[Accidental central venous administation of 0.1 % chlorhexidine mouthwash]. / Akzidentelle zentralvenöse Verabreichung von 0,1 %iger Chlorhexidinmundspüllösung.

Medication errors are frequent and a serious safety concern. Chlorhexidine (CHX) is used daily in healthcare as a disinfectant. Its accidental intravascular injection is scarcely described. Serious complications, such as acute respiratory distress syndrome (ARDS) could be a consequence. We describe a case of central venous administration of 0.1% CHX mouthwash, its potential complications and possibilities of treatment. In contrast to another case report our patient had no detectable adverse side effects. The immediate hemofiltration and cleansing of the i. v. line may have contributed to this favorable outcome.

Application of Benford's law: a valuable tool for detecting scientific papers with fabricated data? : A case study using proven falsified articles against a comparison group.

BACKGROUND: In naturally occurring numbers the frequencies of digits 1-9 in the leading position are counterintuitively distributed because the frequencies of occurrence are unequal. Benford-Newcomb's law describes the expected distribution of these frequencies. It was previously shown that known fraudulent articles consistently violated this law. OBJECTIVE: To compare the features of 12 known fraudulent articles from a single Japanese author to the features of 13 articles in the same research field from other Japanese authors, published during the same time period and identified with a Medline database search. RESULTS: All 25 articles were assessed to determine whether the data violated the law. Formulas provided by the law were used to determine the frequencies of occurrence for the first two leading digits in manually extracted numbers. It was found that all the known fraudulent papers violated the law and 6 of the 13 articles used for comparison followed the law. Assuming that the articles in the comparison group were not falsified or fabricated, the sensitivity of assessing articles with Benford-Newcomb's law was 100% (95% confidence interval CI: 73.54-100%) but the specificity was only 46.15% (95% CI: 19.22-74.87%) and the positive predictive value was 63.16% (95% CI: 38.36-83.71%). CONCLUSION: All 12 of the known falsified articles violated Benford-Newcomb's law, which indicated that this analysis had a high sensitivity. The low specificity of the assessment may be explained by the assumptions made about the articles identified for comparison. Violations of Benford-Newcomb's law about the frequencies of the leading digits cannot serve as proof of falsification but they may provide a basis for deeper discussions between the editor and author about a submitted work.

[Ventilator-associated pneumonia (VAP) : A risk already at the time of anesthetic induction]. / Ventilatorassoziierte Pneumonie (VAP) : Bereits ein Thema bei der Narkoseeinleitung.

BACKGROUND: Ventilator-associated pneumonia (VAP) is one of the most common and preventable infections in mechanically ventilated patients. It is associated with a high mortality rate. To prevent VAP, various strategies address this issue using "VAP-bundles", which are implemented in many intensive care units. The risk of acquiring VAP starts with the induction of anesthesia, strictly speaking at the time of intubation. This article considers measures to prevent VAP during general anesthesia in adult patients (>18 years). Procedures beyond standard hygienic precautions for VAP prevention are reviewed. METHODS: A literature search in different databases (PubMed, Cochrane, Ovid und CINAHL) over the last five years. RESULTS: Beyond standard hygienic precautions, microaspiration should be avoided to prevent VAP. During mechanical ventilation at least 5 cm H2O PEEP is advised. Continuous monitoring and adjustment of cuff pressure is necessary. All patients mechanically ventilated after general anesthesia for more than 24 h should be intubated with an ETT with a port for subglottic suctioning.

[Management for the operating room]. / Management für den Operationsbereich.

Business companies, which in the current times also includes hospitals, must create customer benefits and as a prerequisite for this must sustainably generate profits. Management in the world of business means the formation and directing of a company or parts of a company on a permanent basis, whereby management in this context is not exercising power but function. This concept of management is exemplary developed in this article for the important services sector of the operating room (OR) and individual functions, such as resource control, capacity planning and materials administration are presented in detail. Some OR-specific management challenges are worked out. From this it becomes clear that the economic logic of the most efficient implementation possible is not a contradiction of medical ethics, enabling the most effective treatment possible for patients while safeguarding the highest possible levels of safety and quality. The article aims to build a bridge for medical specialists to the language and world of commerce, emphasizing the profession-based competence and hopefully to arouse interest to go into more detail.

[From financial to scientific fraud : methods to detect discrepancies in the medical literature]. / Vom Finanz- zum Wissenschaftsbetrug : Methode, den Irrungen in der medizinischen Literatur beizukommen.

