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Survival from avalanche burial is dependent on time to extraction, breathing ability, air pocket oxygen content, and avoiding rebreathing of carbon dioxide (COA prospective randomized crossover experimental field study enrolled 20 healthy subjects in Hemsedal, Norway in March 2019. Subjects underwent in randomized order two sessions (receiving 2 litres per minute of air in front of mouth/nose into the air pocket or no air) in a simulated avalanche scenario with extensive monitoring serving as their own control.A significant increase comparing Control vs Intervention were documented for minimum and maximum end-tidal COParticipants subject to simulated avalanche burial can maintain physiologic parameters within normal levels for a significantly longer period if they receive supplemental air in front of their mouth/nose into the air pocket. This may extend the time for potential rescue and lead to increased survival.

To improve the safety of healthcare systems, it is necessary to understand harm-related events that occur in these systems. In mental health services, particular attention is paid to harm arising from the actions of patients against themselves or others. The primary intention of examining these adverse events is to inform changes to care provision so as to reduce the likelihood of the recurrence of such events. The predominant approach to investigating adverse incidents has relied on the cause-and-effect conceptualisation of past events. Whilst the merits of approaches which are reliant on cause-and-effect narratives have been questioned, alternatives models to explain adverse incidents in health settings have not been theoretically or empirically tested. This novel article (i) examines the notion of causation (and the related notion of omission) in the context of explaining adverse events in mental health settings, and (ii) draws on a long-established discipline devoted to the study of how the past is interpreted (namely historiography) to theoretically investigate the innovative application of two historiographical approaches (i.e. counterfactual analysis and historical materialism) to understanding adverse events in mental health settings.

BackgroundOptimal prehospital management and treatment of patients with accidental hypothermia is a matter of frequent debate, with controversies usually revolving around the subject of rewarming. The rule of thumb in primary emergency care and first aid for patients with accidental hypothermia has traditionally been to be refrain from prehospital active rewarming and to focus on preventing further heat loss. The potential danger of active external rewarming in a prehospital setting has previously been generally accepted among the emergency medicine community based on a fear of potential complications, such as “afterdrop”, “rewarming syndrome”, and “circum-rescue collapse”. This has led to a reluctancy from health care providers to provide patients with active external rewarming outside the hospital. Different theories and hypotheses exist for these physiological phenomena, but the scientific evidence is limited. The research question is whether the prehospital use of active external rewarming is dangerous for patients with accidental hypothermia. This systematic review intends to describe the acute unfavourable adverse effects of active external rewarming on patients with accidental hypothermia.MethodsA literature search of the Cochrane Library, MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL], and SveMed+ was carried out, and all articles were screened for eligibility. All article formats were included.ResultsTwo thousand three hundred two articles were screened, and eight articles met our search criteria. Three articles were case reports or case series, one was a prospective study, two were retrospective studies, one article was a literature review, and one article was a war report from the Napoleonic Wars.ConclusionsOne of the main findings in this article was the poor scientific quality and the low number of articles meeting our inclusion criteria. When conducting this review, we found no scientific evidence of acceptable quality to prove that the use of active external rewarming is dangerous for patients with accidental hypothermia in a prehospital setting. We found several articles claiming that active external rewarming is dangerous, but most of them do not cite references or provide evidence.

This paper estimates a random-coefficients structural model of the demand for car model engine variants. It uses a new identification approach that assumes the mean unobserved quality is the same for all engine variants within a model. The demand estimates imply that absolute markups increase in horsepower within a car model, while percentage markups are constant or falling in horsepower. The estimated results–as well as simulations of a simple theory model–show that prices are not typically cost-plus-fixed-fee, and absolute markups may increase in quality.

