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Resident logbooks (RLBs) documenting clinical case exposure are widespread in medical education despite evidence of poor accuracy. Electronic health records (e.g., anesthesia information management systems [AIMS]) may provide advantages for auditing longitudinal case exposure. We evaluated the agreement between AIMS and RLBs for tracking case exposure during anesthesiology residency. We performed a historical cohort study with anesthesiology residents (2011–2018, all of whom used a RLB contemporaneously with AIMS) working in a multisite academic health sciences network. The primary outcome was total case-load logging; secondary outcomes were volumes for seven surgical specialties (general, gynecology, neuro, orthopedic, thoracic, urology, and vascular surgery). Correlation of case numbers tracked by AIMS vs RLB was assessed using Pearson correlation; agreement was determined using Bland–Altman plots and intraclass correlation coefficients (ICC). Data from 27 anesthesiology residents were collected. Overall, mean (standard deviation) case numbers were generally greater with AIMS vs RLB [649 (103) vs 583 (191); P = 0.049). Total case volumes between systems had moderate correlation (r = 0.50) and agreement (intraclass correlation coefficient [ICC], 0.42; 95% CI, 0.34 to 0.59). Bland–Altman plots showed variable agreement between AIMS and RLB data [mean (SD) bias = 66 (166) cases]. For general, gynecology, neuro, orthopedic, thoracic, urology, and vascular surgery, there was a range of poor to moderate agreement (ICC, 0.23–0.57) between AIMS and RLB. For anesthesiology resident case-logging, the number of cases logged in an AIMS was higher with lower variance compared with RLBs. Anesthesia information management systems vs RLB data showed low–moderate correlation and agreement. Given the additional time and resources required for RLBs, AIMS may be a superior method for tracking cases where available. more...

Spinal anesthesia, as a basic skill, needs to have a consideration in the design of the learning process in any training program. This study aimed to follow up on the learning curve of the junior r... more...

INTRODUCTION: Anesthesia residents are deemed competent based on subjective and objective metrics. Knowledge acquisition and procedural skill is often difficult to accurately measure. Inspecting tangible metrics of perioperative efficiency may provide a source for reliable evaluation. METHODS: Retrospective case-log database review yielded 3072 surgical cases involving residents over 5 years. Primary variable investigated was the time from surgery completion to exit from operating room. Other variables recorded included day of week, attending anesthesiologist name, attending surgeon name, patient age, sex, American Society of Anesthesiologists physical status (ASA PS) classification, and inpatient versus day surgery status. RESULTS: After controlling for procedure duration time, inpatient status, ASA PS, surgeon, and attending anesthesiologist, resident training time had high statistical significance. In the fully adjusted model, 1 year of resident training was associated with a reduction in emergence time by 28 seconds. A 1-hour increase in procedure time was associated with an increase in emergence time of 34 seconds. CONCLUSIONS: Although a statistically significant correlation between anesthesia resident training time and emergence time was demonstrated, the clinical significance is likely low given the relatively small amount of actual time saved. We caution the value of using perioperative metrics (e.g., emergence time) for evaluating anesthesia resident competency, until such metrics have undergone significant validation. more...

Background Similar to other sub-Saharan countries, Ethiopia suffers from a severe shortage of adequately trained health professionals. Academic partnerships can support sustainable training programs and build capacity for low-resource settings. 3D modeling and simulation-based training provide necessary tools, especially for rarely-encountered clinical situations, such as needle cricothyroidotomy. Methods Departments of Anesthesiology, Otolaryngology, and Learning Health Sciences collaborated to develop a low-cost, high-fidelity simulator and Cricothryoidotomy Skills Maintenance Program (CSMP). Twelve anesthesia residents at St. Paul's Hospital Medical Millennium College in Addis Ababa, Ethiopia participated in CSMP. The program consisted of a didactic session with presentation and demonstration and an immersive CICO scenario. Program evaluation was performed using pre/post-training knowledge and 2 procedural performance assessments-the CSMP Global Rating Scale and the Checklist. With consent, performances were videotaped and rated independently by 3 University of Michigan faculty. Results Improvements were identified in all areas, including residents' knowledge, measured by mean summed test scores (Mpre = 3.31,Mpost = 4.46,p = 0.003), time to perform cricothyroidotomy (Mpre = 96.64,Mpost = 72.82,p = 0.12), residents' performance quality, measured by overall mean Global ratings, (Mpre = 0.20; Mpost = 0.70) with improvements identified at the item-level, p = 0.001 with moderate-large effect sizes, and residents' ability to complete tasks, measured by mean Checklist ratings (Mpre = 0.51,Mpost = 0.90, with item-level improvements observed, p ≤ 0.01, with small-large effect sizes. Residents' self-reported confidence also improved (Mpre = 1.69, Mpost = 3.08,p = 0.001). Conclusion Our work shows that cricothyroidotomy skills taught to anesthesia residents at SPHMMC with a 3D printed laryngotracheal model improves knowledge, skills, and confidence. The creation of a low-cost, high-fidelity simulator and a CSMP has the potential to impact patient care and safety world-wide. more...

