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The present study features the development of new risk categories and recidivism estimates for the Violence Risk Scale (VRS), a violence risk assessment and treatment planning tool. We employed a combined North American multisite sample (

Purpose This multi-site study examines patient, parent, and pediatric provider perspectives on what is most important for successful transition. Design and Methods Using the Transition Readiness Assessment Questionnaire, 190 participants recruited from two pediatric IBD centers selected the top five skills they considered “most important for successful transition.” Rankings were summarized and compared by group. Results While patients, parents, and clinicians all identified “calling the doctor about unusual changes in health” and “taking medications correctly and independently” as being important, each stakeholder group qualitatively and statistically differed in terms of transition readiness skills emphasized. Patients endorsed “calling the doctor about unusual changes in health” and “being knowledgeable about insurance coverage,” as being most important to successful transition while parents emphasized health monitoring and problem solving. Pediatric providers emphasized adherence to treatment and reporting unusual changes in health. There were statistically significant differences in endorsement rates across participants for seven transition readiness skills. Patients agreed with providers 80% of the time and with their parents 40% of the time. Parent-provider agreement was 60%. Conclusions Although there was some overlap across groups, areas of emphasis differed by informant. Patients emphasized skills they need to learn, parents emphasized skills they most likely manage for their children, and providers emphasized skills that directly impact their provision of care. Practice Implications Patient, parent, and provider beliefs all need to be considered when developing a comprehensive transition program. Failure to do so may result in programs that do not meet the needs of youth with IBD.

Although the incidence of major adverse events in surgical daycare centres is low, these critical events may not be managed optimally due to the absence of resources that exist in larger hospitals. We aimed to study the impact of operating theatre critical event checklists on medical management and teamwork during whole-team operating theatre crisis simulations staged in a surgical daycare facility. We studied 56 simulation encounters (without and with a checklist available) divided between an initial session and then a retention session several months later. Medical management and teamwork were quantified via percentage adherence to key processes and the Team Emergency Assessment Measure, respectively. In the initial session, medical management was not improved by the presence of a checklist (56% without checklist vs. 62% with checklist; p = 0.50). In the retention session, teams performed significantly worse without the checklists (36% without checklist vs. 60% with checklist; p = 0.04). We did not observe a change in non-technical skills in the presence of a checklist in either the initial or retention sessions (68% without checklist vs. 69% with checklist (p = 0.94) and 69% without checklist vs. 65% with checklist (p = 0.36), respectively). Critical events checklists do not improve medical management or teamwork during simulated operating theatre crises in an ambulatory surgical daycare setting.

Background:Regional anesthesia improves postoperative analgesia and enhances quality of recovery (QoR) after ambulatory surgery. This randomized, double-blinded, parallel-group, placebo-controlled trial examines the effects of multilevel ultrasound-guided paravertebral blocks (PVBs) and total intravenous anesthesia on QoR after ambulatory breast tumor resection.Methods:Sixty-six women were randomized to standardized general anesthesia (control group) or PVBs and propofol-based total intravenous anesthesia (PVB group). The PVB group received T1–T5 PVBs with 5 ml of 0.5% ropivacaine per level, whereas the control group received sham subcutaneous injections. Postoperative QoR was designated as the primary outcome. The 29-item ambulatory QoR tool was administered in the preadmission clinic, before discharge, and on postoperative days 2, 4, and 7. Secondary outcomes included block success, pain scores, intra- and postoperative morphine consumption, time to rescue analgesia, incidence of nausea and vomiting, and hospital discharge time.Results:Data from sixty-four patients were analyzed. The PVB group had higher QoR scores than control group upon discharge (146 vs. 131; P < 0.0001) and on postoperative day 2 (145 vs. 135; P = 0.013); improvements beyond postoperative day 2 lacked statistical significance. None of the PVB group patients required conversion to inhalation gas–based general anesthesia or experienced block-related complications. PVB group patients had improved pain scores on postanesthesia care unit admission and discharge, hospital discharge, and postoperative day 2; their intraoperative morphine consumption, incidence of nausea and vomiting, and discharge time were also reduced.Conclusion:Combining multilevel PVBs with total intravenous anesthesia provides reliable anesthesia, improves postoperative analgesia, enhances QoR, and expedites discharge compared with inhalational gas- and opioid-based general anesthesia for ambulatory breast tumor resection.

The Vanderbilt University Library, in collaboration with the university’s Department of Athletics Stratton Foster Academic Support Center, established an initiative to better acquaint the counselors at the center with the library and its resources. Through conversation, both sides realized there were many opportunities to make the relationship stronger, resulting in year-round support for student athletes. The partnership, now in its fourth year, has evolved to meet the needs of both the students and support staff.

In 2007, the World Health Organization created a Surgical Safety Checklist (SSC) that encompassed a simple set of surgical safety standards. The threefold purpose of this study was to add ambulatory-specific items to the SSC, to introduce the items into an ambulatory surgical facility, and to determine if patient outcomes regarding postoperative pain and nausea/vomiting improved following implementation. In addition, safety attitudes, antibiotic timing, regional anesthesia/nerve blocks, preemptive pain medications, prophylactic antiemetics, length of stay, and hospital admission were also assessed. After Research Ethics Board approval, staff complete a Safety Attitudes Questionnaire. Seven items were added to the SSC. Data were then collected on 180 surgical cases before SSC implementation and 195 cases following implementation. Compliance with each section of the SSC was assessed. On postoperative day one, the median (97.5% confidence interval [CI]) difference between pre- and post-implementation pain scores was 0.5 (97.5% CI, 0 to 1; P = 0.13), and the median difference in the rate of post-discharge nausea/vomiting was −8.4% (97.5% CI, −17.9 to 1.1; P = 0.06). There was no improvement in safety attitudes or any of the secondary outcomes, with the exception of the use of preemptive pain medications. Compliance with the three sections of the checklist, i.e., BRIEFING, TIME OUT, and DEBRIEFING was 99.49%, 97.95%, and 96.92%, respectively. There was low compliance in verbalization of the added “ambulatory-specific items”. Potential reasons for lack of uptake and integration include poor “user” buy-in, an overly lengthy checklist, and lack of prioritization of ambulatory-specific items. A shortened SSC was developed based on the results of this study. This trial was registered at ClinicalTrials.gov ID: NCT00934310.

