Publications by authors named "Bastian Grande"

22 Publications

  • Page 1 of 1

Associations of form and function of speaking up in anaesthesia: a prospective observational study.

Br J Anaesth 2021 Sep 9. Epub 2021 Sep 9.

Simulation Centre, University Hospital Zurich, Zurich, Switzerland; ETH Zurich, Zurich, Switzerland. Electronic address:

Background: Speaking up with concerns in the interest of patient safety has been identified as important for the quality and safety of patient care. The study objectives were to identify how anaesthesia care providers speak up, how their colleagues react to it, whether there is an association among speak up form and reaction, and how this reaction is associated with further speak up.

Methods: Data were collected over 3 months at a single centre in Switzerland by observing 49 anaesthesia care providers while performing induction of general anaesthesia in 53 anaesthesia teams. Speaking up and reactions to speaking up were measured by event-based behaviour coding.

Results: Instances of speaking up were classified as opinion (59.6%), oblique hint (37.2%), inquiry (30.7%), and observation (16.7%). Most speak up occurred as a combination of different forms. Reactions to speak up included short approval (36.5%), elaboration (35.9%), no verbal reaction (26.3%), or rejection (1.28%). Speaking up was implemented in 89.1% of cases. Inquiry was associated with an increased likelihood of recipients discussing the respective issue (odds ratio [OR]=13.6; 95% confidence interval [CI], 5.9-31.5; P<0.0001) and with a decreased likelihood of implementing the speak up during the same induction (OR=0.27; 95% CI, 0.08-0.88; P=0.03). Reacting with elaboration to the first speak up was associated with decreased further speak up during the same induction (relative risk [RR]=0.42; 95% CI, 0.21-0.83; P=0.018).

Conclusion: Our study provides insights into the form and function of speaking up in clinical environments and points to a perceived dilemma of speaking up via questions.
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http://dx.doi.org/10.1016/j.bja.2021.08.014DOI Listing
September 2021

Pulmonary fibrosis combined with lung cancer following lung transplantation: should we do more?

Transl Lung Cancer Res 2021 Mar;10(3):1588-1593

Department of Thoracic Surgery and Organ Transplantation, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.

Currently, lung transplantation is the standard of care for patients with end-stage lung disease, with interstitial lung disease (ILD) being the most common reason in the recent years In the other hand, in cases where stage II and III lung cancer have been identified following lung transplantation, long-term survival outcomes are poor when compared to lung cancer patients that have not received a lung transplant because the use of immunosuppressant and the problem of rejection and infection and the treatment of recurrence and so on. However, there is no statistical difference observed in stage I (pT1N0M0) patients. In this paper we report about a patient with ILD receiving left lung transplantation in the early time. A lesion of the right lung which was considered the normal ILD tissue and without enough attention. Post-transplant it showed progress and finally the whole right lung (native lung) was occupied by the tumor. Some ground glass changes could also be found in the transplanted lung several months later. A secondary lung transplant was performed for this patient, and there has been no postoperative recurrence thus far. For lung transplant patients with high-risk factors, effective surveillance methods are required for the early detection of lung cancer.
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http://dx.doi.org/10.21037/tlcr-21-46DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8044479PMC
March 2021

Avatar-based patient monitoring in critical anaesthesia events: a randomised high-fidelity simulation study.

Br J Anaesth 2021 May 8;126(5):1046-1054. Epub 2021 Apr 8.

Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland. Electronic address:

Background: Failures in situation awareness cause two-thirds of anaesthesia complications. Avatar-based patient monitoring may promote situation awareness in critical situations.

Methods: We conducted a prospective, randomised, high-fidelity simulation study powered for non-inferiority. We used video analysis to grade anaesthesia teams managing three 10 min emergency scenarios using three randomly assigned monitoring modalities: only conventional, only avatar, and split-screen showing both modalities side by side. The primary outcome was time to performance of critical tasks. Secondary outcomes were time to verbalisation of vital sign deviations and the correct cause of the emergency, perceived workload, and usability. We used mixed Cox and linear regression models adjusted for various potential confounders. The non-inferiority margin was 10%, or hazard ratio (HR) 0.9.