Background and Aims: Emergence time, or the duration between incision closure and extubation, is costly nonoperative time. Efforts to improve operating room efficiency and identify trainee progress make such time intervals of interest. We sought to calculate the incidence of prolonged emergence (i.e., >15 min) for patients under the care of clinical anesthesia (CA) residents. We also sought to identify factors from resident training, medical history, anesthetic use, and anesthesia staffing, which affect emergence. Material and Methods: In this single-center, historical cohort study, perioperative information management systems provided data for surgical cases under resident care at a tertiary care center in the United States from 2006 to 2008. Using multiple logistic regression, the effects of variables on emergence was analyzed. Results: Of 7687 cases under the care of 27 residents, the incidence of prolonged emergence was 13.9%. Emergence prolongation decreased by month in training for 1st-year (CA-1) residents (r2 = 0.7, P < 0.001), but not for CA-2 and CA-3 residents. Mean patient emergence time differed among 27 residents (P < 0.01 for 58.4% or 205/351 paired comparisons). In a model restricted to 1st-year residents, patient male gender, American Society of Anesthesiologists (ASA) physical status >II, emergency surgical case, operative duration ≥2 h, and paralytic agent use were associated with higher frequency of prolonged emergence, while sevoflurane or desflurane use was associated with lower frequency. Attending anesthesiologist handoff was not associated with longer emergence. Conclusion: Incidence of prolonged emergence from general anesthesia differed significantly among trainees, by resident training duration, and for patients with ASA >II. more...

Background Senior anesthesia residents must acquire competency in crisis management for operating room (OR) emergencies. We conducted problem based learning (PBL) OR emergency scenarios for anesthesia residents, focused on emergencies in ‘Airway’, ‘Circulation’, ‘Central venous catheter’, and ‘Pain management complications’. Non-technical skills are an integral component of team-based OR emergency management. Methods Prior to integrated OR emergency clinical and non-technical skills PBL training, participating 35 anesthesia residents completed two 5-point scale surveys regarding frequency of emergency experiences in the operating room, and self-confidence for anesthesia-related crisis management. Repeat administration of the self-confidence survey was completed immediately following PBL training. Results Post-PBL resident clinical management self- confidence improved (P more...

Our department monitors the quality of anesthesiologists’ clinical supervision and provides each anesthesiologist with periodic feedback. We hypothesized that greater differentiation among anesthesiologists’ supervision scores could be obtained by adjusting for leniency of the rating resident. From July 1, 2013 to December 31, 2015, our department has utilized the de Oliveira Filho unidimensional nine-item supervision scale to assess the quality of clinical supervision provided by faculty as rated by residents. We examined all 13,664 ratings of the 97 anesthesiologists (ratees) by the 65 residents (raters). Testing for internal consistency among answers to questions (large Cronbach’s alpha > 0.90) was performed to rule out that one or two questions accounted for leniency. Mixed-effects logistic regression was used to compare ratees while controlling for rater leniency vs using Student t tests without rater leniency. The mean supervision scale score was calculated for each combination of the 65 raters and nine questions. The Cronbach’s alpha was very large (0.977). The mean score was calculated for each of the 3,421 observed combinations of resident and anesthesiologist. The logits of the percentage of scores equal to the maximum value of 4.00 were normally distributed (residents, P = 0.24; anesthesiologists, P = 0.50). There were 20/97 anesthesiologists identified as significant outliers (13 with below average supervision scores and seven with better than average) using the mixed-effects logistic regression with rater leniency entered as a fixed effect but not by Student’s t test. In contrast, there were three of 97 anesthesiologists identified as outliers (all three above average) using Student’s t tests but not by logistic regression with leniency. The 20 vs 3 was significant (P < 0.001). Use of logistic regression with leniency results in greater detection of anesthesiologists with significantly better (or worse) clinical supervision scores than use of Student’s t tests (i.e., without adjustment for rater leniency). more...

