Crew Resource Management Training for Surgical Teams, A Fragmented Landscape.

OBJECTIVE: Medical Crew Resource Management (CRM) training courses are designed to increase patient safety by reducing the effects of human errors. These training courses are most popular in surgery and a wide range of medical CRM training courses for surgical teams is now available. However, the effects of these CRM training courses on patient outcomes are inconclusive. Although surgical teams feel the need to be trained in team collaboration skills, they are often puzzled about what criteria to apply when choosing a medical CRM training course. This study aimed to compare CRM training courses on didactic components and simulation-exercises to explore if these courses are interchangeable. METHODS: In this qualitative study, semi-structured interviews were conducted among 10 main CRM training providers of surgical teams in the Netherlands. RESULTS: Although a large variety was found in the content of CRM training courses, the most substantial differences were found in the simulation-exercises. Nine out of 10 trainers stated that standard simulation-exercises would be a step forward to ensure quality in CRM trainings. According to the trainers, the implementation of medical CRM can reduce human errors and as a result, preventable patient complications. They suggested a quality standard for CRM trainers in the medical field to ensure the quality of medical team training as a way to reach this. CONCLUSIONS: Medical CRM training courses are diverse and noninterchangeable. Trainers expect that if CRM becomes part of surgical training and is embedded in operating theatre culture, it could be of great value for patients and professionals.

Value of an electronic tutorial for image interpretation in ultrasound-guided regional anesthesia.

BACKGROUND AND OBJECTIVES: Use of ultrasound-guided regional anesthesia (UGRA) requires considerable training. An embedded electronic tutorial as an element of an ultrasound machine may help to identify sonoanatomy for novices. Therefore, we investigated whether an electronic tutorial could improve accuracy or speed of performance in identifying anatomical structures. METHODS: Thirty-five novices in UGRA participated in a workshop on brachial plexus sonoanatomy. Following a lecture and training in handling of ultrasound machines and hand-eye coordination, participants were randomized in either group S, using a standard ultrasound machine, or group T, using the same type of machine with an onboard electronic tutorial. Each participant had to identify 27 anatomical structures from the brachial plexus of a volunteer. A correctly identified structure scored 1 point. An experienced observer noted scores and time required. Scores ± SD (in %) and times ± SD (in seconds) were compared between groups by analyses of independent-samples t test and analysis of variance. Influence of anesthesia experience was determined by multivariate analyses. RESULTS: Group T scored significantly higher (16.8 ± 3.6 [62%] vs. 13.4 ± 4.4 [50%], P = 0.018), whereas time required was longer (1053 ± 244 vs. 740 ± 244 seconds, P = 0.001). Multivariate analysis revealed that experience had no influence on scores or time required. Examination of structures took more time in the beginning than at the end in group T. CONCLUSIONS: An electronic tutorial can help novices in UGRA identify anatomical structures. A significant increase in correct identifications was gained at the expense of significantly longer time required for this process. Increased time required may partly be related to unfamiliarity with the tutorial.

Discrepant perceptions of communication, teamwork and situation awareness among surgical team members.

OBJECTIVE: To assess surgical team members' differences in perception of non-technical skills. DESIGN: Questionnaire design. SETTING: Operating theatres (OTs) at one university hospital, three teaching hospitals and one general hospital in the Netherlands. PARTICIPANTS: Sixty-six surgeons, 97 OT nurses, 18 anaesthetists and 40 nurse anaesthetists. METHODS: All surgical team members, of five hospitals, were asked to complete a questionnaire and state their opinion on the current state of communication, teamwork and situation awareness at the OT. RESULTS: Ratings for 'communication' were significantly different, particularly between surgeons and all other team members (P ≤ 0.001). The ratings for 'teamwork' differed significantly between all team members (P ≤ 0.005). Within 'situation awareness' significant differences were mainly observed for 'gathering information' between surgeons and other team members (P < 0.001). Finally, 72-90% of anaesthetists, OT nurses and nurse anaesthetists rated routine team briefings and debriefings as inadequate. CONCLUSIONS: This study shows discrepancies on many aspects in perception between surgeons and other surgical team members concerning communication, teamwork and situation awareness. Future research needs to ascertain whether these discrepancies are linked to greater risk of adverse events or to process as well as systems failures. Establishing this link would support implementation and use of complex team interventions that intervene at multiple levels of the healthcare system.

