[Role-specific targets and teamwork in the operating room]. / Rollenspezifische Ziele und Teamarbeit im OP.

BACKGROUND: The primary goal of a surgical team is the successful performance of an operation on a patien; however, this primary goal can show discrepancies from the goals of individual team members. The main causes for differences of interests can be variations in subjective preferences and organizational differences. Subjective preferences are due to the values held by those involved. These values are of an intrinsic nature and therefore difficult to change. Another reason for individual goals is that hospitals and universities are professional bureaucracies. Experts working in professional bureaucracies are known to identify themselves to a greater extent with their respective profession than with their institution; however, teams in the operating room (OR) have to work together in multidisciplinary teams. The main goal of this analysis is to document role-specific targets and motivations within teams. METHODS: This was a case study at a university hospital with 40 operating rooms. The data collection resulted from the three pillars of the goal documentation instrument, which includes expert interviews, a utility analysis and card placement as a basis for communicative validation. The results were analyzed with a systematic method as a qualitative content analysis. The four-pillar success model, which maps aspects of a successful hospital, was used as a deductive coding scheme. The four pillars represent the level of medical quality (process, structure and outcome quality), economy and efficiency, client satisfaction (patients and referring physicians) and employee satisfaction. At a university hospital an additional focus is on research and teaching. In addition to the four pillar success model as a deductive coding scheme, an inductive coding scheme was introduced. Approximately 10% of the employees from each professional group (surgeons, anesthesiologists, OR nurses, nurse anesthetists) were interviewed resulting in 65 interviews overall. The interviews were conducted within a time span of 4 months. RESULTS: Considering the main categories quality of medical care, economy and efficiency, patient satisfaction and employee satisfaction as well as research and teaching, surgeons thought the categories of economy and efficiency (37%) and quality of medical care (34%) to be the most important. For anesthesiologists, however, the category of employee satisfaction (38%) was most important, followed by the category of economy and efficiency (31%). For the OR nurses as well as for the nurse anesthetists the category of employee satisfaction was of highest priority (61% and 57%, respectively). CONCLUSION: The results show that considering the main categories no dimension is equally important for the participating professional groups. This can result in goal conflicts. Additionally, the ad hoc teams make it impossible for team building to occur, making it difficult for the professional groups to adapt to each other and the individual goals. This presents a high potential for conflict. The difference in the perception of the importance of employee satisfaction is a crucial factor for emerging conflicts in the OR, as employee satisfaction correlates with productivity and patient satisfaction. Knowing and communicating the different goals is a first step for optimizing the OR management system.

[General Practice in a University Emergency Department - Concept, Implementation and Evaluation]. / Allgemeinmedizin in einer universitären Notaufnahme ­ Konzept, Umsetzung und Evaluation.

Background: Accident and emergency departments (A&E) are facing increasing numbers of patients. While hospitalization rates have remained nearly constant, there has been an increase in outpatient cases. Therefore, at Hannover Medical School (MHH), general practitioners (GPs) have been integrated in A&E. Methods: In 2014, all GP contacts within the A&E were evaluated on the basis of hospital routine data and by an additional questionnaire. It contained questions about who initiated the admission, about medical examinations and tests and the patient-related admission decisions. Results: In 2014, GPs in A&E treated 1 646 patients. 76% of the patients were self-referrals and 23% referrals from primary care physicians. The most prevalent diagnoses were back pain, gastroenteritis and hypertension. GPs in A&E did not need any additional specialist involvement in most cases. 81% of the patients were sent home, most of them with the advice to consult their GPs (59%), and 22% to consult a specialist. Repeated visits were scarce. Conclusion: Deploying GPs in A&E represents a promising concept to cope with the rising number of patients in A&E. However, further studies are needed to examine the accuracy of the GPs' diagnosis-related decisions and patient satisfaction.

[Legal position of non-medical personnel in hospitals]. / Rechtliche Stellung nichtärztlichen Personals im Krankenhaus.

There are currently many assistant professions in the German healthcare system which have either a more nursing or a more medical character. All these assistant professions have in common that as yet they do not require uniform training criteria but members of these professions undertake some aspects of medical activities. At the center lies the difficulty of more political than legal discussion on whether members of these assistant professions and also nursing personnel are allowed to or should undertake medical activities. This article illuminates the legal status quo.

[Simplifying post-treatment rehabilitation claim forms]. / Ein Weg aus dem Dickicht des Formulardschungels bei der Einleitung von Anschlussrehabilitation bzw. Anschlussheilverfahren.

