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Coronary artery bypass grafting represents one of the most commonly performed cardiac surgeries worldwide. Recently, interest has increased in providing patients with a less invasive approach to cardiac surgery, such as thoracotomy and endoscopic techniques using robotic technology as an alternative to traditional sternotomy. As the population gets older, the need for additional methods to provide care for sick patients will continue to expand. These advancements will further allow physicians to provide cardiac surgical procedures with less pain and faster recovery for patients.

The application and evolution of total endoscopic robotic cardiac surgery (TERCS) has become greater as institutions and surgeons become more comfortable with robotic technology. Over the years many improvements have been made to facilitate technically challenging cardiac procedures using robotics and increase overall survival and quality of life for these patients. However, a dedicated multidisciplinary approach led by a core group of clinicians is necessary for good patient experience and outcomes. In addition, good communication and performance improvement measures with attention to detailed perioperative management are essential to a successful robotic cardiac program.

This highlights in our specialty for 2019 begin with the ongoing major developments in transcatheter valve interventions. Thereafter, the advances in left ventricular assist devices are reviewed. The recent focus on conduit selection and robotic options in coronary artery bypass surgery are then explored. Finally, this special articles closes with a discussion of pulmonary hypertension in noncardiac surgery, anesthetic technique in cardiac surgery, as well as postoperative pneumonia and its outcome consequences.

Objective: The present study investigated outcomes in patients with vasoplegia after cardiac surgery treated with angiotensin II plus standard-of-care vasopressors. Vasoplegia is a common complication in cardiac surgery with cardiopulmonary bypass and is associated with significant morbidity and mortality. Approximately 250,000 cardiac surgeries with cardiopulmonary bypass are performed in the United States annually, with vasoplegia occurring in 20%to-27% of patients. Design: Post-hoc analysis of the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) study. Setting: Multicenter, multinational study. Participants: Sixteen patients with vasoplegia after cardiac surgery with cardiopulmonary bypass were enrolled. Interventions: Angiotensin II plus standard-of-care vasopressors (n = 9) compared with placebo plus standard-of-care vasopressors (n = 7). Measurements and Main Results: The primary endpoint was mean arterial pressure response (mean arterial pressure ≥75 mmHg or an increase from baseline of ≥10 mmHg at hour 3 without an increase in the dose of standard-of-care vasopressors). Vasopressor sparing and safety also were assessed. Mean arterial pressure response was achieved in 8 (88.9%) patients in the angiotensin II group compared with 0 (0%) patients in the placebo group (p = 0.0021). At hour 12, the median standard-of-care vasopressor dose had decreased from baseline by 76.5% in the angiotensin II group compared with an increase of 7.8% in the placebo group (p = 0.0013). No venous or arterial thrombotic events were reported. Conclusion: Patients with vasoplegia after cardiac surgery with cardiopulmonary bypass rapidly responded to angiotensin II, permitting significant vasopressor sparing.

Patients undergoing cardiovascular surgery may be exposed to heparin before surgery, during cardiopulmonary bypass (CPB), or in the immediate postoperative period. For this reason, cardiovascular surgery patients are at increased risk for heparin-induced thrombocytopenia (HIT), occurring in 1 to 3% of patients. The diagnosis of HIT can be difficult, if based solely on the development of thrombocytopenia, because cardiac surgical patients have multiple reasons to be thrombocytopenic. Several clinical scoring systems have been developed to reduce unnecessary testing and better define the pretest probability of HIT, which we will review in detail with a diagnostic algorithm. In addition, we will cover the prevention and treatment HIT.

Since the 1960s when the first aortic surgical aortic valve replacement (SAVR) was performed, continuous growth in the field of valvular technology has occurred. Although SAVR remains a lifesaving procedure, minimally invasive transcatheter aortic valve replacement has revolutionized and expanded aortic valve replacement to patients who were not previously SAVR candidates, increasing their quality of life and survival. Since its introduction in the United States in 2011, the technology and practice have rapidly expanded. Hybrid techniques have been developed that combine surgical access to the vasculature with valvular deployment over transcatheter systems. This literature review aims to describe the differences between the current available valve technologies, review approaches to surgical technique, discuss anesthetic considerations, and look forward to future directions, trends, and challenges.

