Long-term effects of a prehospital telemedicine system on structural and process quality indicators of an emergency medical service.

The benefits of a telemedical support system for prehospital emergency medical services include high-level emergency medical support at the push of a button: delegation of drug administration, diagnostic assistance, initiation of therapeutic measures, or choice of hospital destination. At various European EMS sites telemedical routine systems are shortly before implementation. The aim of this study was to investigate the long-term effects of implementing a tele-EMS system on the structural and procedural quality indicators and therefore performance of an entire EMS system. This retrospective study included all EMS missions in Aachen city between 2015 and 2021. Regarding structural indicators of the EMS system, we investigated the overall number of emergency missions with tele-EMS and onsite EMS physicians. Furthermore, we analyzed the distribution of tracer diagnosis and process quality with respect to the time spans on the scene, time until teleconsultation, duration of teleconsultation, prehospital engagement time, and number of simultaneous teleconsultations. During the 7-year study period, 229,384 EMS missions were completed. From 2015 to 2021, the total number of EMS missions increased by 8.5%. A tele-EMS physician was consulted on 23,172 (10.1%) missions. The proportion of telemedicine missions increased from 8.6% in 2015 to 12.9% in 2021. Teleconsultations for missions with tracer diagnoses decreased during from 43.7% to 30.7%, and the proportion of non-tracer diagnoses increased from 56.3% to 69.3%. The call duration for teleconsultation decreased from 12.07 min in 2015 to 9.42 min in 2021. For every fourth mission, one or more simultaneous teleconsultations were conducted by the tele-EMS physician on duty. The implementation and routine use of a tele-EMS system increased the availability of onsite EMS physicians and enabled immediate onsite support for paramedics. Parallel teleconsultations, reduction in call duration, and increase in ambulatory onsite treatments over the years demonstrate the increasing experience of paramedics and tele-EMS physicians with the system in place. A prehospital tele-EMS system is important for mitigating the current challenges in the prehospital emergency care sector.

[Update tele-emergency medicine : Status quo and perspectives]. / Update Telenotfallmedizin : Status quo und Ausblick.

CURRENT STATUS OF EMERGENCY MEDICINE IN GERMANY: Increasing numbers of rescue missions in recent years have led to a growing staff shortage of paramedics as well as physicians in the emergency medical system (EMS) with an urgent need for optimized usage of resources. One option is the implementation of a tele-EMS physician system, which has been established in the EMS of the City of Aachen since 2014. IMPLEMENTATION OF TELE-EMERGENCY MEDICINE: In addition to pilot projects, political decisions lead to the introduction of tele-emergency medicine. The expansion is currently progressing in various federal states, and a comprehensive introduction has been decided for North Rhine-Westphalia and Bavaria. The adaptation of the EMS physician catalog of indications is essential for the integration of a tele-EMS physician. STATUS QUO OF TELE-EMERGENCY MEDICINE: The tele-EMS physician offers the possibility of a long-term and comprehensive EMS physician expertise in the EMS regardless of location and, therefore, to partially compensate for a lack of EMS physicians. Tele-EMS physicians can also support the dispatch center in an advisory capacity and, for example, clarify secondary transport. A uniform qualification curriculum for tele-EMS physicians was introduced by the North Rhine and Westphalia-Lippe Medical Associations. OUTLOOK: In addition to consultations from emergency missions, tele-emergency medicine can also be used for innovative educational applications, for example, in the supervision of young physicians or recertification of EMS staff. A lack of ambulances could be compensated for by a community emergency paramedic, who could also be connected to the tele-EMS physician.

Immobilization in Emergency Medical Service - Are CSR and NEXUS-Criteria Considered? A Matched-Pairs Analysis Between Trauma Patients Treated by Onsite EMS Physicians and Patients Treated by Tele-EMS Physicians.