Many different claim forms are used when starting rehabilitation following inpatient treatment, resulting in high administrative overheads for hospital staff, financial institutions and government agencies as well as patient allocation inefficiencies. We describe the problems ensuing on multiple and incompatible claim forms. On the basis of a survey of extant forms, we describe the content of a unified claim form that can be accepted by all insurers and which is optimised for hospital use. A model procedure for the development of a nationwide unified claim form allows for the assessment of the task's complexity and duration. Nevertheless, quality of care and efficiency considerations support a recommendation of standardisation of rehabilitation claim forms. On this basis the authors appeal to all relevant health-care players to enter into the enterprise of standardisation and to pursue this goal consistently.

[Analysis of work flow in a radiology center using multi-moment-analysis: methodical principles]. / Analyse der Arbeitsabläufe eines radiologischen Zentrums mittels Multimoment-Häufigkeits-Studie: Methodische Grundlagen.

Radiology departments at hospitals are closely watched for their economy. The introduction of fast scanner technology usually triggers questions about simultaneously reducing final report times. The aim of the present study was first to examine, if the multi-moment analysis (MMH) is an appropriate method for structural and quantitative analysis of complex work flows in Radiology, and second, if factors negatively influencing the core processes can be quantitatively evaluated. The study was performed in the Departments of Radiology and Neuroradiology at a major University Hospital in Northern Germany. Randomized monitoring of the workflow of more than 80 doctors and radiology technicians assistants resulted in 800 observations per workplace. The high observation rate yielded a high accuracy (95% confidence interval width of less than +3,5%) to determine the proportion of different work patterns. MMH proved to be an appropriate means to analyze and quantify complex work flows at a university radiology centre. Different workplaces could be compared and total daily labor time could be derived from the observations. Circadian variabilities could be differentiated. The potential of the MMH to guide workflow optimization was identified. On the basis of data collected, MMH restructuring and control systems can be planned.

[A bit of business administration--no problem for physicians: Master of Business Administration as panacea?]. / Das bisschen Betriebswirtschaft - für Arzte kein Problem : Der Master of Business Administration als Wundermittel?

Medical professionals with additional economic qualifications are in high demand. For doctors who aim for leading positions at medical institutions the most popular additional qualification is a Master of Business Administration (MBA). The demands on executive managers in hospitals have without any doubt changed in recent years requiring them to be trained in basic economic understanding, human resource management etc. in addition to having excellent medical training. However, MBA programs differ from one academic institution to the next. Due to the lack of standardized schedules in MBA programs it cannot be ascertained whether a candidate received adequate training and can offer the skills necessary for a higher level medical profession. In this paper the author suggests that specific training in individually required skills would be more reasonable and effective rather than encouraging medical staff to pursue academic studies leading to an MBA.

[Outlier cases in surgical disciplines. Micro-economic and macro-economic problems]. / Ausreisserfälle in den operativen Disziplinen. Betriebswirtschaftliche und volkswirtschaftliche Problematik.

Postoperative complications will always occur and the negative impact puts strain on patients, relatives and the attending physicians. The conversion to a remuneration system based on flat rates (diagnosis-related groups) presents additional economic problems for hospitals in some resource-intensive treatments. This particularly pertains to extremely cost-intensive cases in which costs succeed revenue by the factor of 2 and are often surgical procedures. Here the economic risk increases with the number of interventions performed. Despite improvements in the remuneration system this problem persists. An improved payment for these treatments is desirable. To achieve this it is necessary to systematically analyze the extremely cost-intensive cases by experts of different medical disciplines to create a data basis for a proposal of a cost-covering payment.

[The hospital emergency plan - basics and general structure]. / Der Notfallplan des Krankenhauses: Grundlagen und allgemeine Struktur.

