The effects of team-training in intensive care medicine: A narrative review.

PURPOSE: Research into team-training within healthcare is growing exponentially. We aim to evaluate the effects of team-training within intensive care medicine (ICM) through a review of the literature and a narrative synthesis of the results. MATERIALS AND METHODS: A search of OVID Medline, EMBASE and Scopus databases was undertaken. Keywords and MESH headings included were "team-based learning", "team-training", "interdisciplinary training", "intensive care medicine", "ICU", "intensive care unit", "critical care teams" and "critical care". Relevant papers were then analysed for a narrative synthesis. RESULTS: Our search identified 187 articles. A total of 27 papers were analysed and their outcomes were evaluated based on the Kirkpatrick four step model of evaluation. CONCLUSIONS: Team-training has been studied in multiple ICU team types, with crew resource management (CRM) and TeamSTEPPS curricula commonly used to support teaching via simulation. Clinical skills taught have included ALS provision, ECMO initiation, advanced airway management, sepsis management and trauma response skills. Team-training in ICU is well received by staff, facilitates clinical learning, and can positively alter staff behaviors. Few clinical outcomes have been demonstrated and the duration of the behavioral effects is unclear.

Redesigning clinical office practices to improve performance levels in an individual practice association model HMO.

Independent Health, a large health maintenance organization in western New York, is participating in a national initiative to redesign the way healthcare is delivered in the clinical office setting. The Idealized Design of Clinical Office Practices (IDCOP) project aims to initiate profound change in the ways physicians deliver care and treatment in the office; the focus is on demonstrating improvements in access to care, patient care, patient and staff satisfaction, and financial performance. Two clinical prototype test sites have successfully implemented an "open access policy," which enables most patients to see their physician on the day an appointment is requested. The two test sites also found improved clinical indicators (for diabetes and coronary heart disease) that positively affected the health of patients; reduced waiting time, enriching the overall experience of the office visit; and improved patient and staff satisfaction with the operational and care delivery modifications. This article describes the findings of the IDCOP initiative at Independent Health.

Serotonergic modulation of hippocampal pyramidal cells in euthermic, cold-acclimated, and hibernating hamsters.

Serotonergic fibers project to the hippocampus, a brain area previously shown to have distinctive changes in electroencephalograph (EEG) activity during entrance into and arousal from hibernation. The EEG activity is generated by pyramidal cells in both hibernating and nonhibernating species. Using the brain slice preparation, we characterized serotonergic responses of these CA1 pyramidal cells in euthermic, cold-acclimated, and hibernating Syrian hamsters. Stimulation of Shaffer-collateral/commissural fibers evoked fast synaptic excitation of CA1 pyramidal cells, a response monitored by recording population spikes (the synchronous generation of action potentials). Neuromodulation by serotonin (5-HT) decreased population spike amplitude by 54% in cold-acclimated animals, 80% in hibernating hamsters, and 63% in euthermic animals. The depression was significantly greater in slices from hibernators than from cold-acclimated animals. In slices from euthermic animals, changes in extracellular K+ concentration between 2.5 and 5.0 mM did not significantly alter serotonergic responses. The 5-HT1A agonist 8-hydroxy-2(di-n-propylamino)tetralin mimicked serotonergic inhibition in euthermic hamsters. Results show that 5-HT is a robust neuromodulator not only in euthermic animals but also in cold-acclimated and hibernating hamsters.

Effects of hypergravic fields on serotonergic neuromodulation in the rat hippocampus.

The effects of 7 day exposure to 2G fields on serotonergic modulation at two synapses on a hippocampal pathway were examined by recording dentate gyrus and CA1 pyramidal cell layer electrical activity. Serotonin decreased the amplitude of the population spike (synchronous action potentials in hundreds of neurons) in both the dentate gyrus and CA1 regions of rats exposed to 2G fields for 7 days. The inhibition, averaging 26 +/- 4% (mean +/- SEM) in the dentate gyrus and 80 +/- 5% in the CA1 region, was not significantly different from inhibitory responses observed in 1G controls. The 5-HT1A agonist 8-OH-DPAT mimicked this inhibition in the dentate and CA1 regions of 1G rats. 8-OH-DPAT responses were not affected by exposure to 2G fields. We conclude that the hippocampus contains surplus 5-HT receptors so that decreases in receptor density reported in receptor binding studies do not result in a decrease in modulatory capability. A model to account for the physiological pathway that relates gravitational field strength to 5-HT receptor density without changing the effectiveness of 5-HT neuromodulation is discussed.