Background: The NEXUS-low-risk criteria (NEXUS) and Canadian C-spine rule (CSR) are clinical decision tools used for the prehospital spinal clearance in trauma patients, intending to prevent over- as well as under immobilization. Since 2014, a holistic telemedicine system is part of the emergency medical service (EMS) in Aachen (Germany). This study aims to examine whether the decisions to immobilize or not by EMS- and tele-EMS physicians are based on NEXUS and the CSR, as well as the guideline adherence concerning the choice of immobilization device. Methods: A single-site retrospective chart review was undertaken. Inclusion criteria were EMS physician and tele-EMS physician protocols with traumatic diagnoses. Matched pairs were formed, using age, sex and working diagnoses as matching criteria. The primary outcome parameters were the criteria documented as well as the immobilization device used. The evaluation of the decision to immobilize based on the criteria documented was defined as secondary outcome parameter. Results: Of a total of 247 patients, 34% (n = 84) were immobilized in the EMS physician group and 32.79% (n = 81) in the tele-EMS physician group. In both groups, less than 7% NEXUS or CSR criteria were documented completely. The decision to immobilize or not was appropriately implemented in 127 (51%) in the EMS-physician and in 135 (54, 66%) in the tele-EMS physician group. Immobilization without indication was performed significantly more often by tele-EMS physicians (6.88% vs 2.02%). A significantly better guideline adherence was found in the tele-EMS physician group, preferring the vacuum mattress (25, 1% vs 8.9%) over the spineboard. Conclusion: It could be shown that NEXUS and CSR are not applied regularly, and if so, mostly inconsistently with incomplete documentation by both EMS- and tele-EMS physicians. Regarding the choice of the immobilization device a higher guideline adherence was shown among the tele-EMS physicians.

Shedding light into the black box of out-of-hospital respiratory distress-A retrospective cohort analysis of discharge diagnoses, prehospital diagnostic accuracy, and predictors of mortality.

BACKGROUND: Although respiratory distress is one of the most common complaints of patients requiring emergency medical services (EMS), there is a lack of evidence on important aspects. OBJECTIVES: Our study aims to determine the accuracy of EMS physician diagnostics in the out-of-hospital setting, identify examination findings that correlate with diagnoses, investigate hospital mortality, and identify mortality-associated predictors. METHODS: This retrospective observational study examined EMS encounters between December 2015 and May 2016 in the city of Aachen, Germany, in which an EMS physician was present at the scene. Adult patients were included if the EMS physician initially detected dyspnea, low oxygen saturation, or pathological auscultation findings at the scene (n = 719). The analyses were performed by linking out-of-hospital data to hospital records and using binary logistic regressions. RESULTS: The overall diagnostic accuracy was 69.9% (485/694). The highest diagnostic accuracies were observed in asthma (15/15; 100%), hypertensive crisis (28/33; 84.4%), and COPD exacerbation (114/138; 82.6%), lowest accuracies were observed in pneumonia (70/142; 49.3%), pulmonary embolism (8/18; 44.4%), and urinary tract infection (14/35; 40%). The overall hospital mortality rate was 13.8% (99/719). The highest hospital mortality rates were seen in pneumonia (44/142; 31%) and urinary tract infection (7/35; 20%). Identified risk factors for hospital mortality were metabolic acidosis in the initial blood gas analysis (odds ratio (OR) 11.84), the diagnosis of pneumonia (OR 3.22) reduced vigilance (OR 2.58), low oxygen saturation (OR 2.23), and increasing age (OR 1.03 by 1 year increase). CONCLUSIONS: Our data highlight the diagnostic uncertainties and high mortality in out-of-hospital emergency patients presenting with respiratory distress. Pneumonia was the most common and most frequently misdiagnosed cause and showed highest hospital mortality. The identified predictors could contribute to an early detection of patients at risk.

Impacts and Lessons Learned of the First Three COVID-19 Waves on Cross-Border Collaboration in the Field of Emergency Medical Services and Interhospital Transports in the Euregio-Meuse-Rhine: A Qualitative Review of Expert Opinions.