Fraud is as old as Mankind. There are an enormous number of historical documents which show the interaction between truth and untruth; therefore it is not really surprising that the prevalence of publication discrepancies is increasing. More surprising is that new cases especially in the medical field generate such a huge astonishment. In financial mathematics a statistical tool for detection of fraud is known which uses the knowledge of Newcomb and Benford regarding the distribution of natural numbers. This distribution is not equal and lower numbers are more likely to be detected compared to higher ones. In this investigation all numbers contained in the blinded abstracts of the 2009 annual meeting of the Swiss Society of Anesthesia and Resuscitation (SGAR) were recorded and analyzed regarding the distribution. A manipulated abstract was also included in the investigation. The χ(2)-test was used to determine statistical differences between expected and observed counts of numbers. There was also a faked abstract integrated in the investigation. A p<0.05 was considered significant. The distribution of the 1,800 numbers in the 77 submitted abstracts followed Benford's law. The manipulated abstract was detected by statistical means (difference in expected versus observed p<0.05). Statistics cannot prove whether the content is true or not but can give some serious hints to look into the details in such conspicuous material. These are the first results of a test for the distribution of numbers presented in medical research.

[Who is suited as operation room manager? Evaluation process for hospitals and candidates]. / Wer ist zum OP-Manager geeignet? : Evaluationsanleitung für Krankenhäuser und Bewerber.

Operation room (OR) management is not an end in itself. The challenge is more to organize the complex, inhomogeneous and interference-prone machinery of intraoperative service provision according to business objectives. Although business objectives may differ in some details the ultimate consequence is always to assure the quality of medical care along with adhering to the general economic conditions. The narrower the economic framework the smaller the company's tolerance to unprofessional OR management. Consequently, it can be noticed that OR management has become of age. An internal socialization as frontline leader is no longer sufficient for taking over a job profile which, regarding the risks of revenues and costs belongs to the top management of a company. Prior to looking for a future OR manager it is mandatory to develop a profile of qualifications tailored to the company. In the following selection process the important thing is to identify the candidate who fits best to the developed profile. This paper sees itself as an assistance in the development of such a company-specific qualification profile for an OR manager. On the basis of knowledge, skills and characteristics, different manager typologies are developed, facilitating the successful evaluation in a selection process for both the company and the candidate.

[Management of short-term absence in a hospital : empirical investigations for implementation of an intervention protocol]. / Management von Kurzfehlzeiten im Krankenhaus : Empirische Untersuchung zur Implementierung eines Interventionsprotokolls.

Short-term absence is an important cost factor and its impact is a challenge for all management levels. In this study the effectiveness of a supportive intervention scheme for the reduction of hospital short-term absenteeism is demonstrated. Short-term absenteeism is defined here as being away from the working place for less than 5 days. The study design, which was created by forming an intervention and reference group at a departmental level, ensured neutrality of the participants and therefore high reliability of the results produced. A total of 2,398 employees in 74 organizational units were included. The intervention group included 27 organizational units and the reference group 22. In 25 units employees were either randomized into the control or the reference group. Of the employees 986 were randomized into the intervention group and 1,412 into the control group. Before the formal implementation of the intervention concept, the absence rate was 1.51% in the control group and 1.48% in the intervention group (not significant). In the units of the intervention study arm the absence rate was reduced by 30% to 1.16%. When comparing the results at the employee level, the absence rate in the intervention group was significantly lower than in the control group (0.78% versus 1.17%, p<0.01). Furthermore the effects of the intervention concept were sustained even after the formal ending of the intervention period. This activity has a significant influence on both the absenteeism statistics and the hospital's performance. An implementation of the scheme mainly in the core departments of the hospital, such as the operating theatre, anesthesiology and intensive care has proven to be very helpful.

Different Learning Curves for Axillary Brachial Plexus Block: Ultrasound Guidance versus Nerve Stimulation.

Little is known about the learning of the skills needed to perform ultrasound- or nerve stimulator-guided peripheral nerve blocks. The aim of this study was to compare the learning curves of residents trained in ultrasound guidance versus residents trained in nerve stimulation for axillary brachial plexus block. Ten residents with no previous experience with using ultrasound received ultrasound training and another ten residents with no previous experience with using nerve stimulation received nerve stimulation training. The novices' learning curves were generated by retrospective data analysis out of our electronic anaesthesia database. Individual success rates were pooled, and the institutional learning curve was calculated using a bootstrapping technique in combination with a Monte Carlo simulation procedure. The skills required to perform successful ultrasound-guided axillary brachial plexus block can be learnt faster and lead to a higher final success rate compared to nerve stimulator-guided axillary brachial plexus block.

