[Development of a competence catalogue for physicians in training for curriculum creation with respect to delivery room training]

BACKGROUND

Anesthesiologic expertise is used at various points in the delivery room. The natural turnover of professionals requires continuous education and training for patient care. In a first survey among consultants and trainees, the desire for a delivery room-specific anesthesiologic curriculum has emerged. In order to enable a curriculum with decreasing supervision, a competence-oriented catalogue is used in many medical fields. The gain in competence develops gradually. The participation of practitioners should be obligatory to avoid a differentiation between theory and practice. The structural framework of curriculum development by Kern et al. provides the learning objective analysis after further evaluation. In the sense of specific learning objective definition, the present study aims to describe the competences for anesthetists in the delivery room.

METHODS

An expert group (active in the anesthesiology delivery room environment) developed a set of items via a two-step online Delphi survey. The experts were recruited from the German Society for Anesthesiology and Intensive Care Medicine (DGAI). We evaluated the resulting parameters for relevance and validity in a larger collective. Lastly, we used factorial analyses to identify factors that could be used to group items into relevant scales. In total, 201 participants took part in the final validation survey.

RESULTS

During the prioritization process of Delphi analyses, competencies such as neonatal care were not followed up. Not all items developed are exclusively delivery room-related, such as managing a difficult airway. Other items are specific to the environment of obstetrics. One example is integration of spinal anesthesia into the obstetric context. Some items are exclusively related to the delivery room, such as in-house standards of care in obstetrics as a basic skill. After validation, a competence catalogue with 8 scales with a total of 44 competence items resulted (Kayser-Meyer-Olkin criterion 0.88).

CONCLUSION

A catalogue of relevant learning objectives for anesthetists in training could be developed. It specifies the generally required content of anesthesiologic training in Germany. Specific patient groups, such as patients with congenital heart defects, are not mapped. Competencies that could also be learned outside the delivery room, should be learned before the rotation. This enables the focus on the delivery room items, especially for those to be trained who do not work in a hospital with obstetrics. The catalogue needs to be revised for completeness for its own working environment. Particularly in hospitals that do not have a pediatrician available, neonatal care becomes significant. Didactic methods, such as entrustable professional activities, have to be tested and evaluated. These enable competence-based learning with decreasing supervision and reflect the reality in hospitals. As not every clinic can provide the necessary resources for this a nationwide provision of documents would be helpful.

Bedarfsanalyse zur Curriculumsentwicklung für die anästhesiologische Kreißsaalversorgung – eine deutschlandweite Umfrage

Hintergrund

Die anästhesiologische Tätigkeit in der Kreißsaalumgebung impliziert die Besonderheiten der 200 %-Letalität, die beschreibt, dass Notfallsituationen Mutter und Kind betreffen können. Ein Umstand, der die Notwendigkeit einer besonderen Sorgfalt in der Mitarbeiterausbildung und -auswahl eindrücklich unterstreicht. Gleichwohl existiert derzeit keine detaillierte Beschreibung der notwendigen Kompetenzen in dieser Arbeitsumgebung. Die vorliegende Studie soll die Ausbildungssituation in der anästhesiologischen Weiterbildung beschreiben und im Hinblick auf die Notwendigkeit eines Curriculums analysieren.

Methodik

In einer multizentrischen Beobachtungsstudie wurden Ärzt:innen in Weiterbildung (AiW) und ausbildende Fachärzt:innen (FÄ) nach Methoden der Einarbeitung, Feedbackgabe, übernommenen Tätigkeiten und Bedarf eines Curriculums befragt. Teilnehmende wurden über die Mitgliedsdatenbank der DGAI angeschrieben und konnten onlinebasiert den 11 Items umfassenden Fragebogen beantworten.

Ergebnisse

Insgesamt wurden 495 Fragebogen (FÄ 329;166 AiW) abgeschlossen. Fachärzt:innen und AiW machen unterschiedliche Angaben zur Durchführung von Abschlussgesprächen (59,6 % vs. 10 %) und der Unterstützung durch ein Curriculum (76,3 % vs. 15,7 %). Unabhängig vom Weiterbildungsjahr werden von AiW Kaiserschnitte unter Supervisionsstufe „Rufweite“ durchgeführt. Die Periduralanästhesie (PDA) ist während der Einarbeitung die am seltensten durchgeführte Maßnahme. Beide Gruppen schätzen den Nutzen bzw. den Wert einer Beschreibung von Lernzielen und der Verfügbarkeit eines Curriculums als hoch ein.

Schlussfolgerung

Die Unterstützung der Einarbeitung wird von FÄ und AiW teilweise unterschiedlich beantwortet. Einzelne seltene durchgeführte Maßnahmen, wie die PDA, bedürfen künftig einer gesonderten Aufmerksamkeit. Die Beschreibung von Lernzielen und die Curriculumsentwicklung werden ausdrücklich gewünscht.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00101-022-01172-1) enthält den Fragebogen zur Arbeit.

[Stocked medications in emergency medical service vehicles staffed by physicians-is prehospital treatment according to current guidelines possible?]

Background

High quality of care in prehospital emergency medicine is characterized by guideline-based therapy. The basic prerequisite for this therapy is the availability of the required drugs in accordance with the current guideline recommendations. It is currently unclear whether this is guaranteed nationwide. There is no uniform standard regarding which drugs must be stocked in emergency medical services (EMS) vehicles staffed by physicians in Germany. The aim of the present study is to identify important diagnoses and the drugs required for their therapy. In a second step, medical directors throughout Germany were interviewed about current drugs available in their physician-staffed EMS vehicles and these were compared with the previously defined diagnosis-dependent drug lists.