Background: In the Euregio-Meuse-Rhine (EMR), cross-border collaboration is essential for resource-saving and needs-based patient care within the emergency medical service (EMS) systems and interhospital transport (IHT). However, at the onset of the novel coronavirus SARS-COV-2 (COVID-19) pandemic, differing national measures highlighted the fragmentation within the European Union (EU) in its various approaches to combating the pandemic. To assess the consequences of the pandemic in the EMR border area, the aim of this study was to analyze the effects and "lessons learned" regarding cross-border collaboration in EMS and IHT. Method: A qualitative study with 22 semi-structured interviews was carried out. Experts from across the EMR area, including the City of Aachen, the City region of Aachen, the District of Heinsberg (Germany), South Limburg (The Netherlands), and the Province of Limburg, as well as Liège (Belgium), took part. The interviews were coded and analyzed according to changes in cross-border collaboration before and during the pandemic, as well as lessons learned and recommendations. Results: Each EU member country within the EMR area, addressed the pandemic individually with national measures. Cross-border collaboration between regional actors was hardly or not at all addressed at the national level during political decision- or policymaking. Previous direct communication at the personal level was replaced by national procedures, which made regular cross-border collaboration significantly more difficult. The cross-border transfer regulations of patients with COVID-19 proved to be complex and led, among other things, to patients being transported to hospitals far outside the border region. Collaboration continues to be seen as valuable and Euregional emergency services including hospitals work well together, albeit to different degrees. The information and data exchange should, however, be more transparent to use resources more efficiently. Conclusion: Effective Euregional collaboration of emergency services is imperative for public safety in a multi-border region with strong economic, cultural, and social cross-border links. Our findings indicate that existing (pre-pandemic) structures which included regular meetings of senior managerial staff in the region and a number of thematic working groups were helpful to deal with and to compensate for the disruptions during the crisis. Regional cross-border agreements that are currently based on mutual but more or less informal arrangements need to be formalized and better promoted and recognized also at the national and EU level to increase resilience. The continuous determination of synergies and good and best practices are further approaches to support cross-border collaboration especially in preparation for future crises.

[Quality of documentation and treatment in the non-physician staffed ambulance: a retrospective analysis of emergency protocols from the city of Aachen]. / Dokumentations- und Behandlungsqualität im Rettungsdienst: eine retrospektive Analyse von Einsatzprotokollen in der Stadt Aachen.

BACKGROUND: Each year there are 7.3 million emergencies for the German rescue service, trend rising and around 59% of the emergency patients are treated by paramedics only; however, most of the studies focus on physicians, while their practical skills at the scene are rarely necessary. Accordingly, the responsibility for the patient lies with the paramedics most of the time. Their duty is to execute life-saving measures, stabilize the patient for the transport and the regular documentation of the operation. Retrospectively, the emergencies can only be analyzed based on the emergency protocols, which are mostly paper-based and handwritten. That causes an increased effort in the evaluation, which makes studies for the whole country hardly feasible. As of now there are only few data on quality of healthcare and documentation by the paramedics. Both were analyzed in this survey based on the emergency protocols. METHOD: A retrospective analysis of emergency protocols from June to July 2018 took place in Aachen, a major German city. A specific feature of Aachen is a 24­h available emergency physician via telemedicine. The quality of documentation and healthcare was analyzed by including standard operating procedures. Primary endpoints were the frequency of documentation, the achievement of complete documentation, the correct indications for a physician, the development of critical vital signs and the average on-scene time of the ambulance. RESULTS: Overall, 1935 protocols were analyzed. A complete documentation was achieved in 1323 (68.4%) suspected diagnoses, 456 (23.6%) anamneses, 350 (18.1%) initial and 52 (2.7%) vital signs at handover. Based on the documentation, there were 531 cases (27%) of patients treated by paramedics only, even though a physician would have been indicated. Out of those patients 410 critical initial vital signs were documented of which 69 (16.8%) improved, while there was no documentation of vital signs at handover in 217 (52.9%). Also, there was a significantly prolonged on-scene time for patients with belated indications for an emergency physician with 15:02 min in comparison to 13:05 min for patients without indications. CONCLUSION: Deficient documentation was found in multiple cases and several important vital signs for a complete differential diagnosis were missing. Furthermore, a quarter of all patients might have benefited from an emergency physician as they were taken to hospital with no or insufficient treatment, despite standard operating procedures. From a forensic point of view there is an alarmingly incomplete documentation of vital signs at handover. The on-scene time in general was within the predetermined time frame, but can still be reduced in different scenarios. Overall, we recommend strict adherence to the standard operating procedures and algorithms, to remove unnecessary documentation and implement a structured quality assurance. Moreover, the quality of treatment might benefit from the rising number of more specialized paramedics and an increasing use of telemedicine.

