[Latent safety threats in a pediatric emergency department: Using in situ simulation to test a new trauma room concept]

INTRODUCTION

Structured emergency room concepts have been shown to contribute to patient safety. Until now there has been no uniform emergency room concept for critically ill and seriously injured children and adolescents in the emergency room at the Altona Children's Hospital in Hamburg. This concept has been newly developed in interdisciplinary cooperation and includes the use of new clinical premises as well as new responsibilities and team compositions. The introduction of new processes and rooms for handling emergencies is associated with a risk of overlooking latent safety deficiencies or detecting them only after the process has been implemented. This may have a direct impact on patient safety. Before moving to new clinical premises, in situ simulation can be helpful to identify and to resolve latent safety threats in advance. Therefore, this method was chosen to test the newly created emergency room concept in the future emergency room at the Altona Children's Hospital.

METHODS

Two in situ simulations were carried out in the future real emergency room. Latent safety threats detected by the observation team and the participants (medical and nursing staff of the Altona Children's Hospital from the departments of pediatric surgery, traumatology, orthopedics, pediatrics, anesthesia, intensive care medicine, radiology, emergency medicine) were collected using free text notes after the simulations and evaluated retrospectively. In order to better deal with these latent safety threats, the observations were classified into different categories: working environment (e.g., lack of equipment, unfavorable positioning of material), process (e.g., lack of defined responsibilities in the team) and other safety threats that did not fall into one of the two categories defined.

RESULTS

A total of 51 latent safety threats were identified during the two in situ simulations. Of these, 22 (43.1%) were assigned to the "working environment" category, 20 (39.2%) to the "process" category and 9 (17.7%) to the "other safety threats" category. Of the latent safety threats identified, 46 (90.2 %) could be resolved before the emergency room was put into operation. For the non-recoverable safety threats, safety concepts were developed in order to further minimize the risk of patient hazard.

DISCUSSION

With the help of this study, it could be shown that the implementation of in situ simulation before the commissioning of new clinical premises and the introduction of new processes can contribute to the detection of latent safety threats in an interdisciplinary German pediatric emergency department.

A comparison of intervention and conservative treatment for angulated fractures of the distal forearm in children (AFIC): study protocol for a randomized controlled trial

Background

Angulated fractures of the distal forearm are very frequent lesions in childhood. Currently, there are no standard guidelines on whether these children should be treated conservatively with a cast; with reduction and a cast; or with reduction, pinning and a cast under anesthesia.

Minor prospective and retrospective studies have shown that the distal physis of the forearm possesses high remodeling capacity leading to reliable correction of malalignment.

The aim of this trial is to answer the question about whether operative and conservative treatment show equivocal results.

Methods/Design

This is a prospective, multinational, multicenter, randomized, observer-blinded, actively controlled, parallel group trial, with 24 months of observation.

The primary objective of this trial is to assess whether or not the long-term functional outcome in remodeling patients is inferior to patients receiving closed reduction and K-wire pinning.

The trial should include 742 patients with acute fracture. The patients will be included in 30 medical centers in Germany, Switzerland and Austria.

All patients 5 to 11 years of age presenting at the emergency department with an angulated distal fracture of the forearm will be randomized online after informed consent.

The primary endpoint is the Cooney Score after 24 months. The secondary endpoint is the grade of radiological displacement at 12/24 months.

Discussion

Therapy of angulated fractures is a matter of intensive debate. Primary manipulation and pinning under general anesthesia is recommended in order to avoid malalignment. No major study has proven the advantage of manipulation and pinning over immobilization alone. Should remodeling appear to be a safe alternative, manipulation under general anesthesia, K-wire pinning and removal of pins could be avoided, thus sparing significant costs.

Trial registration

DRKS00004874, 30 October 2013.

[Do paediatric and adult surgeons follow different approaches to physeal fractures?]

INTRODUCTION

The treatment of paediatric fractures is the concern of several different surgical specialties. There has been no scientific investigation on the different concepts of paediatric (PS) and adult surgeons (AS).

METHODS

62 paediatric traumatologists were asked concerning their experience with physeal fractures of the leg, including ten cases.

RESULTS

Growth disturbances was estimated to be more rare by PS. On evaluation of the examples there were no significant differences in the judgement of degree and direction of the displacement. For displaced fractures, PS rather preferred closed reduction and immobilisation, whereas AS favoured osteosynthesis.

DISCUSSION

There were no basic differences between PS and AS in the treatment of lower limb fractures. AS tend to act more invasively. At the same time they are more concerned about growth disturbances.

Does the evocation of traumatic memories confound subsequent working memory performance in posttraumatic stress disorder (PTSD)?

The role of heightened arousal has been previously discussed as a contributor to neurocognitive impairment in posttraumatic stress disorder (PTSD). To investigate whether psychological effects (distraction, re-location of resources) elicited by the evocation of traumatic memories impact on subsequent cognitive performance in PTSD, two parallel versions of a working memory task were administered to 33 trauma-exposed participants (15 with and 18 without PTSD). Between first and second working memory assessment a trauma-related interview was conducted including the narration of the trauma. Levels of working memory impairment in PTSD patients remained unchanged. This study provides preliminary evidence that neurocognitive impairment is not secondary to psychological effects induced by the evocation of traumatic memories. Nevertheless, it is recommended that future PTSD research should devote more care to the order in which trauma-related and other dependent variables such as cognitive tests are presented to participants.

