Johannes Wacker

Adrenergic receptor genotype but not perioperative bisoprolol therapy may determine cardiovascular outcome in at-risk patients undergoing surgery with spinal block: the Swiss Beta Blocker in Spinal Anesthesia (BBSA) study: a double-blinded, placebo-controlled, multicenter trial with 1-year follow-up

Background:Neuraxial blockade is used as primary anesthetic technique in one third of surgical procedures. The authors tested whether bisoprolol would protect patients at risk for cardiovascular complications undergoing surgery with spinal block. Methods:The authors performed a double-blinded, placebo-controlled, multicenter trial to compare the effect of bisoprolol with that of placebo on 1-yr composite outcome including cardiovascular mortality, nonfatal myocardial infarction, unstable angina, congestive heart failure, and cerebrovascular insult. Bisoprolol was given orally before and after surgery for a maximum of 10 days. Adrenergic receptor polymorphisms and safety outcome measures of bisoprolol therapy were also determined. Results:A total of 224 patients were enrolled. Spinal block could not be established in 5 patients. One hundred ten patients were assigned to the bisoprolol group, and 109 patients were assigned to the placebo group. The mean duration of treatment was 4.9 days in the bisoprolol group and 5.1 days in the placebo group. Bisoprolol therapy reduced mean heart rate by 10 beats/min. The primary outcome was identical between treatment groups and occurred in 25 patients (22.7%) in the bisoprolol group and 24 patients (22.0%) in the placebo group during the 1-yr follow-up (hazard ratio, 0.97; 95% confidence interval, 0.55–1.69; P = 0.90). However, carriers of at least one Gly allele of the β1-adrenergic receptor polymorphism Arg389Gly showed a higher number of adverse events than Arg homozygous (32.4% vs. 18.7%; hazard ratio, 1.87; 95% confidence interval, 1.04–3.35; P = 0.04). Conclusions:Perioperative bisoprolol therapy did not affect cardiovascular outcome in these elderly at-risk patients undergoing surgery with spinal block.

Speaking up is related to better team performance in simulated anesthesia inductions: an observational study.

BACKGROUND:Our goal in this study was to test the relationship between speaking up—i.e., questioning, correcting, or clarifying a current procedure—and technical team performance in anesthesia. Hypothesis 1: team members’ higher levels of speaking up are related to higher levels of technical team performance. Hypothesis 2: team members will react to speaking up by either clarifying their procedure or initiating a procedural change. Hypothesis 3: higher levels of speaking up during an earlier phase of teamwork will be related to higher levels of speaking up during a later phase. METHODS:This prospective observational study involved 2-person ad hoc anesthesia teams performing simulated inductions of general anesthesia with minor nonroutine events (e.g., bradycardia) in a large teaching hospital. Subjects were registered anesthesia nurses and residents. Each team consisted of 1 nurse and 1 resident. Synchronized video and vital parameter recordings were obtained. Two trained observers blinded to the hypotheses coded speaking up and further team communication and coordination behavior on the basis of 12 distinct categories. All teamwork measures were quantified as percentage of total time spent on the respective teamwork category. Two experienced staff anesthesiologists blinded to the hypotheses evaluated technical team performance using a Delphi-validated rating checklist. Hypotheses 1 and 3 were tested using linear regression with residents’ and nurses’ levels of speaking up as 2 separate predictor variables. Hypothesis 2 was analyzed using lag sequential analysis, resulting in Z values representing the extent to which the observed value for a conditional transition significantly differs from its unconditional value. RESULTS:Thirty-one nurses and 31 residents participated. Technical team performance could be predicted by the level of speaking up from nurses (R2 = 0.18, P = 0.017) but not from residents (R2 = 0.19, P = 0.053); this result supports Hypothesis 1 for nurses. Supporting Hypothesis 2, residents reacted to speaking up with clarifying the procedure by providing information (Z = 18.08, P < 0.001), initiating procedural change by giving instructions (Z = 4.74, P < 0.001) and team member monitoring (Z = 3, P = 0.0013). Likewise, nurses reacted with clarifying the procedure by providing or evaluating information (Z = 16.09, P < 0.001; Z = 3.72, P < 0.001) and initiating procedural change by providing assistance (Z = 0.57, P < 0.001). Indicating a trend for Hypothesis 3, nurses’ level of speaking up before intubation predicted their level of speaking up during intubation (R2 = 0.15, P = 0.034), although this did not reach the Bonferroni-corrected significance level of P = 0.025. No respective relationship was found for residents (R2 = 0.15, P = 0.096). CONCLUSIONS:This study provides empirical evidence and shows mechanisms for the positive relationship between speaking-up behavior and technical team performance.