Results: We analysed 52 teams performing 154 simulations. For performance of critical tasks during a scenario, split-screen was non-inferior to conventional (HR=1.13; 95% confidence interval [CI], 0.96-1.33; not significant in test for superiority); the result for avatar was inconclusive (HR=0.98; 95% CI, 0.83-1.15). Avatar was associated with a higher probability for verbalisation of the cause of the emergency (HR=1.78; 95% CI, 1.13-2.81; P=0.012). We found no evidence for a monitor effect on perceived workload. Perceived usability was lower for avatar (coefficient=-23.0; 95% CI, -27.2 to -18.8; P<0.0001) and split-screen (-6.7; 95% CI, -10.9 to -2.4; P=0.002) compared with conventional.

Conclusions: This study showed non-inferiority of split-screen compared with conventional monitoring for performance of critical tasks during anaesthesia crisis situations. The patient avatar improved verbalisation of the correct cause of the emergency. These results should be interpreted considering participants' minimal avatar but extensive conventional monitoring experience.
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http://dx.doi.org/10.1016/j.bja.2021.01.015DOI Listing
May 2021

Predictors of blood loss in lung transplant surgery-a single center retrospective cohort analysis.

J Thorac Dis 2019 Nov;11(11):4755-4761

Department of Anesthesiology, University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland.

Background: This retrospective study aims to identify clinical predictors of intraoperative blood loss during lung transplantation. While for other surgical specialties predictors of blood loss have been identified such as previous likewise located surgery, poor preoperative health status of patients, blood coagulation status, and use of extra corporeal circulation, predictors of blood loss during lung transplantation are not yet established.

Methods: A total of 326 lung transplants were performed between January 2000 and February 2014 at a tertiary hospital. The primary aim was to associate blood loss with the following potential predictors: pulmonary arterial hypertension, pre- or intraoperative extracorporeal life support (ECLS), previous thoracic surgery, previous lung transplant, and Charlson Comorbidity Index (CCI). Postoperative complications and 30-day mortality were secondary endpoints of the study.

Results: Median estimated blood loss during lung transplant was 1,500 mL (IQR, 1,000-2,875 mL). Pre- and intraoperative ECLS (P=0.02, P<0.001) independently increased blood loss by 59% and 107%, respectively. The higher blood loss during re-transplant marginally missed the significance level (P=0.05). Pulmonary arterial hypertension, previous thoracic surgery and high CCI were not associated with increased blood loss. As secondary outcomes, postoperative complications were more common in patients with a higher blood loss (P=0.04) but was not associated with higher 30-day mortality (P=0.18).

Conclusions: Pre- and intraoperative ECLS were significant risk factors for higher blood loss during lung transplantation. Higher blood loss was associated with higher incidence of postoperative complications but not with a higher 30-day mortality.
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http://dx.doi.org/10.21037/jtd.2019.10.61DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6940236PMC
November 2019

Establishing a non-intubated thoracoscopic surgery programme for bilateral uniportal sympathectomy.

Swiss Med Wkly 2019 Apr 17;149:w20064. Epub 2019 Apr 17.

Department of Thoracic Surgery, University Hospital Zurich, Switzerland.

Aim Of The Study: Non-intubated, video-assisted thoracoscopic surgery (NiVATS) has been successfully developed in several centres worldwide. Local anaesthesia techniques and techniques to perform thoracoscopic surgery on a spontaneously breathing lung are the two key elements which must be adopted to establish a NiVATS programme. We established NiVATS by performing bilateral, uniportal sympathectomies, and compared it to classical video-assisted thoracoscopic surgery (VATS) under general anaesthesia with double-lumen intubation.

Methods: Ten consecutive bilateral VATS sympathectomies were compared with ten consecutive NiVATS procedures. Nineteen of the procedures were for palmar hyperhidrosis and one was for facial blushing. Duration of anaesthesia, surgery and hospitalisation, perioperative complications, side effects and quality of life before and after sympathectomy were analysed.

