Amy N. DiLorenzo

Effect of a Cognitive Aid on Adherence to Perioperative Assessment and Management Guidelines for the Cardiac Evaluation of Noncardiac Surgical Patients

Background:The 2007 American College of Cardiologists/American Heart Association Guidelines on Perioperative Cardiac Evaluation and Care for Noncardiac Surgery is the standard for perioperative cardiac evaluation. Recent work has shown that residents and anesthesiologists do not apply these guidelines when tested. This research hypothesized that a decision support tool would improve adherence to this consensus guideline. Methods:Anesthesiology residents at four training programs participated in an unblinded, prospective, randomized, cross-over trial in which they completed two tests covering clinical scenarios. One quiz was completed from memory and one with the aid of an electronic decision support tool. Performance was evaluated by overall score (% correct), number of incorrect answers with possibly increased cost or risk of care, and the amount of time required to complete the quizzes both with and without the cognitive aid. The primary outcome was the proportion of correct responses attributable to the use of the decision support tool. Results:All anesthesiology residents at four institutions were recruited and 111 residents participated. Use of the decision support tool resulted in a 25% improvement in adherence to guidelines compared with memory alone (P < 0.0001), and participants made 77% fewer incorrect responses that would have resulted in increased costs. Use of the tool was associated with a 3.4-min increase in time to complete the test (P < 0.001). Conclusions:Use of an electronic decision support tool significantly improved adherence to the guidelines as compared with memory alone. The decision support tool also prevented inappropriate management steps possibly associated with increased healthcare costs.

Initial results of a structured rotation in hematology and transfusion medicine for anesthesiology residents.

STUDY OBJECTIVE To develop and evaluate a new curriculum in transfusion medicine for anesthesiology residents. STUDY DESIGN Quasi-experimental study. SETTING Single center, pilot curriculum in the anesthesiology residency program at a university-affiliated medical center. PARTICIPANTS Group TM consisted of residents who participated in the one month-long transfusion medicine rotation in postgraduate year 2 (PGY2; n = 9). The comparison group (non-TM) consisted of residents who had no exposure to the transfusion medicine rotation (n = 21). MEASUREMENTS We compared results of the 2009 American Board of Anesthesiology In-Training Exam (ABA-ITE) 2009 by residents of our program with the national performance of residents in the first clinical anesthesia year (AMG CA1 = PGY-2) and second clinical anesthesia year (AMG CA2 = PGY-3) on transfusion medicine/hematology knowledge. Performance on a pre-test and post-test of those who took part in the transfusion medicine curriculum, and overall performance on the ABA-ITE, of departmental residents who had and had not participated in the Transfusion Medicine curriculum within the target knowledge area of hematology/transfusion medicine and compared against national peer performance data, was assessed. An anonymous electronic survey (5-Point Likert scale) was used to assess the perceived educational value of the curriculum. MAIN RESULTS Transfusion medicine-related knowledge of anesthesia residents markedly improved from the pre- to post-rotation examination and on the ABA-ITE. In the ABA-ITE 2009, the TM group performed better than their national peers (AMG CA1 and CA2) in the hematology content area. The post-rotation anonymous resident survey indicated high resident satisfaction. CONCLUSIONS A structured transfusion medicine curriculum improved anesthesiology resident knowledge in transfusion medicine and was associated with high learner satisfaction.

Evaluating practice-based learning and improvement: efforts to improve acceptance of portfolios.

INTRODUCTION The Accreditation Council for Graduate Medical Education (ACGME) recommends resident portfolios as 1 method for assessing competence in practice-based learning and improvement. In July 2005, when anesthesiology residents in our department were required to start a portfolio, the residents and their faculty advisors did not readily accept this new requirement. Intensive education efforts addressing the goals and importance of portfolios were undertaken. We hypothesized that these educational efforts improved acceptance of the portfolio and retrospectively audited the portfolio evaluation forms completed by faculty advisors. METHODS Intensive education about the goals and importance of portfolios began in January 2006, including presentations at departmental conferences and one-on-one education sessions. Faculty advisors were instructed to evaluate each residents portfolio and complete a review form. We retrospectively collected data to determine the percentage of review forms completed by faculty. The portfolio reviews also assessed the percentage of 10 required portfolio components residents had completed. RESULTS Portfolio review forms were completed by faculty advisors for 13% (5/38) of residents during the first advisor-advisee meeting in December 2005. Initiation of intensive education efforts significantly improved compliance, with review forms completed for 68% (26/38) of residents in May 2006 (P < .0001) and 95% (36/38) in December 2006 (P < .0001). Residents also significantly improved the completeness of portfolios between May and December of 2006. DISCUSSION Portfolios are considered a best methods technique by the ACGME for evaluation of practice-based learning and improvment. We have found that intensive education about the goals and importance of portfolios can enhance acceptance of this evaluation tool, resulting in improved compliance in completion and evaluation of portfolios.

A Smartphone-based Decision Support Tool Improves Test Performance Concerning Application of the Guidelines for Managing Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy.