Background Part task training (PTT) focuses on dividing complex tasks into components followed by intensive concentrated training on individual components. Variable priority training (VPT) focuses on optimal distribution of attention when performing multiple tasks simultaneously with the goal of flexible allocation of attention. This study explored how principles of PTT and VPT adapted to anesthesia training would improve first-year anesthesiology residents' management of simulated adverse airway and respiratory events. The authors hypothesized that participants with PTT and VPT would perform better than those with standard training. Methods Twenty-two first-year anesthesia residents were randomly divided into two groups and trained over 12 months. The control group received standard didactic and simulation-based training. The experimental group received similar training but with emphasis on PTT and VPT techniques. Participant ability to manage seven adverse airway and respiratory events were assessed before and after the training period. Performance was measured by the number of correct tasks, making a correct diagnosis, assessment of perceived workload, and an assessment of scenario comprehension. Results Participants in both groups exhibited significant improvement in all metrics after a year of training. Participants in the experimental group were able to complete more tasks and answered more comprehension questions correctly. There was no difference in perceived workload or the number of correct diagnoses between groups. Conclusion This study in part confirmed the study hypotheses. The results suggest that VPT and PTT are promising adjuncts to didactic and simulation-based training for management of adverse airway and respiratory events. more...

Study objective We compare laryngoscopy performance and overall intubation success in trauma airways when primary airway management alternated between emergency medicine and anesthesia residents on an every-other-day basis. Methods Data on all trauma intubations during approximately 3 years were prospectively collected. Primary airway management was assigned to emergency department (ED) residents on even days and anesthesia residents on odd days. Emergency medicine residents intubated patients who arrived without notification or who needed immediate intubation before anesthesia arrived. The study was conducted in an inner-city, Level I trauma center with approximately 50,000 ED patients and 1,800 major trauma cases a year. Main outcomes were success or failure at laryngoscopy and the number of laryngoscopy attempts needed for intubation. Results Six hundred fifty-eight trauma patients were intubated during the study period. Laryngoscopy was successful in 654 of 656 cases. Two (0.3%) patients underwent cricothyrotomy after failed laryngoscopy, and 2 (0.3%) patients had awake nasal intubation without laryngoscopy. The specific number of laryngoscopy attempts was unknown in 6 cases (3 from each service), resulting in 650 cases for laryngoscopy performance analysis. Overall, 87% of patients were intubated on first attempt, and 3 or more attempts occurred in 2.9% of patients. Laryngoscopy performance by service (broken down by 1, 2, and ≥3 attempts) was as follows: emergency medicine 86.4%, 11%, and 2.6% versus anesthesia 89.7%, 6.7%, and 3.6%. Analysis by service was done by using Wilcoxon Mann-Whitney testing ( P =.225). Conclusion There were no differences in laryngoscopy performance and intubation success in trauma airways managed on an every-other-day basis by emergency medicine versus anesthesia residents. [ Ann Emerg Med. 2004;43:48-53.] more...

Background: Valid methods are needed to identify anesthesia resident performance gaps early in training. However, many assessment tools in medicine have not been properly validated. The authors designed and tested use of a behaviorally anchored scale, as part of a multiscenario simulation-based assessment system, to identify high- and low-performing residents with regard to domains of greatest concern to expert anesthesiology faculty. Methods: An expert faculty panel derived five key behavioral domains of interest by using a Delphi process (1) Synthesizes information to formulate a clear anesthetic plan; (2) Implements a plan based on changing conditions; (3) Demonstrates effective interpersonal and communication skills with patients and staff; (4) Identifies ways to improve performance; and (5) Recognizes own limits. Seven simulation scenarios spanning pre-to-postoperative encounters were used to assess performances of 22 first-year residents and 8 fellows from two institutions. Two of 10 trained faculty raters blinded to trainee program and training level scored each performance independently by using a behaviorally anchored rating scale. Residents, fellows, facilitators, and raters completed surveys. Results: Evidence supporting the reliability and validity of the assessment scores was procured, including a high generalizability coefficient (ρ2 = 0.81) and expected performance differences between first-year resident and fellow participants. A majority of trainees, facilitators, and raters judged the assessment to be useful, realistic, and representative of critical skills required for safe practice. Conclusion: The study provides initial evidence to support the validity of a simulation-based performance assessment system for identifying critical gaps in safe anesthesia resident performance early in training. more...

Simulation in residency training is becoming more popular but there is limited evidence showing that it can improve a resident’s fund of knowledge, particularly in anesthesiology. We looked at whether a bronchoscopy simulation could improve performance on a thoracic anesthesia knowledge test administered both before and after using the simulator. Fourteen first-year anesthesiology residents completed the study with an average improvement on the test of 28% (p 0.05). We conclude that bronchoscopy simulation is an effective method of educating anesthesiology residents. more...

