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      Pay for performance – motivation to succeed in Advanced Trauma Life Support courses – a question of background or funding? Translated title: Leistung gegen Geld – die Motivation zum Bestehen von Advanced Trauma Life Support-Kursen – eine Frage von fachlichem Hintergrund oder Finanzierung der Kursgebühr?

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          Abstract

          Objective: To correlate students’ performance with their professional background and motivation to take part in Advanced Trauma Life Support (ATLS) courses. We base our analysis on the self-determination theory that differentiates intrinsic (ambition to perform by individual itself) from extrinsic motivation (incentive by external stimuli).

          Design: We present a non-blinded, monocentric, non-randomized descriptive study of 376 students taking part in an ATLS course at one course site in Germany. Part of a two-day ATLS course are two written tests; we correlate test scores with background information provided by the students in a questionnaire of 13 items (age, sex, adress, board certification, specialty, subspecialty, position, hospital level of care, hospital operator and hospital participation in trauma network, motivation, funding source, condition of funding).

          Setting: The students were recuited at the BG Trauma Center Ludwigshafen (Germany), a large 528-bed trauma center and one of 13 ATLS course sites in Germany.

          Participants: 449 ATLS course students taking part in ATLS courses at the above-mentioned course site from February 2009 to May 2010 were sent a questionnaire asking for their background. All 449 course students were eligible to participate. 376 (83.7%) questionnaires were returned, pre- and post-test results of all students aquired and included into our calculations. 312 (83%) were male and 64 (17%) female. The majority (59.3%) of recruited students came from trauma surgery, 21.8% from anesthesiology, 8% from general surgery, 4% from abdominal surgery, 0.5% from vascular or thoracic surgery each and 5.9% from other specialties.

          Results: Neither age, sex, subspecialty, hospital level of care, hospital operator, or hospital participation in trauma network played a role with respect to motivation or test results. The high degree of intrinsic motivation of consultants (92.3%) had no impact on their test results. Anesthesiologists were higher motivated (75.6% intrinsically motivated) in contrast to all surgical colleagues (63.6%), which showed significant differences in the pre- (89.8% vs. 85.3%, p=0.03) but not the post-test. Of all 13.6% students who were self-payers, 94.1% were intrinsically motivated; the 86.2% whose course fee was accounted for were less likely to be intrinsically motivated (63.9%). Sponsoring however did not have a negative impact on test results. Conditional funding (sponsored only on passing both tests) was detrimental to motivation: 0% of these individuals were intrinsically motivated and they scored significantly lower (82.5%) than all other students in the post-test (86.9%, p=0.002). Overall, intrinsically motivated students overtopped extrinsically motivated students in the post-test (88.0% vs. 83.4%, p<0.001).

          Conclusions: ATLS course participation is not compulsory for medical doctors in Germany. Intrinsic motivation to take part in these courses is a key prerequisite to increase performance, irrespective of the background of the students. Intrinsically motivated students are ready to invest into their education and vice versa. Conditional funding (course fee only sponsored on passing the course) evokes no intrinsic motivation at all and causes worse results.

          Zusammenfassung

          Ziele: Korrelation der Testergebnisse von Teilnehmern an Advanced Trauma Life Support (ATLS)-Kursen mit deren fachlichen Hintergrund und Motivation. Die Auswertung basiert auf der Selbstbestimmungstheorie, die zwischen intrinsischer (Eigenantrieb) und extrinsischer Motivation (externe Anreize) unterscheidet.

          Material und Methoden: Wir stellen eine unverblindete, monozentrische, nicht-randomisierte, deskriptive Studie mit 376 Teilnehmern vor. Die Teilnehmer wurden an der Berufsgenossenschaftlichen Unfallklinik in Ludwigshafen, einem großen Trauma-Zentrum mit 528 Betten und einem von 13 ATLS-Kursorten in Deutschland, rekrutiert.