Materials and methods

After a structured guideline search, tracer diagnoses were defined and relevant drugs were assigned to them. The levels of evidence and recommendations were also considered. In a second step, this was compared with the current drugs available in physician-staffed EMS vehicles.

Results

A total of 156 different medications were identified. The median number of medications stocked was 58; the minimum number of medications stocked was 35 at one site, while multiple sites stocked a maximum of 77 medications .

Discussion

The present study investigated stocked medications in physician-staffed EMS vehicles. Overall, compared to a 2011 study, drug availability has improved. Most of the recommended medications are available in physician-staffed vehicles in Germany. The data from this study can be used by EMS throughout Germany to evaluate their preparedness.

Effect of mannitol on platelet function during elective craniotomy in adult patients with brain tumor

BACKGROUND

Mannitol is used in the treatment of raised intracranial pressure (ICP). The aim of this study was to investigate whether mannitol (MAN) leads to a relevant deterioration in platelet function in routine neurosurgical procedures.

METHODS

Thirty-eight patients undergoing elective craniotomy due to a brain tumor with elevated ICP were included. After induction of anaesthesia a blood sample was taken (T1). The patients then received 1 g-kg-1 MAN within 30 minutes. The second blood sample (T2) was obtained 60 minutes after T1. Blood samples were examined by means of aggregometry (Multiplate®) and PFA-100® tests.

RESULTS

No patient had clinical signs of increased bleeding. We could not find any deterioration in the aggregometry using Multiplate®, neither in the adenosinediphosphate (ADP), the arachidonic acid (ASPI), or the thrombin receptor activating protein (TRAP) test. PFA-100® closing times (cT) showed a significant prolongation between T1 and T2: collagen/adenosindiphosphate (COL/ADP) test 79s [70/99] and 91s [81/109]; p=0.002); collagen/epinephrine (COL/EPI) test 109s [92/129] and 122s [94/159]; p=0.0004). A subgroup analysis showed that the patients who received isotonic balanced infusions only, had no prolongation of cT, whereas the patients who received additionally gelatine solution had a significant prolongation.

COL/ADP

78s [70/98] and 91s [82/133]; p=0.0004). COL/EPI: test 111s [92/128] and 127s [103/146]; p=0.0026). Except for individual outliers, the measured values were in the normal range.

CONCLUSIONS

In this study, we found no clinically relevant deterioration of platelet function in neurosurgical patients with increased ICP after administration of MAN. Changes that occurred were all within normal ranges.

Influence of presence in an inter-professional simulation training of the emergency caesarean section: a cross-sectional questionnaire study

Purpose

Emergency training using simulation is a method to increase patient safety in the delivery room. The effect of individual training concepts is critically discussed and requires evaluation. A possible influence factor of success can be the perceived reality of the participants. The objective of this study was to investigate whether the presence in a simulated emergency caesarean section improves subjective effect of the training and evaluation.

Methods

In this observation study, professionals took part in simulated emergency caesarean sections to improve workflow and non-technical skills. Presence was measured by means of a validated questionnaire, effects and evaluation by means of a newly created questionnaire directly after the training. Primary outcome was a correlation between presence and assumed effect of training and evaluation.

Results

106 participants (70% of course participants) answered the questionnaires. Reliability of the presence scale was good (Cronbach’s alpha 0.72). The presence correlated significantly with all evaluated items of non-technical skills and evaluation of the course. The factor “mutual support” showed a high effect size (0.639), the overall evaluation of the course (0.395) and the willingness to participate again (0.350) a medium effect. There were no differences between the professional groups.

Conclusion

The presence correlates with the assumed training objectives and evaluation of the course. If training is not successful, it is one factor that needs to be improved.

Further development of crew resource management training : Needs assessment by means of teamwork-context analysis in anesthesia and intensive care teams

BACKGROUND

Teams in anesthesia and intensive care work as high responsibility teams (HRT). Success in this environment partly depends on the use of nontechnical skills which can be learned through simulation-based training. A teamwork context analysis could help to identify training requirements for crew resource management training.

MATERIAL AND METHODS

We used a multicentric observational cross-sectional study design utilizing survey methodology to evaluate the teamwork context of different work environments, using the 62-item TAKAI inventory. We surveyed anesthesia and intensive care staff from nine hospitals in Germany which provide varying levels of care.

RESULTS

In total, 128 people (44.5% male, 53.9% female) from 9 German hospitals participated in the study. The topics "interconnectedness: departments", "interconnectedness: information flow", "dynamics", "polytely", "velocity of the team's movement", "velocity of system changes", "hierarchy" and "hierarchy: leadership", "shared task mental model", "shared team mental model" and all aspects of the scale "adaptive behaviors" were identified as focal aspects to be implemented into Crew-Resource-Management (CRM) training for the evaluated work environments.

CONCLUSION

The TAKAI scales meet quality criteria (Cronbach's alpha > 0.6) and are appropriate for use in the analysis of the teamwork environment. The results indicate many similarities between the work contexts surveyed but also slight differences. TAKAI can be an additional method to design an appropriate simulation training program for HRT in anesthesia and intensive care medicine as there does not seem to be a one-size-fits-all simulation concept. For a special focus on the needs of a work context, the easy to perform TAKAI analysis in the needs analysis step is worthwhile.