Interactions of Team Mental Models and Monitoring Behaviors Predict Team Performance in Simulated Anesthesia Inductions

In the present study, we investigated how two team mental model properties (similarity vs. accuracy) and two forms of monitoring behavior (team vs. systems) interacted to predict team performance in anesthesia. In particular, we were interested in whether the relationship between monitoring behavior and team performance was moderated by team mental model properties. Thirty-one two-person teams consisting of anesthesia resident and anesthesia nurse were videotaped during a simulated anesthesia induction of general anesthesia. Team mental models were assessed with a newly developed measurement tool based on the concept-mapping technique. Monitoring behavior was coded by two organizational psychologists using a structured observation system. Team performance was rated by two expert anesthetists using a performance-checklist. Moderated multiple regression analysis revealed that team mental model similarity moderated the relationship between team monitoring and performance; a higher level of team monitoring in the absence of a similar team mental model had a negative effect on performance. Furthermore, team mental model similarity and accuracy interacted to predict team performance. Our findings provide new insights on factors influencing the relationship between team processes and team performance in health care. When investigating the effectiveness of a specific team coordination behavior, team cognition has to be taken into account. This represents a necessary and compelling extension of the popular process-outcome relationship on which previous teamwork research in health care has focused. Moreover, the current study adds further external validity to the concept of team mental models by highlighting its usefulness in health care.

Managing Nonroutine Events in Anesthesia: The Role of Adaptive Coordination

Objective: This field study aimed at examining the role of anesthesia teams’ adaptive coordination in managing changing situational demands, such as in nonroutine events (NREs). Background: Medical teams’ ability to adapt their teamwork (e.g., their coordination activities) to changing situational demands is crucial to team performance and, thus, to patient safety. Whereas the majority of previous studies on the matter have focused on critical but rare events, it has recently been pointed out that the effective management of NREs is a key challenge to medical teams. Hence this study investigated the relationship between coordination activities, NRE occurrence, and team performance. Method: We videotaped 22 anesthesia teams during standard anesthesia induction and recorded data from the vital signs monitor and the ventilator. Coordination was coded by a trained observer using a structured observation system. NREs were recorded by an experienced staff anesthesiologist using all three video streams. Checklist-based team performance assessment was also performed by an experienced staff anesthesiologist. Results: We found that anesthesia teams adapt their coordination activities to changing situational demands. In particular, the increased occurrence of NREs caused an increase in the time the teams spent on task management. A stronger increase in the teams’ task management (i.e., more adaptive coordination) was related to their performance. Conclusion: Our results emphasize the importance of adaptive coordination in managing NREs effectively. Application: This study provides valuable information for developing novel team training programs in health care that focus on adaptation to changing task requirements, for example, when faced with NREs.