Chest compression devices are useful during mountain rescue but may cause a delay in transport if not immediately available. The aims of this prospective observational study were to compare manual and mechanical cardiopulmonary resuscitation (CPR) during transport on a sledge connected to a snowmobile with a non-moving setting and to compare CPR quality between manual and two mechanical chest compression devices.Sixteen healthcare providers simulated four different combined CPR scenarios on a sledge in a non-moving setting and during transport and two mechanical chest compression devices during transport on the sledge. The study was conducted in May 2015 in a mountain in Norway. The primary outcome measures were compression rate (compressions per minute), compression depth in millimetres, leaning (incomplete chest wall release after compression in millimetres) and chest compression fraction (fraction of total time were compression were performed). The results were analysed by descriptive and graphical methods and paired t-tests were used to compare the differences between techniques.We did not observe a significant difference between moving and non-moving conditions with respect to manual compression rate (p=0.34), compression depth (p=0.50) or leaning (p=0.92). However, both the manual compression depth (p0.001) and the leaning (p=0.04) showed a significantly larger variance during the moving runs.Manual chest compression is possible on a snowmobile during transport even in challenging terrain. This experimental study shows that high-quality chest compressions and manual ventilation can be performed in an intubated patient during a short-term transportation on a sledge.

This article analyses the use of coercive measures in two national institutions for high-security psychiatry in Norway – Kriminalasylet (Criminal Asylum) and Reitgjerdet – during the period 1895–1978. Historical study of coercion in psychiatry is a fruitful approach to new insight into the moral and ethical considerations within the institutions. We approach the topic through a qualitative study of patient case files and ward reports from the institutions’ archives, as well as a comprehensive quantification of the coercive measures used. The data show shifting considerations of humane treatment and changes in the respect for human dignity in the institutions’ practices. They also show that technological developments, such as the introduction of new psychopharmaceuticals, did not necessarily lead to higher standards of treatment.

Artikkelen analyserer tvang ved Kriminalasylet under asylets to første bestyrere, Waldemar Bødtker og Hans Evensen, i perioden 1895–1915. Kriminalasylet var en spesialinstitusjon for mannlige kriminelle sinnssyke, og hadde som oppgave både å være en behandlingsanstalt og å sikre samfunnet fra potensielt farlige pasienter. Derfor hadde asylet i praksis en posisjon tilhørende både sinnssykeomsorgen og fengselsvesenet. Det var formelt en medisinsk institusjon, men ansvaret var lagt under Justisdepartementet. Artikkelen argumenterer for at bestyrerne av denne grunn hadde en todelt tilnærming til tvangsmiddelbruk. De fleste pasientene opplevde en hverdag i tråd med psykiatriens daværende idealer om human behandling, samtidig som enkeltpasienter som ble oppfattet som spesielt farlige, levde under et meget strengt tvangsregime med kontrollmetoder hentet fra fengselsvesenet. Dette illustreres gjennom pasienthistorier. Studien bygger blant annet på pasientjournaler og avdelingsrapporter fra asylets arkiv. Åpen tilgang - Creative Commons (CC BY-NC 4.0)

A significant number of patients with intellectual disability (ID) were admitted to forensic mental health asylums during the period 1915–1987. Many of these patients stayed for more than a decade, because of previous offending behaviour. We investigated the daily lives of 262 patients with an ID using casebooks. Two of the patients were studied more in detail. The available documents describe most of these patients as sociable, well-behaved and socially engaged although they missed having contacts outside the hospital. Long-stay patients were studied more in detail. © 2018 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/ .

The drive for effectiveness and productivity in health care combined with a high percentage of adverse events in hospitals occurring in the operating room, suggest that more knowledge about safety in surgery is warranted. As a step in this direction, explorations of safety in surgical operations should account for the unique operational perspective of health care providers. In this article, we explore one particular safety aspect of surgical operations: frontline personnel’s perceptions of operating room time, both in itself and in relation to the WHO’s Surgical Safety Checklist. Specifically, we provide results from a focus group study undertaken in a surgical section of a Norwegian university hospital. The study included a total of 14 participants from the professions that typically comprise an operating team; surgeons, nurses, and anesthetists. Based on a content analysis of the collected material, we believe that strengthening both the structural conditions surrounding surgery and the safety mentality of managers and operating personnel can prevent compromises in safety tasks and instead allow priority to planning, diagnosis and checklists, with associated potential for improvement in awareness, preparedness, and systemizing as well as reduction in total operating room time. This might represent a key factor in improving patient safety in surgical operations. We also identify a need for deeper explorations that shed further light on the complexity of the operating room time phenomenon.