Vasoplegic syndrome, characterized by low systemic vascular resistance and hypotension in the presence of normal or supranormal cardiac function, is a frequent complication of cardiovascular surgery. It is associated with a diffuse systemic inflammatory response and is mediated largely through cellular hyperpolarization, high levels of inducible nitric oxide, and a relative vasopressin deficiency. Cardiopulmonary bypass is a particularly strong precipitant of the vasoplegic syndrome, largely due to its association with nitric oxide production and severe vasopressin deficiency. Postoperative vasoplegic shock generally is managed with vasopressors, of which catecholamines are the traditional agents of choice. Norepinephrine is considered to be the first-line agent and may have a mortality benefit over other drugs. Recent investigations support the use of noncatecholamine vasopressors, vasopressin in particular, to restore vascular tone. Alternative agents, including methylene blue, hydroxocobalamin, corticosteroids, and angiotensin II, also are capable of restoring vascular tone and improving vasoplegia, but their effect on patient outcomes is unclear.

Heparin-induced thrombocytopenia is a profoundly dangerous, potentially lethal, immunologically mediated adverse drug reaction to unfractionated heparin or, less commonly, to low-molecular weight heparin. In this comprehensive review, the authors highlight heparin-induced thrombocytopenia's risk factors, clinical presentation, pathophysiology, diagnostic principles, and treatment. The authors place special emphasis on the management of patients requiring procedures using cardiopulmonary bypass or interventions in the catheterization laboratory. Clinical vigilance of this disease process is important to ensure its recognition, diagnosis, and treatment. Misdiagnosis of the syndrome, as well as misunderstanding of the disease process, continues to contribute to its morbidity and mortality.

Angiotensin II is a novel vasopressor recently approved for the treatment of vasodilatory shock. We describe a case in which Angiotensin II was used to treat post–cardiopulmonary bypass vasoplegic syndrome in a patient who was refractory to standard vasopressors and other rescue therapies. Despite requiring high-dose vasopressors, the patient was extubated within 24 hours and has met key quality metrics defined by The Society of Thoracic Surgeons.

In 2015, the demand for the presence of cardiothoracic anesthesiologists outside of the cardiac operating rooms continues to expand. Most notably, cardiothoracic anesthesiologists now find themselves called on to care for patients postoperatively in the cardiothoracic surgical intensive care unit. This article is the first in this annual series to review relevant contributions in postoperative cardiac critical care that may influence the cardiac anesthesiologist. We explore the use of extracorporeal membrane oxygenation, management of postoperative atrial fibrillation and coagulopathy, metabolic support of the critically ill cardiothoracic surgical patient, and new insights into delirium and acute kidney injury.

Delirium after cardiac surgery remains a common occurrence that results in significant short- and long-term morbidity and mortality. It continues to be underdiagnosed given its complex presentation and multifactorial etiology; however, its prevalence is increasing given the aging cardiac surgical population. This review highlights the perioperative risk factors, tools to assist in diagnosing delirium, and current pharmacological and nonpharmacological therapy options.

In our institution, the vast majority of patients presenting for noncardiac surgery (NCS) while supported by a left ventricular assist device (LVAD) are now cared for by noncardiac-trained anesthesiologists as the result of a decade of educational intervention to effect this transition. This represents a significant departure from the published experiences of other institutions. With institutional review board approval, we queried the database of our anesthesia record keeping system (CompuRecord) to determine various aspects of the perioperative management of these patients from July 1, 2003, through June 30, 2013, during which time 271 NCS procedures were performed on adult patients supported by LVADs. Over the entire study period (2003-2013), anesthetic care was provided by a cardiac anesthesiologist 47% of the time and by a noncardiac anesthesiologist 53% of the time. However, by the time period 2012-2013, 88% of the NCS procedures were staffed by a noncardiac anesthesiologist. Despite the prevalence of continuous flow devices in this series, the use of invasive blood pressure monitoring decreased dramatically by the later years of the study. Vasoactive and inotropic medications were rarely required intraoperatively. No intraoperative cardiac arrests, thromboembolic complications, or device malfunctions occurred. Our conclusion is that NCS procedures on LVAD-supported patients can be safely managed by educated noncardiac anesthesiologists.

ITHIN THE SPECIALTY of critical care medicine, a new subspecialty of cardiothoracic surgical critical care has emerged as a result of the unique physiologic changes and complications associated with cardiothoracic surgery. The demand for cardiovascular critical care is increasing with the aging of the population and is projected to increase markedly over the next 15 years worldwide. 1 New paradigms of nutritional and metabolic support have been introduced in the last decade in critically ill patients, focusing on early, combined enteral nutrition (EN) and parenteral nutrition (PN), intensive insulin therapy for tight glucose control, and specific nutrients to modulate system and organ functions. 2 Although most cardiac surgical patients stay in the intensive care unit (ICU) for 1 to 2 days and do not require nutritional support, a small percentage progress to a more complicated and prolonged course and are at higher risk for complications from catabolism related to their illness. In addition, more patients with advanced heart failure are being admitted to the cardiac surgical ICU for prolonged periods and are malnourished at baseline. 3 This article reviews the current evidence regarding nutrition and metabolic support in cardiac surgical patients in the ICU and provides a framework for a structured approach to improve outcomes in this high-risk population.