Multiple unilateral rib fractures can cause significant pain and morbidity. Continuous nerve block catheters are often maintained while inpatient, and patients are discharged with oral analgesics. However, in many institutions, this dynamic is changing and patients are being managed effectively with outpatient catheters. A 45-year-old male was presented with fractured right ribs 6 through 9. The patient was an anesthesiology resident and was unable to perform his clinical duties. Single paravertebral nerve blocks were performed at right thoracic levels 6–9. At the T7 level, an indwelling catheter was placed. On post-injury day 18, he was able to discontinue the catheter and there were no associated complications. We report a unique case of a patient with multiple rib fractures who was not able to be exposed to potential side effects of opioids. The use of a continuous thoracic paravertebral nerve in an outpatient setting allowed a faster return to function with no adverse events. more...

Remifentanil is a potent micro-opioid receptor agonist that produces intense analgesia. This anilidopiperidine analog of fentanyl was approved by the United States Food and Drug Administration and became commercially available in the United States in 1997. Because of its unique chemical structure, remifentanil must be reconstituted; it has a rapid onset, and because of ester hydrolysis, it has a rapid rate of degradation. Although remifentanil's package insert warns against the potential for addiction, because of its rapid rate of degradation there was little concern that health care workers would abuse this drug. Herein, we report a case of intranasal remifentanil abuse by an anesthesiology resident. more...

Simulators are used for training medical personnel. This report details the use of a human patient simulator for initial clinical experience of anesthesia housestaff with cardiopulmonary bypass.

Background Operating room efficiency is an important concern in most hospitals today. Little work has been reported to evaluate the contribution of anesthesia residents to changes in anesthesia-controlled time-related efficiencies in the operating room. The goal of this study was to measure the impact of the initiation of new residents to the operating room on anesthesia-related time measures of operating room efficiency. Methods Using the computerized operating room information systems, specific data regarding anesthesia-controlled times were extracted over three distinct 2-week periods over the course of 1 academic year. These included the first 2 weeks of July, when most of the operating rooms were staffed by attending physicians working alone; 2 weeks in September when new anesthesia residents were working in a 2:1 ratio with staff; and 2 weeks in May. The induction times, emergence times, and room turnover times were compared over these three periods for first-year anesthesia residents. Standard descriptive statistics were computed. Analysis of variance testing was then conducted comparing each of these time periods. Significance was set at P < 0.05. Results A total of 3,004 surgical procedures were performed during the 2-week study periods in July, September, and May, respectively. For the July, September, and May groups, the mean anesthesia induction times were 17.3, 19.0, and 20.8 min (P = 0.047); the emergence times were 8.7, 9.7, and 10.0 min, (P = 0.024); and the corresponding mean room turnover times were 47.6, 48.5, and 48.6 min (P = 0.907), respectively. Conclusion Although statistically significant time differences were found, these data strongly suggest that the initiation of anesthesia trainees to the operating room has no clinically or economically meaningful adverse effect on the anesthesia-controlled time component of operating room efficiency. more...

Over the last several years, there has been a dramatic increase in the use of anesthesia human patient simulators for educational purposes. Full-scale, computer run simulators are currently being used to teach courses ranging from basic instruction of non-anesthesiologists to the more complicated Anesthesia Crisis Resource Management™,1 for continuing medical education of attending anesthesiologists. At the University of Rochester, the emphasis of our simulator program has been in the education of medical students and anesthesia residents. This chapter will not only provide an outline of the different courses for which we have used the simulator as an educational adjunct, but also to share some of the lessons we have learned that will help in creating a successful educational program. more...

and an examination to identify dental damage was performed by a dental surgeon postoperatively. Results: In predictive values for screening tests to predict the occurrence of dental injury, CBT (a test that combined the two screening tests) was higher than ULBT and MMT for specificity, positive predictive value, and accuracy. The incidence of dental trauma among the levels of resident training was not significantly different. Conclusions: CBT, among the screening tests for predicting difficult intubation, will be helpful in the prediction of dental injury. The various levels of training of residents did not affect the incidence of dental injury during general anesthesia. (Korean J Anesthesiol 2008; 54: 289∼94) more...