Results: Median age was 26.5 years (range 17–55) and mean BMI in the NiVATS group was 21.8 (range 19.1–26.3). NiVATS sympathectomies were performed as outpatient procedures significantly more often (9/10 vs 3/10, p = 0.008). Quality of life was significantly increased after sympathectomy in all patients, with no significant differences between the NiVATS and the VATS groups. There were no differences between the two groups regarding compensatory sweating (40 vs 50%, p = 0.66). The duration of anaesthesia, not including the time required for the surgery, was significantly shorter in the NiVATS group (p <0.001). The duration of surgery, from the first local anaesthesia until the last skin suture, was significantly longer in the NiVATS group (p = 0.04), but showed a constant decline during the learning curve, from 95 minutes initially to 48 minutes for the last procedure. Costs were significantly lower in the NiVATS group (p = 0.04).

Conclusion: Thoracoscopic sympathectomy is a suitable procedure with which to establish a NiVATS programme. Patients are usually young and of healthy weight, facilitating the learning curve for the local anaesthesia techniques and the surgery. Compared to VATS, sympathectomy is more likely to be performed as an outpatient procedure and has a lower cost, while safety and efficacy are maintained.
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http://dx.doi.org/10.4414/smw.2019.20064DOI Listing
April 2019

What is the best strategy for one-lung ventilation during thoracic surgery?

J Thorac Dis 2018 Dec;10(12):6404-6406

Institute of Anesthesiology, Kantonsspital Winterthur, Winterthur, Switzerland.

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http://dx.doi.org/10.21037/jtd.2018.11.100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6344735PMC
December 2018

Anaesthesia management for bronchoscopic and surgical lung volume reduction.

J Thorac Dis 2018 Aug;10(Suppl 23):S2738-S2743

Department of Anaesthesiology and Intensive Care Medicine, University Medical Center, Freiburg, Germany.

Optimizing the patient's condition before the lung volume reduction (LVR) according to recommendations by American College of Cardiology/American Heart Association (ACC/AHA) guideline on perioperative cardiovascular evaluation is mandatory. Implementation of a multimodal analgesia concept and the use short-acting anaesthetics enhances recovery and avoids postoperative pulmonary complications. Normovolemia, normothermia, lung protective ventilation and an evidence-based concept of airway management (i.e., double-lumen tube, bronchus blocker) are suggested for intraoperative management of surgical lung volume reduction (SLVR). General anaesthesia (using remifentanil, propofol and mivacurium) with an i-gel supraglottic airway device should be used for bronchoscopic lung volume reduction (BLVR). Jet ventilation through rigid bronchoscopy or with a jet catheter may be an alternative concept. Experienced consultants should perform anaesthesia for LVR.
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http://dx.doi.org/10.21037/jtd.2018.02.46DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129807PMC
August 2018

Established and potential predictors of blood loss during lung transplant surgery.

J Thorac Dis 2018 Jun;10(6):3845-3848

Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.

Lung transplantation is an established therapeutic procedure for end stage lung diseases. Its success may be impaired by perioperative complications. Intraoperative blood loss and the resulting blood transfusion are among the most common complications. The various factors contributing to increased blood loss during lung transplantation are only scarcely investigated and not yet completely understood. This is in sharp contrast to other surgical fields, as in orthopedic surgery, liver transplantation and cardiac surgery the contributors to blood loss are well identified. This narrative review article aims to highlight the acknowledged factors influencing blood loss in lung transplantation (such as double vs. single lung transplant) and to discuss potential factors that may be of interest for further research or helpful to develop strategies targeting risk factors in order to minimize blood loss during lung transplantation and finally improve patient outcome.
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http://dx.doi.org/10.21037/jtd.2018.05.165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6051840PMC
June 2018

Difficult airway management and training: simulation, communication, and feedback.

Curr Opin Anaesthesiol 2017 Dec;30(6):743-747

aInstitute of Anesthesiology bSimulation Center cInstitute of Anesthesiology, University Hospital of Zurich, Zurich, Switzerland.

Purpose Of Review: Successful and sustainable training and learning of the management of difficult and normal airway is essential for all clinically active anesthesiologists. We emphasize the importance of a continuously updated learning and training environment based on actual knowledge, best available equipment, standardized procedures, and educational theory.