Avalanches may be provoked spontaneously or as a result of human activity, and they trigger the need for considerable rescue resources. Avalanche search and rescue operations are complex and characterised by physical and mental stress. The guidelines for resuscitation of avalanche victims may be perceived as complex and abstruse, which can lead to suboptimal treatment and an increased strain on rescue teams. The purpose of this article is to summarise the principles for medical treatment of avalanche victims.

In many competitive settings, consumers buy multiple product categories, and some prefer to use a single firm, generating complementary cross-category price effects. To study pricing in supermarkets, an organizational form where these effects are internalized, we develop a multi-category, multi-seller demand model and estimate it using UK consumer data. This class of model is used widely in theoretical analysis of retail pricing. We quantify cross-category pricing effects and find that internalizing them substantially reduces market power. We find that consumers inclined to one-stop (rather than multi-stop) shopping have a greater pro-competitive impact because they generate relatively large cross-category effects. (JEL D12, L11, L13, L81)

Based on current weaknesses in the understanding of the mechanisms, factors and positive effects involved in checklist usage, as well as a scarcity of qualitative approaches, the aim of this study was to explore surgical personnel experiences with the World Health Organization's Surgical Safety Checklist, 2 years after implementation. Three focus group interviews were conducted with surgical personnel. An interview guide was designed to assist the interview process, comprised of broad, open-ended questions. Notes and audio recordings were fully transcribed verbatim and subsequently analysed using qualitative content analysis in order to identify emergent meaning units, categories and themes. The checklist improves confidence, team communication and sharing of critical information in the surgical team. However, informants described the occurrence of wrong-site surgery not prevented by the checklist due to preoperative wrong-site marking combined with automated checklist use in the operating room. Using the checklist as a `tic box exercise' was recognized as a safety challenge by all professions, especially during routine surgery. The surgical team balances safety and effectiveness constantly in the operating room. Challenges that need to be addressed include making the Sign-in part a team effort and taking the accompanying pause in performance during the Time-out and the Sign-out, with cross-check of items, in order to avoid automated checklist use. We suggest surgical team training that includes checklist performance, in order to enhance the quality of checklist use.

James Langenfeld and Wenqing Li claim that the market delineating criterion of Oystein Daljord, Lars Sorgard, and Oyvind Thomassen for an asymmetric small, but significant and nontransitory increase in price (SSNIP) is logically inconsistent and tends to define too broad antitrust markets. We show that these claims are false.

Background Safety checklists have become an established safety tool in medicine. Despite studies showing decreased mortality and complications, the effects and feasibility of checklists have been questioned. This systematic review summarises the medical literature aiming to show the effects of safety checklists with a number of outcomes. Methods The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement was used. All studies in which safety checklists were used as an additional tool designed to assure that an operation or task was performed as planned were included. Results The initial search extracted 7408 hits. Twenty-nine articles met the inclusion criteria. Five additional studies were identified by a cross-referencing search. Four groups were made according to outcome measures. One group (n = 7) had ‘hard’ outcome measures, such as mortality and morbidity. The remaining studies, reporting ‘softer’ process-related measures, were divided into three categories: adherence to guidelines (n = 6), human factors (n = 16), and reduction of adverse events (n = 5). The main findings were improved communication, reduced adverse events, better adherence to standard operating procedures, and reduced morbidity and mortality. None of the included studies reported decreased patient safety or quality after introducing safety checklists. Conclusion Safety checklists appear to be effective tools for improving patient safety in various clinical settings by strengthening compliance with guidelines, improving human factors, reducing the incidence of adverse events, and decreasing mortality and morbidity. None of the included studies reported negative effects on safety.

