ObjectiveFostering clinical reasoning is a mainstay of medical education. Based on the clinicopathological conferences, we propose a case-based peer teaching approach called clinical case discussions (CCDs) to promote the respective skills in medical students. This study compares the effectiveness of different CCD formats with varying degrees of social interaction in fostering clinical reasoning.Design, setting, participantsA single-centre randomised controlled trial with a parallel design was conducted at a German university. Study participants (N=106) were stratified and tested regarding their clinical reasoning skills right after CCD participation and 2 weeks later.InterventionParticipants worked within a live discussion group (Live-CCD), a group watching recordings of the live discussions (Video-CCD) or a group working with printed cases (Paper-Cases). The presentation of case information followed an admission-discussion-summary sequence.Primary and secondary outcome measuresClinical reasoning skills were measured with a knowledge application test addressing the students’ conceptual, strategic and conditional knowledge. Additionally, subjective learning outcomes were assessed.ResultsWith respect to learning outcomes, the Live-CCD group displayed the best results, followed by Video-CCD and Paper-Cases, F(2,87)=27.07, p<0.001, partial η2=0.384. No difference was found between Live-CCD and Video-CCD groups in the delayed post-test; however, both outperformed the Paper-Cases group, F(2,87)=30.91, p<0.001, partial η2=0.415. Regarding subjective learning outcomes, the Live-CCD received significantly better ratings than the other formats, F(2,85)=13.16, p<0.001, partial η2=0.236.ConclusionsThis study demonstrates that the CCD approach is an effective and sustainable clinical reasoning teaching resource for medical students. Subjective learning outcomes underline the importance of learner (inter)activity in the acquisition of clinical reasoning skills in the context of case-based learning. Higher efficacy of more interactive formats can be attributed to positive effects of collaborative learning. Future research should investigate how the Live-CCD format can further be improved and how video-based CCDs can be enhanced through instructional support.

Background: In the face of climate change, the protection of vulnerable patients from extreme climatic conditions is of growing interest to the healthcare sector and governments. Inpatients are especially susceptible to heat due to acute illness and/or chronic diseases. Their condition can be aggravated by adverse environmental factors. Installing air conditioning can be seen as an element of public health adaptation because it was shown to improve mortality rates of hospital patients experiencing hot temperatures. Still, the mediating factors and resulting health effects are largely unknown. Method: The PRISMA-ScR guideline was followed for this scoping review. Available evidence on the health effects of Heating, Ventilation, Air Conditioning (HVAC) and fans was searched in Medline, Embase and the Cochrane Library. The focus of the search strategy was on inpatients of the hospital. Grey literature was screened on 14 relevant websites. English and German publications were eligible without restrictions on publication date. Results were charted according to the categories population, intervention, control and outcome together with a qualitative description. Results: The review process yielded eleven publications of which seven were issued after 2003. Seven were clinical trials, three cross-sectional studies and one was a case report. The publications described the installation of HVAC on general wards and in intensive care units. Main topics were heat stress protection and support of thermoregulation, but also the rewarming of hypothermic patients. HVAC use resulted in a recovery effect shown by improved vital signs, reduced cardiac stress, accelerated recuperation and greater physical activity. This protective effect was demonstrated by a shorter hospital stay for patients with respiratory disease and a reduction of mortality for heat illness patients. Conclusion: This scoping review summarises the fragmented evidence on health effects of HVAC and fan utilisation for inpatients. Installing HVAC has the potential to improve patients' outcomes and to make hospital treatment more efficient during heat waves. The application of HVAC could be a promising adaptation measure to mitigate the adverse effects of climate change on health and healthcare systems.

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ZUSAMMENFASSUNGPatienten mit chronischen Lungenkrankheiten sind von den Auswirkungen zunehmender Hitzewellen besonders betroffen, da die Lunge als „Grenzorgan zur Umwelt“ wirkt. COPD- und Asthma-Patienten reagieren mit verstärkter Bronchokonstriktion und stärkerer Entzündungsreaktion der Bronchialschleimhaut auf Hitzestress, was zur Symptomzunahme bis hin zur Hospitalisierung führen kann. Dies führt auch zu einem Anstieg der Mortalität.Zur Prävention von Hitzestress im Krankenhaus können infrastrukturelle Anpassungen wie ein verbesserter Sonnenschutz oder das Anbringen von Kühldecken (konvektionsfreies Air Conditioning) vorgenommen werden. Ebenso können ein Monitoring der Flüssigkeitsaufnahme, körperliche Schonung und effektive Lüftungsregime Hitzestress abmildern. Im Falle Hitze-assoziierter Exazerbationen von COPD-Erkrankungen liegen erste Hinweise auf den therapeutischen Nutzen einer Krankenzimmer-Klimatisierung mit einer Raumtemperatur von 23° C vor. Hierfür bietet sich aufgrund energetischer und hygienischer Vorteile eine innovative Kühlung mithilfe konvektionsfreier Raumklimatisierung an. So könnte Patienten mit Hitze-assoziierter Krankheitsprogression ein ganzheitliches, über die traditionelle medikamentöse Therapie hinausgehendes, Behandlungskonzept angeboten werden.Bei zukünftig häufigerem und intensiverem Hitzestress wird die Notwendigkeit präventiver Maßnahmen für Patienten mit chronischen Atemwegs-Krankheiten steigen. Zusätzlich wird für besonders vulnerable Gruppen der Bedarf an Raumklimatisierung steigen.

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This study explores the concerns, needs, and expectations of inpatients with the goal to develop a patient-centered climate change adaptation agenda for hospitals. Statements of patients from geriatrics, internal medicine, psychiatry, and surgery (N = 25) of a German tertiary care hospital were analyzed using semi-structured interviews and the framework method. Areas of future adaptation were elaborated in joint discussions with transdisciplinary experts. Concerns included the foresight of severe health problems. The requested adaptations comprised the change to a patient-centered care, infrastructural improvements including air conditioning, and adjustments of the workflows. Guidelines for the behavior of patients and medical services appropriate for the climatic conditions were demanded. The patient-centered agenda for adaptation includes the steps of partnering with patients, reinforcing heat mitigation, better education for patients and medical staff, and adjusting work processes. This is the first study demonstrating that hospital patients are gravely concerned and expect adjustments according to climate change. Since heat is seen as a major risk by interviewees, the fast implementation of published recommendations is crucial. By synthesizing inpatients’ expectations with scientific recommendations, we encourage patient-centered climate change adaptation. This can be the start for further collaboration with patients to create climate change resilient hospitals.

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