[Fractures close to the epiphysis in children. Part I: upper extremities]

Fractures in children require special knowledge and skills due to the differences in biological and biomechanical properties of growing skeletons. Children suffer from fractures of the upper extremities much more than fractures of the lower extremities. While fractures of the diaphysis have a high regenerative and proliferation potential, impairment of the growth plate with consecutive disturbance of growth can be found more often in fractures close to the epiphysis. Most epiphysis fractures in children can be identified by a set of 2-plane X-ray images but precise knowledge about the skeletal maturation is required. In order to correctly decide about treatment regimes (conservative versus operative treatment) the limitations and limits of the ability of bone to correct misalignment must be anticipated. Clinical examination following fracture healing is mandatory to recognize differences in length, misalignment and deficits in function, which should receive further treatment.

[The new curriculum for surgery in Hamburg, Germany]

In October 2004, the medical faculty of Hamburg University started a program to restructure completely clinical teaching according to new state regulations of June 2002. In this new curriculum design, the surgical disciplines were horizontally and vertically interconnected and integrated, with a focus on practical training and problem-based teaching. This study describes the concept of clinical teaching and presents the student evaluation results of the first four blocks with a focus on performance in surgical disciplines. There was high student satisfaction with the new program, compared with results before October 2004 and also with respect to other disciplines within the new curriculum. This was especially true for the practical courses in the newly established skills lab. Future developments in e-learning and practical teaching in the skills lab are necessary to overcome restrictions on medical education due to changes in the German health care system.

Expression of integrin alpha2beta1 in axons and receptive endings of neurons in rat, hairy skin

Integrin alpha2beta1 has been considered as a mechano-chemical transducer in endothelial and muscle cells. However, little data is available to show whether integrins play a role in the process of mechanical transduction in peripheral mechanosensory neurons. Using immunohistochemistry, we demonstrate that cutaneous neurons express the extracellular matrix (ECM) receptor integrin alpha2beta1. Specifically, we show that integrins alpha2 and beta1 are co-localized with peripherin in the receptive endings of cutaneous neurons in rat, hairy skin. Integrin immunofluorescence was minimal along the axons of large diameter neurons. These results, together with findings by other investigators, provide evidence suggesting that integrin alpha2beta1 may be a linking agent between mechanical stress in the ECM and modulation of the neuronal response of mechanically sensitive neurons.

A prospective, randomised comparison of single- vs. multiple-dose antibiotic prophylaxis in penetrating trauma

This study was designed to compare the clinical efficacy of a single dose of ceftriaxone with cefoxitin given 3 times a day for 3 days.

METHODS

Patients had to have a penetrating injury to only one part of the body, reach the hospital within 2 h and be operated on within 16 h after the trauma. Patients were excluded if it appeared likely that they would require mechanical ventilation for more than 24 h. The same applies to open or grade II/III craniocerebral trauma. The end point was the occurrence of infections within 10 days. The costs of antibiotic treatment were also calculated.

RESULTS

96% of the ceftriaxone patients (n = 97) and 95% of the cefoxitin group (n = 98) remained infection-free. In neither treatment group was deep infection, abscess, phlegmon or sepsis seen. No additional surgery or intensive care due to infection was required. At $41.83 vs. $172.16, the average total cost of delivering antibiotic treatment was significantly lower in the ceftriaxone group (p < 0.001).

CONCLUSION

Prophylaxis in penetrating trauma with a single dose of ceftriaxone is safe and has considerable practical and economic advantages.

[Biologic reactions to calcium phosphate ceramic implantations. Results of animal experiments]

Calciumphosphate-ceramics have been intensively investigated as bone replacement materials for more than twenty years. In consequence to numerous experimental as well as clinical implantations Tricalciumphosphate-ceramic and Hydroxyapatite-ceramic proved to be the most suitable substances. Nevertheless, due to several shortcomings, these synthetic bone replacement materials can up to now in no way replace autogenous bone, the 'golden standard', for all indications of the clinical setting. The reason for this is that despite our ever increasing knowledge of materials' and host bed properties we still are unable to securely predict the outcome after the implantation of such synthetic substitutes. The article reviews the most important biological reactions in mammals and explains the underlying causes.

[Forearm fractures in children]

A total of 285 children out of an 8 year period with fractures of the forearm were studied. Of these 175 (62.2%) had a fracture of the distal radius and 51 (18.2%) had a fracture of the distal forearm and there were 42 (14.7%) fractures in the middle or proximal third in this region. Three children with injuries of the distal radial epiphysis had to be treated by percutaneous wire fixation. Except for 2 cases who needed surgery all severe dislocated forearm fractures could be treated by closed reduction. In all cases the children were immobilized with a long upper arm cast for 3 to 4 weeks. Follow-up examinations up to 6 years after injury showed excellent results in distal forearm and distal radial fractures whereas results were only satisfactory in midshaft forearm fractures.

[20 years of selective coronary angiography (1968-1987). The indications, results and therapeutic consequences]

10,975 diagnostic left-heart catheterizations, performed between 1968 and 1987 in 8,436 men and 2,539 women, were analysed regarding indication, results and therapeutic implications. 6,974 patients (64%) had coronary heart disease, 2,573 (23%) a valvar defect and 849 a cardiomyopathy. The proportion of patients with coronary heart disease increased from 21% to 74% during the 20-year period, while that of patient with valvar defects fell from 52% to under 19%. Severe cardiac complications in relation to the procedure occurred in 0.88%, ending fatally in 8 patients (0.07%). 61% of patients with coronary heart disease and 31% of those with valvar defects were treated conservatively. Percutaneous transluminal coronary angioplasty (PTCA) gradually became more common after its introduction in 1977. In 1987, PTCA was indicated as often as a bypass operation.