facts and circumstances in relation with these benefits, such as providing financing of educational training, payments related to the participation in congresses, speaker's fees, consultancy agreements, clinical tests and application evaluation, provision of equipment and staff as well as providing financing thereof, donations to medical facilities and so-called Fördervereine (supporting associations), benefits for research projects, etc.

[Quality assurance based on civil and penal law]. / Qualitätssicherung durch Zivil- und Strafrecht.

The term "quality assurance" primarily concerns the provisions of professional regulations and law relating to health service physicians. It would be too sweeping to regard liability or criminal law as normative parameters for guaranteeing quality assurance in the narrower sense. Nevertheless, along with expert opinions sought within the context of relevant lawsuits, court rulings under civil law and criminal law in effect constitute an indirect form of "quality control". As a consequence, many court decisions act as a standard for the future. Civil law is concerned with determining whether the patient has received the quality of medical service to which he is entitled; for all intents and purposes, the same applies to the judgement of medical treatment under criminal law, whereby all cases, whether civil or criminal, concern diagnostic and therapeutic practice in specific treatment situations, the organisation of treatment and the provision of information. With regard to these areas, a contribution can therefore be made to quality assurance by observing pertinent civil and criminal judicature.

[Procedure following an unforeseen incident: what can one, should one, must one do from the legal point of view?]. / Verhalten nach einem Zwischenfall: Was kann, was sollte, was muss man aus rechtlicher Sicht tun?

The danger that an anaesthesiologist becomes involved in a malpractice lawsuit has greatly increased over the last few years. It is therefore of considerable importance that anaesthesiologists know how they should conduct themselves from a legal point of view, when such a situation arises. Ten recommendations are summarized.

The natural history of asymptomatic carotid artery disease.

PURPOSE: The purpose of this article is to determine the natural history of carotid artery disease among asymptomatic patients with cervical bruits or other risk factors for stroke and to study the value of duplex ultrasonography in predicting future neurologic events. METHODS: Two hundred forty-two asymptomatic, unoperated patients, referred for evaluation of asymptomatic carotid artery disease, were followed prospectively with duplex ultrasonography. RESULTS: Fifteen ischemic strokes (6.2%) and 20 transient ischemic attacks (TIA) (8.3%) occurred in 34 patients during a mean follow-up of 27.4 months. Annual stroke, TIA, and combined event rates were 2.7%, 3.6%, and 6.2%, respectively. Although patients with 80% to 99% lesions had a 20.6% annual event rate, most events occurred contralateral to these lesions; the vessel-specific annual event rate for 80% to 99% disease was 5.1%. Only one of 15 strokes occurred ipsilateral to an 80% to 99% stenosis. Echolucent plaques were associated with TIA and stroke (5.7% annual vessel event rate vs 2.4% for echogenic plaques, p = 0.03). Disease progression was highly correlated with TIA and stroke (p < 0.0001), but it usually occurred in association with rather than before ischemic events, thus proving more useful in explaining pathogenesis than in predicting future events. There was no association between aspirin use and TIA, but patients taking aspirin had a threefold higher annual stroke rate (1.6% vs 4.8%, p = 0.027). CONCLUSIONS: This study, while confirming significant risk for asymptomatic patients with critical stenosis or echolucent plaque, demonstrates the importance of contralateral disease and the absence of orderly progression from minimal disease through high-grade stenosis to symptomatic cerebral ischemia. TIA and stroke commonly occur in association with abrupt, unpredictable, quantum changes in carotid artery disease.