Are the World Health Organization's Patient Safety Learning Objectives Still Up-to-Date: A Group Concept Mapping Study.

BACKGROUND: The World Health Organization (WHO) Patient Safety Curriculum Guide defines learning objectives for patient safety. Current implementation in healthcare education is insufficient. Possible explanations may be obsolescence and/or a shift in needs. We investigated whether overarching topics and specific learning objectives of the WHO Patient Safety Curriculum Guide are still up-to-date, their attributed importance, and their perceived difficulty to achieve. METHODS: Experts on patient safety and medical education from 3 European countries were asked to suggest learning objectives concerning patient safety using group concept mapping. Following 3 successive steps, experts rated ideas by importance and difficulty to achieve. Correlation analyses investigated the relationship between those. Overarching topics of the learning goals (clusters) were identified with multivariate analysis. RESULTS: A total of 119 statements about intended learning objectives on patient safety were generated, of which 86 remained for sorting and rating. Based on multivariate analyses, 10 overarching topics (clusters) emerged. Both the learning objectives and the overarching topics showed high correspondence with the WHO Patient Safety Curriculum Guide. Strong correlations emerged between importance and difficulty ratings for learning objectives and overarching topics. CONCLUSIONS: The WHO Patient Safety Curriculum Guide's learning goals are still relevant and up-to-date. Remarkably, learning objectives categorized as highly important are also perceived as difficult to achieve. In summary, the insufficient implementation in medical curricula cannot be attributed to the content of the learning goals. The future focus should be on how the WHO learning goals can be implemented in existing curricular courses.

Tele-EMS physicians improve life-threatening conditions during prehospital emergency missions.

Almost seven years ago, a telemedicine system was established as an additional component of the city of Aachen's emergency medical service (EMS). It allows paramedics to engage in an immediate consultation with an EMS physician at any time. The system is not meant to replace the EMS physician on the scene during life-threatening emergencies. The aim of this study was to analyze teleconsultations during life-threatening missions and evaluate whether they improve patient care. Telemedical EMS (tele-EMS) physician consultations that occurred over the course of four years were evaluated. Missions were classified as involving potentially life-threatening conditions based on at least one of the following criteria: documented patient severity score, life-threatening vital signs, the judgement of the onsite EMS physician involved in the mission, or definite life-threatening diagnoses. The proportion of vital signs indicating that the patient was in a life-threatening condition was analyzed as the primary outcome at the start and end of the tele-EMS consultation. The secondary outcome parameters were the administered drug doses, tracer diagnoses made by the onsite EMS physicians during the missions, and quality of the documentation of the missions. From January 2015 to December 2018, a total of 10,362 tele-EMS consultations occurred; in 4,293 (41.4%) of the missions, the patient was initially in a potentially life-threatening condition. Out of those, a total of 3,441 (80.2%) missions were performed without an EMS physician at the scene. Records of 2,007 patients revealed 2,234 life-threatening vital signs of which 1,465 (65.6%) were remedied during the teleconsultation. Significant improvement was detected for oxygen saturation, hypotonia, tachy- and bradycardia, vigilance states, and hypoglycemia. Teleconsultation during missions involving patients with life-threatening conditions can significantly improve those patients' vital signs. Many potentially life-threatening cases could be handled by a tele-EMS physician as they did not require any invasive interventions that needed to be performed by an onsite EMS physician. Diagnoses of myocardial infarction, cardiac pulmonary edema, or malignant dysrhythmias necessitate the presence of onsite EMS physicians. Even during missions involving patients with life-threatening conditions, teleconsultation was feasible and often accessed by the paramedics.