Background:The American Society of Regional Anesthesia and Pain Medicine (ASRA) consensus statement on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy is the standard for evaluation and management of these patients. The authors hypothesized that an electronic decision support tool (eDST) would improve test performance compared with native physician behavior concerning the application of this guideline. Methods:Anesthesiology trainees and faculty at 8 institutions participated in a prospective, randomized trial in which they completed a 20-question test involving clinical scenarios related to the ASRA guidelines. The eDST group completed the test using an iOS app programmed to contain decision logic and content of the ASRA guidelines. The control group completed the test by using any resource in addition to the app. A generalized linear mixed-effects model was used to examine the effect of the intervention. Results:After obtaining institutional review board’s approval and informed consent, 259 participants were enrolled and randomized (eDST = 122; control = 137). The mean score was 92.4 ± 6.6% in the eDST group and 68.0 ± 15.8% in the control group (P < 0.001). eDST use increased the odds of selecting correct answers (7.8; 95% CI, 5.7 to 10.7). Most control group participants (63%) used some cognitive aid during the test, and they scored higher than those who tested from memory alone (76 ± 15% vs. 57 ± 18%, P < 0.001). There was no difference in time to completion of the test (P = 0.15) and no effect of training level (P = 0.56). Conclusions:eDST use improved application of the ASRA guidelines compared with the native clinician behavior in a testing environment.

Results of a Flipped Classroom Teaching Approach in Anesthesiology Residents

BACKGROUND In a flipped classroom approach, learners view educational content prior to class and engage in active learning during didactic sessions. OBJECTIVE We hypothesized that a flipped classroom improves knowledge acquisition and retention for residents compared to traditional lecture, and that residents prefer this approach. METHODS We completed 2 iterations of a study in 2014 and 2015. Institutions were assigned to either flipped classroom or traditional lecture for 4 weekly sessions. The flipped classroom consisted of reviewing a 15-minute video, followed by 45-minute in-class interactive sessions with audience response questions, think-pair-share questions, and case discussions. The traditional lecture approach consisted of a 55-minute lecture given by faculty with 5 minutes for questions. Residents completed 3 knowledge tests (pretest, posttest, and 4-month retention) and surveys of their perceptions of the didactic sessions. A linear mixed model was used to compare the effect of both formats on knowledge acquisition and retention. RESULTS Of 182 eligible postgraduate year 2 anesthesiology residents, 155 (85%) participated in the entire intervention, and 142 (78%) completed all tests. The flipped classroom approach improved knowledge retention after 4 months (adjusted mean = 6%; P = .014; d = 0.56), and residents preferred the flipped classroom (pre = 46%; post = 82%; P < .001). CONCLUSIONS The flipped classroom approach to didactic education resulted in a small improvement in knowledge retention and was preferred by anesthesiology residents.

The Impact of Exposure to Liver Transplantation Anesthesia on the Ability to Treat Intraoperative Hyperkalemia: A Simulation Experience

The objective of this study was to assess whether resident exposure to liver transplantation anesthesia results in improved patient care during a simulated critical care scenario. Our hypothesis was that anesthesia residents exposed to liver transplantation anesthesia care would be able to identify and treat a simulated hyperkalemic crisis after reperfusion more appropriately than residents who have not been involved in liver transplantation anesthesia care. Participation in liver transplantation anesthesia is not a mandatory component of the curriculum of anesthesiology training programs in the United States. It is unclear whether exposure to liver transplantation anesthesia is beneficial for skill set development. A high-fidelity human patient simulation scenario was developed. Times for administration of epinephrine, calcium chloride, and secondary hyperkalemia treatment were recorded. A total of 25 residents with similar training levels participated: 13 residents had previous liver transplantation experience (OLT), whereas 12 residents had not been previously exposed to liver transplantations (non-OLT). The OLT group performed better in recognizing and treating the hyperkalemic crisis than the non-OLT group. Pharmacologic therapy for hyperkalemia was given earlier (OLT 53.3 ± 27.0 seconds versus non-OLT 148 ± 104.1 seconds; P < 0.01) and hemodynamics restored quicker (OLT 87.9 ± 24.9 seconds versus non-OLT 219.9 ± 87.1 seconds; P < 0.01). Simulation-based assessment of clinical skills is a useful tool for evaluating anesthesia resident performance during an intraoperative crisis situation related to liver transplantations. Previous liver transplantation experience improves the anesthesia residents ability to recognize and treat hyperkalemic cardiac arrest.