Recent Findings: In the past, most of the training were based on 'learning by doing' under the supervision of superiors or experienced colleagues. This has been recognized as insufficient and training has evolved to its recent level by structuring it into technical, methodological, and behavioral components. Additionally, a large part of it has been shifted away from learning on patients to simulated scenarios in designated environments. The contents, structure, components, and succession of components have been refined according to the steadily evolving and available instruments. Increasingly, team interaction and behavioral aspects gained more attention and became part of standardized education units that are tailored to the learners' clinical role and level of experience.

Summary: We present the details of the Zurich Airway Training and Simulation program, which has been constantly updated to the actual state of knowledge and available equipment.
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http://dx.doi.org/10.1097/ACO.0000000000000523DOI Listing
December 2017

How to debrief teamwork interactions: using circular questions to explore and change team interaction patterns.

Adv Simul (Lond) 2016 15;1:29. Epub 2016 Nov 15.

1University Hospital Zurich, Simulation Center, Rämistrasse 100, 8091 Zurich, Switzerland.

We submit that interaction patterns within healthcare teams should be more comprehensively explored during debriefings in simulation-based training because of their importance for clinical performance. We describe how can be used for that purpose. Circular questions are based on social constructivism. They include a variety of systemic interviewing methods. The goals of circular questions are to explore the mutual dependency of team members' behavior and recurrent behavior patterns, to generate information, to foster perspective taking, to "fluidize" problems, and to put actions into relational contexts. We describe the nature of circular questions, the benefits they offer, and ways of applying them during debriefings.
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http://dx.doi.org/10.1186/s41077-016-0029-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806384PMC
November 2016

SafAIRway: an airway training for pulmonologists performing a flexible bronchoscopy with nonanesthesiologist administered propofol sedation: A prospective evaluation.

Medicine (Baltimore) 2016 Jun;95(23):e3849

Institute of Anesthesiology Simulation Center, University Hospital Zurich ETH Zurich Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland.

Nonanesthesiologist administered propofol (NAAP) sedation for flexible bronchoscopy is controversial, because there is no established airway management (AM) training for pulmonologists. The aim was to investigate the performance and acceptance of a proposed AM algorithm and training for pulmonologists performing NAAP sedation. The algorithm includes using 3 maneuvers including bag mask ventilation (BMV), laryngeal tube (LT), and needle cricothyrotomy (NCT). During training (consisting of 2 sessions with a break of 9 weeks in between), these maneuvers were demonstrated and exercised, followed by 4 consecutive attempts to succeed with each of these devices. The primary outcome was the improvement of completion time needed for a competent airway. Secondary outcomes were the trainees' overall reactions to the training and algorithm, and the perceptions of psychological safety (PS). The 23 staff members of the Department of Pulmonology performed a total of 552 attempts at AM procedures (4 attempts at each of the 3 maneuvers in 2 sessions), and returned a total of 42 questionnaires (4 questionnaires were not returned). Median completion times of LT and NCT improved significantly between Sessions 1 and 2 (P = 0.005 and P = 0.04, respectively), whereas BMV was only marginally improved (P = 0.05). Trainees perceived training to be useful and expressed satisfaction with this training and the algorithm. The perception of PS increased after training. An AM algorithm and training for pulmonologists leads to improved technical AM skills, and is considered useful by trainees and raised their perception of PS during training. It thus represents a promising program.
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http://dx.doi.org/10.1097/MD.0000000000003849DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907671PMC
June 2016

Hands-Off Time for Endotracheal Intubation during CPR Is Not Altered by the Use of the C-MAC Video-Laryngoscope Compared to Conventional Direct Laryngoscopy. A Randomized Crossover Manikin Study.

PLoS One 2016 19;11(5):e0155997. Epub 2016 May 19.

Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland.

Introduction: Sufficient ventilation and oxygenation through proper airway management is essential in patients undergoing cardio-pulmonary resuscitation (CPR). Although widely discussed, securing the airway using an endotracheal tube is considered the standard of care. Endotracheal intubation may be challenging and causes prolonged interruption of chest compressions. Videolaryngoscopes have been introduced to better visualize the vocal cords and accelerate intubation, which makes endotracheal intubation much safer and may contribute to intubation success. Therefore, we aimed to compare hands-off time and intubation success of direct laryngoscopy with videolaryngoscopy (C-MAC, Karl Storz, Tuttlingen, Germany) in a randomized, cross-over manikin study.