This resource contains eight high-fidelity simulation scenarios designed for operating room teams to manage critical events. These scenarios were developed to simulate one of eight critical events for which critical event checklists have been developed. The purpose of this educational module is to allow other facilities to use these scenarios to permit their teams to practice the management of eight specific critical events with and without the use of a critical event checklist. Debriefing templates and scripts are included for the eight scenarios to guide others in the conduct of the debriefing. Evaluations of the performance of the teams are done using two tools, one of which involves the adherence to key processes determined by evidence-based data and expert consensus. The second tool examines the nontechnical skills aspects of the team performance. Included in this resource are the patient's history, physical exam, and laboratory findings, as well as the actual scenario and how it should unfold. Also included are a description of the aids for surgical simulation, PowerPoint orientation presentation, confidentiality forms, mannequin and lab orientation, instructor's guide, citation details for the critical event checklist and the team emergency assessment measure tools, simulation interest group scenario templates, debriefing scripts, and exit questionnaire. The teams that completed these educational sessions had a very positive reaction. On the exit questionnaire, the participants (n = 35) rated the following statements (1 = strongly disagree, 5 = strongly agree): “Managing these simulated scenarios will improve my performance in a similar clinical situation” (Mdn = 5), “The debriefing session helped identify gaps in my practice and to clarify important issues” (Mdn = 5), “The information that I learned about critical perioperative events is relevant and beneficial to my practice” (Mdn = 4), “This session will help me to practice more safely in an ambulatory surgical facility” (Mdn = 4), “Critical event checklists are helpful to deal with critical events in an ambulatory surgical facility” (Mdn = 4), and “Critical event checklists should be available in an ambulatory surgical facility” (Mdn = 5).

Background To determine the effectiveness of high-fidelity simulation for team training, a valid and reliable tool is required. This study investigated the internal consistency, inter-rater reliability and test–retest reliability of two newly developed tools to assess obstetrical team performance. Methods After research ethics board approval, multidisciplinary obstetrical teams participated in three sessions separated by 5–9 months and managed four high-fidelity simulation scenarios. Two tools, an 18-item Assessment of Obstetric Team Performance (AOTP) and a six-item Global Assessment of Obstetric Team Performance (GAOTP) were used. 5 Eight reviewers rated the DVDs of all teams9 performances. Results Two AOTP items were consistently incomplete and omitted from the analyses. Cronbach9s α for the 16-item AOTP was 0.96, and 0.91 for the six-item GAOTP. The eight-rater α for the GAOTP was 0.81 (single-rater intra-class correlation coefficient, 0.34) indicating acceptable inter-rater reliability. The ‘four-scenario’ α for the 12 teams was 0.79 for session 1, 0.88 for session 2, and 0.86 for session 3, suggesting that performance is not being strongly affected by the context specificity of the cases. Pearson9s correlation of team performance scores for the four scenarios were 0.59, 0.35, 0.40 and 0.33, and for the total score across scenarios it was 0.47, indicating moderate test–retest reliability. Conclusions The results from this study indicate that the GAOTP would be a sufficient assessment tool for obstetrical team performance using simulation provided that it is used to assess teams with at least eight raters to ensure a sufficiently stable score. This could allow the quantitative evaluation of an educational intervention.

INTRODUCTION Human factors have been identified as root causes of human error in medicine. The "Anesthetists' Non-Technical Skills (ANTS) system" evaluates the effect of simulation training and debriefing on nontechnical skills (NTS). Studies suggest that residents' NTS may improve after simulation training but the effect on NTS of practicing anesthesiologists is unclear. The purpose of this study was to determine whether high-fidelity simulation training and debriefing improved the NTS of practicing anesthesiologists using the ANTS tool. METHODS In a previous study, 67 practicing anesthesiologists managed a 45-minute standardized anesthetic case using high-fidelity simulation and returned 5 to 9 months later to manage a second case. After Research Ethics Board approval, two blinded video reviewers, trained in the use of the ANTS system, evaluated archived videotapes of the 59 subjects who completed both sessions. Results were analyzed with a mixed-design analysis of variance. Interrater reliability was calculated using the intraclass correlation coefficient. RESULTS Interrater reliability for the ANTS scoring was 0.436, P < 0.05. Overall, ANTS scores improved approximately 5% from session 1 to 2 (P < 0.01), but there was no effect due to debriefing. The situational awareness ANTS category showed a statistically significant effect of debriefing (P < 0.05). CONCLUSIONS The relatively short simulation intervention, the length of time until the posttest was completed, well-developed NTS in practicing physicians, and a tool that might not be the optimal method of measurement may all account for the lack of improvement in NTS of practicing anesthesiologists as demonstrated in this study.