          Teil eines jeden Zweitages-ATLS-Kurses sind zwei schriftliche Tests (Eingangs- und Abschlusstest). Wir korrelierten die hier erzielten Testergebnisse mit Hintergrundinformationen eines Fragebogens mit 13 Items (Alter, Geschlecht, Adresse, Facharztstatus, Facharztdisziplin, Zusatzbezeichnung, Position, Versorgungsstufe des Krankenhauses, Krankenhausträger, Partizipationsstatus im Trauma-Netzwerk, Motivation, Geldquelle, Erfolgsabhängkeit der Fremdfinanzierung).

          Insgesamt 449 Kursteilnehmer zwischen Februar 2009 und Mai 2010 erhielten den o.g. Fragebogen mit der Einladung zum Kurs per Post. Alle 449 Kursteilnehmer waren in unserer Studie teilnahmeberechtigt. 376 (83,7%) der Fragebögen wurden retourniert, die Ergebnisse von Eingangs- und Abschlusstest aller Studienteilnehmer erfasst und in unsere Berechnungen einbezogen. 312 (83%) waren Männer und 64 (17%) Frauen. Die Mehrzahl (59,3%) der rekrutierten Studienteilnehmer waren Unfallchirurgen, 21,8% Anästhesisten, 8% Allgemeinchirurgen, 4% Viszeralchirurgen, 0,5% jeweils Gefäß- und Thoraxchirurgen und 5,9% Ärzte aus anderen Disziplinen.

          Ergebnisse: Weder Alter, Geschlecht, Zusatzbezeichnung(en), Versorgungsstufe, Krankenhausträger noch Partizipationsstatus in Bezug auf das Trauma Netzwerk spielten eine Rolle in Bezug auf Motivation oder Testergebnisse. Den größten Anteil intrinsisch motivierter Teilnehmer verzeichneten Chefärzte (92,3%), jedoch ohne Implikationen auf deren Testergebnisse. Der Anteil intrinsisch motivierter Anästhesisten war höher (75,6%) im Vergleich zu allen Chirurgen (63,6%); dies schlug sich in signifikant besseren Ergebnissen im Eingangs- (89,8% vs. 85,3%, p=0,03), jedoch nicht im Abschlusstest nieder.

          Von den 13,6% aller Selbstzahler waren 94,1% intrinsisch motiviert. Nur 63,9% der 86,2% Fremdfinanzierten waren intrinsisch motiviert. Der Aspekt der Finanzierung der Kursgebühr hatte keine Auswirkungen auf die Testergebnisse. Die erfolgsabhängige Finanzierung der Kursgebühr hatte dabei jedoch einen deutlich negativen Effekt in Bezug auf die Motivation der betroffenen Teilnehmer: niemand aus dieser Gruppe war intrinsisch motiviert und sie erzielte schlechtere Ergebnisse (82,5%) im Abschlusstest im Vergleich zu allen anderen Teilnehmern (86,9%, p=0,002). Generell erreichten alle intrinsisch motivierten Teilnehmer im Abschlusstest bessere Ergebnisse als extrinsisch motivierte (88,0% vs. 83,4%, p<0,001).

          Schlussfolgerungen: Die Teilnahme an ATLS-Kursen ist bislang für Ärzte in Deutschland nicht verpflichtend. Intrinsische Motivation zur Teilnahme an diesen Kursen ist ein Schlüsselfaktor in Bezug auf die Testergebnisse, unabhängig vom fachlichen Hintergrund. Intrinsisch motivierte Teilnehmer sind zu Investitionen in Ihre Ausbildung bereit und vice versa. Erfolgsabhängige Finanzierung der Kursgebühr macht jegliche intrinsische Motivation zunichte und hat schlechtere Testergebnisse zur Folge.

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          Teamwork training improves the clinical care of trauma patients.

          We investigated these questions: Does formal team training improve team behaviors in the trauma resuscitation bay? If yes, then does improved teamwork lead to more efficiency in the trauma bay and/or improved clinical outcomes?
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            Clinical impact of advanced trauma life support.

