Development and alignment of undergraduate medical curricula in a web-based, dynamic Learning Opportunities, Objectives and Outcome Platform (LOOOP).

INTRODUCTION: This study presents a web-based method and its interface ensuring alignment of all parts of a curriculum map including competencies, objectives, teaching and assessment methods, workload and patient availability. Needs, acceptance and effectiveness are shown through a nine-year study. METHODS: After a comprehensive needs assessment, the curriculum map and a web-based interface "Learning Opportunities, Objectives and Outcome Platform" (LOOOP) were developed according to Harden's conceptual framework of 10-steps for curriculum mapping. The outcome was measured by surveys and results of interdisciplinary MCQ-assessments. The usage rates and functionalities were analysed. RESULTS: The implementation of LOOOP was significantly associated with improved perception of the curriculum structure by teachers and students, quality of defined objectives and their alignment with teaching and assessment, usage by students to prepare examinations and their scores in interdisciplinary MCQ-assessment. Additionally, LOOOP improved the curriculum coordination by faculty, and assisted departments for identifying patient availability for clinical training. CONCLUSION: LOOOP is well accepted among students and teachers, has positive effect on curriculum development, facilitates effective utilisation of educational resources and improves student's outcomes. Currently, LOOOP is used in five undergraduate medical curricula including 85,000 mapped learning opportunities (lectures, seminars), 5000 registered users (students, teachers) and 380,000 yearly page-visits.

A first assessment of the safe brain initiative care bundle for addressing postoperative delirium in the postanesthesia care unit.

BACKGROUND: Postoperative delirium (POD) following surgery is a prevalent and distressing condition associated with adverse patient outcomes and an increased healthcare burden. OBJECTIVES: To assess the effectiveness of the Safe Brain Initiative care bundle (SBI-CB) in reducing POD in the postanesthesia care unit (PACU). DESIGN: A multicenter, quality-improvement initiative with retrospective analysis of collected data. SETTING: The study was conducted in the operating rooms and postanesthesia care units (PACUs) of four hospitals across Denmark and Turkey. PATIENTS: The convenience sample of patients were aged ≥18 years, scheduled for surgery, and could communicate verbally. Age, sex, preoperative delirium, and the American Society for Anesthesiology physical status classification were used in statistical methods to control for potential confounding influences. INTERVENTION: The SBI-CB, 18 delirium-reducing recommendations aligned with international guidelines. The intervention included patient education, staff training, coordination meetings across centers, and a dashboard for the monitoring of outcomes in the PACU. MAIN OUTCOME MEASURES: The primary outcome was the POD trend in the PACU during implementation months, assessed through Nu-DESC screening at up to three time points in the PACU. We also examined the length of hospital stay. RESULTS: Data were collected from 18,697 adult patients across four hospitals. Initial POD incidence in the PACU after the first three months was 16.36% across all sites (n = 1021). POD in the PACU was observed across all age groups, with peak incidence in younger (18-35 years) and older (>75 years) patients. General anesthesia and longer surgical duration (>1 h) were identified as significant risk factors for POD in the PACU. Matched patients who experienced POD in the PACU had longer stays in hospital, with a mean increase from 35 to 69 h (p < 0.001). Implementation of the SBI-CB was associated with a decreased risk of POD in the PACU for each month of SBI-CB implementation (adjusted odds ratio 0.96, 95% confidence interval: [0.94, 0.97], p < 0.001). CONCLUSIONS: The presented pragmatic implementation of a multidisciplinary care bundle, encompassing pre-, intra-, and postoperative measures alongside outcome monitoring, has the potential to significantly reduce the incidence of POD in the PACU. Improved patient outcomes may be achieved for general surgical departments with patient cohorts not typically considered at risk for developing POD. TRIAL REGISTRATION: Clinicaltrials.gov, identifier NCT05765162.

Risk factors in critical illness myopathy during the early course of critical illness: a prospective observational study.

INTRODUCTION: Non-excitable muscle membrane indicates critical illness myopathy (CIM) during early critical illness. We investigated predisposing risk factors for non-excitable muscle membrane at onset of critical illness. METHODS: We performed sequential measurements of muscle membrane excitability after direct muscle stimulation (dmCMAP) in 40 intensive care unit (ICU) patients selected upon a simplified acute physiology (SAPS-II) score >OR= 20 on 3 successive days within 1 week after ICU admission. We then investigated predisposing risk factors, including the insulin-like growth factor (IGF)-system, inflammatory, metabolic and hemodynamic parameters, as well as suspected medical treatment prior to first occurrence of abnormal dmCMAP. Nonparametric analysis of two-factorial longitudinal data and multivariate analysis were used for statistical analysis. RESULTS: 22 patients showed abnormal muscle membrane excitability during direct muscle stimulation within 7 (5 to 9.25) days after ICU admission. Significant risk factors for the development of impaired muscle membrane excitability in univariate analysis included inflammation, disease severity, catecholamine and sedation requirements, as well as IGF binding protein-1 (IGFBP-I), but did not include either adjunctive hydrocortisone treatment in septic shock, nor administration of neuromuscular blocking agents or aminoglycosides. In multivariate Cox regression analysis, interleukin-6 remained the significant risk factor for the development of impaired muscle membrane excitability (HR 1.006, 95%-CI (1.002 to 1.011), P = 0.002). CONCLUSIONS: Systemic inflammation during early critical illness was found to be the main risk factor for development of CIM during early critical illness. Inflammation-induced impairment of growth-factor mediated insulin sensitivity may be involved in the development of CIM.