Surgical and transcatheter (Amplatzer) closure of atrial septal defects: a prospective comparison of results and cost.

OBJECTIVE: To compare effectiveness, complications, and cost of Amplatzer with surgical atrial septal defect (ASD) closure. DESIGN: Prospective study. SETTING: Tertiary cardiac referral centre. PATIENTS: 43 consecutive patients (excluding non-UK residents) aged between 2.1 and 56.8 years (median 7) undergoing ASD closure. MAIN OUTCOME MEASURES: Procedural success, complications, regression of right ventricular dilatation (up to one year postprocedure), cost, inpatient stay, and home convalescent time. RESULTS: Amplatzer ASD closure was successful in 24 of 27 (89%) patients. Surgical closure was successful in all 19 cases. Cardiac complications affecting management occurred in three (11%) of the Amplatzer group (two procedural failures, one device embolisation) and 4 of 19 (21%) surgical patients (one pericardial pain, one global pericardial effusion requiring drainage, and one patient with anaemia requiring haematinics in addition to an incidental pericardial effusion and one further incidental pericardial effusion) (p = NS). There were complications that did not affect management in a further 5 of 19 surgical patients. There was no significant difference in regression of right ventricular dilatation by six months postprocedure (median right ventricular end diastolic diameter decrease: Amplatzer group 17.5%, surgical group 15.1%; median cardiothoracic ratio decrease: Amplatzer 7.9%, surgical 7.5%). Both hospital stay and home convalescent times were significantly shorter after Amplatzer closure (median hospital stay: Amplatzer one day, surgery six days; median convalescent time: Amplatzer two weeks, surgery 5.5 weeks). Median cost was similar for both groups (Amplatzer pound5375, surgical pound5412). CONCLUSIONS: Amplatzer ASD closure has a lower chance of success with a single procedure than surgery. Overall, there were more complications in the surgical group but the majority of these were minor and did not require any change in management. Resolution of right ventricular dilatation over the study period was similar for both techniques. Time spent in hospital and away from work or school was shorter for the Amplatzer group. The cost of both techniques was similar.

Primary cardiac carcinosarcoma: a rare, aggressive tumor.

Primary cardiac carcinosarcoma is a rare cardiac tumor, and little is known about its natural history. We treated a man who had no evidence of a cardiac mass at initial echocardiography, but 19 months later he had a large biatrial tumor with left ventricular inflow obstruction. Only palliative resection could be achieved. Four months postoperatively extensive tumor recurrence was found, and he died a month later. Histologic examination showed cells with features of both rhabdomyosarcoma and adenocarcinoma, and the tumor was classified as a primary cardiac carcinosarcoma.

Risk adjustment for older hospitalized persons: a comparison of two methods of data collection for the Charlson index.

To compare Charlson indices based on chart data and ICD-9 data for agreement overall and on rating specific comorbid conditions, and to compare mortality risks associated with these indices. Prospective cohort study. Six general medicine wards at Yale-New Haven Hospital. 524 consecutive patients who had no clinical evidence of delirium at enrollment, admitted between November 6, 1989 and July 31, 1991, aged 70 years or older. Death within 1 year of the index hospital admission date. Scores using the chart-based data were significantly higher than those using ICD-9 data. About half of the individual conditions showed fair-to-good agreement between the two scores, whereas the other half showed poor agreement. A comparison of mortality prediction indicated that the weightings assigned to individual comorbidities differed substantially from those used in Charlson's original index. While mortality prediction of each individual index was comparable, the ICD-9 and chart indices contributed independently to mortality prediction in the presence of the other. Low agreement between Charlson scores based on the two methods of data collection and their cumulative contribution to mortality prediction suggest that these indices may include different information. Our results suggest that the original Charlson index may not provide optimal risk adjustment for elderly general medicine samples. We suggest development of an empirically-derived index of comorbid conditions and weights may be warranted for older general medical patients.

Goals for the care of frail older adults: do caregivers and clinicians agree?