Usage of power by different types of trainers in the education of paramedics - evaluation by means of a validated questionnaire

Objective: Emergency medical services are characterized by a high pressure to act. Dealing with trainees is a challenge. It is known, that the use of power in education subsists: power can be applied in a participative and restrictive way. We investigated the transferability of existing scales to the education system of Emergency medical service trainees. We hypothesized: a restrictive (a) and participative (b) use of power, can be demonstrated in Emergency medical service training, (c) the use of power by educators, who are responsible for theoretical learning, and instructors, who accompany trainees in real-life emergencies, are different and (d) the assessed participatory and restrictive use of power by trainers is negatively correlated. Methods: In a cross-sectional study, 206 trainees of Emergency medical service schools completed a questionnaire. The survey consists of 35 power related items regarding medical educators and practical instructors. Differences in the dimensions of power application were tested. The effect size and the correlation between power dimension were calculated. Results: The reliability of the scales was .92 (practical instructor) and .89 (medical educator) by removing one item. All subscales showed values with higher Cronbach's alpha than .68. Application of participative power differs (p<.00) between practical instructors (mean 64.7; SD 20.3) and medical educators (mean 55.3; SD 17.8). The participatory and the restrictive use of power correlated for medical educators significant negatively (r=-.48; p<.01). Conclusion: In both educator and instructor groups the use of participative power had a greater agreement that the use of restrictive techniques. The practical instructors used participative power slightly more often that did educators due to the dependency on the trainee as a team member. The context of the scales partially overlaps with other descriptions such as leadership and instructor quality.

Change of collective orientation through an interprofessional training with medical students and student nurses depending on presence and professional group

BACKGROUND

Teamwork is an important success factors for patient treatment. The willingness of a healthcare provider to work in a team can be descripted with the construct of "Collective Orientation" (CO). The level of CO can be trained and is related to team performance. In this study, we investigated the effect of a simulator-based interprofessional training on the subject of patient fall in a hospital setting upon participations CO. To evaluate whether the course could be integrated into a longitudinal education concept, the participants were medical students and student nurses. Since effects of simulations can be influenced by the perceived reality, the results were measured as a function of Presence.

METHOD

In this observation study, 62 medical students and student nurses took part in six one-day interprofessional simulation trainings with the topic patient fall. The primary outcome was the mean difference between the CO measured immediately before (T1) and after the training (T2). The Presence of the participants was measured by questionnaire immediately after the course (T2).

RESULTS

Cronbach´s alpha for all scales and measurement points was higher than 0.69. CO increases over all professional groups from M = 3.42 (SD = 0.39) to M = 3.68 (SD = 0.54) significantly (p < .00; r = .5). Only the subscale "Dominance" in the professional group of the student nurses did not increase significantly. There was no correlation between Presence and the change in CO.

CONCLUSION

The questionnaires of CO and Presence can be applied to medical students and student nurses. The simulation course with the topic patient fall influences the CO and can be integrated in a longitudinal curriculum of teamwork training. The subscale "Dominance" of student nurses did not change. Preparatory learning units may increase the effects. The perceived reality of the scenario is not a main success factor.

Training of airway management for anesthesia teams - Measurement of transfer into daily work routine by questionnaire

THEORY

Problems in airway management are rare in anesthesia but when they occur, they have serious consequences for the patient. For this reason, training is recommended for professionals involved in anesthetic care. Here we investigated, if a newly developed technical/ non-technical hybrid airway training would be relevant for daily practice in a tertiary referral hospital.

HYPOTHESES

We hypothesized that: (a) both parts of the validated questionnaires meet the quality criteria for the application in anesthesia teams, (b) even though the team regularly deals with airway management, airway management training is relevant to all professions and (c) contents of the developed training can be integrated into the behaviour of the teams.

METHOD

In this observational study, 104 professionals took part in a one-day technical/non-technical hybrid airway training programme. Participants received a questionnaire six months after training, based on selected scales of the validated tools; "Training Evaluation Inventory" and "Transfer Climate Questionnaire".

RESULTS

The scales of "perceived usefulness", "task cues" and "positive reinforcement" showed good internal consistency and all were rated higher than 3.9 on a 5-point Likert scale (1=complete rejection; 5=fullest approval). The scale "negative reinforcement and punishment" showed satisfactory internal consistency for physicians (rated 2.75 ± 0.8). By removing an item in each case, the scales "attitude towards training" (rated 4.93 ± 0.2) and "extinction" (rated 3.02 ± 0.8) showed satisfactory internal consistency for nurses and anesthetic technicians. "Social Cues" did not meet qualitative criteria. There was no difference in the assessment by the professional groups.

CONCLUSIONS

The presented training course was perceived as useful by both professional groups equally, which supported the interprofessional concept. The content was positively reinforced in practice six months after training and is relevant for professionals who are regularly confronted with the topic "airway management". Scales which meet qualitative criteria for only one profession and the scale "social cues" should be reconsidered in the context of an interprofessional team.

[Complications and success rates of subclavian vein catheterization depending on experience]

BACKGROUND

The infraclavicular puncture of the subclavian vein is a standard procedure for anesthetists. Meanwhile the literature and recommendations are clear and the use of real-time ultrasound guidance is the standard procedure; however, anesthetists will always get into special circumstances were they have to use the landmark technique, so this competence must be preserved. Feared complications of infraclavicular subclavian vein puncture are pneumothorax and arterial puncture. Up to now there is no clear learning curve for the infraclavicular subclavian vein puncture in the landmark technique performed by anesthetists.

OBJECTIVE

The aim of this study was to examine the influence of the puncture experience on the success rate and mechanical complications, such as pneumothorax and arterial puncture in patients who received an infraclavicular subclavian vein puncture with the landmark technique. Three levels of experience were defined for comparison: inexperienced 0-20 punctures, moderately experienced 21-50 and experienced over 50 punctures.