Outcome of liver transplantation and prevalence of liver fibrosis in Crigler-Najjar syndrome.

INTRODUCTION: Crigler-Najjar syndrome (CNS) is a rare inherited disorder that is characterized by high levels of non-hemolytic, unconjugated hyperbilirubinemia leading to brain damage and even death. Liver transplantation (LT) can correct the metabolic defect, but there are little data regarding LT in this patient cohort. The liver parenchyma has been considered to be structurally normal in CNS, but there is growing evidence of clinically silent but histologically significant fibrosis in CNS patients. PATIENTS AND METHODS: We included 13 patients in our retrospective study who underwent LT at our center. Patient survival, graft function, and long-term complications were evaluated over a median follow-up period of 10 years (range: 1-16 years). In addition, the prevalence of histologically relevant fibrosis was characterized. RESULTS: The overall survival among our LT patients was 100%. The graft survival was only 61.5%. During the follow-up period, 5 LT patients had to undergo retransplantation. More than 45% of our patients showed histological signs of fibrosis. CONCLUSION: LT remains the only definite therapeutic option for severe CNS but needs to be considered thoroughly regarding the clinical risk-benefit-ratio and impact on quality of life. Furthermore, hepatic parenchymal injury needs to be considered while evaluating future therapeutic options for CNS.

[Evaluation of the project for the introduction of bystander resuscitation in schools in North Rhine-Westphalia]. / Evaluation des Projekts zur Einführung von Laienreanimation an Schulen in Nordrhein-Westfalen.

BACKGROUND: Teaching of resuscitation measures is not mandatory in all schools in Germany. It is currently limited to individual, partly mandatory projects despite a low bystander resuscitation rate. For this reason, the Ministry for Schools and Education of North Rhine-Westphalia initiated the project "Bystander resuscitation at schools in NRW" in March 2017. OBJECTIVE: The aim of this work was to evaluate this project. MATERIAL AND METHODS: All secondary schools in North Rhine-Westphalia were invited to participate in the project. Medical partners from each administrative district took part, who carried out resuscitation training with existing concepts for teacher or student training. After a 3-year period, the evaluation was carried out using standardized questionnaires for school headmasters, teachers and students. RESULTS: In total, more than 40,000 pupils from 249 schools in NRW could be trained in resuscitation within the project with 6 different concepts. Of the students 85% answered the questions regarding resuscitation correctly and overall felt safe in resuscitation measures. The one-off investment requirement for all schools is roughly 4-6.5 million € and around 340,000 € in each budget year. CONCLUSION: A legal constitution and funding are necessary for a nationwide introduction of resuscitation in schools. All established concepts are effective, therefore each school can use them exactly according to their needs, optimally in a stepped form. Training for teachers should focus on resuscitation.

Comparing the diagnostic concordance of tele-EMS and on-site-EMS physicians in emergency medical services: a retrospective cohort study.

In 2014, a telemedicine system was established in 24-h routine use in the emergency medical service (EMS) of the city of Aachen. This study tested whether the diagnostic concordance of the tele-EMS physician reaches the same diagnostic concordance as the on-site-EMS physician. The initial prehospital diagnoses were compared to the final hospital diagnoses. Data were recorded retrospectively from the physicians' protocols as well as from the hospital administration system and compared. Also, all diagnostic misconcordance were analysed and reviewed in terms of logical content by two experts. There were no significant differences between the groups in terms of demographic data, such as age and gender, as well as regarding the hospital length of stay and mortality. There was no significant difference between the diagnostic concordance of the systems, except the diagnosis "epileptic seizure". Instead, in these cases, "stroke" was the most frequently chosen diagnosis. The diagnostic misconcordance "stroke" is not associated with any risks to patients' safety. Reasons for diagnostic misconcordance could be the short contact time to the patient during the teleconsultation, the lack of personal examination of the patient by the tele-EMS physician, and reversible symptoms that can mask the correct diagnosis.

The role of a checklist for assessing the quality of basic life support performance: an observational cohort study.