The Guidelines to the Practice of Anesthesia Revised Edition 2011 (the guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. Because the guidelines are subject to revision, updated versions are published annually. Whereas previous versions of the guidelines appeared as special supplements to the Canadian Journal of Anesthesia (the Journal), this edition of the guidelines is published within the Journal. This allows for improved archiving and online access to complement the printed version-a new offering for CAS members and Journal subscribers. The Guidelines to the Practice of Anesthesia Revised Edition 2011 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the society cannot guarantee any specific patient outcome. Each anesthesiologist should exercise his or her own professional judgement in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

Performance assessment using high fidelity simulation is problematic, due to the difficulty in developing valid and reliable evaluation tools. The Delphi technique is a consensus based content generation method used for multiple purposes such as policy development, best-evidence practice guidelines and competency assessments. The purpose of this study was to develop checklists using a modified Delphi technique to evaluate the performance of practicing anesthesiologists managing two simulated scenarios.The templates for two simulation scenarios were emailed to five anesthesiologists who were asked to generate performance items. Data were collated anonymously and returned. An a priori decision was made to delete items endorsed by/= 20% of participants. This process of collection, collation and re-evaluation was repeated until consensus was reached. Four independent raters used the checklist to assess three subjects managing the two simulation scenarios. Interrater reliability was assessed using average measures intraclass correlation (ICC) and repeated measures analysis of variance (ANOVA) was used to assess differences in difficulty between scenarios.The final checklists included 131 items for scenario 1 and 126 items for scenario 2. The mean inter-rater reliability was 0.921 for scenario 1 and 0.903 for scenario 2. Repeated measures ANOVA revealed no statistically significant difference in difficulty between scenarios.The Delphi technique can be very useful to generate consensus based evaluation tools with high content and face validity compared to subjective evaluative tools. Since there was no difference in scenario difficulty, these scenarios can be used to determine the effect of educational interventions on performance.

Background The National Confidential Enquiry into Maternal Deaths identified "lack of communication and teamwork" as a leading cause of substandard obstetric care. The authors used high-fidelity simulation to present obstetric scenarios for team assessment. Methods Obstetric nurses, physicians, and resident physicians were repeatedly assigned to teams of five or six, each team managing one of four scenarios. Each person participated in two or three scenarios with differently constructed teams. Participants and nine external raters rated the teams' performances using a Human Factors Rating Scale (HFRS) and a Global Rating Scale (GRS). Interrater reliability was determined using intraclass correlations and the Cronbach alpha. Analyses of variance were used to determine the reliability of the two measures, and effects of both scenario and rater profession (R.N. vs. M.D.) on scores. Pearson product-moment correlations were used to compare external with self-generated assessments. Results The average of nine external rater scores showed good reliability for both HFRS and GRS; however, the intraclass correlation coefficients for a single rater was low. There was some effect of rater profession on self-generated HFRS but not on GRS. An analysis of profession-specific subscores on the HFRS revealed no interaction between profession of rater and profession being rated. There was low correlation between externally and self-generated team assessments. Conclusions This study does not support the use of the HFRS for assessment of obstetric teams. The GRS shows promise as a summative but not a formative assessment tool. It is necessary to develop a domain specific behavioral marking system for obstetric teams.

Investigating protective strategies against chronic neuropathic pain (CNP) after breast cancer surgery entails using valid screening tools. The DN4 (Douleur Neuropathique en 4 questions) is 1 tool that offers important research advantages. This prospective 6-month follow-up study seeks to validate the DN4 and assess its responsiveness in screening for CNP that satisfies the International Association for the Study of Pain (IASP) definition and fulfills its grading system criteria after breast tumor resection with and without paravertebral blocks (PVBs). We randomized 66 females to standardized general anesthesia and sham subcutaneous injections, or PVB and total intravenous anesthesia. The 6-month CNP risk was assessed using the IASP grading system and the DN4 screening tools. We evaluated the DN4 sensitivity, specificity, and responsiveness in capturing the impact of PVB on the CNP risk relative to the IASP grading system. Data from 64 patients showed similar demographic characteristics in both groups. Twenty patients in both groups met the grading system CNP criteria; among these, 18 patients also met the DN4 CNP criteria. Furthermore, 15 patients in both groups did not meet the grading system CNP criteria; among these, 9 patients also did not meet the DN4 CNP criteria. Therefore, the sensitivity and specificity of the DN4 were estimated at 90% and 60%, respectively. Both screening tools suggested that PVB reduced the 6-month CNP risk. Our results suggest that the DN4 can reliably identify CNP at 6 months after breast tumor resection and detect the preincisional PVB effect on the risk of developing such pain.

High-fidelity patient simulation allows students to apply their theoretical knowledge of pharmacology and physiology to practice. The purpose of this study was to determine if experiential education using high-fidelity simulation improves undergraduate performance scores on simulation-based and written examinations. After receiving research ethics board approval, students completed a consent form and then answered a ten question multiple-choice quiz to identify their knowledge regarding the management of cardiac arrhythmias. Four simulation scenarios were presented and students worked through each scenario as a team. Faculty facilitated the sessions and feedback was given using students' videotaped performances as a template for discussion. Performance evaluation scores using predetermined checklists and global rating scales were completed. Students then reviewed the American Heart Association guidelines for the management of unstable cardiac arrhythmias. The afternoon session involved repetition of the four case scenarios with the same teams involved but different team leaders. Students then repeated the quiz they received in the morning. Descriptive statistics, paired t-test and repeated measures analysis of variance (ANOVA) were used to analyse results. Two hundred and ninety-nine students completed the study. There was a statistically significant improvement in performance on the pharmacology written test. Simulation team performance also statistically improved and a good correlation between checklist and global rating scores were demonstrated in all but one scenario. Student evaluation of the experience was extremely positive. High-fidelity simulation can be used to allow students to apply theoretical knowledge to practice in a safe and realistic environment. Results of this study indicate that simulation is a valuable learning experience and bridges the gap between theory and practice. Simulation technology has the potential to provide an enriching venue to examine the role of communication and dynamics of novice learners in team environments.