[Economic benefits of overlapping induction: investigation using a computer simulation model]. / Okonomischer Nutzen der überlappenden Einleitung: Untersuchung mithilfe eines Computersimulationsmodells.

The aim of this study was to investigate the potential economic benefit of overlapping anaesthesia induction given that all patient diagnosis-related groups (AP DRG) are used as the model for hospital reimbursement. A computer simulation model was used for this purpose. Due to the resource-intensive production process, the operating room (OR) environment is the most expensive part of the supply chain for surgical disciplines. The economical benefit of a parallel production process (additional personnel, adaptation of the process) as compared to a conventional serial layout was assessed. A computer-based simulation method was used with commercially available simulation software. Assumptions for revenues were made by reimbursement based on AP DRG. Based on a system analysis a model for the computer simulation was designed on a step-by-step abstraction process. In the model two operating rooms were used for parallel processing and two operating rooms for a serial production process. Six different types of surgical procedures based on historical case durations were investigated. The contribution margin was calculated based on the increased revenues minus the cost for the additional anaesthesia personnel. Over a period of 5 weeks 41 additional surgical cases were operated under the assumption of duration of surgery of 89+/-4 min (mean+/-SD). The additional contribution margin was CHF 104,588. In the case of longer surgical procedures with 103+/-25 min duration (mean+/-SD), an increase of 36 cases was possible in the same time period and the contribution margin was increased by CHF 384,836. When surgical cases with a mean procedural time of 243+/-55 min were simulated, 15 additional cases were possible. Therefore, the additional contribution margin was CHF 321,278. Although costs increased in this simulation when a serial production process was changed to a parallel system layout due to more personnel, an increase of the contribution margin was possible, especially with procedures of shorter duration (<120 min). For longer surgical times, the additional costs for the workforce result in a reduced contribution margin depending on the models chosen to handle overtime of the technical OR personnel. Important advantages of this approach for simulation are the use of the historical production data and the reflection of the specificities of the local situation. Computer simulation is an ideal tool to support operation room management, particularly regarding the planning of resource allocation and the coordination of workflow.

[Damage of the subclavian vein with a thorax drainage]. / Verletzung der V. subclavia mit einer Thoraxdrainage.

The necessity for insertion of a thorax drainage can lead to serious complications. Especially the use of a trocar instead of a mini-thoracotomy has a notable risk of misplacement or complications. Chest tubes per se can perforate the parietal pleura resulting in an extrathoracic position of the tube and contraindications for chest tubes should always be considered. Accidental lacerations of blood vessels should be avoided by a correct technique and a clear indication. A chest X-ray in one plane is not sufficient to prove correct positioning of a chest tube and suspected misplacement of a chest tube has to be assessed radiographically in at least two planes. A case of a fatal complication of a misplaced chest tube causing a laceration of the right subclavian vein is described.

[Simulation-based analysis of novel therapy principles. Effects on the efficiency of operating room processes]. / Simulationsbasierte Analyse neuer Therapieprinzipien. Auswirkungen auf die Leistungsfähigkeit der OP-Prozesse.

BACKGROUND: The introduction of innovative drugs in anesthesiological treatment has the potential to improve perioperative efficiency. This article examines the impact of the new muscle relaxant encapsulator Bridion on emergence from anesthesia and on the efficiency of the perioperative organization. METHODS: To analyze the effects of medical innovations, computer simulation was used as an experimental frame. The simulation was based on a realistic model of an operating room setting and used historical data to study the effect of innovation on the operational performance and the economic outcomes. RESULTS: The use of medical innovations in anesthesiological emergence yields new potentials for a hospital under certain conditions. Due to shorter block times and anesthesia-controlled times, additional benefits for the operating room could be realized. This results in an increase of up to 2.4% additional cases during similar working hours and planning periods. CONCLUSION: The introduction of innovative medicines may reveal more efficient and economical conditions in operating rooms. The overall result depends, for example, on the rate of application of the patient's portfolio or the organization and access rules of the surgical suite. Based on the anesthesia-controlled time no general a priori statement about the economic potentials can be confirmed. Future empirical studies should investigate the impact on quality and economic benefits for the entire patient pathway.

[Controlling and reporting in operating room management: analysis of the state of development]. / Controlling und Berichtswesen im OP-Management: Analyse des Entwicklungsstands.