Background Simulation training has been shown to be an effective teaching tool. Learner management of an intraoperative crisis such as a major cerebrovascular bleed requires effective teamwork, communication, and implementation of key skill sets at appropriate time points. This study establishes a first of a kind simulation experience in a neurosurgery/anesthesia resident (learners) team working together to manage an intraoperative crisis. Methods Using a cadaveric cavernous carotid injury perfusion model, 7 neurosurgery and 6 anesthesia learners, were trained on appropriate vascular injury management using an endonasal endoscopic technique. Learners were evaluated on communication skills, crisis management algorithms, and implementation of appropriate skill sets at the right time. A preanatomic and postanatomic examination and postsimulation survey was administered to neurosurgery learners. Anesthesia learners provided posttraining evaluation through a tailored realism and teaching survey. Results Neurosurgery learners' anatomic examination score improved from presimulation (33.89%) to postsimulation (86.11%). No significant difference between learner specialties was observed for situation awareness, decision making, communications and teamwork, or leadership evaluations. Learners reported the simulation realistic, beneficial, and highly instructive. Conclusions Realistic, first of kind, clinical simulation scenarios were presented to a neurosurgery/anesthesia resident team who worked together to manage an intraoperative crisis. Learners were effectively trained on crisis management, the importance of communication, and how to develop algorithms for future implementation in difficult scenarios. Learners were highly satisfied with the simulation training experience and requested that it be integrated more consistently into their residency training programs. more...

Quality anesthetic care is lacking in low- and middle-income countries (LMICs). Global health leaders call for perioperative capacity reports in limited-resource settings to guide improved health care initiatives. We describe a teaching hospital's resources and the national workforce and education in this LMIC capacity report.A prospective observational study was conducted at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, during 4 weeks in August 2016. Teaching hospital data were generated from observations of hospital facilities and patient care, review of archival records, and interviews with KATH personnel. National data were obtained from interviews with KATH personnel, correspondence with Ghana's anesthesia society, and review of public records.The practice of anesthesia at KATH incorporated preanesthesia clinics, intraoperative management, and critical care. However, there were not enough physicians to consistently supervise care, especially in postanesthesia care units (PACUs) and the critical care unit (CCU). Clean water and electricity were usually reliable in all 16 operating rooms (ORs) and throughout the hospital. Equipment and drugs were inventoried in detail. While much basic infrastructure, equipment, and medications were present in ORs, patient safety was hindered by hospital-wide oxygen supply failures and shortage of vital signs monitors and working ventilators in PACUs and the CCU. In 2015, there were 10,319 anesthetics administered, with obstetric and gynecologic, general, and orthopedic procedures comprising 62% of surgeries. From 2011 to 2015, all-cause perioperative mortality rate in ORs and PACUs was 0.65% or 1 death per 154 anesthetics, with 99% of deaths occurring in PACUs. Workforce and education data at KATH revealed 10 anesthesia attending physicians, 61 nurse anesthetists (NAs), and 7 anesthesia resident physicians in training. At the national level, 70 anesthesia attending physicians and 565 NAs cared for Ghana's population of 27 million. Providers were heavily concentrated in urban areas, and NAs frequently practiced independently. Two teaching hospitals provided accredited postgraduate training modeled after European curricula to 22 anesthesia resident physicians.While important limitations to capacity exist in Ghana, the overall situation is good compared to other LMICs. Many of the challenges encountered resulted from insufficient PACU and CCU provisions and few providers. Inadequate outcomes reporting made analysis and resolution of problem areas difficult. While many shortcomings stemmed from limited funding, strengthening physician commitment to overseeing care, ensuring oxygen supplies are uninterrupted, keeping ventilators in working order, and making vital signs monitors ubiquitously available are feasible ways to increase patient safety with the tools currently in place. more...

An 18-year-old woman, G1P0, presents to Labor & Delivery at 40 weeks estimated gestational age with severe labor pain. Her cervix is 2–3 cm dilated and she urgently requests an epidural (L-1). The anesthesia resident places the epidural uneventfully and doses it liberally since the patient complains of severe pain (L-2). Soon the patient feels much better as the epidural starts to work (L-3). The anesthesia resident has already given a 500 mL “co-load” of lactated Ringer’s solution (LR) and now gives the patient 50 mcgm of phenylephrine IV. He explains to her why it is important for her and her fetus that she labor lying on one side or the other—but not to lie flat on her back—and he stays in the patient’s room doing his documentation long enough to make sure that the neuraxial block is not going too high (L-4). more...

