The German Critical Incident Reporting System for Anesthesiology: CIRSains.

BACKGROUND: In June 2010, the Helsinki Declaration was passed. As a result, an online nationwide critical incident reporting system named CIRSmedical Anaesthesiology (CIRSains) was implemented in Germany. The aim of the article is to evaluate CIRSains for practicability and to provide solutions to the problems detected during evaluation. METHODS: Every medical staff member could take part voluntarily. Data were deidentified. All reports for anesthesiology (1548) were taken into account. Data collection lasted from April 2010 to February 2011. Incident report forms were classified according to World Health Organization and National Patient Safety Agency taxonomy. RESULTS: Most reports (1347; 87.0%) contained American Society of Anaesthesiologists (ASA) classification, stratifying the severity of patients' underlying disease. Only some mentioned patients' age, even less sex. Physicians filed more reports than nurses. Staff-related factors constituted 794 (51.3%) choices, with attention issues (433; 28.0%) and routine violations (143; 9.2%) leading. Clinical processes (443; 28.6%), medication (347; 22.4%), and medical devices (530; 34.2%) were the leading incident category types. Most consequences ranged in low (398; 25.7%) and moderate (826; 53.4%) risk categories. Mitigating factors were barely mentioned. CONCLUSION: CIRSains displays the German effort to establish the Helsinki declaration. Easy accessibility, anonymity, medicolegal safety, and high flexibility resulted in high usage. The study shows a sufficient practicability of the database, but the data input has to be improved for better scientific use, for example, by implementation of more multiple-choice questions. Given the high magnitude and importance of patient safety problems, improving CIRSains remains a priority for the future.

A knowledge- and model-based system for automated weaning from mechanical ventilation: technical description and first clinical application.

To describe the principles and the first clinical application of a novel prototype automated weaning system called Evita Weaning System (EWS). EWS allows an automated control of all ventilator settings in pressure controlled and pressure support mode with the aim of decreasing the respiratory load of mechanical ventilation. Respiratory load takes inspired fraction of oxygen, positive end-expiratory pressure, pressure amplitude and spontaneous breathing activity into account. Spontaneous breathing activity is assessed by the number of controlled breaths needed to maintain a predefined respiratory rate. EWS was implemented as a knowledge- and model-based system that autonomously and remotely controlled a mechanical ventilator (Evita 4, Dräger Medical, Lübeck, Germany). In a selected case study (n = 19 patients), ventilator settings chosen by the responsible physician were compared with the settings 10 min after the start of EWS and at the end of the study session. Neither unsafe ventilator settings nor failure of the system occurred. All patients were successfully transferred from controlled ventilation to assisted spontaneous breathing in a mean time of 37 ± 17 min (± SD). Early settings applied by the EWS did not significantly differ from the initial settings, except for the fraction of oxygen in inspired gas. During the later course, EWS significantly modified most of the ventilator settings and reduced the imposed respiratory load. A novel prototype automated weaning system was successfully developed. The first clinical application of EWS revealed that its operation was stable, safe ventilator settings were defined and the respiratory load of mechanical ventilation was decreased.

High degree of realism in teaching percutaneous coronary interventions by combining a virtual reality trainer with a full scale patient simulator.

The virtual reality coronary angiography simulator "CATHI" (Catheter Instruction System, Mannheim, Germany) simulates coronary arteries with implemented vessel lesions in virtual patients. Like similar systems the software model runs on common PC systems, which are linked to the mechanical device for manual training. We combined the advantages of this skill trainer with the near to reality assembly of a cardiac catheterization laboratory (Cath-lab) by connecting it to a full scale simulator (HPS, METI, Sarasota, FL). We present two methods of synchronizing the heartbeat between both simulation devices. Method A-the hardware solution-uses the electrocardiogram-synchronization signal of the HPS as a pacemaker for CATHI's heartbeat. Method B, a more sophisticated software solution, uses a communication protocol between the HPS software and the CATHI system to realize bi-directional data exchange. In 14 identical courses we performed four different scenarios using the above described setup, all of which had to be undergone by the 143 participants (including nursing staff, experienced- and inexperienced cardiologists). The synchronization of the two systems contributed to a close to reality situation. Scenario control was accomplished via commercially available HPS-software. Tachycardic and bradycardic arrhythmias were predetermined by predefined scenarios of the HPS-software, the trainee's intervention resulting in realistic treatment outcomes. Using either method, the transmitted signals resulted in the same heartbeat in the CATHI-system, making the cardiologic interventions more difficult but more realistic.

[Simulation training for German anesthesiologists--case scenarios and training results]. / Simulatortraining an der Kieler Universitätsklinik für Anästhesiologie - Szenarien und Trainingsergebnisse.

Training of medical personnel using simulation techniques is an acknowledged measure of process optimization and quality assurance in a clinical setting. In 2006, a simulator-based training of anaesthesiologists was introduced in the University Medical Centre of Schleswig-Holstein, Campus Kiel, Germany. The training was performed on a human patient simulator (Meti, Sarasota, USA) and the course was conducted by instructors and engineers from the Simulation Centre Mainz in an operation room equipped with common anaesthesia devices. Special lectures focused at crisis resource management and human errors were held in separate rooms. Parallel daily trainings of 6 physicians and 4 nurses were conducted during 9 days. The training was offered to the anaesthesia personnel of whole Schleswig-Holstein, Germany. A higher and more balanced overall performance of the participants was determined by the instructor teams in comparison to the training results in their own simulation centre. This improved performance was ascribed to the special circumstances of this training namely the familiar surroundings and team members.

High-frequency oscillatory ventilation in adult acute respiratory distress syndrome.

OBJECTIVE: This study examined whether ARDS patients in whom predefined ventilator settings fail to maintain oxygenation and CO2 removal can be safely transitioned to high-frequency oscillatory ventilation (HFOV), and whether HFOV use is efficacious. DESIGN AND SETTING: Prospective observational study in the 14-bed intensive care unit of a university hospital. PATIENTS AND PARTICIPANTS: 42 patients with ARDS (APACHE II score 28 (IQR 24-37) and ventilation time prior HFOV 3.0 days (0.7-9.1). MEASUREMENTS AND RESULTS: Gas exchange parameters and ventilator data were recorded before and during HFOV treatment (-12 h, -6 h, baseline, 10 min, 1 h, 6 h, 12 h, 24 h). Primary endpoints included: (a) PaO2/FIO2 ratio 24 h after start of HFOV treatment or the last point of measurement if HFOV ended within the first 24 h; (b) HFOV-related complications. Post hoc analysis assessed the relationship between outcome and the response to HFOV, and between outcome and time of mechanical ventilation prior to HFOV. At baseline the median PaO2/FIO2 ratio was 95 (IQR 62-129); after 24 h of HFOV the PaO2/FIO2 ratio had increased significantly to 165 (88-225); only one patient developed a unilateral pneumothorax. Of the 42 patients 18 (43%) had died by day 30. Subset analyses showed a significantly higher 30-day mortality rate in patients with at least 3 days of mechanical ventilation prior to HFOV (64%) and in patients without oxygenation improvement after 24 h on HFOV (71%). CONCLUSIONS: HFOV is an effective and safe method to ventilate ARDS patients. Failure to improve oxygenation within 24 h of HFOV is associated with high mortality.