This chapter discusses castration of patients in Norway during the period 1923-45, drawing on patient casebooks from two institutions in Trondheim, Kriminalasylet and Reitgjerdet Hospital. Reitgjerdet functioned as the only high security psychiatric institution in Norway from 1963 to 1987. Almost all of the patients were institutionalized for the rest of their lives, either in Kriminalasylet and Reitgjerdet, or in other health institutions. The chapter explores castration as practised on sex offenders and other patients. It focuses on castration, and presents examples related to sterilization. There was a wish to shift from being considered 'abnormal' and dangerous to the normal and harmless masculinity and sexuality. Swedish gender researcher Bo Nilsson argues that heterosexuality produces power in a legal and forensic psychiatric context. The chapter describes what was considered an 'abnormal sexuality' and how normality perspectives played an important role in the issue of castration.

Avalanches may be provoked spontaneously or as a result of human activity, and they trigger the need for considerable rescue resources. Avalanche search and rescue operations are complex and characterised by physical and mental stress. The guidelines for resuscitation of avalanche victims may be perceived as complex and abstruse, which can lead to suboptimal treatment and an increased strain on rescue teams. The purpose of this article is to summarise the principles for medical treatment of avalanche victims.

When a supermarket cuts its price for one product category it may increase the demand for another by drawing more consumers into the store. We call this a multi-category effect. We contrast the prominent role that the multi-category nature of supermarket shopping has enjoyed in competition policy discussion – and in the theoretical literature on supermarket pricing – with its lack of prominence in the empirical IO literature on pricing incentives for products sold in supermarkets. Using a data set of store-category choices from the UK we document empirical features of supermarket shopping and find that these are consistent with the multi-store multi-category framework of many theoretical models of retail pricing. We report on a project in progress that empirically models consumer demand allowing for multiple demand categories and two store shopping, and describe how the model can be used to measure the empirical importance of multi-category effects in supermarket pricing.

Background: A substantial proportion of anaesthesia-related adverse events are preventable by identification and correction of errors in planning, communication, fatigue, stress, and equipment. The aim of this study was to develop and implement a pre-induction checklist in order to identify and solve problems before induction of anaesthesia. Methods: The checklist was developed in a stepwise manner using a modified Delphi technique, literature search, expert's opinion, and a pilot version, and then implemented in a clinical environment during a 13-week study period. Each list was registered and analysed using statistical process control. The checklist was mandatory, but emergency cases were excluded. Results: The checklist, containing 26 items, was used in 502 (61%) of a total of 829 inductions. Eighty-five checklists (17%) identified one or more missing items. The number of missing items decreased significantly throughout the study period. The most important missing items were lack of a second laryngoscope available, introducer not having been fitted to the endotracheal tube, the endotracheal tube cuff not having been tested, and no separate ventilation bag being available. It took a median of 88.5 s (range 52–118) to perform the checklist when no items were missing. The pre-induction time was the same before and after the checklist was introduced (25.1 vs. 24.3 min, P=0.25). Conclusions: It is possible to develop, introduce, and use a pre-induction checklist even in a hectic and stressful clinical environment. The checklist identified and reduced a surprisingly large number of missing items required in a standard induction protocol.

The Hypothetical Monopolist or Small but Significant Non-transitory Increase in Prices (SSNIP) test defines the relevant market by determining whether a given increase in product prices would be profitable for a monopolist in the candidate market. The U.S. Merger Guidelines do not specify whether the SSNIP test should be performed with an increase in one price, some prices, or all prices in the candidate market. We argue that this should depend on characteristics of the market: if there are asymmetries between products, increasing only one price might be the best way to identify competitive constraints. Katz and Shapiro derive a one-price test criterion of critical loss in terms of the aggregate diversion ratio. Unfortunately, the derivation is incorrect. We show what the correct criterion should be.