A 69-year-old woman undergoing treatment for hypertension and epilepsy was scheduled to undergo cataract surgery. All preoperative examination results were within normal limits. Despite being tense, she walked to the operating room. Approximately 2 minutes after an intravenous line was established by an anesthesia resident, severe hypoxia and bradycardia developed, and she lost consciousness. Cardiopulmonary resuscitation was initiated immediately, and after 1 minute, she regained consciousness, and her breathing and circulation recovered. After admission to the intensive care unit, emergency coronary angiography was performed. The blood flow in all the coronary arteries was normal. However, a decrease in the apical left ventricular wall motion and an increase in the basal wall motion were observed. Based on these findings, Takotsubo cardiomyopathy was diagnosed. The wall motion gradually improved and the patient was discharged from the hospital on postoperative day 15. The respiratory depression and bradycardia were thought to be due to an inadvertent bolus of remifentanil. We surmised that the patient had received a slight amount of retained medication when the anesthesia resident established the intravenous line, which caused severe respiratory depression. It is important to note that adverse effects such as severe respiratory depression and bradycardia can be caused by even small doses of remifentanil. more...

A man underwent placement of a lumbar catheter to drain cerebrospinal fluid at the start of a vascular surgery procedure. On the first postoperative day, an anesthesia resident who had never removed this type of drain removed the drain after consulting with his attending physician. The patient was seen on postoperative day 6 in the vascular surgery clinic reporting drainage from the lumbar drain site that had persisted since hospital discharge. That same day, the anesthesia resident removed another lumbar catheter and noted that the tip appeared different than the previous one. Suspecting that a fragment of the catheter tip may have been retained in the patient, he notified the attending anesthesiologist and the vascular surgery clinic. On examination of the patient’s back, there was a raised area of skin with clear fluid at the lumbar drain site. Imaging was obtained, which confirmed the retained lumbar catheter tip. more...

The obstetrical team (OB) calls the anesthesia resident to inform him that one of the laboring patients will have a cesarean delivery for failure to progress. The anesthesia resident calls his attending: “I am calling to discuss our 24-year-old G1P0 parturient in labor room 8 who will be having a cesarean delivery for failure to progress. The patient’s medical history is significant only for obesity. She denies any surgeries in the past. Her airway examination reveals a Mallampati 3, with good mouth opening, normal thyromental distance, full range of motion, and a short, thick neck. We placed her epidural this morning, and I have been asked to give additional medication (top-up) three times since then. more...

Introduction This is a team-based simulation resource using a SimMan. The resource is designed to expose junior and senior anesthesia residents to a “cannot intubate, cannot ventilate” scenario after a failed spinal anesthetic. Through this experience learners are provided an opportunity to manage a life-threatening airway emergency that plays out in real time, where the correct steps need to be taken in a limited amount of time. Methods This 2-hour session includes a briefing prior to the simulation, the simulation session, and a postsession debriefing. During the session a junior anesthesia resident performs a spinal anesthetic and manages conscious sedation. A senior anesthesia resident manages the situation as an unanticipated difficult airway scenario develops. As this scenario unfolds the team will need to evaluate the preoperative airway. The team will need to recognize the need to call for assistance early in the event, utilize various alternative techniques for airway management, and optimize resource management skills. Results We have used this simulation scenario a total of nine times and a total of 24 residents in two- or three-person groups have participated. The feedback we have received has been very favorable. Discussion This scenario exposes residents to a critical situation which they are likely to encounter during their career as anesthesiologists. This allows them to be able to put theoretical knowledge in practice in a crisis. Errors we observed in the simulator correlated with errors reported to continuous quality improvement. We have found that occasionally residents would fail to follow the American Society of Anesthesiologists guidelines in a crises situation even if they are familiar with these guidelines. The residents tended to “suspend disbelief” and become more involved with the scenario when the simulator responded in a believable way; for instance responding to the oxygen mask being placed over his face. more...

To assess the effectiveness of faculty-specific electronic reminders on increasing faculty compliance with completing daily anesthesia resident evaluations.Retrospective study.Anesthesiology Residency Program at Oregon HealthScience University.41 faculty members on staff from February 2004 through January 2006 were studied for compliance with submitting daily anesthesia resident evaluations 12 months before and 12 months after implementation of a faculty-specific electronic reminder system. Evaluations were entered into a customized, web-based Daily Resident Evaluation database. Data for the reminders were obtained from the Surgical Schedule database. At the end of the study period, data on compliance with our daily resident evaluation system was aggregated by month and compared before versus after system implementation.A total of 1,222 of 3,893 possible evaluations (31.4%) were submitted before the faculty-specific electronic reminder system was in place, with 38 faculty submitting at least one evaluation (93% participation). After the intervention, 1,824 of 4,263 possible evaluations (42.8%) were submitted, with all 41 faculty submitting at least one evaluation (100% participation). The percentage of resident evaluations submitted by the faculty increased from 29.3% to 42.9% (P0.0001) after introducing the faculty-specific reminders. Faculty in the lowest quartile of compliance prior to the intervention showed the largest improvement (446% increase).A faculty-specific electronic reminder system improved faculty compliance with submitting resident evaluations. The faculty members with the lowest compliance prior to implementation of this system benefited the most. more...