Standard operating procedures as a tool to improve medical documentation in preclinical emergency medicine.

AIM: To evaluate the effect of standard operating procedures (SOPs) to improve the completion of patient care documentation items on patient care reports (PCRs) in a physician-staffed, 4500-calls-per-year preclinical ground emergency medical service (EMS) base. METHODS: Two series of PCRs were analysed before (n=505) and after (n=520) the introduction of SOPs. PCR forms were analysed for the rate of completion of documentation comparing prompted data in check boxes and non-prompted data written in blank spaces at the discretion of the emergency physician. The chi2 test for independence was used to assess the effect of SOPs and prompting on data completion rate. RESULTS: SOPs improved the documentation rate of numerous prompted and non-prompted items, independent of whether these items had a high (eg, Glasgow Coma Score: 91.5% vs 95.7%) or a low documentation rate during the pre-SOP period (eg, allergies: 6.2% vs 18.7%). Prompted items were more frequently documented than non-prompted items, both before and after the introduction of SOPs. Lowest rates were found among non-prompted items (eg, 'last meal' 3.6%). CONCLUSIONS: In this EMS base, developing SOPs is an effective tool to improve the quality of PCRs and the rate of completion of documentation items. Check boxes on PCR forms seem to have an important impact as they prompt the initial assessment, treatment and documentation of the actions taken during an EMS call. Consequently, SOPs and check boxes may serve to improve the transition of important information to emergency department staff, and thus contribute to improved patient care.

[Blast injury]. / Das Explosionstrauma--Ein seltener, besonders schwieriger Fall.

The blast injury is characterized by 3 different patterns of injury: blast wave, splintered fragments and displacement of victim's body. Severe external and internal hemorrhage, tension pneumothorax and the lethal trios (hypothermia, acidosis, coagulopathy) require a rapid prehospital and inhospital trauma care according to a standardized protocol. The concepts of damage control resuscitation and damage control surgery have proven to be effective and should be integrated into the treatment.

Nonexcitable muscle membrane predicts intensive care unit-acquired paresis in mechanically ventilated, sedated patients.

OBJECTIVES: : To investigate the predictive value of electrophysiological measurements including validation of muscle membrane excitability on the development of intensive care unit (ICU)-aquired paresis. DESIGN: : Prospective observational study. SETTING: : University ICU. PATIENTS: : Surgical ICU patients selected upon a simplified acute physiology score > or =20 on three successive days within 1 wk after ICU admission. INTERVENTIONS: : We performed serial electrophysiological measurements with onset of critical illness including conventional electrophysiological parameters and compound muscle action potentials after direct muscle stimulation (dmCMAP). Patients' awareness and muscle strength were measured sequentially by Ramsay sedation scale and an additional questionnaire and by Medical Research Council score, respectively. MEASUREMENTS AND MAIN RESULTS: : Among 56 sedated patients 34 patients revealed reduced dmCMAP values <3 mV indicating a myopathic process within 7.5 (5 of 11) days after admission to the ICU. Abnormal dmCMAP anticipated ICU-acquired paresis upon emergence from sedation with a sensitivity and specificity of 83.3% and 88.8%, respectively (positive predictive value of 0.91). Multivariate logistic regression analyses revealed that validating dmCMAP during early course of critical illness had significant diagnostic utility to anticipate ICU-acquired paresis (p = .004; odds ratio = .47; 95% confidence interval = .28-.79). CONCLUSIONS: : Abnormal dmCMAP occurred within the first week after admission to the ICU and pointed towards a myopathic process as the primary cause of ICU-acquired paresis. Validation of dmCMAP with onset of critical illness allows an early prediction of ICU-acquired paresis and adds important information to clinical estimation of the patients' motor function.

[First therapy of drowning accident]. / Ertrinkungsunfälle - Präklinische und klinische Behandlungsstrategien.

Rescue and medical care of people in a drowning accident is a rather rare incident which still needs special attention. The rescue process can be technically challenging and only a well experienced team will be able to act professionally without any time loss. At a first step all team members have to protect themselves. Especially close collaboration of technical and medical rescue teams are of high significance and should be part of future exercises. Hypothermic persons should be protected from further cooling and gently rescued in a horizontally way. If a patient has no circulation continued cardiopulmonary resuscitation and immediate transport as soon as possible to the nearest hospital with an extracorporeal rewarming device is recommended. To avoid any time loss it is essential that the respective hospital is informed immediately and the fastest mode of transport selected. Astonishing cases show that this procedure is very promising even after long time submersion.

Effects of a standard operating procedure on prehospital emergency care of patients presenting with symptoms of the acute coronary syndrome.

To determine whether a standard operating procedure (SOP) for prehospital management of patients with the acute coronary syndrome (ACS) improves the quality of patient care in terms of adherence to treatment guidelines of the European Society of Cardiology. Among a total of 1025 patient medical records collected from a period before and after the introduction of the SOP, 269 records included the working diagnosis of ACS and were then reviewed for guideline adherence. Most aspects of patient evaluation, monitoring, treatment, and hospital allocation were fairly guideline adherent (>70%) before the SOP was introduced and were not affected by the SOP. The percentage of cases in whom sublingual nitrate (55.2 vs. 66.7%) or intravenous morphine (26.9 vs. 43.0%) was administered without contraindications was higher after the SOP had been introduced. Therefore, the use of an SOP in prehospital emergency medicine can partly improve the adherence to guideline recommendations for the treatment of patients with ACS.