Methods: Twenty-six anesthesia residents and twelve anesthesia consultants of the University Hospital Zurich were recruited through a voluntary enrolment. All participants performed endotracheal intubation using direct laryngoscopy and C-MAC in a random order during ongoing chest compressions. Participants were strictly advised to stop chest compression only if necessary.

Results: The median hands-off time was 1.9 seconds in direct laryngoscopy, compared to 3 seconds in the C-MAC group. In direct laryngoscopy 39 intubation attempts were recorded, resulting in an overall first intubation attempt success rate of 97%, compared to 38 intubation attempts and 100% overall first intubation attempt success rate in the C-MAC group.

Conclusion: As a conclusion, the results of our manikin-study demonstrate that video laryngoscopes might not be beneficial compared to conventional, direct laryngoscopy in easily accessible airways under CPR conditions and in experienced hands. The benefits of video laryngoscopes are of course more distinct in overcoming difficult airways, as it converts a potential "blind intubation" into an intubation under visual control.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0155997PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4873178PMC
July 2017

Simulation With PARTS (Phase-Augmented Research and Training Scenarios): A Structure Facilitating Research and Assessment in Simulation.

Simul Healthc 2015 Jun;10(3):178-87

From the Institute of Anesthesiology (C.J.S., A.M., M.D., A.K., D.R.S., B.G.), University Hospital Zürich; and Department of Management, Technology, and Economics Organization (M.W., M.K., G.G.), Work and Technology Group, ETH Zürich, Zürich, Switzerland.

Introduction: Assessment in simulation is gaining importance, as are scenario design methods increasing opportunity for assessment. We present our approach to improving measurement in complex scenarios using PARTS [Phase-Augmented Research and Training Scenarios], essentially separating cases into clearly delineated phases.

Methods: We created 7 PARTS with real-time rating instruments and tested these in 63 cases during 4 weeks of simulation. Reliability was tested by comparing real-time rating with postsimulation video-based rating using the same instrument. Validity was tested by comparing preintervention and postintervention total results, by examining the difference in improvement when focusing on the phase-specific results addressed by the intervention, and further explored by trying to demonstrate the discrete improvement expected from proficiency in the rare occurrence of leader inclusive behavior.

Results: Intraclass correlations [3,1] between real-time and postsimulation ratings were 0.951 (95% confidence interval [CI], 0.794-0.990), 1.00 (95% CI, --to--), 0.948 (95% CI, 0.783-0.989), and 0.995 (95% CI, 0.977-0.999) for 3 phase-specific scores and total scenario score, respectively. Paired t tests of prelecture-postlecture performance showed an improvement of 14.26% (bias-corrected and accelerated bootstrap [BCa] 95% CI, 4.71-23.82; P = 0.009) for total performance but of 28.57% (BCa 95% CI, 13.84-43.30; P = 0.002) for performance in the respective phase. The correlation of total scenario performance with leader inclusiveness was not significant (rs = 0.228; BCa 95% CI. -0.082 to 0.520; P = 0.119) but significant for specific phase performance (rs = 0.392; BCa 95% CI, 0.118-0.632; P = 0.006).

Conclusions: The PARTS allowed for improved reliability and validity of measurements in complex scenarios.
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http://dx.doi.org/10.1097/SIH.0000000000000085DOI Listing
June 2015

Briefing and debriefing during simulation-based training and beyond: Content, structure, attitude and setting.

Best Pract Res Clin Anaesthesiol 2015 Mar 28;29(1):87-96. Epub 2015 Jan 28.