The oral epithelium becomes regionalised proximodistally early in development, and this is reflected by the spatial expression of signalling molecules such as Fgf8 and Bmp4. This regionalisation is responsible for regulating the spatial expression of genes in the underlying mesenchyme. These genes are required for the spatial patterning of bone,cartilage orofacial development and, in mammals, teeth. The mechanism and timing of this important regionalisation during head epithelium development are not known. Using lipophilic dyes to fate map the oral epithelium in chick embryos, we show that the cells that will occupy the epithelium of the distal and the proximal mandible primordium already occupy different spatial locations in the developing head ectoderm prior to the formation of the first pharyngeal arch and neural crest migration. Moreover, the ectoderm cells fated to become proximal oral epithelium express Fgf8 and this expression requires the presence of endoderm. Thus, the first fundamental patterning process in jaw morphogenesis is controlled by the early separation of specific areas of ectoderm that are regulated by ectoderm-endoderm interactions, and does not involve neural crest cells.

UNLABELLED In this study we sought to identify educational gaps in medical students' knowledge using human patient simulation. The Undergraduate Committee developed 10 scenarios based on anesthesia curriculum objectives. Checklists were designed by asking 15 faculty members involved in undergraduate education to propose expected performance items at a level appropriate for medical students. These items consisted of essential performance items as well as critical management omissions. Checklists were used to score students' videotaped performances. Checklist items common to more than one scenario were grouped for data analysis and identification of gaps in achievement of educational objectives. Eighteen groupings of expected performance criteria and 8 groupings of critical management omissions were established. Performance data of 165 students were analyzed. Common management omissions were lack of adequate airway management, failure to check blood pressure, and failure to stop the anesthetic. Students reliably performed defibrillation, notation of vital signs, auscultation of lung fields, and administration of IV fluids. The most common critical omissions were failing to a). call for help, b). take a history/do physical examination, and c). prepare airway equipment. Management and critical omissions noted during performance assessments provide information regarding students' educational needs, enabling faculty to focus attention on demonstrated areas of weakness. IMPLICATIONS This study involved the use of high-fidelity patient simulation that offers standardized clinical experiences that can detect gaps in medical students' knowledge base and clinical performance. This information can be used by faculty to focus their teaching efforts to ensure competency in important educational areas.

To gather information regarding the global use of simulation technology in education, evaluation and research in anesthesia.The WorldWide Web was searched and located sites with simulation centres (n = 158) were mailed a 67-item questionnaire requesting information regarding demographics, personnel, education use and research involvement. Comments were solicited. Medical school data only are reported in this article.Two web sites were used to generate the list of simulation centres. Sixty responses were received (38%), with 41 emanating from medical schools. Seventy-seven percent of centres were involved in undergraduate education and 85% in postgraduate education. Few centres were involved in evaluation and/or competency assessments. Sixty-one percent of centres indicated ongoing research with a further 25% interested in international collaboration. University or university departmental-based funding largely supported simulation technology used in medical schools. The lack of financial and human resources was the single most common problem identified by respondents.From the survey responses received, opportunities for the simulator to be used for the assessment of performance appear to be under-utilized. This may be due to the lack of research in this area, lack of standardized, valid and reliable tests and the fact that most centres have only recently acquired this technology. Further research supporting the use of the simulator in education and evaluation is required.

Objective: To evaluate the effectiveness of nitroglycerin as a uterine relaxant for preterm labour, fetal extraction at Caesarean section, external version, embryo transfer, cervical dilation for first trimester pregnancy termination, and primary dysmenorrhea. Design: A systematic review of randomized control trials (RCTs) of nitroglycerin in obstetrics and gynaecology. Methods: We searched PubMed (1966–2001), the Cochrane Controlled Trials Register, and the International Journal of Obstetric Anesthesia using text terms "nitroglycerin," "glyceryl trinitrate", "uterus," "uterine," and "relaxation." The last search was conducted in January 2001. References from review articles and abstracts from major scientific meetings (1997-2000) were reviewed for relevant publications. RCTs comparing nitroglycerin to either placebo or another therapeutic intervention (ritodrine, magnesium sulphate, and prostaglandin) and whose quality score was equal to or greater than 2 were included (Class I evidence as described in the Report of the Canadian Task Force on the Periodic Health Exam). Results: Sixty articles were retrieved of which 13 were RCTs. Nitroglycerin was more effective for arresting preterm labour than placebo but not more effective when compared to ritodrine or magnesium. Nitroglycerin was not superior to placebo for uterine relaxation for either fetal extraction at Caesarean section or for external version. There were no differences in ease of embryo transfers when nitroglycerin spray was compared to placebo. In first trimester pregnancy terminations, less force was required to dilate the cervix when nitroglycerin was compared to no treatment.The incidence of preeclampsia was not reduced by nitroglycerin but fewer complications were noted when compared to the placebo group. In patients with primary dysmenorrhea, nitroglycerin significantly decreased pain. Conclusion: Although nitroglycerin is widely used, its superiority over currently used tocolytic agents is unproven. (Class C recommendation) Nitroglycerin has been demonstrated to decrease pain associated with dysmenorrhea. (Class A recommendation)

Mouse mandible primodia in vitro explant cultures are an excellent model for investigating tooth development. Mandibular arch epithelial-mesenchymal tissue recombinations and implantation of beads soaked in signaling proteins have revealed much about the early events of odontogenesis. These approaches do, however, suffer from several disadvantages, in particular the nonphysiological nature of beads soaked in very high concentrations of proteins and the inability to directly manipulate receptor and transcription factor gene expression. We have utilized the technique of DNA electroporation to deliver targeted gene expression to defined areas of mandibular arch epithelium or mesenchyme. This approach is being used to (a) ectopically express epithelial signals such as Shh and Bmp-4, (b) inhibit BMP and FGF signaling by expression of dominant negative receptors and antagonists, and (c) misexpress transcriptional factors in the mesenchyme. The technical aspects of electroporation are discussed, as well as preliminary findings.