Author(s): Donovan, Anne L; Braehler, Matthias R; Robinowitz, David L; Lazar, Ann A; Finlayson, Emily; Rogers, Stephanie; Douglas, Vanja C; Whitlock, Elizabeth L; Anesthesia Resident Quality Improvement Committee | Abstract: BackgroundPostoperative delirium is a common and serious problem for older adults. To better align local practices with delirium prevention consensus guidelines, we implemented a 5-component intervention followed by a quality improvement (QI) project at our institution.MethodsThis hybrid implementation-effectiveness study took place at 2 adult hospitals within a tertiary care academic health care system. We implemented a 5-component intervention: preoperative delirium risk stratification, multidisciplinary education, written memory aids, delirium prevention postanesthesia care unit (PACU) orderset, and electronic health record enhancements between December 1, 2017 and June 30, 2018. This was followed by a department-wide QI project to increase uptake of the intervention from July 1, 2018 to June 30, 2019. We tracked process outcomes during the QI period, including frequency of preoperative delirium risk screening, percentage of "high-risk" screens, and frequency of appropriate PACU orderset use. We measured practice change after the interventions using interrupted time series analysis of perioperative medication prescribing practices during baseline (December 1, 2016 to November 30, 2017), intervention (December 1, 2017 to June 30, 2018), and QI (July 1, 2018 to June 30, 2019) periods. Participants were consecutive older patients (≥65 years of age) who underwent surgery during the above timeframes and received care in the PACU, compared to a concurrent control group l65 years of age. The a priori primary outcome was a composite of perioperative American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use (Beers PIM) medications. The secondary outcome, delirium incidence, was measured in the subset of older patients who were admitted to the hospital for at least 1 night.ResultsDuring the 12-month QI period, preoperative delirium risk stratification improved from 67% (714 of 1068 patients) in month 1 to 83% in month 12 (776 of 931 patients). Forty percent of patients were stratified as "high risk" during the 12-month period (4246 of 10,494 patients). Appropriate PACU orderset use in high-risk patients increased from 19% in month 1 to 85% in month 12. We analyzed medication use in 7212, 4416, and 8311 PACU care episodes during the baseline, intervention, and QI periods, respectively. Beers PIM administration decreased from 33% to 27% to 23% during the 3 time periods, with adjusted odds ratio (aOR) 0.97 (95% confidence interval [CI], 0.95-0.998; P = .03) per month during the QI period in comparison to baseline. Delirium incidence was 7.5%, 9.2%, and 8.5% during the 3 time periods with aOR of delirium of 0.98 (95% CI, 0.91-1.05, P = .52) per month during the QI period in comparison to baseline.ConclusionsA perioperative delirium prevention intervention was associated with reduced administration of Beers PIMs to older adults. more...

Background Perioperative efficiency has been studied, although little is known about patient and personnel factors associated with a timely operating room start. We hypothesize that patient, personnel factors, and induction-order decisions are associated with anesthesia induction time. Methods An institutional database was used to identify the anesthesia induction time of adults undergoing first-start, elective operations from January 2014 to May 2017 at an academic quaternary care center. Data included patient demographics; surgeon and anesthesiologist, as well as their seniority (years since initial board certification); certified registered nurse anesthetist versus anesthesia resident staffing; and use of neuraxial anesthesia. Times were measured as minutes from scheduled start to induction. Univariate and multivariate analyses were performed to identify factors associated with induction time. Results We identified 15,823 cases. Predictors of later induction included add-on cases (1,224 cases were add-ons, 7.73%), American Society of Anesthesiologists classification ≥ 3, neuraxial anesthesia, and certified registered nurse anesthetist staffing. Surgeon seniority—but not gender—affected induction time. In 11,093 cases (70.1%), the anesthesiologist was scheduled for multiple first starts with a choice of which patient to induce first. Surgeon gender was predictive of induction order, with cases of male surgeons induced first more frequently than female surgeons’ (47.0% vs 44.1%, P = .02). Cases staffed by anesthesiology residents were more likely to be induced first compared with those staffed by certified registered nurse anesthetists (52.1% vs 41.5%, P Conclusion Patient and personnel factors affect the order of case induction, but induction time is most dependent on patient factors. Hospitals should focus on improving preparedness and limiting bias to create a more equitable and efficient perioperative process. more...