HE INADVERTENT INTRODUCTION of air during cardiac surgery into the ascending aorta before aortic cross-clamping is a rare but potentially catastrophic complication. 1 Cardiac surgeons and anesthesiologists must be prepared to deal with this emergency, because rapid and decisive action can prevent or attenuate severe neurologic injury that may result from an air embolism. The authors present a case of an air embolism during mitral valve repair surgery that was treated successfully with early detection and management. A continuous quality improvement process following a previous instance of air embolism contributed to the successful outcome. CASE PRESENTATION * A 62-year-old woman with a history of severe mitral regurgitation, chronic atrial fibrillation, and mildly dysfunctional left ventricular systolic function presented for mitral valve repair. The patient was monitored with an electrocardiogram, pulse oximetry, a left radial arterial catheter, a right internal jugular pulmonary artery catheter, bispectral index (BIS) monitor (Aspect Medical Systems, Newton, MA), and cerebral oximetry monitoring (FORE-SIGHT, CASMED, Branford, CT). After median sternotomy, the patient was cannulated for cardiopulmonary bypass with an ascending aortic cannula, separate bicaval venous cannulation, an aortic root catheter for antegrade cardioplegia, and a retrograde coronary sinus cardioplegia cannula. Immediately after initiation of cardiopulmonary bypass and before application of the aortic cross-clamp, air was noted in the cardioplegia line. The surgeon instructed the perfusionist to immediately stop flushing through the aortic root catheter. The aorta then was inspected by transesophageal echocardiography, which showed air in the aortic arch and descending aorta. The BIS monitor showed an abrupt reduction from 28 to 0 and then recovered in less than a minute. The cerebral oximetry monitor also showed an abrupt bilateral reduction from 66 to 45 with quick recovery. The patient was placed immediately placed in steep Trendelenburg position, the mean arterial pressure was raised to 120 mmHg, and the patient was cooled to 241C. One hundred percent inspired fraction of oxygen was used during the resuscitation period to reduce bubble size. Retrograde perfusion via the superior vena cava at a flow of 500 mL/min for 5 minutes was performed with the aortic root vent turned on to aspirate air. Cardiopulmonary bypass then was resumed and the aortic cross-clamp was applied. The patient was maintained at 281C for the next hour and then slowly rewarmed to 35 degrees. The remainder of the surgery was uneventful, and the patient was weaned from bypass using epinephrine at 50/ng/kg/min.

Objectives Blood lactate is frequently used to guide management in critically ill patients. In patients undergoing mitral valve surgery, an elevated lactate level is frequently observed; however, overall mortality is low. The authors hypothesized that hyperlactemia is not a useful predictor of poor outcomes in this patient population. The main aim of this study was to explore how blood lactate level and lactate clearance are associated with 30-day mortality and major adverse events in patients undergoing mitral valve surgery. Design This was a retrospective database review. Logistic regression analysis was performed to assess the associations of perioperative factors with blood lactate in the intensive care unit (ICU). Setting Tertiary-care teaching hospital. Participants The study comprised 917 patients undergoing mitral valve surgery. Interventions None. Measurements and Main Results The majority of patients (71.8%) had elevated blood lactate ≥2 mmol/L on ICU admission; however, within 24 hours, 85.1% of all patients had normal lactate values. Overall 30-day mortality was 2.29% (n = 21). The combination of lactate ≥7 mmol/L on ICU admission and a persistent elevated blood lactate level 24 hours after ICU admission provides an excellent prediction of 30-day mortality (C statistic = 0.85). However, even a significantly elevated lactate level on ICU admission was well-tolerated in the majority of patients as long as lactate values normalized within 24 hours. Male sex, longer cardiopulmonary bypass time, blood transfusion in the ICU, and an elevated blood lactate level on ICU admission and 12 hours after ICU admission all were independent risk factors of clearance failure. Conclusions An elevated blood lactate level is common after mitral valve surgery and is well-tolerated in the majority of patients. Adding lactate clearance improved the predictive value of the blood lactate level.