The anesthesia computer-controlled patient simulator offers a valuable experiential learning experience for undergraduate medical students. The purpose of this study was to gather students' opinions of the simulator learning experiences and to study and analyze their comments regarding the nature of the learning. All fourth-year medical students were invited to participate in a simulator session during their anesthesia rotation. A satisfaction survey was administered and the qualitative data were analyzed. A total of 145 students completed the questionnaire (100% return rate). Most students (88%) reported the session to be a positive learning experience that provided opportunities for applying their knowledge in a realistic environment. Some students indicated a lack of comfort in the environment but this did not appear to inhibit performance. Student comments highlighted the value of the learning experience and provided insights into the nature of the learning. The computer-controlled patient simulator offers new and challenging opportunities for medical students to apply their knowledge and practice working through an Anesthesia case without endangering patient safety.

Background The availability of simulator technology at the University of Toronto (Toronto, Ontario, Canada) provided the opportunity to compare the efficacy of video-assisted and simulator-assisted learning. Methods After ethics approval from the University of Toronto, all final-year medical students were invited to participate in the current randomized trial comparing video-based to simulator-based education using three scenarios. After an introduction to the simulator environment, a 5-min performance-based pretest was administered in the simulator operating room requiring management of a critical event. A posttest was administered after students had participated in either a faculty-facilitated video or simulator teaching session. Standardized 12-point checklist performance protocols were used for assessment purposes. As well, students answered focused questions related to the educational sessions on a final examination. Student opinions regarding the value of the teaching sessions were obtained. Results One hundred forty-four medical students participated in the study (scenario 1, n = 43; scenario 2, n = 48; scenario 3, n = 53). There was a significant improvement in posttest scores over pretest scores in all scenarios. There was no statistically significant difference in scores between simulator or video teaching methods. There were no differences in final examination marks when the two educational methods were compared. Student opinions indicated that the experiential simulator sessions were more enjoyable and valuable than the video teaching sessions. Conclusions Both simulator and video types of faculty-facilitated education offer a valuable learning experience. Future work is needed that addresses the long-term effects of experiential learning in the retention of knowledge and acquired skills.

Evidence suggests that breakdowns in communication and a lack of situation awareness contribute to poor performance of medical teams. In this pilot study, three interprofessional obstetrical teams determined the feasibility of using the situation awareness global assessment technique (SAGAT) during simulated critical event management of three obstetrical scenarios. After each scenario, teams were asked to complete questionnaires assessing their opinion of how their performance was affected by the introduction of questions during a SAGAT stop. Fifteen obstetrical professionals took part in the study and completed the three scenarios in teams consisting of five members. At nine questions per stop, more participants agreed or strongly agreed that there were too many questions per stop (57.1%) than when we asked six questions per stop (13%) and three questions per stop (0%). A number of interprofessional differences in response to this interprofessional experience were noted. A team SAGAT score was determined by calculating the proportion of correct responses for each individual. Higher scores were associated with better adherence to outcome times, although not statistically significant. A robust study design building on our pilot data is needed to probe the differing interprofessional perceptions of SAGAT and the potential association between its scores and clinical outcome times.

We evaluated in this qualitative systematic review the efficacy of increasing central blood volume on the incidence of hypotension after spinal anesthesia for elective cesarean delivery. Randomized controlled trials investigating any method of increasing central blood volume before the initiation of obstetric spinal anesthesia were sought by using MEDLINE (1966-2000), Embase (January 1988-April 2000), and the Cochrane Library (Issue 1, 2000). Additional reports from retrieved and review articles, hand searching of non-MEDLINE journals, and abstracts of major anesthesia meetings (1994-1999) were located. The primary outcome was the incidence of hypotension. Secondary outcomes included: ephedrine use, Apgar scores, umbilical cord pH values, and maternal nausea and vomiting. Twenty-three articles met our inclusion criteria with the use of crystalloid preload, colloid preload, and mechanical methods of increasing central volume. Crystalloid preload was inconsistent in preventing hypotension, whereas colloid appeared to be effective in all but one study. Leg wrapping and thromboembolic stockings decreased the incidence of hypotension compared with leg elevation or control. Few differences in fetal outcomes or maternal nausea and vomiting were reported. Increasing central blood volume by using colloid and leg wrapping decreases but does not abolish the incidence of hypotension before spinal anesthesia for elective cesarean delivery.We performed a systematic review to determine whether fluid loading reduced the incidence of low blood pressure after spinal anesthesia for cesarean delivery. Although no technique totally eliminates the occurrence of hypotension, colloid administration (starch or gelatin containing fluids) and leg wrapping were the most effective.

To compare the hypnotic effects of a bedtime dose of zolpidem, triazolam, and placebo."Double-blind, randomized, placebo- and active-controlled, parallel-group" trial.Six Canadian hospitals.357 patients (aged 19 to 71 years) hospitalized the night before a surgical procedure.At bedtime, each patient received either zolpidem 10 mg, triazolam 0.25 mg, or placebo, and was allowed to sleep for a maximum of 8 hours.Outcome measures were subjective in nature and included a morning questionnaire, visual analog scales, and observation forms by study personnel. All continuous variables were analyzed by analysis of variance. All categorical data were compared using the Cochran-Mantel-Haenszel (CMH) test, and the percentage of patients asleep was compared using a CMH chi-square analysis. When significant overall treatment effects were observed, pairwise comparisons were undertaken. Compared with the placebo group, the following parameters were significantly (p0.001) different in the zolpidem and triazolam groups: sleep latency was shorter, total sleep time was longer, patients fell asleep more easily, and the number of patients awake 2 hours after drug administration was lower. There were no differences between any groups in next-morning somnolence or ability to concentrate. Both drugs were well tolerated, with adverse event incidence rates nearly identical to placebo.In patients suffering from transient insomnia, a single dose of zolpidem 10 mg was as effective as triazolam 0.25 mg, and both were more effective than placebo and were well tolerated.