Background: It is widely believed that placing a patient who has been subjected to suspension trauma in a horizontal position after rescue may cause rescue death. The discussion whether position is important has been dominated by non-medical personnel. Subsequently, this has led to a general advice on emergency treatment of these patients, which may cause incorrect or even fatal treatment. Methods: To determine whether there is any medical evidence supporting that horizontal positioning after suspension trauma may cause rescue death, the authors located publications, reports, expert opinions and other sources of information addressing the acute treatment of suspension trauma. These sources were then evaluated. Results: Several thousand hits regarding suspension trauma were located on the internet and five articles on the PubMed. Although most of them warned of the dangers of rescue death brought about by assuming the horizontal position after prolonged suspension, the authors found no clinical studies, and none of the sources offered any conclusive evidence as to whether the horizontal position increases the risk of rescue death. Neither the authors, nor the suspension trauma experts who were contacted, had ever experienced or heard of case reports supporting the causal relation between the horizontal position and rescue death. Conclusions: After evaluating the current literature, the authors found no support for the view that the horizontal position may be potentially fatal for patients exposed to suspension trauma. In the absence of any evidence to the contrary, the authors suggest that the initial management of patients who have had suspension trauma should follow normal guidelines for the acute care of traumatised patients, without special modifications.

Headache is the cardinal symptom of acute mountain sickness (AMS). The headache normally worsens, with increased cerebral affection and the development of high-altitude cerebral edema (HACE). A Norwegian expedition aimed to climb Baruntse (7129 m) in Nepal in 2003. At 5400 m a 35-year-old man felt exhausted. The next day he aborted his attempt at further climbing as a result of extreme fatigue. Over the next 24 hours he developed cough, dyspnea, and severe hypoxia before progressing to ataxia and blurred vision. At no point did he experience headache or nausea. The patient was evacuated by helicopter. He improved immediately after descent and recovered completely within a week. The speed of progression from AMS to HACE varies. Abrupt onset of HACE is occasionally reported. High-altitude pulmonary edema (HAPE) may induce severe hypoxia that can lead to rapid development of HACE. High-altitude cerebral edema in the setting of HAPE was the most likely diagnosis despite the unusual lack of headache. Rapid onset of HAPE with subsequent severe desaturation should raise awareness of the development of HACE, even in the absence of headache.

Introduction Hypothermia is associated with increased morbidity and mortality in trauma patients and poses a challenge in pre-hospital treatment. The aim of this study was to identify equipment to prevent, diagnose, and treat hypothermia in Norwegian pre-hospital services. Method In the period of April-August 2011, we conducted a survey of 42 respondents representing a total of 543 pre-hospital units, which included all the national ground ambulance services, the fixed wing and helicopter air ambulance service, and the national search and rescue service. The survey explored available insulation materials, active warming devices, and the presence of protocols describing wrapping methods, temperature monitoring, and the use of warm i.v. fluids. Results Throughout the services, hospital duvets, cotton blankets and plastic “bubble-wrap” were the most common insulation materials. Active warming devices were to a small degree available in vehicle ambulances (14%) and the fixed wing ambulance service (44%) but were more common in the helicopter services (58-70%). Suitable thermometers for diagnosing hypothermia were lacking in the vehicle ambulance services (12%). Protocols describing how to insulate patients were present for 73% of vehicle ambulances and 70% of Search and Rescue helicopters. The minority of Helicopter Emergency Medical Services (42%) and Fixed Wing (22%) units was reported to have such protocols. Conclusion The most common equipment types to treat and prevent hypothermia in Norwegian pre-hospital services are duvets, plastic “bubble wrap”, and cotton blankets. Active external heating devices and suitable thermometers are not available in most vehicle ambulance units.