Information regarding the impact of provider characteristics on perioperative outcomes in the spine surgery setting is limited. Existing studies primarily consider the impact of surgical provider volume. This analysis sought to identify the impact of anesthesiologist and surgeon volume and experience as well as anesthesia care team composition on adverse outcomes following anterior cervical discectomy and fusions (ACDF) and posterior lumbar fusions (PLF). We identified 5900 patients who underwent ACDF or PLF procedures at a high-volume orthopedic institution from 2005 to 2014. Provider characteristics of interest were anesthesiologist and surgeon volume and experience along with anesthesia care team composition. Multivariable logistic regression models were used to evaluate the outcomes of any complication, cardiopulmonary complication, and prolonged length of stay (> 7 days). Intraclass correlation coefficients were calculated to determine how much variation in outcomes could be explained by provider characteristics. There were no significant relationships between provider characteristics and perioperative outcomes among ACDF patients. Within the PLF cohort, surgeon annual case volume > 25 was associated with decreased odds of prolonged length of stay, while anesthesia resident involvement was associated with increased odds of prolonged length of stay. Surgeon characteristics explained the greatest proportion of variation in outcomes while anesthesiologist characteristics explained the least. Anesthesia provider volume and experience did not significantly impact the odds of adverse outcome for ACDF and PLF patients. Higher surgeon volume was exclusively associated with decreased odds of prolonged length of stay following PLF. Further study is necessary to determine if these relationships persist in a less-specialized setting. These slides can be retrieved under Electronic Supplementary Material. more...

Objective Cerebrospinal fluid drainage catheter-related complications can be reduced by following strict guidelines during their introduction, maintenance, and removal. The authors therefore aimed to determine whether simulation-based learning would improve senior anesthesiology residents’ patient care performance during the insertion and management of these catheters compared to interactive problem-based learning (PBL) using the Anaesthetists’ Non-Technical Skills global rating scale (ANTS). Design Prospective randomized trial. Setting Vascular or hybrid operating rooms in a large academic tertiary care center. Participants Senior anesthesia (categorical anesthesia-3) residents rotating through the vascular rotation at the Cleveland Clinic main campus in the period between December 2014 and June 2017. Intervention Simulation-based learning versus PBL. Measurements and Main Results The primary outcome was the composite score (ANTS global rating scale) achieved by participating residents as evaluated by their supervising anesthesiologists. Out of 28 residents who completed the study, N = 13 were randomized to simulation-based learning and N = 15 residents to the PBL approach. The median (first quartile, third quartile) composite score was 16 (14, 16) and 16 (13, 16) for the simulation-based learning and PBL groups, respectively. There was no significant difference in staff evaluation of the 2 study groups (p = 0.48) with an estimated odds (95% confidence interval) of getting a better staff evaluation score of 1.9 (0.3-10.6) times higher comparing simulation versus traditional training groups. Conclusion Compared to interactive PBL, simulation-based learning does not result in a statistically significant improvement in anesthesia resident performance during insertion and management of cerebrospinal fluid drainage catheters. more...

Carotid artery injuries are serious complications of endoscopic endonasal surgery. As these occur rarely, simulation training offers an avenue for technique and algorithm development in resident learners. This study develops a realistic cadaveric model for the training of crisis resource management in the setting of cavernous carotid artery injury. An expanded endonasal approach and right cavernous carotid injury is performed on a cadaveric head. The cadaver's right common carotid artery is cannulated and connected to a perfusion pump delivering pressurized simulated blood. A simulation mannequin is incorporated into the model to allow for vital sign feedback. Surgical and anesthesia resident learners are tasked with obtaining vascular control with a muscle patch technique and medical management over the course of 3 clinical scenarios with increasing complexity. Crisis management instructions for an endoscopic endonasal approach to the cavernous carotid artery and blood pressure control were provided to the learners prior to beginning the simulation. An independent reviewer evaluated the learners on communication skills, crisis management algorithms, and implementation of appropriate skill sets. After each scenario, residents were debriefed on how to improve technique based on evaluation scores in areas of situational awareness, decision-making, communications and teamwork, and leadership. After the simulation, learners provided feedback on the simulation and this data was used to improve future simulations. The benefit of this cadaveric model is ease of set-up, cost-effectiveness, and reproducibility. more...