PURPOSE: Establishing shared treatment goals for patients may improve the quality of care by facilitating achievement of appropriate and desired outcomes. The purpose of this study was to describe types of family caregiver and physician treatment goals for frail elderly patients who had a high prevalence of cognitive impairment, and to ascertain the level of agreement between family caregivers and physicians on principal treatment goals. SUBJECTS AND METHODS: We surveyed family caregivers and physicians for 200 consecutive older adults who were initially evaluated at the outpatient geriatric assessment center of a major teaching hospital. Treatment goals for patients were measured after a comprehensive geriatric assessment. RESULTS: Goals commonly chosen as most important by family caregivers and physicians pertained to day-to-day functioning (61 [31%] family caregivers, 81 [41%] physicians), behavior and emotional health (56 [28%] family caregivers, 50 [25%] physicians), and safety (40 [20%] family caregivers, 29 [15%] physicians). Although a substantial proportion of family caregiver and physician pairs shared at least one goal (157 [79%] of 200), agreement on presence or absence of individual categories of goals was poor (kappas from -0.19 to 0.28), and agreement on the most important goal was also poor (kappa 0.20). CONCLUSIONS: Agreement on treatment goals between family caregivers and physicians for patients at the study site was low. These results suggest that encounters between family caregiver and physician may need improvement. Further research is needed to assess whether lack of agreement is found in other settings, persists over time, and affects achievement of goals and optimal health outcomes.

Cardiac catheter guided surgical closure of an apical ventricular septal defect.

Surgical closure of muscular ventricular septal defects can be difficult. We report a technique in which a preoperatively placed cardiac catheter allowed accurate localization of a residual apical muscular defect at operation. The approach not only allowed improved visualization of the defect from the right side of the heart, but also helped to minimize the size of the left ventriculotomy required for satisfactory closure.

Mitral valve replacement in children: mortality, morbidity, and haemodynamic status up to medium term follow up.

OBJECTIVE: To investigate the outcome of mechanical mitral valve replacement in children after up to 11 years of follow up. DESIGN: Retrospective analysis of case records. Operative survivors underwent echocardiographic studies to define current haemodynamic status and prosthetic valve function. SETTING: Tertiary referral centre. PATIENTS: All 54 children who underwent mitral valve replacement between January 1987 and December 1997. RESULTS: 30 day mortality was 20.3% and was associated with small valve size and supra-annular position. The actuarial freedom from the following events at five years (70% confidence interval (CI)) was: death, including 30 day mortality and transplantation, 68% (70% CI 62% to 75%); bleeding, 89% (70% CI 84% to 94%); non-structural valve dysfunction and reoperation, 92% (70% CI 87% to 97%). The incidence of endocarditis and thromboembolism was low and there was no structural valve failure. Event-free survival was 52% (70% CI 45% to 60%). Low weight, young age, and small valve size increased the chance of death or reoperation. On echocardiography, left ventricular dilatation and wall motion abnormalities were often observed. A high mean gradient over the prosthesis was associated with small valve size but not with length of follow up. CONCLUSIONS: With the use of mechanical prostheses for mitral valve replacement in children, the problem of structural valve failure is no longer an issue. However, the procedure is still associated with a high complication rate, both at surgery and during follow up, and should therefore be reserved for patients in whom valve repair is not technically feasible.

Quality of life in children following mitral valve replacement.

OBJECTIVE: To measure the health related quality of life (QoL) following mitral valve replacement in childhood. DESIGN: Cross sectional study. SETTING: Tertiary referral centre. METHODS: 19 patients, median age (range) 14.4 (9.7-25.4) years, were studied at a median of 7.6 (0.5-11.2) years after their most recent mitral valve replacement. General health status was measured using age specific validated questionnaires. Ten children aged between 9-15 years completed the child health related quality of life questionnaire, and for nine older patients the UK version of the short form 36 was used. Specific questions were added to the existing questionnaires to study the effect of long term anticoagulation treatment. RESULTS: All patients in the younger age group reported impaired QoL. Five rated their QoL within the range of children with chronic physical disabilities, and in the remaining five it was worse. In the older age group, all but two patients perceived their QoL as normal or near normal compared with a reference population matched for sex and age. Having regular blood tests had a negative effect on QoL in three young children, and one older patient reported impaired QoL related to taking daily warfarin tablets. CONCLUSIONS: In this small group, the effect of mitral valve replacement on QoL appears to be age specific, with more impairment in younger children. Long term anticoagulation treatment is well tolerated in most patients.

Older person's preferences for home vs hospital care in the treatment of acute illness.