A hospital emergency plan commonly consists of three main chapters dealing with the general aspects of emergency operation and the special aspects of external and internal emergencies. The extent of these chapters is restricted to general understanding and is completed by special instructions (emergency action plan, staff lists, material lists, situation plans) for each department. Due to its security significance, the emergency plan is handled confidential. External emergencies include mass casualty incidents, incidents with a large number of intoxicated patients, the care of patients with dangerous infectious diseases and NBC emergencies. Internal emergencies include fire and other environmental threats, the breakdown of the electrical power and water supply, the breakdown of the telephone system and other situations like bomb threat and taking of hostages. Any emergency call is sent to a special emergency phone, and a defined, experienced physician decides to activate the emergency plan. With the change from routine to emergency service, a chain of command is installed. The hospital staff deals with administrational and organizational aspects, whereas the medical staff is in charge of immediate patients' care. For each external emergency, the deployment of personnel and material and the basic organizational aspects are ordered. Comparable preparations are given for internal emergencies. To achieve realistic emergency planning, repeated evaluations and practical exercises are necessary. Furthermore, a basic independence of the hospital with respect to stocks, preparation and sterilization of instruments and catering is essential to ensure its function even under adverse conditions.

An anaesthetic minimum dataset and report format. Society for Computing and Technology in Anaesthesia (SCATA). European Society for Computing and Technology in Anaesthesia (ESCTAIC).

The dataset necessary to produce reports for anaesthetic training purposes is described, together with appropriate definitions. The format for a standard report that may be used in a logbook is also described. These have been accepted by the Royal College of Anaesthetists. The German Anaesthetic Society (Deutsche Gesellschaft für Anaesthesiologie und Intensivmedizin, DGAI) has accepted the dataset and definitions.

Computing tools for quality assurance.

Computing systems for quality assessment in the operative departments, in anaesthesia and intensive care were developed at the Altona General Hospital, Hamburg. The main goals were to support quality assurance as a tool for the medical staff which they can use actively in their routine work and to reorganize uneconomical forms of clinical data handling. The most important characteristics of the tools presented here are flexibility of the databases and applications, openness to individual configurations and integration of quality assessment, activity audits and clinical routine under the primacy of medical documentation. Research is aimed at new forms of medical documentation, problem-oriented presentation and focusing of clinical data in the context of quality assurance programs.

Epidural analgesia in colonic surgery: results of a randomized prospective study.

Colonic surgery patients were studied to measure: the influence of continuous thoracic epidural analgesia (TEA) on a postoperative pain score, the time till onset of defaecation, blood loss, postoperative temperature elevations, rate of bacterial contamination of wounds and urine, and general surgical complications. Group I patients (n = 57) received general anaesthesia and TEA for the operation, followed by continuous TEA (0.25 per cent bupivacaine) for 72 h. Group II patients (n = 59) received general anaesthesia for the operation, followed by systemic analgesia on request. Significant beneficial effects of TEA in group I were demonstrated by lower pain scores in the first 24 h after surgery and earlier defaecation. However, there were fewer temperature elevations in group II. There was no significant difference between the groups in terms of positive bacteriological cultures, blood loss, need for postoperative mechanical ventilation and complications. However, there was a trend toward a higher rate of rectal anastomotic breakdown, increased blood replacement and intensive care therapy, and longer hospitalization in group I. These results do not suggest any significant beneficial therapeutic effect of continuous TEA in colonic surgery compared with a conventional systemic analgesic regimen. In selected patients (i.e. those with severe pain or those prone to develop postoperative ileus) continuous TEA may be beneficial.

[Computer-assisted documentation and performance data processing in the intensive care unit. Description of a custom development]. / Computergestützte Dokumentation und Leistungserfassung auf der Intensivstation. Vorstellung einer Eigenentwicklung.

Computer-aided documentation of medical and performance data processing seems to be imperative for every intensive-care unit in the future. It is the rational approach to deal with therapy-related information management as well as organizational and administrative tasks. This custom-made program is based on data collected from 3600 intensive-care patients. It serves 3 objectives: 1. documentation of relevant therapeutic data, 2. information exchange with other departments, 3. thorough analysis of topics related to intensive-care medicine. Based on a microsoft disc operating system, the programme contains not only the data base but also word processing and statistical capacities. Optional choice by menu guarantees easy handling and helps to create a high acceptance.

Evoked cerebral potential correlates of C-fibre activity in man.

CO2 laser emitted radiant heat pulses of 20 ms duration were used to activate predominantly slowly conducting nociceptive cutaneous afferents in man. Stimuli of two-fold individual pain threshold caused stinging and burning pain and elicited cerebral potentials with latencies consistent with A delta-fibre activity. After preferential block of the myelinated nerve fibres by pressure only the burning pain remained with significantly increased reaction time (about 1433 ms). The A delta-fibre-induced evoked potential components disappeared, and a marked ultralate positive component became visible with mean peak latency of 1260 ms, consistent with C-fibre activity.