Effects of three hydration beverages on exercise performance during 60 hours of heat exposure.

Without adequate hydration, profound heat stress and dehydration can occur in people who work in hot environments. This study evaluated the effectiveness of three beverages on temperature regulation, cardiovascular response, and work performance during 60 h of dry heat exposure. Volunteer subjects lived in a climatic chamber in simulated desert conditions varying from 25-45 degrees C at 20% relative humidity. They performed three submaximal exercise sessions on a motorized treadmill at 4-h intervals each day. All of the subjects consumed one of three beverages: a water placebo, a 5% carbohydrate-electrolyte drink, or a 4% carbohydrate-electrolyte drink containing 1% glycerol, during each 60-h session. During exercise, the rating of perceived exertion and heart rate were similar for all beverages and all sessions, but oxygen consumption, core body and average skin temperatures, and sweat rate differed among beverages and sessions. Water alone appeared to provide adequate hydration for working in desert conditions over the 60 h when compared to carbohydrate-electrolyte beverages, with or without a small amount of glycerol.

Quantitative effects of physical therapy on muscular and functional performance in subjects with osteoarthritis of the knees.

Osteoarthritis (OA) of the knees is a functionally limiting disability. Physical therapy (PT) is considered a useful treatment for OA, although evidence is qualitative. The purpose of this study was to quantitatively measure the effects of a 3-month PT program (n = 40; 20 men and 20 women) with knee OA. Muscle function and functional assessment parameters were measured. All data were analyzed by repeated measures analysis of variance (p < 0.05). There were no significant changes in handgrip strength and endurance, limb volume, or angular velocity after PT. Maximal muscle length was significantly increased. Muscle strength significantly increased for the hamstrings (9% and 19%) and quadriceps (8% and 24%) for the men and women, respectively. Endurance improved for the quadriceps (26% and 39%) and hamstrings (18% and 28%) for men and women, respectively. Functionally, there were significant improvements in the ability to climb stairs, rise from a chair, and walk. Walking time (50 ft) and the difficulty and pain of performing various activities decreased. Most improvements had occurred after 1 month of PT. For the first time, the effects of a PT program have been quantitatively measured for patients with knee OA.

The physiology of spacecraft and space suit atmosphere selection.

The majority of the environmental factors which comprise the spacecraft and space suit environments can be controlled at "Earth normal" values, at optimum values, or at other values decided upon by spacecraft designers. Factors which are considered in arriving at control values and control ranges of these parameters include physiological, engineering, operational cost, and safety considerations. Several of the physiological considerations, including hypoxia and hyperoxia, hypercapnia, temperature regulation, and decompression sickness are identified and their impact on spacecraft and space suit atmosphere selection are considered. The past experience in controlling these parameters in U.S. and Soviet spacecraft and space suits and the associated physiological responses are reviewed. Current areas of physiological investigation relating to environmental factors in spacecraft are discussed, particularly decompression sickness which can occur as a result of change in pressure from Earth to spacecraft or spacecraft to space suit. Physiological considerations for long-term lunar or Martian missions will have different impacts on atmosphere selection and may result in the selection of atmospheres different than those currently in use.

Thermal dependence of serotonergic modulation of neural activity in the hamster.

1. The modulatory effect of serotonin on CA1 pyramidal cells in the hamster (Mesocricetus auratus) hippocampus was examined over a range of temperatures. 2. Following repetitive Schaffer collateral/commissural stimulation, changes in the amplitude of population spikes (the synchronous firing of CA1 pyramidal cells) were recorded in the hamster, a hibernator. Amplitudes were measured after 10 microM serotonin was added to and then withdrawn from the perfusing medium with the temperature of the bath fixed at different temperatures. 3. Between 35 degrees C and 15 degrees C a depression in population spike amplitude of at least 10% was seen in 36 of 43 trials, with an average depression of 68%. No significant temperature dependence of the depressive effect was seen. 4. Following the removal of serotonin from the perfusate, the spike amplitude was enhanced over the same range of temperatures, averaging 33% higher than control values. The enhancement was most pronounced at 35 degrees C and 15 degrees C and smallest at 25 degrees C. 5. Thus, over the entire temperature range of 35 degrees C to 15 degrees C, serotonin exerted a dual modulatory effect on the spike amplitude, a depression followed by an enhancement. Serotonin's modulatory effects on pyramidal cell excitation persist over temperatures encountered as the hamster enters hibernation.