BACKGROUND: Although the home is expanding as a potential site for acute illness treatment, little is known about patients' preferences for home vs the hospital. OBJECTIVE: To determine older persons' preferences for home or hospital as a treatment site for acute illness and factors associated with preference. METHODS: Two hundred forty-six community-dwelling persons aged 65 years or older hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia were identified in 2 urban teaching hospitals and received telephone interviews 2 months after hospitalization. They were asked their preference for home or hospital treatment, given the availability of equivalent therapies and outcomes at the 2 sites and a nursing visit and several hours of home health aide assistance daily in the home. They were also asked about changes in preference with changes in the description of the outcome or the availability of services. RESULTS: If home and hospital offered equivalent outcomes, 46% of the sample preferred treatment at home. Preferences were heavily dependent on the outcome of the illness, physician opinion about the best site of care, and the provision of house calls. Higher education, white race, living with a spouse, being deeply religious, and having 2 or more dependencies in activities of daily living were associated with a preference for home treatment. CONCLUSIONS: Under conditions of equivalent outcome, preferences for treatment site are almost equally divided between home and hospital. Explicit elucidation of preferences is necessary if patients' preferences are to play a meaningful role in decision making about site of care.

Goals in geriatric assessment: are we measuring the right outcomes?

Previous evaluative studies of outpatient geriatric assessment have focused on a limited set of outcomes related to functioning, health services utilization, and costs. The purpose of this study was to identify important goals for care as described by patients and family caregivers being cared for in this setting. Using a cross-section of 226 consecutive sets of patients and their primary family caregivers, physicians, and case managers, goals of care for individual patients were coded from open-ended interview responses. The most common categories of goals expressed by family caregivers were obtaining education and referrals (57.5%) and improving social and family relationships (53.0%). The process of establishing and meeting such goals should be explicitly included in the design of future evaluations of outpatient geriatric assessment.

A pollen model in the rat for testing adjuvant activity of air pollution components.

During the last decades, the prevalence of allergy has increased worldwide. Allergic rhinitis ("hay fever") and asthma are two of the most common allergic diseases. A possible cause for increased allergy to pollen is air pollution. The increase of industrialization and the number of diesel engines associated with diesel exhaust particles (DEP) in the air parallel the increase in allergic airway diseases. To investigate the adjuvant effect of DEP in pollen allergy, Brown Norway (BN) rats were sensitized intranasally or intratracheally with timothy grass pollen (Phleum pratense) with or without DEP (3 mg/ml). Intranasal sensitization (200 microl, 10 mg/ml) was performed daily for 5 consecutive days and intratracheal sensitization (200 microl, 10 mg/ml) was performed once. Challenge with pollen was performed at day 21 similarly to the sensitization protocol. Blood samples were taken at day 28 after the first sensitization. The binding of DEP to pollen grains was studied by scanning electron microscopy and the inflammatory response in the lung was studied by light microscopy. Immunoglobulin E (IgE) and IgG(1) responses against pollen grains were measured by digoxigenin (DIG) enzyme-linked immunosorbent assay (ELISA). Scanning electron microscopy revealed a mixture of free DEP and DEP associated with pollen grains. Both intranasal and intratracheal routes of administration of pollen grains induced inflammatory reactions in the lung with an influx of macrophages, eosinophilic granulocytes, and granuloma formation. Pollen grains were localized in the alveoli after both intranasal and intratracheal administration and were surrounded by macrophages. The number and localization of pollen grains were similar for both routes of administration. After coexposure with DEP, DEP-loaded macrophages were found around the pollen. Localization, inflammatory reaction, and integrity of pollen were similar to those seen without DEP. At day 28, specific IgE and IgG(1) antibodies were found in serum of rats immunized intranasally or intratracheally. IgE antibody response was higher in rats immunized with pollen grains and DEP than in rats immunized with pollen only (dilution mean +/- SEM: 59.4 +/- 4.6 vs. 27 +/- 5.1). The IgG(1) antibody response was much higher compared to the IgE response (factor of 10(4)), but the level of IgG(1) antibodies was only slightly increased by DEP (dilution mean +/- SEM: 24.2 +/- 2.0 x 10(4) vs. 16.1 +/- 2.1 x 10(4)). In conclusion, the intranasal application of pollen in the BN rat is a suitable and elegant method to evoke inflammatory reactions in the lung and pollen-specific IgE responses measured by DIG ELISA. Finally, this model gives similar results on adjuvant activity of DEP found in the ovalbumin models presented previously.

