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To compare outcomes and costs between major teaching and nonteaching hospitals on a national scale by closely matching on patient procedures and characteristics.Teaching hospitals have been shown to often have better quality than nonteaching hospitals, but cost and value associated with teaching hospitals remains unclear.A study of Medicare patients at 340 teaching hospitals (resident-to-bed ratios ≥ 0.25) and matched patient controls from 2444 nonteaching hospitals (resident-to-bed ratios0.05).We studied 86,751 pairs admitted for general surgery (GS), 214,302 pairs of patients admitted for orthopedic surgery, and 52,025 pairs of patients admitted for vascular surgery.In GS, mortality was 4.62% in teaching hospitals versus 5.57%, (a difference of -0.95%,0.0001), and overall paired cost difference = $915 (P0.0001). For the GS quintile of pairs with highest risk on admission, mortality differences were larger (15.94% versus 18.18%, difference = -2.24%, P0.0001), and paired cost difference = $3773 (P0.0001), yielding $1682 per 1% mortality improvement at 30 days. Patterns for vascular surgery outcomes resembled general surgery; however, orthopedics outcomes did not show significant differences in mortality across teaching and nonteaching environments, though costs were higher at teaching hospitals.Among Medicare patients, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used in general surgery, and to some extent vascular surgery, but this was not apparent in orthopedic surgery.

PURPOSE OF REVIEW Millions of perioperative crises (e.g. anaphylaxis, cardiac arrest) may occur annually. Critical event debriefing can offer benefits to the individual, team, and system, yet only a fraction of perioperative critical events are debriefed in real-time. This publication aims to review evidence-based best practices for proximal critical event debriefing. RECENT FINDINGS Evidence-based key processes to consider for proximal critical event debriefing can be summarized by the WATER mnemonic: Welfare check (assessing team members' emotional and physical wellbeing to continue providing care); Acute/short-term corrections (matters to be addressed before the next case); Team reactions and reflections (summarizing case; listening to team member reactions; plus/delta conversation); Education (lessons learned from the event and debriefing); Resource awareness and longer term needs [follow-up (e.g. safety/quality improvement report), local peer-support and employee assistance resources]. A cognitive aid to accompany this mnemonic is provided with the publication. SUMMARY There is growing literature on how to conduct proximal perioperative critical event debriefing. Evidence-based best practices, as well as a cognitive aid to apply them, may help bridge the gap between theory and clinical practice. In this era of increased attention to burnout and wellness, the consideration of interventions to improve the quality and frequency of critical event debriefing is paramount.

Summary Communication is critical to safe patient care. In this issue of the British Journal of Anaesthesia, Jaulin and colleagues show that use of a Post-Anaesthesia Team Handover (PATH) checklist is associated with fewer hypoxaemia events in the PACU, reduced handover interruptions, and other important metrics related to improved communication. The PATH checklist provides a link within a broader chain of safety checklists and other interventions that comprise a perioperative chain of survival.

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation. The authors’ objective was to understand barriers to debriefing, characterize quantifiable patterns and qualitative themes, and learn potential solutions through a mixed-methods study of actual critical events experienced by anesthesia personnel. Methods At a large academic medical center, anesthesiology residents and a small number of attending anesthesiologists were audited and/or interviewed for the occurrence and patterns of debriefing after critical events during their recent shift, including operating room crises and disruptive behavior. Patterns of the events, including event locations and event types, were quantified. A comparison was done of the proportion of cases debriefed based on whether the event contained a critical communication breakdown. Qualitative analysis, using an abductive approach, was performed on the interviews to add insight to quantitative findings. Results During a 1-yr period, 89 critical events were identified. The overall debriefing rate was 49% (44 of 89). Nearly half of events occurred outside the operating room. Events included crisis events (e.g., cardiac arrest, difficult airway requiring an urgent surgical airway), disruptive behavior, and critical communication breakdowns. Events containing critical communication breakdowns were strongly associated with not being debriefed (64.4% [29 of 45] not debriefed in events with a communication breakdown vs. 36.4% [16 of 44] not debriefed in cases without a communication breakdown; P = 0.008). Interview responses qualitatively demonstrated that lapses in communication were associated with enduring confusion that could inhibit or shape the content of discussions between involved providers. Conclusions Despite the value of proximal debriefing to reducing provider burnout and improving wellness and learning, failure to debrief after critical events can be common among anesthesia trainees and perhaps anesthesia teams. Modifiable interpersonal factors, such as communication breakdowns, were associated with the failure to debrief.