A multidisciplinary patient care plan was developed to facilitate early discharge following autogenous breast reconstruction and included (1) preadmission patient education, (2) perioperative multimodal pain management, (3) intraoperative nerve blocks, and (4) postdischarge telephone advice. This study evaluated the success of this care plan in the first 18 months after its implementation.A retrospective cohort study of all consecutive women undergoing pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction (November of 2009 to May of 2011) was performed. The primary outcome was time to discharge; secondary outcomes included complications, readmission, and self-report pain at discharge. Predictors of discharge time were analyzed using stepwise multivariable regression modeling.Ninety-one women (mean age, 50.0 ± 8.5 years) underwent pedicled TRAM flap reconstruction (76 percent unilateral and 81 percent delayed), with 77 percent receiving the intended multimodal analgesia protocol. Mean time to discharge was 38.7 ± 27.6 hours. Overall, 40 percent of patients were discharged within 24 hours, but successful early discharge increased significantly over the study period. Key predictors of shorter time to discharge were use of multimodal analgesia, lower American Society of Anesthesiologists class, and surgery more than 6 months after implementation of the care plan.The authors' initial experience has supported the safety and feasibility of expedited discharge following pedicled TRAM flap breast reconstruction, with adherence to the authors' care plan improving steadily over the study period. Multimodal pain management proved a key modifiable factor in facilitating early discharge. A prospective study is currently underway to evaluate patient-reported quality of recovery following ambulatory surgery in this population.

Spinal anaesthesia has been used since the 1800s but, due to a number of complications, the popularity of this technique has waxed and waned. In the 1950s, it was the most widely used method of anaesthesia and analgesia in obstetrics but it fell out of fashion with the arrival of the epidural technique which allowed a continuous method of delivering analgesia with relatively few complications. Hypotension and the high incidence of postdural puncture headaches were two reasons for the decline in the popularity of spinal anaesthesia in the young, otherwise healthy pregnant population. With the development of newer needles and bevel designs and methods whereby the incidence of hypotension can be minimized, spinal anaesthesia is making a reappearance in obstetrical anaesthesia spheres. The purpose of this article is to review the history, effects, technique, indications, contraindications and complications of this method of anesthesia as it applies to the obstetrical patient.

Sepsis in the parturient may be difficult to recognize in light of the physiological changes associated with pregnancy. The purposes of this report are to highlight the signs and symptoms which indicate an underlying septic process and the management of these patients in the peripartum period. This 32-yr-old GII PI woman with twin gestation presented at 36 wk in labour. Her temperature was 35.3 degrees C, she was normotensive and had a normal white blood cell count. After epidural anaesthesia was administered for Caesarean section, she became apnoeic, pulseless and unresponsive. Despite aggressive cardiopulmonary resuscitation, neither she nor her twin babies survived. Post mortem blood work revealed a considerable left shift of her white blood count (> 60% bands) and an anion gap acidosis. Autopsy revealed evidence of widespread Group A beta-haemolytic streptococcal sepsis. Diagnosis of sepsis in the parturient involves assessment of the patient's temperature, WBC and differential and acid-base status. Evaluation of the intravascular volume must precede anaesthetic intervention. Epidural anaesthesia may be considered in the labouring and Caesarean section patient who has been fluid-resuscitated. Emergency operative delivery may result in cardiovascular compromise in the patient with severe sepsis.

The Guidelines to the Practice of Anesthesia Revised Edition 2012 (the guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. Because the guidelines are subject to revision, updated versions are published annually. Whereas previous versions of the guidelines appeared as special supplements to the Canadian Journal of Anesthesia (the Journal), this edition of the guidelines is published within the Journal. This allows for improved archiving and online access to complement the printed version--a new offering for CAS members and Journal subscribers. The Guidelines to the Practice of Anesthesia Revised Edition 2012 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the society cannot guarantee any specific patient outcome. Each anesthesiologist should exercise his or her own professional judgement in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

To determine the effectiveness of high-fidelity simulation for team training, a valid and reliable tool is required. This study investigated the internal consistency, inter-rater reliability and test-retest reliability of two newly developed tools to assess obstetrical team performance.After research ethics board approval, multidisciplinary obstetrical teams participated in three sessions separated by 5-9 months and managed four high-fidelity simulation scenarios. Two tools, an 18-item Assessment of Obstetric Team Performance (AOTP) and a six-item Global Assessment of Obstetric Team Performance (GAOTP) were used.(5) Eight reviewers rated the DVDs of all teams' performances.Two AOTP items were consistently incomplete and omitted from the analyses. Cronbach's α for the 16-item AOTP was 0.96, and 0.91 for the six-item GAOTP. The eight-rater α for the GAOTP was 0.81 (single-rater intra-class correlation coefficient, 0.34) indicating acceptable inter-rater reliability. The 'four-scenario' α for the 12 teams was 0.79 for session 1, 0.88 for session 2, and 0.86 for session 3, suggesting that performance is not being strongly affected by the context specificity of the cases. Pearson's correlation of team performance scores for the four scenarios were 0.59, 0.35, 0.40 and 0.33, and for the total score across scenarios it was 0.47, indicating moderate test-retest reliability.The results from this study indicate that the GAOTP would be a sufficient assessment tool for obstetrical team performance using simulation provided that it is used to assess teams with at least eight raters to ensure a sufficiently stable score. This could allow the quantitative evaluation of an educational intervention.