Older persons' perceptions of home and hospital as sites of treatment for acute illness.

PURPOSE: Home care is increasingly being used as a substitute for hospital care. This study examined older patients' perceptions of the home and of the hospital as treatment sites for acute illness and the patient characteristics that are associated with these perceptions. SUBJECTS AND METHODS: A series of questions derived from open-ended interviews supplemented by literature review were administered by telephone in a cross-sectional, descriptive study to community-dwelling persons age 65 years or older who had been hospitalized 2 months earlier with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia. RESULTS: Among 246 participants, nearly equal proportions agreed with statements that the home and the hospital would be comfortable sites of care (54% versus 55%), that the home and the hospital would provide rapid recovery (41% versus 37%), and that home treatment and hospital treatment would be burdensome on family and friends (40% versus 33%). Although 93% would feel safe in the hospital, only 42% would feel safe at home. Perceptions were not associated with sociodemographic characteristics, primary diagnosis, self-rated health, depression, or social support. Functionally dependent patients had more positive perceptions of treatment at home. CONCLUSIONS: Evaluation of perceptions of home and hospital can facilitate assessing the acceptability of shifting acute care from hospital to home. Our findings suggest that successful expansion of acute home care will require flexibility in the use of home and hospital as well as education to change perceptions about the safety and efficacy of treatment at home.

Older persons' preferences for site of terminal care.

BACKGROUND: Little is known about patients' preferences for site of terminal care. OBJECTIVE: To describe older persons' preferences for home or hospital as the site of terminal care and to explore potential reasons for their preferences. DESIGN: Cross-sectional quantitative and qualitative interviews. SETTING: Participants' homes. PATIENTS: Community-dwelling persons 65 years of age or older who were recently hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia and were not selected according to life expectancy; 246 patients participated in quantitative interviews and 29 participated in qualitative interviews. MEASUREMENTS: Preference for site of terminal care and the reasons for that preference. RESULTS: In quantitative interviews, 118 patients (48%) preferred terminal care in the hospital, 106 (43%) preferred home, and 22 (9%) did not know. One third changed their preference when asked about their preference in the event of a nonterminal illness. Reasons for preference identified during qualitative interviews included the desire to be with family members and concerns about burden to family members and their ability to provide necessary care. Concern about long-term care needs resulted in preference for a nursing home when choice was not constrained to home and hospital. CONCLUSIONS: Preference for home as the site of care for terminal illness exceeds existing practice. However, the current debate about home versus hospital as the ideal site for end-of-life care may ignore an important issue to older persons--namely, the care of disabilities that precede death.

Endocarditis as the first presentation of AIDS in infancy.

A two month old Ugandan boy underwent surgery for an obstructive right ventricular vegetation associated with disseminated Staphylococcus aureus infection. Both the child and his mother subsequently tested positive for HIV infection. Very little is know about the incidence of endocarditis in paediatric patients with AIDS. To our knowledge this is the first case reported of disseminated S aureus infection associated with endocarditis and an obstructing vegetation in an HIV positive infant with a structurally normal heart. The initial signs and symptoms for endocarditis were atypical, a reflection of the overwhelming infection in an immunocompromised patient. Severe infections may have an atypical presentation in immunosuppressed patients. AIDS needs to be considered in these patients, especially if they come from populations with endemic HIV infection.

The influence of marital quality and attachment styles on traumatic grief and depressive symptoms.

Few studies have examined the relationship between marital quality and adjustment to the impending loss of a terminally ill spouse. Most studies of marital quality and grief have been based on retrospective reports of the marriage rather than pre-loss assessments. Here, we tested the pre-loss cross-sectional effects of having a security-enhancing marriage on traumatic grief and depressive symptoms among 59 caregivers aged 50 and over of terminally ill spouses. We also examined whether insecure attachment styles were associated with traumatic grief and depressive symptoms. Findings suggest that security-increasing marriages and insecure attachment styles put spouses at risk for elevated traumatic grief symptoms. Results also indicate that marital quality and attachment style did not interact and that neither was significantly associated with depressive symptoms. The differences in the relationship of marital quality and attachment styles to the two outcomes suggest that the etiology of traumatic grief and depressive symptoms may be distinct.