Umfrage zur aktuellen Situation der Regionalanästhesie im deutschsprachigen Raum

The practice of regional anaesthesia in German speaking countries was investigated by a survey. The first part of the trilogy contains the presentation and evaluation of the data about quality assurance and training concepts. In 2002 questionnaires were mailed to 750 randomly selected departments of anaesthesia and 384 hospitals participated (51.2%). The overall proportion of regional anaesthesia was 23% and in Switzerland it was significantly higher (adults: 48%; children: 31%). Of the hospitals 19% had no person who was responsible for quality assurance. The number of puncture attempts was unlimited in 59% of the hospitals. The first training steps were observed closely (complete observation: 81%). The exact beginning (48%) and end (15%/13%) of the training were often not fixed, 80% of all anaesthesia departments requested an improvement in the training for peripheral and 53% for neuroaxial regional anaesthesia techniques. Regional anaesthesia plays a highly important role. Concepts of training and quality assurance that are backed up by evidence-based medicine should be worked out to improve the training and further education in regional anaesthesia.     

Classification and consequences of errors in otolaryngology

Objective: To develop a preliminary classification system for errors in otolaryngology. Methods: A retrospective, anonymous survey was distributed to 2,500 members of the American Academy of Otolaryngology–Head and Neck Surgery (AAO‐HNS). Respondents were asked whether an error had occurred in their practice in the last 6 months, and if so, to describe the error, its consequences, and any corrective action taken. Results: There were 466 (18.6%) responses. Two hundred ten (45% of respondents) otolaryngologists reported 216 errors. A classification system for errors in otolaryngology was developed. Errors were classified as related to history and physical (1.4%), differential or final diagnosis (1.4%), testing (10.4%), surgical planning (9.9%), wrong‐site surgery (6.1%), anesthesia‐related (3.3%), wrong drug/dilution on the surgical field (3.8%), technical (19.3%), retained foreign body (0.9%), equipment‐related (9.4%), postoperative care (8.5%), medical management (13.7%), nursing/ancillary (0.5%), administrative (6.6%), communication (3.8%), and miscellaneous (0.9%). There were 78 cases of major morbidity and 9 deaths. If these data are representative, there may be more than 2,600 episodes of major morbidity and more than 165 deaths related to medical error in otolaryngology patients annually. Conclusions: Human error in otolaryngology occurs in all practice components, including diagnostic, treatment, surgical, communication, and administrative. Types of errors reported by otolaryngologists differ from those reported by other specialists. Error classification systems may need to reflect each specialty's realm of practice. Errors in otolaryngology cause appreciable morbidity and mortality. Quantitative study of errors and the development of targeted prevention and amelioration strategies should be a high priority.     

Evaluation of reliability for urine mucopolysaccharidosis screening by dimethylmethylene blue and Berry spot tests

BACKGROUND: The mucopolysaccharidosis (MPS) are a group of inherited metabolic disorders resulting from the deficiency of the enzyme responsible for intralysosomal catabolism of glycosaminoglycans (GAGs). GAGs are progressively accumulated in multiple tissues and released into the corporal fluids. The first laboratory approximation to MPS diagnosis is the identification of an increased urinary GAG excretion. For this, several semiquantitative and quantitative methods have been developed. The aim of this retrospective statistical study was to evaluate the reliability of MPS urine screening for the semiquantitative Berry spot test (BST) and the quantitative dimethylmethylene blue test (DMB). METHODS: The 24-h-urine samples (n = 246) were tested through BST, DMB, and for GAG excretion pattern by one-dimensional electrophoresis or thin layer chromatography. RESULTS: the 204 samples that demonstrated a normal GAG excretion pattern were considered as non-MPS samples. Forty-two samples presented an abnormal GAG excretion pattern. Enzyme analysis was available for 31 out of 42 patients (31/42), confirming that all were affected by MPS. Urinary GAG concentrations of MPS patients by DMB were increased 1.04- to 7.1-folds, compared to age-related normal levels. The sensitivity was 100% for DMB and 93.6% for BST. DMB demonstrated a specificity of 74.5%, while BST a specificity of 53.9%. The specificity of MPS screening increased to 84.3%, considering conjunctly DMB and BST. CONCLUSION: The DMB is a sensitive method, however, inclusion of BST could increase the specificity of MPS urine screening.     