MATERIAL AND METHODS

Post hoc analysis of a previously published noninferiority study to examine the influence of ventilation on the pneumothorax rate in the subclavian vein puncture using the landmark technique. This analysis included 1021 anesthetized patients who were included in the original study between August 2014 and October 2017. Demographic data as well as the number of puncture attempts, puncture success, the overall rate of mechanical complications, pneumothorax rate and arterial puncture rates were calculated.

RESULTS

The overall rate of mechanical complications (pneumothorax + arterial puncture) was significantly higher in the inexperienced group (0-21) compared to the experienced group (>50, 15% vs. 8.5%, respectively, p = 0.023). This resulted in an odds ratio of 0.52 (confidence interval, CI: 0.32-0.85, p = 0.027). Likewise, the rate of puncture attempts in the group of inexperienced (0-20) with 1.85 ± 1.12 was significantly higher than in the group of experienced (>50, 1.58 ± 0.99, p = 0.004) and resulted in an odds ratio of 0.59 (CI: 0.31-0.96, p = 0.028). Although the puncture attempts of the moderately experienced (21-50) compared to the inexperienced (0-20) was not significant lower, we found an odds ratio of 0.69 (CI: 0.48-0.99, p = 0.042). The rate of successful puncture was 95.1% in the experienced group versus 89.3% in the inexperienced group (p = 0.001), which resulted in an odds ratio of 2.35 (CI: 1.28-4.31, p = 0.018). When viewed individually, no significant differences were found for pneumothorax and arterial puncture.

CONCLUSION

In this post hoc analysis of the puncture of the subclavian vein using the landmark technique, we found a significant reduction of puncture attempts and overall mechanical complications. At least 50 punctures seem to be necessary to achieve the end of the learning curve; however, the landmark technique should only be used under special circumstances, when real-time ultrasound is not available. Anesthetists who want to complete their repertoire and learn the landmark technique should always perform a static ultrasound examination before starting the puncture in order to reduce complications due to anatomical variations or thrombosis.

Current Approach for External Cephalic Version in Germany

Introduction Fetal breech presentation at terms occurs in 3 - 6% of pregnancies. External cephalic version can reduce the number of cesarean sections and vaginal breech deliveries. Different approaches are used to carry out external cephalic version. This study looked at the different approaches used in Germany and compared the approach used with the recommendations given in German and international guidelines. Material and Methods An anonymized online survey of 234 hospitals in Germany was carried out in 2018. In addition to asking about hospital structures, questions also focused on how external version was carried out in practice (preparations, tocolysis, anesthetics, etc.), on relative and absolute contraindications and on the success rate. Results 37.2% of the hospitals approached for the survey participated in the study. Of these, 98.8% performed external version procedures. The majority of participating hospitals were university hospitals (26.4%) and maximum care hospitals (35.6%) with an average number of more than 2000 births per year (60.9%). External cephalic version is the preferred (61.7%) obstetrical procedure to deal with breech presentation, rather than vaginal breech birth or primary cesarean section. 45.8% of respondents carry out external version procedures on an outpatient basis, and 42.1% of hospitals perform the procedure as an inpatient intervention, especially from the 37th week of gestation. Prior to performing an external version procedure, 21.6% of surveyed institutions carry out a vaginal examination to evaluate possible fixation of the fetal rump. 95.5% of institutions used fenoterol for tocolytic therapy; the majority using it for continuous tocolysis (70.2%). 1 - 3 attempts at external version (8.4%) were usually carried out by a specific senior physician. In most cases, no analgesics were administered. The reported rate of emergency cesarean sections was very low. The most common indication for emergency C-section was pathological CTG (56,7%). The assessment of relative and absolute contraindications varied, depending on the surveyed hospital. 67.5% asked patients to empty their bladders before carrying out external version, while 10.8% carried out external version when the bladder was filled. The reported success rate was more than 45%. After successful version, only 14.8% of hospitals arranged for patients to wear an abdominal binder. For 32.4%, the decision to apply an abdominal binder was taken on a case-by-case basis. Conclusion The approach used in Germany to carry out external cephalic version is based on the (expired) German guideline on breech presentation. Based on the evidence obtained, a number of individual recommendations should be re-evaluated. More recent international guidelines could be useful to update the standard procedure.

Expectations, training and evaluation of intensive care staff to an interprofessional simulation course in Germany - Development of a relevant training concept

Objective: Increasingly, intensive care units (ICU) are operated by teams of physicians and nurses with specialist training in anaesthesia and intensive care. The aims of our study were to evaluate any prior experience, expectations and the requisites for interprofessional ICU simulation-based training (SBT), and to evaluate a newly designed training course incorporating these findings. Methods: The study was laid out as a cross-sectional study and is projected in three steps. First, questionnaires were sent out to ICU nurses and physicians from 15 different hospitals in a greater metropolitan area (> million citizens). Based upon this survey a one-day ICU simulator course designed for 12 participants (6 nurses and 6 physicians) was developed, with evaluation data from four subsequent courses being analysed. Results: In the survey 40% of nurses and 57% of the physicians had had prior exposure to SBT. Various course formats were explored with respect to duration, day of the week, and group composition. After completing the course, the majority deemed a full working day in interprofessional setting to be most appropriate (p<0.001). The scenarios were considered relevant and had a positive impact on communication, workflow and coping with stress. Conclusion: Currently SBT is not a mainstream tool used by German ICU teams for further education, and this lack of familiarity must be taken into consideration when preparing SBT courses for them. We developed a nontechnical skills training course for ICU teams which was undertaken in the setting of simulated clinical scenarios (pertinent to their work environment). The participants found the course's content to be relevant for their daily work, rated the course's impact on their workplace practices as being good and advocated for longer training sessions.