            The Advanced Trauma Life Support (ATLS) course sponsored by the American College of Surgeons Committee On Trauma (ACSCOT) presents a standardized method of initial trauma care. This study attempted to measure any changes in morbidity and mortality in trauma patients after the introduction of ATLS training. Over a 3-year period (May 1996 to September 1997-pre-ATLS period; December 1997 to April 1999-post-ATLS period), 63 trauma patients with an Injury Severity Scale (ISS) > or =16 (n = 31, pre-ATLS and n = 32, post-ATLS) were prospectively studied in two community teaching hospitals. There was no significant difference in mortality rate between groups (48% [15 of 31] pre-ATLS vs. 30% [10 of 32] post-ATLS; P = .203, Fisher exact test). Mortality rates within the ISS range of 16 to 25 were 64% (nine of 14 pre-ATLS) versus 29% (five of 17 post-ATLS), and for the ISS 26 to 35 subgroup, 40% (four of 10 pre-ATLS) versus 25% (two of eight post-ATLS), and within the ISS 36 to 75 subgroup, 29% (two of seven pre-ATLS) versus 43% (three of seven post-ATLS). There was a significant difference in mortality during the first 60 minutes after admission: 0.0% post-ATLS versus 24.2% pre-ATLS (P = .002, Fisher exact test (95% confidence interval ranged from 12-45% in the pre-ATLS group and 0-11% in the post-ATLS group). According to the TRISS methodology (a worldwide-accepted mathematical method to calculate chances of survival through logistical regression),ATLS improved outcome from sub-"Major Trauma Outcome Study" (MTOS) standard results (z = -2.9 to a MTOS standard result z = -0.49). Our data demonstrate that introduction of the ATLS program significantly improved trauma patient outcome in the first hour after admission, as well as improvement from sub-MTOS standard to MTOS standard levels.
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              Improved trauma management with advanced trauma life support (ATLS) training.

              To determine the value of advanced trauma life support (ATLS) training for medical staff in a major incident situation, based upon performance in a simulated exercise. A major incident exercise was used to assess the management of trauma victims arriving in hospital suffering from multiple or life threatening injuries. The effect of ATLS training, or exposure to an abbreviated form of ATLS training, on the management of patients with simulated life threatening traumatic injuries was examined. The treatment offered by medical staff of different grades and varying exposure to ATLS training was compared. Medical staff who had undertaken ATLS training attained a higher number of ATLS key treatment objectives when treating the simulated trauma victims. Medical staff who have either undertaken the full ATLS course or an abbreviated form of the course were more effective in their management of the simulated trauma cases.
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                Author and article information

                Journal
                GMS Interdiscip Plast Reconstr Surg DGPW
                GMS Interdiscip Plast Reconstr Surg DGPW
                GMS Interdiscip Plast Reconstr Surg DGPW
                GMS Interdisciplinary Plastic and Reconstructive Surgery DGPW
                German Medical Science GMS Publishing House
                2193-8091
                05 December 2017
                2017
                : 6
                : Doc16
                Affiliations
                [1 ]Clinic of orthopedic surgery, trauma surgery and sports traumatology, Krankenhaus Hetzelstift, Neustadt an der Weinstrasse, Germany
                [2 ]Clinic of orthopedic surgery and trauma surgery, Kreiskrankenhaus Bergstraße, Heppenheim, Germany
                [3 ]MDKN – Geschäftsbereich Behandlungsfehler, Hannover, Germany
                [4 ]SRH-Hochschule Heidelberg, Department for social studies and law, Heidelberg, Germany
                [5 ]BG Trauma Center Ludwigshafen, Department of trauma surgery and orthopedics, Ludwigshafen, Germany
                Author notes
                *To whom correspondence should be addressed: Christoph Georg Wölfl, Clinic of orthopedic surgery, trauma surgery and sports traumatology, Krankenhaus Hetzelstift, Stiftstraße 10, 67434 Neustadt an der Weinstrasse, Germany, Phone: +49-6321-859-2006, E-mail: christoph.woelfl@ 123456marienhaus.de
                Article
                iprs000118 Doc16 urn:nbn:de:0183-iprs0001182
                10.3205/iprs000118
                5717918
                29214123
                044a0d38-3215-40d6-8d7b-e860d87de3c6
                Copyright © 2017 Klein et al.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at http://creativecommons.org/licenses/by/4.0/.

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                Article

                advanced trauma life support,atls,motivation,incentives,test performance

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