The role of ketamine anesthesia in the prehospital, emergency department and operating theater settings is not well defined. A nonsystematic review of ketamine was performed by authors from Australia, Europe, and North America. Results were discussed among authors and the final manuscript accepted. Ketamine is a useful agent for induction of anesthesia, procedural sedation, and analgesia. Its properties are appealing in many awkward clinical scenarios. Practitioners need to be cognizant of its side effects and limitations.

Background Checklists are common in some medical fields, including surgery, intensive care and emergency medicine. They can be an effective tool to improve care processes and reduce mortality and morbidity. Despite the seemingly rapid acceptance and dissemination of the checklist, there are few studies describing the actual process of developing and implementing such tools in health care. The aim of this study is to explore the experiences from checklist development and implementation in a group of non-medical, high reliability organisations (HROs). Method A qualitative study based on key informant interviews and field visits followed by a Delphi approach. Eight informants, each with 10-30 years of checklist experience, were recruited from six different HROs. Results The interviews generated 84 assertions and recommendations for checklist implementation. To achieve checklist acceptance and compliance, there must be a predefined need for which a checklist is considered a well suited solution. The end-users ("sharp-end") are the key stakeholders throughout the development and implementation process. Proximity and ownership must be assured through a thorough and wise process. All informants underlined the importance of short, self-developed, and operationally-suited checklists. Simulation is a valuable and widely used method for training, revision, and validation. Conclusion Checklists have been a cornerstone of safety management in HROs for nearly a century, and are becoming increasingly popular in medicine. Acceptance and compliance are crucial for checklist implementation in health care. Experiences from HROs may provide valuable input to checklist implementation in healthcare.

Background Checklists have been used extensively as a cognitive aid in aviation; now, they are being introduced in many areas of medicine. Although few would dispute the positive effects of checklists, little is known about the process of introducing this tool into the health care environment. In 2008, a pre-induction checklist was implemented in our anaesthetic department; in this study, we explored the nurses' and physicians' acceptance and experiences with this checklist. Method Focus group interviews were conducted with a purposeful sample of checklist users (nurses and physicians) from the Department of Anaesthesia and Intensive Care in a tertiary teaching hospital. The interviews were analysed qualitatively using systematic text condensation. Results Users reported that checklist use could divert attention away from the patient and that it influenced workflow and doctor-nurse cooperation. They described senior consultants as both sceptical and supportive; a head physician with a positive attitude was considered crucial for successful implementation. The checklist improved confidence in unfamiliar contexts and was used in some situations for which it was not intended. It also revealed insufficient equipment standardisation. Conclusion Our findings suggest several issues and actions that may be important to consider during checklist use and implementation.

This paper estimates the demand for car model variants instead of looking only at demand for models in terms of the ’baseline’ variant of each model as done in the literature. The data has sex and age of the buyer for every car sold in Norway 2000-2004, in addition to characteristics of the cars. The demand model uses this information to estimate taste coefficients which depend on demographic characteristics. Anested logit model and a generalised nested logit model are used to induce correlation in the logit error between products with observable and unobservable similarities. Results indicate that it may be problematic to have different logit errors for every product when the number of products is very high, even when allowing for flexible correlation patterns.

I estimate a pure-characteristics discrete choice model of the demand for automobile engine and body style variants, using market-level data. Revealed preference bounds and imposed bounds on the willingness to pay for characteristics as a percentage of product price are sufficient to identify nonparametric taste distributions. Substitution patterns as determined by closest substitutes appear very realistic. The model can be estimated on a single cross-section of data.

Using a structural model of demand for automobile engine variants, this paper finds that there is second-degree price discrimination: markups increase with engine size. Still, average markups are lower than when models have just one engine. The paper develops the first empirical demand framework suitable for markets with variants. There is an unobserved product characteristic and a consumer-specific logit term for classes of products, but both are fixed across variants. Fixed effects control for unobservables. The literature’s assumption of orthogonality between unobserved and observed product character

The SSNIP test for market definition requires information about demand substitution and profitability. If detailed information about demand is not available, observed effects of a shock in the industry may be an alternative source of evidence. In the existing literature, shock analysis has unfortunately not been clearly linked to the SSNIP test. The lack of a rigorous framework may confuse the interpretation of the effects of shocks. We illustrate how a shock can be evaluated within the SSNIP framework with a minimum of data. We apply our criterion to a capacity expansion in the ferry market in the North Sea.