Impact of Simulator-Based Crisis Resource Management Training on Collective Orientation in Anaesthesia: Pre-Post Survey Study With Interprofessional Anaesthesia Teams

THEORY

Individuals have different qualities, levels of willingness, and degrees of engagement for working in teams. This behaviour is termed 'Collective Orientation' (CO). Collective orientation can be trained and has a positive influence on team processes. Here, we investigated the effect of a simulator-based, Crisis Resource Management team training upon the participants' CO.

HYPOTHESES

We hypothesized (1) the scales of CO and Presence for lab-based microworld research (PLBMR) are applicable to the German anaesthesia teams, (2) the CO can be influenced by means of simulation training, (3) the training effect is dependent on sex and/or profession, and (4) the change of CO depends on the perceived presence of the participants in the scenario.

METHOD

In a pre-post study, 66 nurses and doctors from various anaesthetic departments took part in a 1-day training course to improve non-technical skills. The primary outcome was the mean difference between the CO measured (via questionnaires) immediately before (T1) and after (T2) training. The change was then tested for dependence upon other variables, such as sex, professional group, and immersion into the simulation scenarios.

RESULTS

Collective orientation improved significantly after training (mean difference: 0.2; P < .001; dz = 0.53). Considering the subscales, affiliation increased significantly (P < .001; dz = 0.59), whereas dominance remained unchanged. Furthermore, no correlation was found regarding sex, professional group, or immersion into the simulation scenarios.

CONCLUSIONS

Our study demonstrated that simulation-based training improves the participants' COs, primarily by increasing affiliation. Subjective scenario reality did not significantly influence this. Nonetheless, it remains unclear as to what factors categorically resulted in this benefit. The shared experience in the course by all team members might trigger the effects. However, further studies are needed to identify the modifiable factors that can improve teamwork attitudes.

Induction chemotherapy (IC) followed by radiotherapy (RT) versus cetuximab plus IC and RT in advanced laryngeal/hypopharyngeal cancer resectable only by total laryngectomy-final results of the larynx organ preservation trial DeLOS-II

Background

The German multicenter randomized phase II larynx organ preservation (LOP) trial DeLOS-II was carried out to prove the hypothesis that cetuximab (E) added to induction chemotherapy (IC) and radiotherapy improves laryngectomy-free survival (LFS; survival with preserved larynx) in locally advanced laryngeal/hypopharyngeal cancer (LHSCC).

Patients and methods

Treatment-naïve patients with stage III/IV LHSCC amenable to total laryngectomy (TL) were randomized to three cycles IC with TPF [docetaxel (T) and cisplatin (P) 75 mg/m2/day 1, 5-FU (F) 750 mg/m2/day days 1-5] followed by radiotherapy (69.6 Gy) without (A) or with (B) standard dose cetuximab for 16 weeks throughout IC and radiotherapy (TPFE). Response to first IC-cycle (IC-1) with ≥30% endoscopically estimated tumor surface shrinkage (ETSS) was used to define early responders; early salvage TL was recommended to non-responders. The primary objective was 24 months LFS above 35% in arm B.

Results

Of 180 patients randomized (July 2007 to September 2012), 173 fulfilled eligibility criteria (A/B: larynx 44/42, hypopharynx 41/46). Because of 4 therapy-related deaths among the first 64 randomized patients, 5-FU was omitted from IC in the subsequent 112 patients reducing further fatal toxicities. Thus, IC was TPF in 61 patients and TP in 112 patients, respectively. The primary objective (24 months LFS above 35%) was equally met by arms A (40/85, 47.1%) as well as B (41/88, 46.6%). One hundred and twenty-three early responders completed IC+RT; their overall response rates (TPF/TP) were 94.7%/87.2% in A versus 80%/86.0% in B. The 24 months overall survival (OS) rates were 68.2% and 69.3%.

Conclusions

Despite being accompanied by an elevated frequency in adverse events, the IC with TPF/TP plus cetuximab was feasible but showed no superiority to IC with TPF/TP regarding LFS and OS at 24 months. Both early response and 24 months LFS compare very well to previous LOP trials and recommend effective treatment selection and stratification by ETSS.

Clinical trial information

NCT00508664.

Changes of collective orientation through a medical student's anaesthesia simulation course - simulation-based training study with non-technical skills debriefing versus medical debriefing

BACKGROUND

Non-technical skills (NTS) are known to have a positive impact on quality of medical care. The team performance enhancing behaviour, as an example for NTS, is termed "Collective Orientation" (CO). In this study, we investigated the effect of a simulator-based anaesthesia training upon student's CO in relation to medical and TeamGAINS (guided team self-correction, advocacy-inquiry and systemic-constructivist techniques) debriefing. We hypothesized (a) the scale collective orientation, as demonstrated in other team setting, is applicable to fourth year German medical students, (b) collective orientation increases by a four-hour anaesthesia simulation course, (c) the change in collective orientation can be influenced by type of debriefing.

METHOD

All classes of an anaesthesia module (4th year medical students) were randomized into two groups. Students took part in a four-hour simulation course with team scenarios, supported by a simulated nurse. In group one the trainer focused on a debriefing on medical problems and in group two, a debriefing according to the specifications of the TeamGAINS concept was conducted. The primary outcome was the mean difference between the collective orientation measured (via questionnaires) immediately before (T1) and after (T2) training.

RESULTS

Cronbach's alpha for all scales and measurement points was higher than 0.72. The scale "affiliation" decreases in the group medical debriefing MD = 0.1 (p = 0.008; r = 0.31) and was unchanged in the group TeamGAINS. "Dominance" increases in both groups. The values were MD = 0.19 (p = 0.003; r = 0.25) for medical debriefing and MD = 0.22 (p = 0.01; r = 0.40) for TeamGAINS debriefing.