BACKGROUND: Training lay rescuers in Basic Life Support (BLS) is essential to improve bystander cardiopulmonary resuscitation (CPR) rates; in addition, simple methods are needed to provide feedback on CPR performance. This study evaluated whether a simple observational checklist can be used by BLS instructors to adequately measure the quality of BLS performance as an alternative to other feedback devices. METHODS: The BLS performances of 152 first-year medical students (aged 21.4 ± 3.9 years) were recorded on video, and objective data regarding the quality of the BLS were documented using Laerdal PC SkillReporting software. The performances were categorized according to quality. Ten BLS instructors observed the videos and completed a ten-point checklist based on the Cardiff Test of BLS (version 3.1) to assess the performances. The validity of the checklist was reviewed using interrater reliability as well as by comparing the checklist-based results with objective performance data. RESULTS: Matching the checklist-based evaluation with the objective performance data revealed high levels of agreement for very good (82%) and overall insufficient (75%) performances. Regarding the checklist-based evaluation, interrater reliability depended on the checklist item; thus, some items were more easily identified correctly than others. The highest and lowest levels of agreement were observed for the items "undressed torso" and "complete release between compressions" (mean joint-probability 95 and 67%, respectively). CONCLUSIONS: The observational checklist adequately distinguished sufficient from insufficient BLS performances and offered an assessment of items not incorporated by SkillReporting software such as the initial assessment or undressing the chest. Although its usefulness was reduced for scaling intermediate performance groups, the checklist may be overall a useful rating tool in BLS-training if objective feedback devices are not available, for example, due to large groups of participants or limited training time.

Handover training for medical students: a controlled educational trial of a pilot curriculum in Germany.

OBJECTIVE: The aim of this study was to implement and evaluate a newly developed standardised handover curriculum for medical students. We sought to assess its effect on students' awareness, confidence and knowledge regarding handover. DESIGN: A controlled educational research study. SETTING: The pilot handover training curriculum was integrated into a curriculum led by the Departments of Anesthesiology and Intensive Care (AI) at the University Hospital. It consisted of three modules integrated into a 4-week course of AI. Multiple types of handover settings namely end-of-shift, operating room/postanaesthesia recovery unit, intensive care unit, telephone and discharge were addressed. PARTICIPANTS: A total of n=147 fourth-year medical students participated in this study, who received either the current standard existing curriculum (no teaching of handover, n=78) or the curriculum that incorporated the pilot handover training (n=69). OUTCOME MEASURES: Paper-based questionnaires regarding attitude, confidence and knowledge towards handover and patient safety were used for pre-assessment and post-assessment. RESULTS: Students showed a significant increase in knowledge (p<0.01) and self-confidence for the use of standardised handover tools (p<0.01) as well as accurate handover performance (p<0.01) among the pilot group. CONCLUSION: We implemented and evaluated a pilot curriculum for undergraduate handover training. Students displayed a significant increase in knowledge and self-confidence for the use of standardised handover tools and accuracy in handover performance. Further studies should evaluate whether the observed effect is sustained across time and is associated with patient benefit.

[Patient handoffs in undergraduate medical education: A systematic analysis of training needs]. / Patientenübergaben in der Ausbildung? Eine systematische Analyse des Trainingsbedarfs unter Medizinstudierenden.

BACKGROUND: Insufficient handoffs lead to an increase in the risk of complications and malpractice, treatment delays, prolonged hospital stays, costs and patient complaints. The German Society for Anesthesiology and Intensive Care (DGAI) and the European Resuscitation Council (ERC) recommend the implementation of a communication procedure according to the SBAR concept. So far, there have been few curricular requirements in Germany regarding handoffs. METHODS: As part of the EU-funded PATIENT project an online-based cross-sectional needs analysis was conducted in three countries. In Aachen, 237 medical students answered 45 items concerning handoffs in three sections: A: skills (relevance and self-assessment), B: clinical experience (agreement), C: curricula content (presence and relevance). Data was recorded using a Likert scale (0-7). RESULTS: The students rated an adequate handoff performance as highly important (M=6.8; SD: ±0.6) and their own expertise as low (M=4.0; SD: ±1.3). A high training need was identified for writing discharge letters and performing accurate handoffs. The students were aware of the link between adequate handoffs and patient safety (M=6.5; SD: ±0.9). They considered standardized handoff procedures as an important curricular component (M=6.1; SD: ±1.1). From their point of view, the handling of medical errors is underrepresented in the curriculum (61.7 %). CONCLUSION: A need for handoff training was revealed, especially regarding transfers and discharges. Accordingly, learning objectives were determined and training modules developed and integrated into the curriculum in Aachen.