Carbon monoxide (CO) is formed wherever incomplete combustion of carbonaceous products occurs.(1) CO is the leading cause of poisoning in the United States, and common sources of CO poisoning include housefires, automobile exhaust, water heaters, kerosene space heaters, and furnaces.(2) Stoves used for cooking and heating during outdoor activities also produce significant amounts of CO. Mountain climbers have been reported to succumb to fumes generated by small cook stoves.(3) The aim of this study was to investigate if burning a cooking stove inside a tent is a potential health hazard. Seven healthy male volunteers used a cooking stove inside a small tent for 120 minutes. CO levels in the ambient tent air were measured in addition to hearth rate (HR) and pulse oximetry (SpO2). Venous blood samples were obtained every 15 minutes for measurement of carboxyhemoglobin (COHb). After 2 hours, all the subjects had significant CO levels in their blood (mean COHb = 21.5%). Mean SpO2, also fell from 98% to 95.3% (P.05), whereas mean HR increased from 63 to 90 beats/min (P.05). Kerosene camping stoves do produce CO when burned in a small tent. The concentration is high enough to cause significant COHb levels in venous blood after 120 minutes' stay in the tent.

Background Mnazi Mmoja Hospital is a tertiary hospital in Zanzibar serving a population of 1.2 million. The emergency department was overcrowded and understaffed and the hospital management initiated a quality improvement project. The aim of this article is to describe the approach, methods and main results of this quality improvement process. Methods The Plan-Do-Study-Act (PDSA) method was used in a five-circle process. In addition, a consensus-based approach was performed to identify areas of improvement. Results Over a period of 6 months, regular staff meetings were implemented, a registration system was developed and implemented, the numbers of patients with simple problems were reduced, a simple triage tool was developed and implemented and an emergency room was established. Conclusions Change and improvement in health care are achievable despite limited financial resources if a comprehensive, robust and simple system is used. Involvement of all stakeholders from the start, identification and use of change agents, regular feedback and a focus on human resources rather than equipment have been key factors for the success of this project.

Background Accidental hypothermia increases mortality and morbidity in trauma patients. Various methods for insulating and wrapping hypothermic patients are used worldwide. The aim of this study was to compare the thermal insulating effects and comfort of bubble wrap, ambulance blankets / quilts, and Hibler's method, a low-cost method combining a plastic outer layer with an insulating layer. Methods Eight volunteers were dressed in moistened clothing, exposed to a cold and windy environment then wrapped using one of the three different insulation methods in random order on three different days. They were rested quietly on their back for 60 minutes in a cold climatic chamber. Skin temperature, rectal temperature, oxygen consumption were measured, and metabolic heat production was calculated. A questionnaire was used for a subjective evaluation of comfort, thermal sensation, and shivering. Results Skin temperature was significantly higher 15 minutes after wrapping using Hibler's method compared with wrapping with ambulance blankets / quilts or bubble wrap. There were no differences in core temperature between the three insulating methods. The subjects reported more shivering, they felt colder, were more uncomfortable, and had an increased heat production when using bubble wrap compared with the other two methods. Hibler's method was the volunteers preferred method for preventing hypothermia. Bubble wrap was the least effective insulating method, and seemed to require significantly higher heat production to compensate for increased heat loss. Conclusions This study demonstrated that a combination of vapour tight layer and an additional dry insulating layer (Hibler's method) is the most efficient wrapping method to prevent heat loss, as shown by increased skin temperatures, lower metabolic rate and better thermal comfort. This should then be the method of choice when wrapping a wet patient at risk of developing hypothermia in prehospital environments.