Leadership in anaesthesia teams: the most effective leadership is shared

Background Leadership plays a crucial role in teams working in complex environments, and research has shown that shared leadership where all team members perform leadership functions is an effective strategy. The authors aimed to describe shared leadership patterns during anaesthesia induction and show how they are linked to team performance. Methods 12 anaesthesia teams consisting of one resident and one nurse during a simulated anaesthesia induction including a non-routine event (asystole) were videotaped, and two kinds of leadership behaviour (content-oriented and structuring) were coded. Team performance was operationalised as the reaction time to the non-routine event. The amount of leadership sharedness was compared between low- and high-performing teams by performing a univariate analysis of variance. Wilcoxon signed-rank tests were used to analyse the distribution of the two kinds of leadership behaviour among team members. Results Statistical analysis revealed that in high-performing teams, residents and nurses shared their leadership, while in low-performing teams, residents showed significantly higher levels of leadership behaviour than nurses. Further analyses revealed different distributions of leadership functions among team members. While residents of low-performing teams assumed both kinds of leadership behaviour, members of high-performing teams seemed to have distinct leadership roles: nurses mainly used content-oriented leadership behaviour, and residents tended to show structuring leadership behaviour. Conclusions The study documents the effectiveness of shared leadership in situations with high task complexity and indicates that a clear distribution of content-oriented and structuring leadership among team members is an effective strategy. The findings have implications for training in shared leadership and also give rise to a number of recommendations for further research. ClinicalTrials (http://www.clinicaltrials.gov) registration number is NCT00706108.

Adaptation in anaesthesia team coordination in response to a simulated critical event and its relationship to clinical performance

BACKGROUND Recent studies in anaesthesia and intensive care indicate that a teams ability to adapt its coordination activities to changing situational demands is crucial for effective teamwork and thus, safe patient care. This study addresses the relationship between adaptation of team coordination and markers of clinical performance in response to a critical event, particularly regarding which types of coordination activities are used and which team member engages in those coordination activities. METHODS Video recordings of 15 two-person anaesthesia teams (anaesthesia trainee plus anaesthesia nurse) performing a simulated induction of general anaesthesia were coded, using a structured observation system for coordination activities. The simulation involved a critical event-asystole during laryngoscopy. Clinical performance was assessed using two separate reaction times related to the critical event. RESULTS Analyses of variance revealed a significant effect of the critical event on team coordination: after the occurrence of the asystole, team members adapted their coordination activities by spending more time on information management-a specific type of coordination activity (F(1,28)=15.17, P=0.001). No significant effect was found for task management. The increase in information management was related to faster decisions regarding how to respond to the critical event, but only for trainees and not for nurses. CONCLUSIONS Our findings support the claim that adaptation of coordination activities is related to improved team performance in healthcare. Moreover, adaptation and its relationship to team performance were found to vary with regard to type of coordination activities and team member.

Monitoring and talking to the room: autochthonous coordination patterns in team interaction and performance

This paper builds on and extends theory on team functioning in high-risk environments. We examined 2 implicit coordination behaviors that tend to emerge autochthonously within high-risk teams: team member monitoring and talking to the room. Focusing on nonrandom patterns of behavior, we examined sequential patterns of team member monitoring and talking to the room in higher- and lower-performing action teams working in a high-risk health care environment. Using behavior observation methods, we coded verbal and nonverbal behaviors of 27 anesthesia teams performing an induction of general anesthesia in a natural setting and assessed team performance with a Delphi-validated checklist-based performance measure. Lag sequential analyses revealed that higher-performing teams were characterized by patterns in which team member monitoring was followed by speaking up, providing assistance, and giving instructions and by patterns in which talking to the room was followed by further talking to the room and not followed by instructions. Higher- and lower-performing teams did not differ with respect to the frequency of team member monitoring and talking to the room occurrence. The results illustrate the importance of patterns of autochthonous coordination behaviors and demonstrate that the interaction patterns, as opposed to the behavior frequencies, discriminated higher- from lower-performing teams. Implications for future research and for team training are included. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Substitutes for leadership in anaesthesia teams and their impact on leadership effectiveness

In this study we aim to increase our understanding of leadership in anaesthesia teams by investigating the relationship between substitutes for leadership, leadership behaviour, and team performance in situations with varying levels of routine and standardization. The present study relied on video recordings of 12 anaesthesia teams in a simulated setting with the occurrence of a nonroutine event. Clinical team performance was measured by the speed of adequate team reaction to this event. The leadership behaviours observed were coded either as content oriented (e.g., information transmission) or structuring (e.g., assigning tasks). Results showed that leadership behaviour changed depending upon the level of routine of a situation, the degree of standardization, and, to some extent, on the experience of team members. Leadership tends to be positively related to team performance during nonroutine and low standardized situations but negatively related to team performance in routine and highly standardized situations. Furthermore, leadership is only slightly related to team member experience. This study improves our understanding of influences of substitutes for leadership on successful leadership behaviour in anaesthesia teams. The findings also lead to suggestions for both further research and the enhancement of team leadership in critical care.