Comparison of a newly established emotional stimulus approach to a classical assessment-driven approach in BLS training: a randomised controlled trial.

OBJECTIVE: The study objective was to implement two strategies (short emotional stimulus vs announced practical assessment) in the teaching of resuscitation skills in order to evaluate whether one led to superior outcomes. SETTING: This study is an educational intervention provided in one German academic university hospital. PARTICIPANTS: First-yearmedical students (n=271) during the first3 weeks of their studies. INTERVENTIONS: Participants were randomly assigned to one of two groups following a sequence of random numbers: the emotional stimulus group (EG) and the assessment group (AG). In the EG, the intervention included watching an emotionally stimulating video prior to the Basic Life Support (BLS) course. In the AG, a practical assessment of the BLS algorithm was announced and tested within a 2 min simulated cardiac arrest scenario. After the baseline testing, a standardised BLS course was provided. Evaluation points were defined 1 week and 6 months after. PRIMARY OUTCOME MEASURES: Compression depth (CD) and compression rate (CR) were recorded as the primary endpoints for BLS quality. RESULTS: Within the study, 137 participants were allocated to the EG and 134 to the AG. 104 participants from EG and 120 from AG were analysed1 week after the intervention, where they reached comparable chest-compression performance without significant differences (CR P=0.49; CD P=0.28). The chest-compression performance improved significantly for the EG (P<0.01) and the AG (P<0.01) while adhering to the current resuscitation guidelines criteria for CD and CR. CONCLUSIONS: There was no statistical difference between both groups' practical chest-compression-performance. Nevertheless, the 2 min video sequence used in the EG with its low production effort and costs, compared with the expensive assessment approach, provides broad opportunities for applicability in BLS training.

Influence of learning styles on the practical performance after the four-step basic life support training approach - An observational cohort study.

BACKGROUND: Learning and training basic life support (BLS)-especially external chest compressions (ECC) within the BLS-algorithm-are essential resuscitation training for laypersons as well as for health care professionals. The objective of this study was to evaluate the influence of learning styles on the performance of BLS and to identify whether all types of learners are sufficiently addressed by Peyton's four-step approach for BLS training. METHODS: A study group of first-year medical students (n = 334) without previous medical knowledge was categorized according to learning styles using the German Lernstilinventar questionnaire based on Kolb's Learning Styles Inventory. Students' BLS performances were assessed before and after a four-step BLS training approach lasting 4 hours. Standardized BLS training was provided by an educational staff consisting of European Resuscitation Council-certified advanced life support providers and instructors. Pre- and post-intervention BLS performance was evaluated using a single-rescuer-scenario and standardized questionnaires (6-point-Likert-scales: 1 = completely agree, 6 = completely disagree). The recorded points of measurement were the time to start, depth, and frequency of ECC. RESULTS: The study population was categorized according to learning styles: diverging (5%, n = 16), assimilating (36%, n = 121), converging (41%, n = 138), and accommodating (18%, n = 59). Independent of learning styles, both male and female participants showed significant improvement in cardiopulmonary resuscitation (CPR) performance. Based on the Kolb learning styles, no significant differences between the four groups were observed in compression depth, frequency, time to start CPR, or the checklist-based assessment within the baseline assessment. A significant sex effect on the difference between pre- and post-interventional assessment points was observed for mean compression depth and mean compression frequency. CONCLUSIONS: The findings of this work show that the four-step-approach for BLS training addresses all types of learners independent of their learning styles and does not lead to significant differences in the performance of CPR.