CONCLUSION

The collective orientation questionnaire can be applied to fourth year medical students. Simulation courses influence the attitude towards teamwork. The influence is negatively to the subscale "affiliation" by a "medical debriefing" and independently regardless of the nature of the debriefing for the subscale "dominance". We recommend a debriefing for medical students using the TeamGAINS approach to clarify the connection between the individual performance and non-technical skills. Anaesthesia simulation courses have the potential being a part of a longitudinal education curriculum for teaching non-technical skills.

Albumin combined with Mannitol impairs whole blood coagulation and platelet function in vitro

BACKGROUND

The indication of hydroxyethyl starch is currently under critical discussion and albumin 5% (ALB) has an increasing use in the operating theatre. Therefore, ALB is routinely used in neurosurgical procedures and often combined with mannitol 20% (MAN). Purpose of this in vitro study was to determine the influence of the combination of MAN and ALB on blood coagulation and platelet function.

METHODS

22 healthy volunteers were included into this study and 21 analysed. Blood was obtained and diluted into five groups: (1) 7% dilution with MAN, (2) 10% dilution with ALB (3) 17% dilution with isotonic balanced electrolyte solution, (4) 17% dilution with MAN + ALB and (5) undiluted blood as control group (CON). Rotational thrombelastometry via ROTEM® (EXTEM, FIBTEM-Test) and thrombocyte aggregometry via Multiplate® (ASPI, ADP and TRAP-test) were used to detect differences within the intervention groups and compared to the control group.

RESULTS

The maximum clot firmness in the FIBTEM test decreased under the normal range with the combination of MAN+ALB: 8mm (5.5-11) compared to CON: 15mm (12.5-20), p<0.05. Platelet function (ADP-test) showed significant decreases for ALB: 51 AUC (40-84) and MAN+ALB: 54 AUC (41-68) compared to CON: 92 AUC (75-101), p<0.05. Except in clotting time all other EXTEM tests of MAN+ALB subgroup showed significant impairment on blood coagulation compared to the control group.

CONCLUSIONS

In this in vitro study clinically relevant dilutions of MAN+ALB showed a significant inhibition of blood coagulation and platelet function. Further in vivo studies are necessary to confirm these results.

Instructors for on-the-job training of advanced paramedics - definition of competencies and development of a quality management tool for a "High Responsibility Organization"

Objective: The psychological demands placed upon the emergency medical services, assures them of their place amongst High Responsibility Organizations. A high pressure to act and an irreversibility of situations are integral features of their workplaces. After the emergency services' job profiles were restructured in Germany, the practical stage of paramedic training is now undertaken in these conditions. That is, they are trained by a supervising instructor whilst caring for critically ill patients. This paper aims to describe the requisite skills for such an instructor, formulate the associated competences as learning objectives, and develop a quality-measuring instrument for the description of training situations. Methods: The compilation of a competence catalogue was done via a two-step process: following a Delphi survey with an expert panel of practical trainers and trainees, a large cohort of parameters were validated in terms of their relevance. Those factors that formed scales together were identified. Results: After validating the results of the Delphi analysis, six scales (composed of 25 items in toto) were defined. They included the areas of "Training during times of action", "Training during periods of calm", "Background and practical relevance", "Character and personality traits", "Pedagogical competencies" and "Organizational behaviour". Conclusion: For the first time, a competency catalogue has been developed for instructors working in the emergency medical services from German-speaking countries. The catalogue focuses upon clinical training during the acute care of critically ill patients. The scales and items can be used for training-the-trainers, and also quality monitoring. Further research needs to focus on the application of the catalogue in clinical practice and evaluate the need for situational customization.

[Care of Patients During Emergency Caesarian Section - Evaluation of Quality Characteristics from the Patients Point of View]

BACKGROUND

An emergency caesarian section can be a terrifying experience for expectant mothers. Fear for her own life as well as her unborn child's is a traumatic event that can result in the development of post-traumatic stress disorder (PTSD). The aim of this survey was to define scales and items that describe the quality of care of parturients in cases of emergency caesarian section.

METHODS

A pool of items was developed via a 2-step online Delphi survey administered to women who had undergone an emergency caesarian section. The resulting parameters were evaluated for relevance and validity in a larger patient collective. Lastly, we identified factors that could be grouped into relevant scales.

RESULTS

After validating the results of the Delphi survey, 5 scales with 18 items were identified. They encompassed the following dimensions: "team external effect," "mother's level of information," "subjective evaluation," "personal integrity," and "after-care." These items could explain 58.2% of total variance and provide a stable factorial solution (KMO 0.76).

CONCLUSION

To our knowledge, this is the first time a German criteria checklist has been developed to evaluate the care of expectant mothers undergoing an emergency caesarian section. This checklist can be used in addition to medical outcomes to measure quality of care. Further studies are needed to evaluate practical implementation and its impact on patient care.

[Simulation as a Training Method for the Professionalization of Teams]

Simulation as an educational method can be applied to the training of processes, technical and non-technical skills. This article focuses on the role of simulation in crisis resource management and non-technical skills. A realistic work environment requires well-trained staff regarding simulation technology and communication. A training (unit) is divided into three sections. During the briefing the team is introduced to the scenario. Afterwards, the patient is treated by an interdisciplinary team. Communication under the pressure of action, even if one does not agree with the approach of the colleagues, should be practiced. After the scenario a structured debriefing is conducted. The trainer supervises the reflection of the teams' actions. Various methods such as "guided team self-correction", "advocacy-inquiry" and the "TeamGAINS"-approach are available for this decisive phase of the training. A safe environment is guaranteed, video recordings will never leave the training. Active experimentation, concrete experiences and accurate reflection are the key factors of success for the method simulation. Positive effects on critical incidents, resuscitation outcome and improvement of team climate can be observed after simulation training.