Background: Teamwork and communication have been identified as root causes of sentinel events involving infant death and injury during delivery. However, despite the emphasis on team training as a way to improve maternal and fetal safety outcomes, valid and reliable markers of obstetrical team performance are not available to assess curricular efficacy. Objectives: The objective of this study was to develop and assess the usability of two obstetrical behavioural marking systems for use with simulation entitled Assessment of Obstetrical Team Performance (AOTP) and Global Assessment of Obstetrical Team Performance (GAOTP). Methods: In a previous study, obstetrical teams were videotaped managing simulated emergency obstetrical scenarios. In the current study, 13 reviewers reviewed these videotapes and generated a list of behaviours judged to negatively or positively affect the teams’ performances. Qualitative analysis using research team consensus and NVivo generated themes and subthemes. Research team members developed descriptors for poor and excellent team performance for each of the behaviours. Subsequently, the usability of the prototypes was assessed by an additional 14 reviewers. Results: In total, the reviewers identified 1294 items, which were sorted into 6 themes and 18 subthemes of obstetrical team performance. In terms of usability, the median amount of time that participants spent completing the AOTP was 7.5 min (range 1.5 to 50 min) and 75% thought the time requirement was moderate and manageable. Conclusion: Feedback regarding usability suggests that the AOTP allows for an accurate reflection of raters’ assessments of the performance of the team, and as a whole, it is comprehensive, quick and easy to use. Studies are underway to establish the validity and reliability of the AOTP and GAOTP.

The Guidelines to the Practice of Anesthesia Revised Edition 2010 (the guidelines) were prepared by the Canadian Anesthesiologists’ Society (CAS), which reserves the right to determine their publication and distribution. Because the guidelines are subject to revision, updated versions are published annually. Whereas previous versions of the guidelines appeared as special supplements to the Canadian Journal of Anesthesia (the Journal), this edition of the guidelines is published within the Journal. This allows for improved archiving and online access to complement the printed version—a new offering for CAS members and Journal subscribers. The Guidelines to the Practice of Anesthesia Revised Edition 2010 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the society cannot guarantee any specific patient outcome. Each anesthesiologist should exercise his or her own professional judgement in determining the proper course of action for any patient’s circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

Background Research into adverse events in hospitalized patients suggests that a significant number are preventable. The purpose of this randomized, controlled study was to determine if simulation-based debriefing improved performance of practicing anaesthetists managing high-fidelity simulation scenarios. Methods The anaesthetists were randomly allocated to Group A: simulation debriefing; Group B: home study; and Group C: no intervention and secondary randomization to one of two scenarios. Six to nine months later, subjects returned to manage the alternate scenario. Facilitators blinded to study group allocation completed the performance checklists (dichotomously scored checklist, DSC) and Global Rating Scale of Performance (GRS). Two non-expert raters were trained, and assessed all videotaped performances. Results Interim analysis indicated no difference between Groups B and C which were merged into one group. Seventy-four subjects were recruited, with 58 complete data sets available. There was no significant effect of group on pre-test scores. A significant improvement was seen between pre- and post-tests on the DSC in debriefed subjects (pre-test 66.8%, post-test 70.3%; F 1,57 =4.18, P =0.046). Both groups showed significant improvement in the GRS over time ( F 1,57 =5.94, P =0.018), but no significant difference between the groups. Conclusions We found a modest improvement in performance on a DSC in the debriefed group and overall improvement in both control and debriefed groups using a GRS. Whether this improvement translates into clinical practice has yet to be determined.

Background There are not enough clinical data from rare critical events to calculate statistics to decide if the management of actual events might be below what could reasonably be expected (i.e. was an outlier). Objectives In this project we used simulation to describe the distribution of management times as an approach to decide if the management of a simulated obstetrical crisis scenario could be considered an outlier. Design Twelve obstetrical teams managed 4 scenarios that were previously developed. Relevant outcome variables were defined by expert consensus. The distribution of the response times from the teams who performed the respective intervention was graphically displayed and median and quartiles calculated using rank order statistics. Results Only 7 of the 12 teams performed chest compressions during the arrest following the 'cannot intubate/cannot ventilate' scenario. All other outcome measures were performed by at least 11 of the 12 teams. Calculation of medians and quartiles with 95% CI was possible for all outcomes. Confidence intervals, given the small sample size, were large. Conclusion We demonstrated the use of simulation to calculate quantiles for management times of critical event. This approach could assist in deciding if a given performance could be considered normal and also point to aspects of care that seem to pose particular challenges as evidenced by a large number of teams not performing the expected maneuver. However sufficiently large sample sizes (i.e. from a national data base) will be required to calculate acceptable confidence intervals and to establish actual tolerance limits.

Barriers to simulation-based education in postgraduate and continuing education for anesthesiologists have not been well studied. We hypothesized that the level of training may influence attitudes towards simulation-based education and impact on the use of simulation. This study investigated this issue at the University of Toronto which possesses two sites equipped with high-fidelity patient simulators.A 40-question survey of experiences, perceptions, motivations and perceived barriers to simulation-based education, was distributed to 154 anesthesiologists attending a departmental conference. Data were analyzed using descriptive statistics and associations between responses were assessed using either the Chi-Square statistic or a one-way analysis of variance.The rate of response was 58%. Residents had experienced simulation-based education (96%) more often than staff (58%) and fellows (36%), (P0.001 respectively). Residents had also attended more simulation sessions than staff and fellows (mean 2.8 vs 1.05 and 1.04, P0.001 respectively). Residents and fellows found simulation-based education more relevant for their training than staff (88% vs 65%, P0.05). Eighty-one percent of the respondents identified at least one significant barrier that prevents or limits them from attending simulator sessions. Staff anesthesiologists perceived multiple barriers and identified 'time' and 'financial issues' as significant barriers.Anesthesiologists' level of training influences their attitudes towards and their perceptions of simulation-based education. This survey has identified perceived barriers that may limit a wider utilization of simulation. These results may be used to implement targeted actions such as course design, incentives, and information strategies, which could improve access and future use of simulation.