The influence of standardisation and task load on team coordination patterns during anaesthesia inductions

Background: The use of different forms of coordination according to situational demands plays a crucial role in teams working in complex environments. This study aimed to describe patterns of coordinative actions (CAs) as they occur during anaesthesia induction and to analyse the influence of two crucial situational factors on these patterns, namely the amount of existing standards and the level of task load. Methods: 23 anaesthesia inductions were videotaped, and CAs of the anaesthesia teams were coded. The coding system distinguished between implicit and explicit coordination, coordination via leadership and heedful inter-relating as the individual effort to reach smooth coordination. Five phases within anaesthesia inductions were determined according to their level of standardisation and task load. Results: Overall, 67.7% of all CAs were rated as explicit CA and 32.3% as implicit CAs. When we considered the duration of those CAs, we found the reverse tendency (coordination was explicit 40% of the time and implicit 60% of the time). In highly standardised phases, we observed less explicit coordination, less leadership behaviour and less heedful interrelating compared with less standardised phases. In high-task-load phases, we observed more heedful interrelating than in low-task-load phases. Conclusions: The anaesthesia teams relied greatly on implicit coordination, which contrasts with findings indicating a performance benefit through explicit coordination in other work settings. Standardisation in the form of written departmental directives may have a supportive effect on coordination by partially substituting for other forms of coordination. The effect of high task load should be tested further in a simulator setting, where high task load can be induced in a more controlled fashion.

Stem cell-like human endothelial progenitors show enhanced colony-forming capacity after brief sevoflurane exposure: preconditioning of angiogenic cells by volatile anesthetics.

BACKGROUND: Endothelial progenitor cells play a pivotal role in tissue repair, and thus are used for cell replacement therapies in “regenerative medicine.” We tested whether the anesthetic sevoflurane would modulate growth or mobilization of these angiogenic cells. METHODS: In an in vitro model, mononuclear cells isolated from peripheral blood of healthy donors were preconditioned with sevoflurane (3 times 30 min at 2 vol% interspersed by 30 min of air). Colony-forming units were determined after 9 days in culture and compared with time-matched untreated control. Using magnetic cell sorting, CD133+/CD34+ endothelial progenitors were enriched from human umbilical cord blood, and vascular endothelial growth factor (VEGF), VEGFR2 (KDR), granulocyte colony-stimulating factor (G-CSF), STAT3, c-kit, and CXCR4 expressions were determined in sevoflurane-treated and untreated cells by real-time reverse transcriptase polymerase chain reaction. In a volunteer study with crossover design, we tested whether sevoflurane inhalation (<1 vol% end-tidal concentration) would mobilize endothelial progenitor cells from the bone marrow niche into the circulation using flow cytometry of peripheral blood samples. VEGF and G-CSF plasma levels were also measured. RESULTS: In vitro sevoflurane exposure of mononuclear cells enhanced colony-forming capacity and increased VEGF mRNA levels in CD133+/CD34+ cord blood cells (P = 0.017). Sevoflurane inhalation in healthy volunteers did not alter the number of CD133+/CD34+ or KDR+/CD34+ endothelial progenitors in the circulation, but increased the number of colony-forming units (P = 0.034), whereas VEGF and G-CSF plasma levels remained unchanged. CONCLUSIONS: Sevoflurane preconditioning promotes growth and proliferation of stem cell-like human endothelial progenitors. Hence, it may be used to promote perioperative vascular healing and to support cell replacement therapies.