[Interdisciplinary Simulation of Emergency Caesarean Section to Improve Subjective Competence]

The emergency caesaran section is a gynecological emergency situation which is potentially life-threatening for mother and child. In the management of these time-critical situations human factors as well as the competence of the crisis resource management team have been shown to be important factors for success. The concept "simulation" has not been validated as a training tool for professional competence of multidisciplinary teams in the delivery suite. The aim of this study was, to assess the competence gain by subjective evaluation of the team members after taking part in an emergency caesarian section training which is integrable into the daily clinic setting. Method 36 members of a multidisciplinary team of a delivery suite took part in a 4-hourly "high-fidelity" simulation training "emergency caesarian section". Scenarios were created around the case setting of eclampsia with bradycardia of the child, uterus rupture, placenta abruption and cord prolapse. Each participant was involved in 2 scenarios as either a spectator or a team member. Using a questionnaire, the course performance and debriefing were evaluated and the subjective professional competence in Crisis Resource Management were recorded. Results  In the collective of the trainee (over/equal 5 years), 25% had no experience in any cases of emergency caesarean in practice. On a scale of 1 to 6 (1=very good, 6=fail) the course was given an overall mark of 1.4 and a mark of 1.8 for its relevance to daily work. 6 months after the training, participants rated their competencies in prioritising necessary actions, following treatment plans, communicating among the team members as well as integrating new information as significantly improved. Conclusion  The 4-hour simulation training can be easily integrated into everyday clinical practice. The participants marked the course scenarios as realistic and relevant for their clinical practice. The number of years of prior work experience is not significanty related with the experience in rare emergency situations. The interdisciplinary team training is a way to improve individual performance as well as to establish and practise interdisciplinary emergency concepts.

Nomogram based overall survival prediction in stereotactic body radiotherapy for oligo-metastatic lung disease

BACKGROUND

Radical local treatment of pulmonary metastases is practiced with increasing frequency due to acknowledgment and better understanding of oligo-metastatic disease. This study aimed to develop a nomogram predicting overall survival (OS) after stereotactic body radiotherapy (SBRT) for pulmonary metastases.

PATIENTS AND METHODS

A multi-institutional database of 670 patients treated with SBRT for pulmonary metastases was used as training cohort. Cox regression analysis with bidirectional variable elimination was performed to identify factors to be included into the nomogram model to predict 2-year OS. The calibration rate of the nomogram was assessed by plotting the actual Kaplan-Meier 2-year OS against the nomogram predicted survival. The nomogram was externally validated using two separate monocentric databases of 145 and 92 patients treated with SBRT for pulmonary metastases.

RESULTS

The median follow up of the trainings cohort was 14.3months, the 2-year and 5-year OS was 52.6% and 23.7%, respectively. Karnofsky performance index, type of the primary tumor, control of the primary tumor, maximum diameter of the largest treated metastasis and number of metastases (1 versus >1) were significant prognostic factors in the Cox model (all p<0.05). The calculated concordance-index for the nomogram was 0.73 (concordance indexes of all prognostic factors between 0.54 and 0.6). Based on the nomogram the training cohort was divided into 4 groups and 2-year OS ranged between 24.2% and 76.1% (predicted OS between 30.2% and 78.4%). The nomogram discriminated between risk groups in the two validation cohorts (concordance index 0.68 and 0.67).

CONCLUSIONS

A nomogram for prediction of OS after SBRT for pulmonary metastases was generated and externally validated. This tool might be helpful for interdisciplinary discussion and evaluation of local and systemic treatment options in the oligo-metastatic setting.

KEY MESSAGE

A nomogram for prediction of overall survival after stereotactic body radiotherapy (SBRT) for pulmonary metastases was developed and externally validated. This tool might be helpful for interdisciplinary discussion and evaluation of local and systemic treatment options in the oligo-metastatic setting.

Simulating a patient's fall as a means to improve routine communication: Joint training for nursing and fifth-year medical students

BACKGROUND

Physicians and nursing staff interact as a team on a daily basis in hospital settings. However, both educational paths offer few opportunities to establish contact with the other professional group. Neither professional group can practice its later role with the other group in a "safe" learning environment. Routine interprofessional collaboration is described as being in need of great improvement and carries with it the potential for conflict. To improve interprofessional communication and task management, a simulation-based emergency training session for nursing students and fifth-year medical students was developed at the KRH Klinikum Nordstadt in Hanover, Germany. As a pilot project, the course was held twice in the form of a one-day session with ten nursing and four medical students.

PROJECT

Using the example of a patient's fall, course participants were able to observe and actively treat multiple simulated patients. Following each simulation the trainer conducted a comprehensive debriefing. The course was then evaluated using a questionnaire.

RESULTS

The evaluation of the team training showed a high level of acceptance among the two participating professional groups. On a scale of 1 (hardly applicable) to 5 (strongly applicable), the course was given a 4 by both professional groups for its relevance to daily work. In the open-ended written responses praise was specifically given for the opportunity to learn how to switch perspectives as a result of the simulation exercises.

CONCLUSION

A common emergency on the hospital ward offers a good opportunity to establish and practice interprofessional team skills. With the knowledge gained about communication and the ability to change viewpoints, participants are able to improve their team skills. Participants demonstrated a high degree of acceptance for the training program.