University Hospital Zurich, Zurich, Switzerland. Electronic address:

In this article, we review the debriefing literature and point to the dilemma that although debriefings especially intend to enhance team (rather than individual) learning, it is particularly this team setting that poses risks for debriefing effectiveness (e.g., preference-consistent information sharing, lack of psychological safety inhibiting structured information sharing, ineffective debriefing models). These risks can be managed with a mindful approach with respect to content (e.g., specific learning objectives), structure (e.g., reactions phase, analysis phase, summary phase), attitude (e.g., honesty, curiosity, holding the trainee in positive regard) and setting (e.g., briefings to provide orientation and establish psychological safety). We point to the potential of integrating systemic methods such as circular questions into debriefings, discuss the empirical evidence for debriefing effectiveness and highlight the importance of faculty development.
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http://dx.doi.org/10.1016/j.bpa.2015.01.002DOI Listing
March 2015

An Anesthesia Preinduction Checklist to Improve Information Exchange, Knowledge of Critical Information, Perception of Safety, and Possibly Perception of Teamwork in Anesthesia Teams.

Anesth Analg 2015 Oct;121(4):948-956

From the Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland; Organization, Work and Technology Group, ETH Zurich, Zurich, Switzerland; Department of Anesthesia and Intensive Care Medicine, Regional Hospital Männedorf, Männedorf, Switzerland; Division of Biostatistics, Institute of Social and Preventive Medicine, University of Zurich, Zurich, Switzerland; and Crew Resource Management, Swiss International Air Lines Ltd., Zurich Airport, Kloten, Switzerland.

Background: An anesthesia preinduction checklist (APIC) to be performed before anesthesia induction was introduced and evaluated with respect to 5 team-level outcomes, each being a surrogate end point for patient safety: information exchange (the percentage of checklist items exchanged by a team, out of 12 total items); knowledge of critical information (the percentage of critical information items out of 5 total items such as allergies, reported as known by the members of a team); team members' perceptions of safety (the median scores given by the members of a team on a continuous rating scale); their perception of teamwork (the median scores given by the members of a team on a continuous rating scale); and clinical performance (the percentage of completed items out of 14 required tasks, e.g., suction device checked).

Methods: A prospective interventional study comparing anesthesia teams using the APIC with a control group not using the APIC was performed using a multimethod design. Trained observers rated information exchange and clinical performance during on-site observations of anesthesia inductions. After the observations, each team member indicated the critical information items they knew and their perceptions of safety and teamwork.

Results: One hundred five teams using the APIC were compared with 100 teams not doing so. The medians of the team-level outcome scores in the APIC group versus the control group were as follows: information exchange: 100% vs 33% (P < 0.001), knowledge of critical information: 100% vs 90% (P < 0.001), perception of safety: 91% vs 84% (P < 0.001), perception of teamwork: 90% vs 86% (P = 0.028), and clinical performance: 93% vs 93% (P = 0.60).

Conclusions: This study provides empirical evidence that the use of a preinduction checklist significantly improves information exchange, knowledge of critical information, and perception of safety in anesthesia teams-all parameters contributing to patient safety. There was a trend indicating improved perception of teamwork.
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http://dx.doi.org/10.1213/ANE.0000000000000671DOI Listing
October 2015

Intubation with VivaSight or conventional left-sided double-lumen tubes: a randomized trial.

Can J Anaesth 2015 Jul 6;62(7):762-9. Epub 2015 Feb 6.

Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.

Introduction: Double-lumen endotracheal tubes (DLTs), which are commonly used for single-lung ventilation during surgery, are difficult to insert. In addition, they often move during surgical lung manipulation which can cause life-threatening complications. Flexible bronchoscopy is used routinely to establish and confirm proper DLT placement. The newly designed VivaSight DLT has an integrated camera, allowing continuous visualization of its position in the trachea. We hypothesized that the time to intubation using the VivaSight DLT would be faster than with a conventional DLT.

Methods: We enrolled 40 adults scheduled for thoracic surgery. Patients were randomized to conventional DLT (n = 20) or VivaSight DLT (n = 20). Time to intubation was our primary outcome. Secondary outcomes were insertion success without flexible bronchoscopy, frequency of tube displacement, ease of insertion, quality of lung collapse, postoperative complaints, and airway injuries.

Results: Time [mean (SD)] to successful intubation was significantly faster with the VivaSight DLT [63 (58) sec] compared with the conventional DLT [97 (84) sec; P = 0.03]. The VivaSight DLTs were correctly inserted during all attempts. When malpositioning of the VivaSight DLT occurred, it was easily remedied, even in the lateral position. The devices were comparable with respect to postoperative coughing, hoarseness, and sore throat. Airway injuries tended to be more common with the VivaSight DLT, although this study was underpowered for airway injuries.