This study aimed to assess the impact of data-driven didactic sessions on metrics including fund of knowledge, resident confidence in clinical topics, and stress in addition to American Board of Anesthesiology In-Training Examination (ITE) percentiles.Observational mixed-methods study.Classroom, video-recorded e-learning.Anesthesiology residents from two academic medical centers.Residents were offered a data-driven didactic session, focused on lifelong learning regarding frequently asked/missed topics based on publicly-available data.Residents were surveyed regarding their confidence on exam topics, organization of study plan, willingness to educate others, and stress levels. Residents at one institution were interviewed post-ITE. The level and trend in ITE percentiles were compared before and after the start of this initiative using segmented regression analysis.Ninety-four residents participated in the survey. A comparison of pre-post responses showed an increased mean level of confidence (4.5 ± 1.6 vs. 6.2 ± 1.4; difference in means 95% CI:1.7[1.5,1.9]), sense of study organization (3.8 ± 1.6 vs. 6.7 ± 1.3;95% CI:2.8[2.5,3.1]), willingness to educate colleagues (4.0 ± 1.7 vs. 5.7 ± 1.9;95% CI:1.7[1.4,2.0]), and reduced stress levels (5.9 ± 1.9 vs. 5.2 ± 1.7;95% CI:-0.7[-1.0,-0.4]) (all p 0.001). Thirty-one residents from one institution participated in the interviews. Interviews exhibited qualitative themes associated with increased fund of knowledge, accessibility of high-yield resources, and domains from the Kirkpatrick Classification of an educational intervention. In an assessment of 292 residents from 2012 to 2020 at one institution, there was a positive change in mean ITE percentile (adjusted intercept shift [95% CI] 11.0[3.6,18.5];p = 0.004) and trajectory over time after the introduction of data-driven didactics.Data-driven didactics was associated with improved resident confidence, stress, and factors related to wellness. It was also associated with a change from a negative to positive trend in ITE percentiles over time. Future assessment of data-driven didactics and impact on resident outcomes are needed.

A saying often attributed to George Bernard Shaw is ‘The single biggest problem in communication is the illusion that it has taken place.’ While it has been debated who originally made this statement, this expression has been used across several industries in different ways.1–4 Communication is an essential aspect of patient safety. One could argue for expanding this proverb to emphasise the importance of recognising that communication at key moments is intrinsically valuable: the biggest problems in communication are the illusion that it has taken place and the assumption that it is not necessary. Over the past 100 years, cognitive aids for crisis events during patient care have been called for, developed, refined and examined.5–12 While much of this literature comes from high-risk industries and medical simulation, there is increasing supporting evidence from healthcare on how these tools can act as cognitive aids in clinical settings. Regarding terminology, we cite a review article on emergency manuals (EMs): ‘EMs are context-relevant sets of cognitive aids, such as crisis checklists, that are intended to provide professionals with key information for managing rare emergency events. Synonyms and related terms include crisis checklists; emergency checklists and cognitive aids, a much broader term, although often also used to describe tools for use during emergency events specifically.’13 Published accounts from healthcare professionals who experienced real-life events have described the power of these tools to prevent errors of omission, commission and lapses in communication.14–18 These events can be both common in large health systems and rare at the level of the individual clinician.10 It is also hard to predict when they will occur. These attributes create a meaningful role to study crisis checklists, EMs and other cognitive aids using medical simulation, particularly in healthcare settings (such as the emergency department (ED)) where …

Critical event debriefing (CED) or ‘hot debriefings’ (HoDs) can be described as a trigger-based, immediate postevent, interprofessional, expertly facilitated conversation where clinicians recount, reflect on, and improve personally and as a team.1 The process and experience of clinicians who cared for the patient is more complex and involves thoughts and emotions that go beyond the ‘case’ or ‘resuscitation’ and the debriefing itself.2 The American Heart Association guidelines for neonatal resuscitation highlight ‘team debriefing’ as a key step in their cognitive aid.3 There is evidence that implementing a ‘Cold Debrief’ programme for teams that care for patients in cardiac arrest improves outcomes4 yet in practice 33% of events are routinely debriefed.5 Critical events in anaesthesia are debriefed infrequently and those associated with communication breakdowns were even less likely to be debriefed6. How do we fuel …

Debriefing after perioperative crises (eg, cardiac arrest, massive hemorrhage) is a well-described practice that can provide benefits to individuals, teams, and health systems. Debriefing has also been embraced by high-stakes industries outside of health care. Yet, in studies of actual clinical practice, there are many critical events that do not get debriefed. This article explores the gap that exists between principle and reality and the factors and strategies to offer opportunities to reflect on actual critical events, when indicated, across the increasing scope of environments where anesthesia care is provided.