Objectives/Hypothesis Deliberate hypotension, reverse Trendelenburg position, and hyperventilation are techniques utilized during functional endoscopic sinus surgery to attempt to reduce surgical bleeding. These methods may predispose patients to cerebral ischemia. Cerebral oximetry has not been investigated extensively within otolaryngologic surgery. Our study sought to address the question of whether cerebral oximetry is feasible in the FESS population and evaluate whether the data provided may be useful in the assessment of cerebral perfusion. Study Design Prospective, blinded, observational trial. Methods We designed a prospective, blinded, observational trial of patients undergoing functional endoscopic sinus surgery using cerebral oximetry monitoring. Collected data included mean arterial blood pressure (MAP), end-tidal carbon dioxide (EtCO2), cerebral saturation (SctO2), postanesthesia care unit (PACU) length of stay, and incidence of postoperative nausea and vomiting (PONV). Results Thirty-one subjects were enrolled into the study. Univariate analyses showed cross-correlation between concurrent EtCO2 values and SctO2 of 0.43 (95% CI: 0.27 to 0.59) and between present EtCO2 and the SctO2 5 minutes later of 0.46 (95% CI: 0.33 to 0.59). MAP was not significantly cross-correlated with SctO2. Patients who had an SctO2 below 60% at any time had a median (interquartile range [IQR]) PACU length of stay of 167 (IQR, 95–386) minutes. Patients whose cerebral saturation did not fall below 60% at any time had a median PACU length of stay of 103 (IQR, 76–155) minutes. This difference did not reach statistical significance (P = .257). The median (IQR) maximum decline in SctO2 for patients with PONV was 11.2% (IQR, 8.2%–13.1%) and for patients without PONV was 7.1% (IQR, 5.1%–9.8%) (P = .126). Conclusions Cerebral oximetry monitoring was feasible during functional endoscopic sinus surgery. This study demonstrated a cross-correlation between EtCO2 and SctO2, but not MAP and SctO2. A longer PACU length of stay and higher rate of PONV were seen but did not reach statistical significance. Level of Evidence 2b Laryngoscope, 125:E127–E131, 2015

The Model for End Stage Liver (MELD) score is validated to predict pretransplant mortality. However, as a predictor of postoperative outcomes, its utility has proven inconsistent. Recently developed MELD-Lactate models better predict 30-day survival as compared with the MELD and MELD-Sodium scores. We compared the MELD-Lactate, original MELD, and MELD-Sodium formulae and the initial postoperative lactate as predictors of 30-day and in-hospital mortality following liver transplantation. Adult patients (n = 989) undergoing orthotopic liver transplant between 2002 to 2013 were included. In addition to the previous models, the first postoperative lactate value and a newly derived Mount Sinai MELD-Lactate score and associated c-statistics were compared. The Mount Sinai MELD-Lactate model yielded the highest c-statistic value (0.749), followed by the original MELD-Lactate (0.740), initial lactate value (0.729), postoperative MELD (0.653), and MELD-Sodium (0.641) models in predicting survival at 30 days following liver transplantation. For in-hospital mortality, the original MELD-Lactate model had slightly higher c-statistic (0.739) compared with the Mount Sinai MELD-Lactate model (0.734). Despite the distribution differences in the MELD-Lactate models, the model validation results, both from cross-validation and bootstrap methods, were similar. Postoperative MELD-Lactate and isolated postoperative lactate values were moderately predictive of 30-day and in-hospital mortality following liver transplantation in this patient cohort.

Article-at-a-Glance Background In 2008 New York-Presbyterian Hospital (NYP)/Weill Cornell Medical Center, New York City, the largest not-for-profit, nonsectarian hospital in the United States, created and implemented a novel approach—the Housestaff Quality Council (HQC)—to engaging housestaff in quality and patient safety activities. Methods The HQC represented an innovative collaboration between the housestaff, the Department of Anesthesiology, the Division of Quality and Patient Safety, the Office of Graduate Medical Education, and senior leadership. As key managers of patient care, the housestaff sought to become involved in the quality and patient safety decision- and policy-making processes at the hospital. Its members were determined to decrease or minimize adverse events by facilitating multimodal communication, ensuring smart work flow, and measuring outcomes to determine best practices. The HQC, which also included frontline hospital staff or managers from areas such as nursing, pharmacy, and information technology, aligned its initiatives with those of the division of quality and patient safety and embarked on two projects—medication reconciliation and use of the electronic medical record. More than three years later, the resulting improvements have been sustained and three new projects—hand hygiene, central line–associated bloodstream infections, and patient handoffs—have been initiated. Conclusions The HQC model is highly replicable at other teaching institutions as a complementary approach to their other quality and patient safety initiatives. However, the ability to sustain positive momentum is dependent on the ability of residents to invest time and effort in the face of a demanding residency training schedule and focus on specialty-specific clinical and research activities.