Simulating a patient's fall as a means to improve routine communication: Joint training for nursing and fifth-year medical students

BACKGROUND

Physicians and nursing staff interact as a team on a daily basis in hospital settings. However, both educational paths offer few opportunities to establish contact with the other professional group. Neither professional group can practice its later role with the other group in a "safe" learning environment. Routine interprofessional collaboration is described as being in need of great improvement and carries with it the potential for conflict. To improve interprofessional communication and task management, a simulation-based emergency training session for nursing students and fifth-year medical students was developed at the KRH Klinikum Nordstadt in Hanover, Germany. As a pilot project, the course was held twice in the form of a one-day session with ten nursing and four medical students.

PROJECT

Using the example of a patient's fall, course participants were able to observe and actively treat multiple simulated patients. Following each simulation the trainer conducted a comprehensive debriefing. The course was then evaluated using a questionnaire.

RESULTS

The evaluation of the team training showed a high level of acceptance among the two participating professional groups. On a scale of 1 (hardly applicable) to 5 (strongly applicable), the course was given a 4 by both professional groups for its relevance to daily work. In the open-ended written responses praise was specifically given for the opportunity to learn how to switch perspectives as a result of the simulation exercises.

CONCLUSION

A common emergency on the hospital ward offers a good opportunity to establish and practice interprofessional team skills. With the knowledge gained about communication and the ability to change viewpoints, participants are able to improve their team skills. Participants demonstrated a high degree of acceptance for the training program.

Generation of prostate IMAT plans adaptable to the inter-fractional changes of patient geometry

We present the results of 2-Step generation of adaptable IMAT plans for prostate carcinoma cases. The 2-Step IMAT plans show clinical and dosimetric equivalence to the reference SmartArc™-generated VMAT plans. The 2-Step plans are adapted to inter-fractional changes of prostate-rectum geometry using 2-Step adaptation rules for a cohort of ten adaptation cases. The adapted 2-Step IMAT plans show statistically significant improvement (Wilcoxon 1-tail p < 0.05) of target coverage and of rectum sparing when compared to isocenter relocated plans.

Patients with recurrent glioblastoma multiforme. Initial experience with p-[(131)I]iodo-L-phenylalanine and external beam radiation therapy

AIM

The objective of this study was to assess the feasibility, dosimetry, tolerability and efficacy of systemically administrated p-[(131)I]iodo-L-phenylalanine ((131)IPA) combined with hypo-fractionated external beam radiation therapy (EBRT) in patients with recurrent glioblastoma multiforme (GBM).

PATIENTS, METHODS

Five patients (2 women, 3 men, aged 27-69) with recurrent GBM and exhaustion of regular therapy options were included. All had a positive O-(2-[(18)F]Fluoroethyl)-L-tyrosine positron emission tomography (FET-PET) and pretherapeutic dosimetry was performed. Tumour targeting was verified by (131)IPA-SPECT up to six days after radiotracer administration. After (131)IPA therapy, patients were treated with hypo-fractionated EBRT in six fractions of 5 Gy (n = 4) or in eleven fractions of 2 Gy in one case.

RESULTS

Based on the individual dosimetry, the patients received a single intravenous administration of 2 to 7 GBq of (131)IPA, resulting in radiation absorbed doses to the blood of 0.80-1.47 Gy. The treatment was well tolerated; only minor complaints of nausea and vomiting that responded to ondansetron and pantoprazol were noticed in the first two patients. After preventive medication, the last three patients had no complaints during therapy. In none of the patients a decrease of leukocyte or thrombocyte counts below the baseline level or the lower normal limit was observed. Tumour doses from (131)IPA were low (≤ 1 Gy) and all patients died three to eight (median 5.5) months after therapy.

CONCLUSION

In this initial experience, treatment of GBM with (131)IPA in combination with EBRT was demonstrated to be safe and well tolerated, but less effective than suggested by the animal studies.

Comparison of preoperative short-course radiotherapy and long-course radiochemotherapy for locally advanced rectal cancer

BACKGROUND

The purpose of this work was to perform a single institution comparison between preoperative short-course radiotherapy (SC-RT) and long-course radiochemotherapy (LC-RCHT) for locally advanced rectal cancer.

METHODS

A total of 225 patients with clinical stage UICC II-III rectal cancer were treated with SC-RT (29 Gy in 10 twice daily fractions followed by immediate surgery; n = 108) or LC-RCHT (54 Gy in 28 fractions with simultaneous 5-fluorouracil (5-FU) ± oxaliplatin chemotherapy followed by delayed surgery; n = 117). All patients in the LC-RCHT cohort and patients in the SC-RT with pathological UICC stage ≥ II received adjuvant chemotherapy. Before 2004, the standard of care was SC-RT with LC-RCHT reserved for patients where downstaging was considered as required for sphincter preservation or curative resection. In the later period, SC-RT was practiced only for patients unfit for radiochemotherapy.

RESULTS

Patients in the LC-RCHT cohort had a significantly higher proportion of cT4 tumors, clinical node positivity, and lower tumor location. The 5-year local control (LC) and overall survival (OS) were 91% and 66% without differences between the SC-RT and LC-RCHT groups. Acute toxicity was increased during LC-RCHT (grade ≥ II 1% vs. 33%) and there were no differences in postoperative complications. Severe late toxicity grade ≥ III was increased after SC-RT (12% vs. 3%). Of patients aged >  80 years, 7 of 7 patients and 4 of 9 patients received curative surgery after SC-RT and LC-RCHT, respectively.

CONCLUSION

Despite the fact that patients with worse prognostic factors were treated with LC-RCHT, there were no significant differences in LC and OS between the SC-RT and LC-RCHT group. Age > 80 years was identified as a significant risk factor for LC-RCHT and these patients could be treated preferably with SC-RT.