Conclusion: The VivaSight DLT camera allowed faster insertion and facilitated initial positioning. It also confirmed proper tube positioning intraoperatively and facilitated repositioning when necessary. This trial was registered at clinicaltrials.gov: NCT01807676.
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http://dx.doi.org/10.1007/s12630-015-0329-8DOI Listing
July 2015

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

J Appl Psychol 2014 Nov 15;99(6):1254-67. Epub 2014 Sep 15.

Institute of Anaesthesiology, University Hospital Zurich.

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).
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http://dx.doi.org/10.1037/a0037877DOI Listing
November 2014

In response.

Anesth Analg 2013 May;116(5):1184-1186

ETH ZurichZurich, Switzerland Institute of PsychologyUniversity of ZurichZurich, Switzerland Institute of Physicians for Anaesthesia and Intensive CareKlinik Hirslanden ZurichZurich, Switzerland Département de Psychologie, Industrial Psychology and Human FactorsUniversity of FribourgFribourg, Switzerland Institute of AnesthesiologyUniversity Hospital ZurichZurich, Switzerland.

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http://dx.doi.org/10.1213/ANE.0b013e31828c43f3DOI Listing
May 2013

Team coordination during cardiopulmonary resuscitation.

J Crit Care 2013 Aug 15;28(4):522-3. Epub 2013 May 15.

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http://dx.doi.org/10.1016/j.jcrc.2013.03.009DOI Listing
August 2013

TeamGAINS: a tool for structured debriefings for simulation-based team trainings.

BMJ Qual Saf 2013 Jul 22;22(7):541-53. Epub 2013 Mar 22.

Organization, Work, Technology Group, Department of Management, Technology, and Economics, ETH Zurich, Switzerland.

Background: Improving patient safety by training teams to successfully manage emergencies is a major concern in healthcare. Most current trainings use simulation of emergency situations to practice and reflect on relevant clinical and behavioural skills. We developed TeamGAINS, a hybrid, structured debriefing tool for simulation-based team trainings in healthcare that integrates three different debriefing approaches: guided team self-correction, advocacy-inquiry and systemic-constructivist techniques.

Methods: TeamGAINS was administered during simulation-based trainings for clinical and behavioural skills for anaesthesia staff. One of the four daily scenarios involved all trainees, whereas the remaining three scenarios each involved only two trainees with the others observing them. Training instructors were senior anaesthesiologists and psychologists. To determine debriefing quality, we used a post-test-only (debriefing quality) and a pre-post-test (psychological safety, leader inclusiveness), no-control-group design. After each debriefing all trainees completed a self-report debriefing quality scale which we developed based on the Debriefing Assessment for Simulation in Healthcare and the Observational Structured Assessment of Debriefing. Perceived psychological safety and leader inclusiveness were measured before trainees' first (premeasure) and after their last debriefing (postmeasure) at which time trainees' reactions to the overall training were measured as well.

Results: Four senior anaesthetists, 29 residents and 28 nurses participated in a total of 40 debriefings resulting in 235 evaluations. Utility of debriefings was evaluated as highly positive. Pre-post comparisons revealed that psychological safety and leader inclusiveness significantly increased after the debriefings.

Conclusions: The results indicate that TeamGAINS could provide a useful debriefing tool for training anaesthesia staff on all levels of work experience. By combining state-of-the-art debriefing methods and integrating systemic-constructivist techniques, TeamGAINS has the potential to allow for a surfacing, reflecting on and changing of the dynamics of team interactions. Further research is necessary to systematically compare the effects of TeamGAINS' components on the debriefing itself and on trainees' changes in attitudes and behaviours.
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http://dx.doi.org/10.1136/bmjqs-2012-000917DOI Listing
July 2013

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

Anesth Analg 2012 Nov 25;115(5):1099-108. Epub 2012 Sep 25.

ETH Zurich, CH-8032 Zurich, Switzerland.

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 (R(2) = 0.18, P = 0.017) but not from residents (R(2) = 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 (R(2) = 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 (R(2) = 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.
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November 2012
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