The operating room (OR) is one of the most expensive facilities in most hospitals. The demands on a professional and process-oriented controlling and reporting in the OR are increased due to the increasingly more limited financial margins at the end of the diagnosis related groups (DRG) convergence phase. This study gives an overview of the current situation for cost calculation, controlling and reporting in OR management in German hospitals in 2007. The data from 69 hospitals were evaluated and this represents the largest currently available data pool on this topic.

[Anaesthetists learn--do institutions also learn? Importance of institutional learning and corporate culture in clinics]. / Anästhesisten lernen--lernen Institutionen auch? Bedeutung von institutionellem Lernen und Unternehmenskultur in der Klinik.

In only a few contexts is the need for substantial learning more pronounced than in health care. For a health care provider, the ability to learn is essential in a changing environment. Although individual humans are programmed to learn naturally, organisations are not. Learning that is limited to individual professions and traditional approaches to continuing medical education is not sufficient to bring about substantial changes in the learning capacity of an institution. Also, organisational learning is an important issue for anaesthesia departments. Future success of an organisation often depends on new capabilities and competencies. Organisational learning is the capacity or processes within an organisation to maintain or improve performance based on experience. Learning is seen as a system-level phenomenon as it stays in the organisation regardless of the players involved. Experience from other industries shows that learning strategies tend to focus on single loop learning, with relatively little double loop learning and virtually no meta-learning or non-learning. The emphasis on team delivery of health care reinforces the need for team learning. Learning organisations make learning an intrinsic part of their organisations and are a place where people continually learn how to learn together. Organisational learning practice can help to improve existing skills and competencies and to change outdated assumptions, procedures and structures. So far, learning theory has been ignored in medicine, due to a wide variety of complex political, economic, social, organisational culture and medical factors that prevent innovation and resist change. The organisational culture is central to every stage of the learning process. Learning organisations move beyond simple employee training into organisational problem solving, innovation and learning. Therefore, teamwork and leadership are necessary. Successful organisations change the competencies of individuals, the systems, the organisation, the strategy and the culture.

Efficacy and safety of pregabalin in treatment refractory patients with various neuropathic pain entities in clinical routine.

AIMS: Conventional approaches to the management of neuropathic pain (NeP) often yield unsatisfactory results. We aimed to investigate pregabalin, a gamma-aminobutyric acid (GABA)-analogue, in a wide range of pregabalin naive patients with treatment refractory NeP. METHODS: Investigator-initiated, 4-week, open, prospective multicentre study in tertiary care. Pregabalin was prescribed at physicians' discretion based on patients' individual responses and tolerability, with or without concomitant analgesics. Consecutive patients were requested to fill in questionnaires at baseline and after 14 and 28 days with numerical pain rating scales (0, none; 10, worst possible), sleep rating scales, parts of the Brief Pain Inventory, Pain Experience Scale, Short Questionnaire on Current Burden and the SF-12 health-related quality of life scale. RESULTS: In 55 patients, the mean pregabalin dose was 142 +/- 26 mg at day 1 and 348 +/- 161 mg at day 28. The mean pain score decreased from 6.5 +/- 1.7 to 5.5 +/- 1.9 at day 14 and to 4.9 +/- 1.8 at day 28 (-24.6%, p < 0.0001). Significant and rapid improvements were noted in the sleep interference score (p < 0.00001), Short Questionnaire on Current Burden (p < 0.01) and SF-12 (somatic score p < 0.001; psychological score p < 0.01). Pregabalin was well tolerated, and only three patients (5%) discontinued treatment prematurely. CONCLUSIONS: Our findings suggest that pregabalin is an effective and well-tolerated drug in difficult-to-treat NeP patients under daily clinical practice conditions. A flexible dosing approach appears appropriate to ensure patient compliance and treatment success.

[Role expectations of various professional groups in the operating theatre]. / Rollenerwartungen unterschiedlicher Berufsgruppen im OP.