Purpose of review The landscape of medical education continues to evolve. Educators and learners must stay informed on current medical literature, in addition to focusing efforts on current educational trends and evidence-based methods. The present review summarizes recent advancements in anesthesiology education, specifically highlighting trends in e-learning and telesimulation, and identifies possible future directions for the field. Recent findings Websites and online platforms continue to be a primary source of educational content; top websites are more likely to utilize standardized editorial processes. Podcasts and videocasts are important tools desired by learners for asynchronous education. Social media has been utilized to enhance the reach and visibility of journal articles, and less often as a primary educational venue; its efficacy in comparison with other e-learning platforms has not been adequately evaluated. Telesimulation can effectively disseminate practical techniques and clinical knowledge sharing, extending the capabilities of simulation beyond previous restrictions in geography, space, and available expertise. Summary E-learning has changed the way anesthesiology learners acquire knowledge, expanding content and curricula available and promoting international collaboration. More work should be done to expand the principles of accessible and collaborative education to psychomotor and cognitive learning via telesimulation.

Objective Traditionally, surgical educators have relied upon participant survey data for the evaluation of educational interventions. However, the ability of such subjective data to completely evaluate an intervention is limited. Our objective was to compare resident and attending surgeons’ self-assessments of coaching sessions from surveys with independent observations from analysis of intraoperative and postoperative coaching transcripts. Design Senior residents were video-recorded operating. Each was then coached by the operative attending in a 1:1 video review session. Teaching points made in the operating room (OR) and in post-OR coaching sessions were coded by independent observers using dialogue analysis then compared using t-tests. Participants were surveyed regarding the degree of teaching dedicated to specific topics and perceived changes in teaching level, resident comfort, educational assessments, and feedback provision between the OR and the post-OR coaching sessions. Setting A single, large, urban, tertiary-care academic institution. Participants Ten PGY4 to 5 general surgery residents and 10 attending surgeons. Results Although the reported experiences of teaching and coaching sessions by residents and faculty were similar (Pearson correlation coefficient = 0.88), these differed significantly from independent observations. Observers found that residents initiated a greater proportion of teaching points and had more educational needs assessments during coaching, compared to the OR. However, neither residents nor attendings reported a change between the 2 environments with regard to needs assessments nor comfort with asking questions or making suggestions. The only metric on which residents, attendings, and observers agreed was the provision of feedback. Conclusions Participants’ perspectives, although considered highly reliable by traditional metrics, rarely aligned with analysis of the associated transcripts from independent observers. Independent observation showed a distinct benefit of coaching in terms of frequency and type of learning points. These findings highlight the importance of seeking different perspectives, data sources, and methodologies when evaluating clinical education interventions. Surgical education can benefit from increased use of dialogue analyses performed by independent observers, which may represent a viewpoint distinct from that obtained by survey methodology.

Purpose Preoperative clinics are an increasingly common mechanism for preoperative evaluation. Factors predicting prolonged visit times are poorly understood. Our objective was to identify patient factors that would allow non-medically trained staff to determine appropriate scheduling needs. Methods At the preoperative assessment center of a tertiary care hospital, patient data were prospectively collected on 25 risk factors hypothesized to be related to a prolonged visit length, defined as greater than the unit benchmark of 75 min. The association between these risk factors and prolonged visit length was assessed. Results Data were collected on 1053 patients seen at the preoperative center over a two month period. The median patient age was 58 years (interquartile range [IQR]: 47, 67). A total of 446 patients (42%) had a prolonged visit length. Significant multivariate predictors of a prolonged visit length were: age greater than 80 years ( p = 0.003), taking >6 prescription medications ( p = 0.0002), functional status of p = 0.002), currently having > 3 medical providers ( p = 0.0005), inability to explain details of one's medical history ( p = 0.001), and planned ICU postoperative stay ( p = 0.0004). Conclusions Predictors of prolonged visit length include factors that can be obtained prior to the date of evaluation. Scheduling models integrating such predictors into workflow processes have the potential to improve patient care and allow for more efficient use of resources for the preoperative assessment.

BACKGROUND Failure-to-rescue (FTR), originally developed to study quality of care in surgery, measures an institution's ability to prevent death after a patient becomes complicated. OBJECTIVES Develop an FTR metric modified to analyze acute myocardial infarction (AMI) outcomes. RESEARCH DESIGN Split-sample design: a random 20% of hospitals to develop FTR definitions, a second 20% to validate test characteristics, and an out-of-sample 60% to validate results. SUBJECTS Older Medicare beneficiaries admitted to short-term acute-care hospitals for AMI between 2009 and 2011. MEASURES Thirty-day mortality and FTR rates, and in-hospital complication rates. RESULTS The 60% out-of-sample validation included 234,277 patients across 1142 hospitals that admitted at least 50 patients over 2.5 years. In total, 72.1% of patients were defined as Medically Complicated (complex on admission or subsequently developed a complication or died without a recorded complication) of whom 19.3% died. Spearman r between hospital risk-adjusted 30-day mortality and FTR was 0.89 (P

Crisis checklists and emergency manuals are cognitive aids that help team performance and adherence to evidence-based practices during operating room crises. Resources to enable local implementation and training (key for effective use) are linked at http://www.emergencymanuals.org. Supplemental Digital Content is available in the text.