Background Standardized scenarios can be used for performance assessments geared to the level of the learner. The purpose of this study was to validate checklists used for the assessments of medical students' performance using high-fidelity patient simulation. Methods Our undergraduate committee designed 10 scenarios based on curriculum objectives. Fifteen faculty members with undergraduate educational experience identified items considered appropriate for medical students' performance level and identified items that, if omitted, would negatively affect grades. Items endorsed by less than 20% of faculty were omitted. For remaining items, weighting was calculated according to faculty responses. Students managed at least one scenario during which their performance was videotaped. Two raters independently completed the checklists for three consecutive sessions to determine inter-rater reliability. Validity was determined using Cronbach's α with an α≥0.6 and ≤0.9 considered acceptable internal consistency. Item analysis was performed by recalculating Cronbach's α with each item deleted to determine if that item contributed to a low internal consistency. Results 135 students participated in the study. Inter-rater reliability of the two raters determined on the third session was 0.97 and therefore one rater completed the remaining performance assessments. Cronbach's α for the 10 scenarios ranged from 0.16 to 0.93 with two scenarios demonstrating acceptable internal consistency with all items. Three scenarios demonstrated acceptable internal consistency with one item deleted. Conclusions Five scenarios developed for this study were shown to be valid when using the faculty criteria for expected performance level.

To determine the correlation between global ratings and criterion-based checklist scores, and inter-rater reliability of global ratings and criterion-based checklist scores, in a performance assessment using an anesthesia simulator.All final-year medical students at the University of Toronto were invited to work through a 15-minute faculty-facilitated scenario using an anesthesia simulator. Students' performances were videotaped and analyzed by two faculty using a 25-point criterion-based checklist and a five-point global rating of competency (1 = clear failure, 5 = superior performance). Correlations between global ratings and checklist scores, as well as specific performance competencies (knowledge, technical skills, and judgment), were determined. Checklist and global scores were converted to percentages; means of the two marks were compared. Mean reliability of a single rater for both checklist and global ratings was determined.The correlation between checklist and global ratings was.74. Mean ratings of both checklist and global scores were low (58.67, SD = 14.96, and 57.08, SD = 24.27, respectively); these differences were not statistically significant. For a single rater, the mean reliability score across rater pairs for checklist scores was.77 (range.58-.93). Mean reliability score across rater pairs for global ratings was.62 (.40-.77). Global ratings correlated more highly with technical skills and judgment (r =.51 and r =.53, respectively) than with knowledge. (r =.24)Inter-rater reliability was higher for checklist scores than for global ratings; however, global ratings demonstrated acceptable inter-rater reliability and may be useful for competency assessment in performance assessments using simulators.

To examine the validity and reliability of performance assessment of undergraduate students using the anesthesia simulator as an evaluation tool.After ethics approval and informed consent, 135 final year medical students and 5 elective students participated in a videotaped simulator scenario with a Link-Med Patient Simulator (CAE-Link Corporation). Scenarios were based on published educational objectives of the undergraduate curriculum in anesthesia at the University of Toronto. During the simulator sessions, faculty followed a script guiding student interaction with the mannequin. Two faculty independently viewed and evaluated each videotaped performance with a 25-point criterion-based checklist. Means and standard deviations of simulator-based marks were determined and compared with clinical and written evaluations received during the rotation. Internal consistency of the evaluation protocol was determined using inter-item and item-total correlations and correlations of specific simulator items to existing methods of evaluation.Mean reliability estimates for single and average paired assessments were 0.77 and 0.86 respectively. Means of simulator scores were low and there was minimal correlation between the checklist and clinical marks (r = 0.13), checklist and written marks (r = 0.19) and clinical and written marks (r = 0.23). Inter-item and item-total correlations varied widely and correlation between simulator items and existing evaluation tools was low.Simulator checklist scoring demonstrated acceptable reliability. Low correlation between different methods of evaluation may reflect reliability problems with the written and clinical marks, or that different aspects are being tested. The performance assessment demonstrated low internal consistency and further work is required.

One hundred and forty-three students and 18 faculty at the University of Toronto participated in a study of the anaesthesia simulator as an evaluation tool. Both student and faculty opinions regarding the experience were elicited using questionnaires with a five-point scale, 1 = strongly disagree, 5 = strongly agree. Faculty and student opinion were similar and positive with respect to the use of the simulator and matching of educational objectives, its use as a learning experience, its use as an evaluation tool and the need for familiarity with the tool before use as an assessment method. This study supports the use of the simulator as an evaluation tool based on faculty and student opinions provided that prior exposure to the environment is offered.

Epidural anesthesia was a commonly used technique for elective Cesarean section. Recently, because of the availability of non-cutting spinal needles, many institutions have changed from epidural to spinal anesthesia. The purpose of this study was to compare maternal satisfaction between epidural and spinal anesthesia for elective Cesarean section with a new satisfaction tool.We studied healthy parturients in a randomized, double-blinded pilot study in which patients were assigned to receive either epidural (n = 13) or spinal (n = 14) anesthesia for elective Cesarean section. Two and 24 hr postoperatively, patients completed a validated 22-point maternal satisfaction questionnaire and a 10-cm visual analog score (VAS) for satisfaction. Maternal satisfaction scores were compared between groups.There was no difference in demographics, complications or technical failures between groups. Mean satisfaction scores on the questionnaire (0-154) at two and 24 hr were 130.23 +/- 11.36 and 129.54 +/- 16.70 for the epidural group and 116.92 +/- 18.47 and 115.92 +/- 15.71 for the spinal group (P = 0.04 and P = 0.03 respectively). No difference in VAS scores was noted. The presence of minor side effects including pruritus contributed to the lower satisfaction in the spinal group at 24 hr.This pilot study demonstrated higher maternal satisfaction with epidural than with spinal anesthesia for elective Cesarean section. This may be related to the increased side effects caused by neuraxial morphine. The satisfaction questionnaire was able to elucidate differences not detected with a global VAS for satisfaction. Further study with a larger patient population is required to confirm these data.