BACKGROUND: Clearly defined professional roles have the advantage that team members know what they are expected to do and what their expectations of other professional groups are. For the definition of roles a distinct number of interactions between persons are a prerequisite. In a typical operations room (OR) team members are not constantly involved and are often exchanged. Interactions between personnel are not strong enough to fulfil the designing process of role shaping. In this study the possible substitution of defined roles by a distinct professional culture in an OR was studied. METHODS: Using a shortened form of the SYMLOG questionnaire, 179 persons working in the ORs of 2 Swiss hospitals were interviewed. The three main professional groups in the OR setting were represented in this cohort: anaesthesia personnel (physicians and nurses), surgeons and operating room technicians and nurses. The SYMLOG questionnaire allows the rating of sympathy, influence and goal orientation of the professional groups. RESULTS: Surgeons and anaesthetists had the strongest influence and higher ratings for goal orientation. In comparison, the influence of members of the nursing profession was less valued. All three professional groups rated themselves higher than in the perception of the other professional groups. CONCLUSIONS: It is concluded that in this analysis the role definition was not clear. Optimization is therefore possible which could reduce conflict potential and contribute to a higher productivity.

[Operation room management in quality control certification of a mainstream hospital]. / OP-Management im KTQ-Zertifizierungsprozess eines Schwerpunktkrankenhauses.

We report the results of our study concerning the organisation of operating room (OR) capacity planned 1 year in advance. The use of OR is controlled using 2 global controlling numbers: a) the actual time difference between the expected optimal and previously calculated OR running time and b) the punctuality of starting the first operation in each OR. The focal point of the presented OR management concept is a consensus-oriented decision-making and steering process led by a coordinator who achieves a high degree of acceptance by means of comprehensive transparency. Based on the accepted running time, the optimal productivity of OR's (OP_A(%) can be calculated. In this way an increase of the overall capacity (actual running time) of ORs was from 40% to over 55% was achieved. Nevertheless, enthusiasm and teamwork from all persons involved in the system are vital for success as well as a completely independent operating theatre manager. Using this concept over 90% of the requirements for the new certification catalogue for hospitals in Germany was achieved.

[The Gini coefficient. A numerical grading for the degree of standardization of surgical subspecialities]. / Der Gini-Koeffizient. Kennzahl für den Standardisierungsgrad operativer Fachabteilungen.

BACKGROUND AND GOAL: General hospitals are under pressure especially under payment by DRGs (diagnosis related groups), therefore, a general trend for specialized surgical centers is obvious. For this reason knowledge of the level of standardization is important and allows strategical management of surgical subspecialties. MATERIALS AND METHODS: The Gini coefficient (GC, range: 0-1) is a measurement of the level of standardization when an economical ABC analysis is performed. Low GC values are typical for low levels of standardization. All surgical cases coded by ICD-9-CM in 1 of the 8 central operation rooms in a Swiss general teaching hospital over a period of 30 months were included. The database was analyzed by the ABC method. Due to the ABC analysis the GC for each speciality was specified. RESULTS AND DISCUSSIONS: In data period 1 a total of 11,573 and in data period 2 3,449 operations done by 7 specialities were evaluated. The GC for the Pareto distribution was 0.86. Neurosurgery had a value of only 0.34, which means that nearly every operation was unique. The highest level of standardization was reached by vascular surgery with a GC of 0.68. Compared with other industries the degree of standardization in our general hospital is low as measured by the GC. CONCLUSIONS: The GC is a valuable and objective measurement of the different procedures and standardization of surgery of given surgical subspecialties. It can be calculated from the operation room management (ORM) database and allows an objective analysis of the variety of surgical procedures per subspecialty. In this study the GC was implicated in an ORM setting for the first time.

[Teamwork in the operating theatre. Effect on quality of decision-making]. / Teambildung im Operationssaal. Auswirkungen auf die Entscheidungsqualität.

German hospitals face growing economic pressure. Due to the reimbursement system with diagnosis-related groups (DRGs), revenues from capitation fees have to be earned by each clinic. This leads to minimization of resources for every single case. Cost effectiveness is also realised through shorter hospital stays, reduction of hospital beds and a steady rise in cases per year. As a consequence, all employees are confronted with an increasing workload. Compensation of these working conditions can be achieved by human engineering. Despite statements from politicians and hospital leadership in order to cope with this situation, reality is far away: overwork, shorter or missing recreation periods, pressure of time and low income of staff members have turned hospitals into a deterring workplace. If satisfaction of elementary needs such as adherence to break times, is not achieved shortly, politicians and hospital leadership will find out that without motivated and satisfied staff there will not be efficient performance. The present article addresses this issue and gives examples for increasing efficiency through motivation. Focus is on cooperation in the operation room, advantages and risks of teamwork and auxiliary measures for improvement. The aim is to underline how complex and fragile working in an operation room proceeds and how little is done to support this process. Finally, examples are described which improve teamwork, motivation, efficiency and efficacy.