This chapter describes the concept of crew resource management and development of crisis resource management within the healthcare arena to present a framework for interprofessional team training. Key principles and studies within crew/crisis resource management (CRM) are evaluated and integrated to help the reader develop the tools necessary to design appropriate and effective simulations relevant to all involved team members. Emphasis is placed on how the key principles within CRM can go wrong in a healthcare environment and what can be learned from these failures, with tools and techniques for improved skill building and enhanced awareness of the role of CRM and interprofessional team training on patient care and improved outcomes.

Purpose This qualitative study sought to characterize the role of debriefing after real critical events among anesthesia residents at the Hospital of the University of Pennsylvania. Method From October 2016 to June 2017 and February to April 2018, the authors conducted 25 semistructured interviews with 24 anesthesia residents after they were involved in 25 unique critical events. Interviews focused on the experience of the event and the interactions that occurred thereafter. A codebook was generated through annotation, then used by 3 researchers in an iterative process to code interview transcripts. An explanatory model was developed using an abductive approach. Results In the aftermath of events, residents underwent a multistage process by which the nature of critical events and the role of residents in them were continuously reconstructed. Debriefing-if it occurred-was 1 stage in this process, which also included stages of internal dialogue, event documentation, and lessons learned. Negotiated in each stage were residents' culpability, reputation, and the appropriateness of their affective response to events. Conclusions Debriefing is one of several stages of interaction that occur after a critical event; all stages play a role in shaping how the event is interpreted and remembered. Because of its dynamic role in constituting the nature of events and residents' role in them, debriefing can be a high-stakes interaction for residents, which can contribute to their reluctance to engage in it. The function and quality of debriefing can be assessed in more insightful fashion by understanding its relation to the other stages of event reconstruction.

BACKGROUND: Teaching hospitals typically pioneer investment in new technology and cultivate workforce characteristics generally associated with better quality, but the value of this extra investment is unclear. OBJECTIVE: Compare outcomes and costs between major teaching and non-teaching hospitals by closely matching on patient characteristics. DESIGN: Medicare patients at 339 major teaching hospitals (resident-to-bed (RTB) ratios ≥ 0.25); matched patient controls from 2439 non-teaching hospitals (RTB ratios

In spite of recent efforts in gathering multimodal databases containing a big number of traits, a huge amount of users and covering multiple realistic scenarios, there is still a lack of touch-less realistic samples, video recordings for some traits and the use of infrared cameras which allows, among others, to avoid lighting influence and test recently appeared biometric techniques such as hand vein recognition. For this reason, a new realistic multimodal database composed of 8,160 hand, iris and face videos has been captured. To this end, a total of 60 contributors have participated in three separated acquisition sessions in which three different cameras have been used, covering different ranges of the light spectrum: visible light and two different infrared wavelengths. To simulate real-world working conditions, the database has been recorded in an indoor environment with different lightings and backgrounds. In addition, due to the relevance of performing evaluation experiments in such a way that a reliable comparison of the results can be accomplished, an evaluation protocol is provided at the end of this paper. Moreover, performance results are provided for several biometric traits in mono- and multi- modalities that can be used as a baseline.

Previous literature on preoperative evaluation focuses on the impact on the day of surgery cancellations and delays; however, the framework of cancellations and delays at the time of the elective outpatient preoperative anesthesia visit has not been categorized. We describe the current model in the preoperative clinic at Brigham and Women's Hospital, examining the pattern of cancellations at the time of this preoperative visit and the framework used for categorizing the issues involved. Looking at this broader framework is important in an era of patient-centered care; we seek to identify targets to modify the preoperative assessment and adequately assess and capture the spectrum of issues involved. Elective cases evaluated in the preoperative clinic were reviewed over 10 months. Characteristics of cancelled and noncancelled cases were compared. In-depth analysis of issues related to cancellation was done; 1-year follow-up was completed. Cancellation patterns included categories encompassing clinical, financial, alignment with patient values and goals, compliance, and social issues. The period of preoperative assessment can therefore be leveraged to review a number of domains that can adversely affect surgical outcomes and improve patient-centered care. Also, our framework allows the institution to benchmark these patterns over time; increases in cancellations at the time of the preoperative anesthesia clinic visit for specific categories can prompt an opportunity to examine and improve preoperative workflow.