Status quo and current trends of operating room management in Germany.

PURPOSE OF REVIEW: Ongoing healthcare reforms in Germany have required strenuous efforts to adapt hospital and operating room organizations to the needs of patients, new technological developments, and social and economic demands. This review addresses the major developments in German operating room management research and current practice. RECENT FINDINGS: The introduction of the diagnosis-related group system in 2003 has changed the incentive structure of German hospitals to redesign their operating room units. The role of operating room managers has been gradually changing in hospitals in response to the change in the reimbursement system. Operating room managers are today specifically qualified and increasingly externally hired staff. They are more and more empowered with authority to plan and control operating rooms as profit centers. For measuring performance, common perioperative performance indicators are still scarcely implemented in German hospitals. In 2008, a concerted time glossary was established to enable consistent monitoring of operating room performance with generally accepted process indicators. These key performance indicators are a consistent way to make a procedure or case - and also the effectiveness of the operating room management - more transparent. SUMMARY: In the presence of increasing financial pressure, a hospital's executives need to empower an independent operating room management function to achieve the hospital's economic goals. Operating room managers need to adopt evidence-based methods also from other scientific fields, for example management science and information technology, to further sustain operating room performance.

How work context affects operating room processes: using data mining and computer simulation to analyze facility and process design.

The complexity of the operating room (OR) requires that both structural (eg, department layout) and behavioral (eg, staff interactions) patterns of work be considered when developing quality improvement strategies. In our study, we investigated how these contextual factors influence outpatient OR processes and the quality of care delivered. The study setting was a German university-affiliated hospital performing approximately 6000 outpatient surgeries annually. During the 3-year-study period, the hospital significantly changed its outpatient OR facility layout from a decentralized (ie, ORs in adjacent areas of the building) to a centralized (ie, ORs in immediate vicinity of each other) design. To study the impact of the facility change on OR processes, we used a mixed methods approach, including process analysis, process modeling, and social network analysis of staff interactions. The change in facility layout was seen to influence OR processes in ways that could substantially affect patient outcomes. For example, we found a potential for more errors during handovers in the new centralized design due to greater interdependency between tasks and staff. Utilization of the mixed methods approach in our analysis, as compared with that of a single assessment method, enabled a deeper understanding of the OR work context and its influence on outpatient OR processes.

Amantadine sulfate reduces experimental sensitization and pain in chronic back pain patients.

We investigated if established psychophysical measures of enhanced experimental sensitization in chronic musculoskeletal pain can be reduced by adjuvant treatment with a N-methyl-d-aspartate receptor antagonist, amantadine sulfate, and whether a reduction in sensitization might be accompanied by a concurrent improvement in clinical pain. Sensitization was evaluated by an experimental tonic heat model of short-term sensitization with concurrent subjective and behavioral psychophysical scaling. Twenty-six patients with chronic back pain were included in the randomized, double-blind, placebo-controlled study and received daily dosages of either placebo or 100 mg of amantadine sulfate during a 1-wk treatment. Participants completed quantitative sensory testing of pain thresholds and experimental sensitization before and after treatment and clinical pain ratings before, during, and after treatment. Experimental sensitization and clinical pain were reduced in patients receiving verum. Initially, experimental sensitization was enhanced in patients, with early sensitization at nonpainful intensities of contact heat and enhanced sensitization at painful intensities, as shown previously. After 1 wk of treatment, experimental sensitization was reduced with amantadine sulfate but not with placebo. We conclude that adjuvant chronic pain treatment with N-methyl-d-aspartate receptor antagonists might be beneficial for chronic pain if enhanced sensitization is involved and that the quantitative sensory test of temporal summation may be used to verify this.

Relationship among cardiac index, inspiration/expiration ratio, and perfluorocarbon dose during partial liquid ventilation in an oleic acid model of acute lung injury in sheep.

BACKGROUND: The aim of this study was to demonstrate the influence of different inspiration/expiration (I/E) ratios on cardiac index (CI) and hemodynamics during partial liquid ventilation (PLV) using a large animal model of acute respiratory failure in a prospective, randomized controlled animal laboratory trial. METHODS: After induction of respiratory failure by right atrial injection of 0.09 mL/kg oleic acid, (1) determination of agreement between reversed Fick and pulmonary artery thermodilution (QTD) techniques with progressive doses of perflubron (LiquiVent, Alliance Pharmaceutical Corp, San Diego, Calif) (n = 7 sheep) and (2) comparison of 4 groups with I/E ratios of 3.4:1, 2:1, 1:1, and 1:2 were performed, applying identical ventilatory patterns in all I/E groups (n = 28 sheep). PLV was established with intratracheal instillation of 25 mL/kg perflubron. Cardiac index was assessed at 15-minute intervals for a 120-minute experimental period by QTD. RESULTS: During progressive doses of PLV, the correlation (r) between Fick and QTD techniques was 0.82. Thermodilution deteriorated after induction of lung injury and recovered after PLV start. Regarding QTD, no significant changes after PLV onset (within-group comparison) and between I/E groups were observed (P < .05). CONCLUSION: The QTD technique is a satisfactory reflector of CI during PLV, and I/E ratio has no significant influence on CI, even using extreme inverse ratio ventilation.

Computer-assisted training system for pars plana vitrectomy.

PURPOSE: To evaluate whether microsurgical steps in vitreoretinal surgery can be taught by a computer-assisted training system. METHODS: This prospective, randomized experimental study included 14 ophthalmic residents and medical students who were completely inexperienced in microsurgery. They were randomized into two groups. The study group underwent training programmes in a computer-assisted training system for simulation of pars plana vitrectomy. The control group did not participate in any in vitro training. In the second phase of the study, participants of both groups performed a pars plana vitrectomy in three pig eyes, which included picking a metallic foreign body from the retinal surface. RESULTS: The amount of retinal detachment and the number of retinal defects at the end of the vitrectomies were smaller, the time needed to remove the foreign body was shorter, the number of retinal lesions associated with the foreign body removal was lower, and the mark given was better in the trained study group than in the untrained group. The relatively small number of study participants did not allow the differences between the study and control groups to reach the 5% level of error probability. CONCLUSIONS: In an animal model, training by a computer-based medical work station for simulation of pars plana vitrectomy showed better outcome measures for trained study participants compared with untrained study participants. Future studies may show whether further refinements of such training programmes will result in statistically significantly better results in surgical outcome parameters.