Rotigotine in Hemodialysis-Associated Restless Legs Syndrome: A Randomized Controlled Trial.

BACKGROUND: Restless legs syndrome (RLS) has been associated with insomnia, decreased quality of life, and increased morbidity and mortality in end-stage renal disease. This randomized controlled trial investigated effects of rotigotine in patients with RLS and end-stage renal disease. STUDY DESIGN: Double-blind placebo-controlled study. SETTING & PARTICIPANTS: Adults with moderate to severe RLS (International RLS Study Group Rating Scale [IRLS] ≥ 15) and Periodic Limb Movement Index (PLMI) ≥ 15 who were receiving thrice-weekly hemodialysis enrolled from sites in the United States and Europe. INTERVENTION: Following randomization and titration (≤21 + 3 days) to optimal-dose rotigotine (1-3mg/24 h) or placebo, patients entered a 2-week maintenance period. Polysomnography was performed at baseline and the end of maintenance. OUTCOMES & MEASUREMENTS: Primary efficacy outcome: reduction in PLMI, assessed by ratio of PLMI at end of maintenance to baseline. Secondary/other outcomes (P values exploratory) included mean changes from baseline in PLMI, IRLS, and Clinical Global Impression item 1 (CGI-1 [severity of illness]) score. RESULTS: 30 patients were randomly assigned (rotigotine, 20; placebo, 10); 25 (15; 10) completed the study with evaluable data. Mean (SD) PLMI ratio (end of maintenance to baseline) was 0.7±0.4 for rotigotine and 1.3±0.7 for placebo (analysis of covariance treatment ratio, 0.44; 95% CI, 0.22 to 0.88; P=0.02). Numerical improvements were observed with rotigotine versus placebo in IRLS and CGI-1 (least squares mean treatment differences of -6.08 [95% CI, -12.18 to 0.02; P=0.05] and -0.81 [95% CI, -1.94 to 0.33; P=0.2]). 10 of 15 rotigotine and 2 of 10 placebo patients were CGI-1 responders (≥50% improvement). Hemodialysis did not affect unconjugated rotigotine concentrations. The most common adverse events (≥2 patients) were nausea (rotigotine, 4 [20%]; placebo, 0); vomiting (3 [15%]; 0); diarrhea (1 [5%]; 2 [20%]); headache (2 [10%]; 0); dyspnea (2 [10%]; 0); and hypertension (2 [10%]; 0). LIMITATIONS: Small sample size and short duration. CONCLUSIONS: Rotigotine improved periodic limb movements and RLS symptoms in the short term among ESRD patients requiring hemodialysis in a small-scale study. No dose adjustments are necessary for hemodialysis patients.

Designing Learning Outcomes for Handoff Teaching of Medical Students Using Group Concept Mapping: Findings From a Multicountry European Study.

PURPOSE: To develop, by consultation with an expert group, agreed learning outcomes for the teaching of handoff to medical students using group concept mapping. METHOD: In 2013, the authors used group concept mapping, a structured mixed-methods approach, applying both quantitative and qualitative measures to identify an expert group's common understanding about the learning outcomes for training medical students in handoff. Participants from four European countries generated and sorted ideas, then rated generated themes by importance and difficulty to achieve. The research team applied multidimensional scaling and hierarchical cluster analysis to analyze the themes. RESULTS: Of 127 experts invited, 45 contributed to the brainstorming session. Twenty-two of the 45 (48%) completed pruning, sorting, and rating phases. They identified 10 themes with which to select learning outcomes and operationally define them to form a basis for a curriculum on handoff training. The themes "Being able to perform handoff accurately" and "Demonstrate proficiency in handoff in workplace" were rated as most important. "Demonstrate proficiency in handoff in simulation" and "Engage with colleagues, patients, and carers" were rated most difficult to achieve. CONCLUSIONS: The study identified expert consensus for designing learning outcomes for handoff training for medical students. Those outcomes considered most important were among those considered most difficult to achieve. There is an urgent need to address the preparation of newly qualified doctors to be proficient in handoff at the point of graduation; otherwise, this is a latent error within health care systems. This is a first step in this process.