Heparin-induced thrombocytopenia is a profoundly dangerous, potentially lethal, immunologically mediated adverse drug reaction to unfractionated heparin or, less commonly, to low-molecular weight heparin. In this comprehensive review, the authors highlight heparin-induced thrombocytopenia's risk factors, clinical presentation, pathophysiology, diagnostic principles, and treatment. The authors place special emphasis on the management of patients requiring procedures using cardiopulmonary bypass or interventions in the catheterization laboratory. Clinical vigilance of this disease process is important to ensure its recognition, diagnosis, and treatment. Misdiagnosis of the syndrome, as well as misunderstanding of the disease process, continues to contribute to its morbidity and mortality.

There is a basis for the assumption that feedback can be used to enhance physicians' performance. Nevertheless, the findings of empirical studies of the impact of feedback on clinical performance have been equivocal.To summarize evidence related to the impact of assessment and feedback on physicians' clinical performance.The authors searched the literature from 1966 to 2003 using MEDLINE, HealthSTAR, the Science Citation Index and eight other electronic databases. A total of 3702 citations were identified.Empirical studies were selected involving the baseline measurement of physicians' performance and follow-up measurement after they received summaries of their performance.Data were extracted on research design, sample, dependent and independent variables using a written protocol.A group of 220 studies involving primary data collection was identified. However, only 41 met all selection criteria and evaluated the independent effect of feedback on physician performance. Of these, 32 (74%) demonstrated a positive impact. Feedback was more likely to be effective when provided by an authoritative source over an extended period of time. Another subset of 132 studies examined the effect of feedback combined with other interventions such as educational programmes, practice guidelines and reminders. Of these, 106 studies (77%) demonstrated a positive impact. Two additional subsets of 29 feedback studies involving resident physicians in training and 18 studies examining proxy measures of physician performance across clinical sites or groups of patients were reviewed. The majority of these two subsets also reported that feedback had positive effects on performance.Feedback can change physicians' clinical performance when provided systematically over multiple years by an authoritative, credible source.The effects of formal assessment and feedback on physician performance are influenced by the source and duration of feedback. Other factors, such as physicians' active involvement in the process, the amount of information reported, the timing and amount of feedback, and other concurrent interventions, such as education, guidelines, reminder systems and incentives, also appear to be important. However, the independent contributions of these interventions have not been well documented in controlled studies. It is recommended that the designers of future theoretical as well as practical studies of feedback separate the effects of feedback from other concurrent interventions.

Clinical vignette-based surveys have been used for more than 30 years to measure variation in physicians' approaches to the diagnosis and treatment of patients with similar health problems. Vignettes offer advantages over medical record reviews, analysis of claims data, and standardized patients. A vignette-based survey can be completed more quickly than a record review or standardized patient program. Research has shown that vignette-based surveys produce better measures of quality of care than medical record reviews when used to measure differential diagnosis, selection of tests, and treatment decisions. Although standardized patients are preferred when measuring communication and physical examination skills, vignettes are more cost-effective than standardized patients when assessing clinical physicians' decision making. Vignettes offer better opportunities to isolate physicians' decision making and to control case-mix variation than do analyses of claims data sets. Clinical vignette-based surveys are simple and economical tools that can be used to characterize physicians' practice variation.