Entwicklung eines Fragebogens zur Erfassung der Qualität der Narkoseaufklärung

Zusammenfassung Als Beitrag zur Versorgungsforschung im stationären Sektor wurde in der vorliegenden Arbeit ein Fragebogen entwickelt, um die anästhesiologische Patientenaufklärung zur Vollnarkose hinsichtlich ihrer Effekte auf die Versorgungsqualität zu untersuchen. Der hierfür entwickelte Fragebogen gliedert sich in einen Fragenteil zur Patientenzufriedenheit und einen Fragenteil zum Informationsgewinn durch die Narkoseaufklärung. In einer ersten Phase wurde der Fragebogen generiert und anschließend anhand von 104 allgemein- und gefäßchirurgischen Patienten der Universität Heidelberg validiert und überarbeitet. Aufgrund der im Pretest gewonnenen Erkenntnisse konnte eine Reduktion des vorläufigen Fragenpools erzielt werden. Somit besteht der endgültige Fragebogen aus 6 Fragen zur Patientenzufriedenheit und aus 6 Fragen zum Informationsgewinn nach der Narkoseaufklärung sowie einer Frage nach der Anzahl vorausgegangener Narkoseaufklärungsgespräche. Im Fragebogenteil zur Patientenzufriedenheit können Angaben auf einer 6-stufigen Skala von –3 ("Aussage trifft nicht zu") bis +3 ("Aussage trifft zu") gemacht werden. Den Bewertungen von –3 bis +3 können Punktwerte von 1–6 zugeordnet werden, um einen aussagekräftigen Punktwertsummenscore als Maß für die "Patientenzufriedenheit" zu erhalten. Der Fragebogenteil zum Informationsgewinn erhält geschlossene Fragen mit jeweils 4 vorgegebenen Antwortmöglichkeiten, hierbei ist jeweils nur eine Antwortalternative dieser Multiple-choice-Fragen durch Ankreuzen als zutreffend zu markieren. Analog zur Messung der Patientenzufriedenheit kann auch hier der Punktwertsummenscore als Maß für den "Informationsgewinn" durch die Narkoseaufklärung errechnet werden. Die vorliegende Arbeit zeigt auf, wie mit einem Fragebogen die Qualität der medizinischen Versorgung bei der anästhesiologischen Aufklärung anhand der Effektparameter "Patientenzufriedenheit" und "Informationsgewinn" evaluiert werden kann. Ein solcher Fragebogen eignet sich zum Vergleich verschiedener Aufklärungsverfahren und kann somit zu einer Verbesserung der Patientenversorgung beitragen.

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Colour Doppler imaging of the interspinous and epidural space

BACKGROUND AND OBJECTIVE: In recent studies, ultrasonic diagnostic imaging has proved useful in the screening of the trajectory of the epidural needle. With regard to possible side-effects of spinal and epidural anaesthesia caused by vessel injury, we aimed to evaluate the usability of Colour Doppler imaging for the depiction of interspinous vessels in prepuncture examination. METHODS: Ultrasonic examination of the L3/4 interspace area was performed in 20 volunteers. Using a 4-MHz and a 7-MHz probe with B-mode and Colour Doppler imaging, respectively, we compared four settings for the quality of vessel depiction in the puncture area. Overall resolution was evaluated according to the distinction of landmarks. Vascular structures were identified by pulsation (B-mode) or blood flow (Doppler). RESULTS: Colour Doppler imaging of the L3/4 interspace was unachievable using the 7-MHz transducer. Vessel detection was possible in 50% of the B-mode images and in all of the 4-MHz Doppler images. Vessels were perceptible from a diameter of 0.5 mm. Veins were the predominantly visible structures. Overall vessel visibility was best using 4-MHz Colour Doppler. CONCLUSIONS: Prepuncture Doppler imaging can provide the epiduralist with information regarding the position of vessels in the needle trajectory. This might help to reduce complications in regional anaesthesia.     

Network therapy: decreased secondary opioid use during buprenorphine maintenance

Network therapy (NT) employs family members and/or friends to support compliance with an addiction treatment carried out in office practice. This study was designed to ascertain whether NT is a useful psychosocial adjunct, relative to a control treatment, for achieving diminished illicit heroin use for patients on buprenorphine maintenance. Patients agreeing to randomization to either NT (N = 33) or medication management (MM, N = 33) were inducted onto short-term buprenorphine maintenance and then tapered to zero dose. NT resulted in significantly more urine toxicologies negative for opioids than MM (65% vs. 45%) and more NT than MM patients (50% vs. 23%) experienced a positive outcome relative to secondary heroin use by the end of treatment. The use of NT in office practice may therefore improve the effectiveness of eliminating secondary heroin use during buprenorphine maintenance. It may also be useful in enhancing compliance with an addiction treatment regimen in other contexts.     

Introducing the electronic patient record (EPR) in a hospital setting: boundary work and shifting constructions of professional identities

Today's healthcare sector is being transformed by several ongoing processes, among them the introduction of new technologies, new financial models and new ways of organising work. The introduction of the electronic patient record (EPR) is representative and part of these extensive changes. Based on interviews with health personnel and office staff in a regional hospital in Norway, and with health administrators and information technology service-centre staff in the region, the article examines how the introduction of the EPR, as experienced by the participants, affects the work practices and boundaries between various professional groups in the healthcare system and discusses the implications this has for the understanding of medical practice. The article shows how the EPR has become part of the professionals' boundary work; expressing shifting constructions of professional identities.