The effect of extended O2 prebreathing on altitude decompression sickness and venous gas bubbles.

The purpose of this study was to determine the effect of extended O2 prebreathing on symptom and bubble incidence during decompressions simulating extravehicular activity. The 38 subjects breathed O2 for a 6-h period prior to decompression to 4.3 psi. The subjects performed upper body exercise for 6 h. Subjects were monitored with a Doppler bubble detector and were encouraged to report all symptoms. Eight subjects were exposed to the same protocol after an 8-h prebreathe. Venous bubbles were detected in 18 of 38 subjects decompressed after the 6-h prebreathe. Four of these subjects reported symptoms of altitude decompression sickness. No symptoms or bubbles were detected in the eight subjects who had prebreathed 8 h. The incidence of symptoms and bubbles when combined with prior data on 3.5- and 4.0-hour prebreathes showed an inverse correlation to pre-breathing time. The incidence of symptoms was higher than has been reported for subjects exposed to decompression of shorter duration with less activity.

Hematological changes following repetitive decompressions during simulated extravehicular activity.

A study was performed to evaluate decompression procedures suggested for use prior to Space Shuttle extravehicular activity. Hematological parameters were measured in 12 male human subjects before and after exposure in an altitude chamber to a 3-day staged decompression schedule, with simulated extravehicular activity. Following the exposure, significant increases occurred in white blood cell count and activated partial thromboplastin time, and platelet aggregate ratio was significantly decreased. Pre-exposure samples from subjects who were susceptible to formation of venous gas emboli (VGE) exhibited a significantly lower degree of ADP-induced platelet aggregation and a significantly higher amount of lymphocyte blastogenic transformation in response to the mitogen phytohemagglutinin than samples from VGE-resistant subjects. The results indicate that, following this decompression profile, small but significant changes occur in several hematological parameters, and that levels of certain parameters may be related to susceptibility to VGE formation during decompression.

Blood biochemical factors in humans resistant and susceptible to formation of venous gas emboli during decompression.

Blood biochemical parameters were measured in 12 male human subjects before and after exposure to a staged decompression protocol, with simulated extravehicular activity, during 3 days. Following the exposure, significant changes occurred in several parameters, including increases in blood urea nitrogen, inorganic phosphate, potassium, and osmolality, and decreases in uric acid and creatinine. Pre-exposure blood samples from subjects who were susceptible to formation of venous gas emboli (VGE) during decompression exhibited significantly greater levels of total cholesterol, high density lipoprotein cholesterol, potassium, inorganic phosphate, calcium, and magnesium. The results indicate that, following this decompression profile, small but significant (P less than 0.05) changes occur in several blood biochemical parameters, and that levels of certain blood factors may be related to susceptibility to VGE formation during decompression.

Investigation of the combined effects of bedrest and mild hypoxia.

Subjects were exposed to an 8-h mild hypoxia exposure (8000 ft. equivalent, 2438 m) with and without a 28-h period of 6 degrees headdown bedrest. Anticipated responses to the bedrest and the hypoxia were observed. There was no indication that bedrest affected the arterial oxygenation or the oxygen gradient across the lungs of the subjects undergoing mild hypoxia. It is concluded that there is no evidence that would preclude an alveolar O2 pressure as low as 69 torr during contingency spacecraft operation.

Tissue gas and blood analyses of human subjects breathing 80% argon and 20% oxygen.

Eight human volunteers, individually studied in a hyperbaric chamber, breathed: 1) air at 1 ATA; 2) 80% argon and 20% oxygen and 1 ATA for 30 min; 3) air at 1 ATA for 30 min; 4) 100% 02 at 1 ATA for 30 min; 5) air at 1 ATA for 30 min; 6) 100% O2 at 2 ATA for 60 min; and 7) 80% argon and 20% oxygen at 1 ATA for 30 min. Oxygen, carbon dioxide, nitrogen, and argon tensions were measured in muscle and subcutaneous tissue by mass spectroscopic analyses. Venous blood obtained at regular intervals was analyzed for coagulation and fibrinolytic factors. Inert gas narcosis was not observed. After breathing argon for 30 min, muscle argon tensions were almost three times subcutaneous tensions. Argon wash-in mirrored nitrogen wash-out. Argon wash-in and wash-out had no effect on tissue Po2 or Pco2. Coagulation and fibrinolytic changes usually associated with vascular bubbles were absent.