d b WHEN CARDIOPULMONARY RESUSCITATION (CPR) has to be prolonged for more than 10 to 30 minutes, survival and neurologic outcomes are dismal.1 This has spurred the institution of rescue extracorporeal membrane oxygenation (ECMO), known as extracorporeal cardiopulmonary resuscitation (ECPR). In this situation, ECMO provides both circulatory and oxygenation support via a system called venoarterial ECMO (VA-ECMO). Vascular access is achieved via the jugular and/or femoral route, and venous blood is drained into the ECMO device, oxygenated, warmed, and pumped back into the arterial system (Fig 1). An added benefit is that ECPR can facilitate therapeutic interventions that potentially could reverse the cause of the cardiac arrest or collapse (eg, emergent coronary revascularization or relief of cardiac tamponade). ECPR also allows the provision of therapeutic hypothermia by precise blood temperature control. There is some evidence, most of it from Taiwan, that ECPR in patients suffering from in-hospital cardiac arrest improves both shortand long-term survival when compared with conventional CPR,2,3 although this finding has not been consistent.1 The Extraorporeal Life Support Organization, a worldwide registry of more han 170 centers,4 has reported a steady increase in the number of atients receiving ECPR over the last 2 decades (Table 1).5 Although ECPR potentially may enhance survival and neurologic outcome, a substantial proportion of patients will nonetheless sustain severe neurologic complications, and there is a 1 in 5 hance of brain death.5 The 3 clinical findings necessary to confirm brain death include coma with a known cause, the absence of brainstem reflexes, and apnea (Table 2). The definitive diagnosis of brain death during ECPR is technically and logistically challenging. Conventional apnea testing is not feasible because oxygenation and carbon dioxide elimination are accomplished by ECMO. The transportation of a patient to the radiology suite for

OBJECTIVES The Total Artificial Heart (Syncardia, Tucson, AZ) is approved for use as a bridge-to-transplant or destination therapy in patients who have irreversible end-stage biventricular heart failure. We present a unique case, in which the inferior vena cava compression by a total artificial heart was initially masked for days by the concurrent placement of an extracorporeal membrane oxygenation cannula. PATIENT This is the case of a 33-year-old man admitted to our institution with recurrent episodes of ventricular tachycardia requiring emergent total artificial heart and venovenous extracorporeal membrane oxygenation placement. CONCLUSION This interesting scenario highlights the importance for critical care physicians to have an understanding of exact anatomical localization of a total artificial heart, extracorporeal membrane oxygenation, and their potential interactions. In total artificial heart patients with hemodynamic compromise or reduced device filling, consideration should always be given to venous inflow compression, particularly in those with smaller body surface area. Transesophageal echocardiogram is a readily available diagnostic tool that must be considered standard of care, not only in the operating room but also in the ICU, when dealing with this complex subpopulation of cardiac patients.

In 2008 New York-Presbyterian Hospital (NYP)/Weill Cornell Medical Center, New York City, the largest not-for-profit, nonsectarian hospital in the United States, created and implemented a novel approach--the Housestaff Quality Council (HQC)--to engaging house-staff in quality and patient safety activities.The HQC represented an innovative collaboration between the housestaff, the Department of Anesthesiology, the Division of Quality and Patient Safety, the Office of Graduate Medical Education, and senior leadership. As key managers of patient care, the housestaff sought to become involved in the quality and patient safety decision- and policy-making processes at the hospital. Its members were determined to decrease or minimize adverse events by facilitating multimodal communication, ensuring smart work flow, and measuring outcomes to determine best practices. The HQC, which also included frontline hospital staff or managers from areas such as nursing, pharmacy, and information technology, aligned its initiatives with those of the division of quality and patient safety and embarked on two projects--medication reconciliation and use of the electronic medical record. More than three years later, the resulting improvements have been sustained and three new projects--hand hygiene, central line-associated bloodstream infections, and patient handoffs--have been initiated.The HQC model is highly replicable at other teaching institutions as a complementary approach to their other quality and patient safety initiatives. However, the ability to sustain positive momentum is dependent on the ability of residents to invest time and effort in the face of a demanding residency training schedule and focus on specialty-specific clinical and research activities.

In meeting the Accreditation Council for Graduate Medical Education (ACGME) core competency requirements, teaching hospitals often find it challenging to ensure effective involvement of housestaff in the area of quality and patient safety (QPS). Because housestaff are the frontline providers of care to patients, and medical errors occasionally occur based on their actions, it is essential for health care organizations to engage them in QPS processes. In early 2008 a Housestaff Quality Council (HQC) was established at New York-Presbyterian Hospital, Weill Cornell Medical Center, to improve QPS by engaging housestaff in policy and decision-making processes and to promote greater housestaff participation in QPS initiatives. It was quickly realized that the success of the HQC was highly contingent on alignment with the institution's overall QPS agenda. To this end, the position of resident QPS officer was created to strengthen the relationship between the hospital's strategic goals and the HQC. The authors describe the success of the resident QPS officers at their institution and observe that by appointing and supporting resident QPS officers, hospitals will be better able to meet their quality and safety goals, residency programs will be able to fulfill their required ACGME core competencies, and the overall quality and safety of patient care can be improved. Simultaneously, the creation of this position will help to create a new cadre of physician leaders needed to further the goals of QPS in health care.