Enhancing Feedback on Professionalism and Communication Skills in Anesthesia Residency Programs

BACKGROUND: Despite its importance, training faculty to provide feedback to residents remains challenging. We hypothesized that, overall, at 4 institutions, a faculty development program on providing feedback on professionalism and communication skills would lead to (1) an improvement in the quantity, quality, and utility of feedback and (2) an increase in feedback containing negative/constructive feedback and pertaining to professionalism/communication. As secondary analyses, we explored these outcomes at the individual institutions. METHODS: In this prospective cohort study (October 2013 to July 2014), we implemented a video-based educational program on feedback at 4 institutions. Feedback records from 3 months before to 3 months after the intervention were rated for quality (0–5), utility (0–5), and whether they had negative/constructive feedback and/or were related to professionalism/communication. Feedback records during the preintervention, intervention, and postintervention periods were compared using the Kruskal-Wallis and &khgr;2 tests. Data are reported as median (interquartile range) or proportion/percentage. RESULTS: A total of 1926 feedback records were rated. The institutions overall did not have a significant difference in feedback quantity (preintervention: 855/3046 [28.1%]; postintervention: 896/3327 [26.9%]; odds ratio: 1.06; 95% confidence interval, 0.95–1.18; P = .31), feedback quality (preintervention: 2 [1–4]; intervention: 2 [1–4]; postintervention: 2 [1–4]; P = .90), feedback utility (preintervention: 1 [1–3]; intervention: 2 [1–3]; postintervention: 1 [1–2]; P = .61), or percentage of feedback records containing negative/constructive feedback (preintervention: 27%; intervention: 32%; postintervention: 25%; P = .12) or related to professionalism/communication (preintervention: 23%; intervention: 33%; postintervention: 24%; P = .03). Institution 1 had a significant difference in feedback quality (preintervention: 2 [1–3]; intervention: 3 [2–4]; postintervention: 3 [2–4]; P = .001) and utility (preintervention: 1 [1–3]; intervention: 2 [1–3]; postintervention: 2 [1–4]; P = .008). Institution 3 had a significant difference in the percentage of feedback records containing negative/constructive feedback (preintervention: 16%; intervention: 28%; postintervention: 17%; P = .02). Institution 2 had a significant difference in the percentage of feedback records related to professionalism/communication (preintervention: 26%; intervention: 57%; postintervention: 31%; P < .001). CONCLUSIONS: We detected no overall changes but did detect different changes at each institution despite the identical intervention. The intervention may be more effective with new faculty and/or smaller discussion sessions. Future steps include refining the rating system, exploring ways to sustain changes, and investigating other factors contributing to feedback quality and utility.

Systemic-to-pulmonary artery pressure ratio as a predictor of patient outcome following liver transplantation

AIM To assess the value of the mean systemic-to-pulmonary artery pressure (MAP/mPAP) ratio for predicting outcomes following orthotopic liver transplant (OLT). METHODS A retrospective data analysis was performed and data (mean arterial blood pressure, mean pulmonary artery pressure and Cardiac Index) were collected at several points during OLT. Outcomes evaluated were duration of postoperative endotracheal intubation [ET; minutes after intensive care unit (ICU) arrival], length of ICU stay, total hospitalization and frequency of immediate postoperative complications. A total of 91 patients were included in the data analysis. Based on the intraoperative course of the MAP/mPAP ratio, 2 hemodynamic responses were identified: Group 1 (MAP/mPAP ratio increase during anhepatic period with postreperfusion recovery, n = 66); and Group 2 (MAP/mPAP ratio with no change during anhepatic period or decreased without recovery, n = 25). RESULTS The main finding was that the lack of increased MAP/mPAP ratio in the anhepatic period was associated with: (1) longer intubation times; and (2) prolonged ICU stays and total hospitalization time, when compared to patients with an increase in MAP/mPAP ratio during the anhepatic period. CONCLUSION The data from this retrospective study should raise awareness to the mean systemic to pulmonary artery pressure ratio as a potential indicator for poor outcome after OLT. Further prospective studies are needed for validation.

Cognitive aid use improves transition of care by graduating medical students during a simulated crisis

Background Residents are expected to have transition of care (ToC) skills upon entering graduate medical education. It is unclear whether experience and training during medical school is adequate. Objective The aim of the project was to assess: 1) graduating medical students’ ability to perform ToC in a crisis situation, and 2) whether using a cognitive aid improves the ToC quality. Methods The authors developed simulation scenarios for rapid response teams and a cognitive aid to assist in the ToC during crisis situations. Graduating medical students were enrolled and randomly divided into teams of three students, randomly assigned into one of two groups: teams using a cognitive aid for ToC (CA), or not using a cognitive aid (nCA). In the scenario, teams respond to a deteriorating patient and then transfer care to the next provider after stabilization. Three faculty reviewed the recording to assess completeness of the ToC and the overall quality. A completeness score was expressed as a fraction of the maximum score. Statistical analysis was performed using a t-test and Mann-Whitney U test. Results A total of 112 senior medical students participated: CA n=19, nCA n=17. The completeness score of the ToC and overall quality improved when using the cognitive aid (completeness score: CA 0.80±0.06 vs. nCA 0.52±0.07, p<0.01; ToC quality: CA 3.16±0.65 vs. nCA 1.92±0.56, p<0.01). Participants’ rating of knowledge and comfort with the ToC process increased after the simulation. Conclusion The completeness of information transfer during the ToC process by graduating medical students improved by using a cognitive aid in a simulated patient crisis.

Faculty Development of Education Researchers in Academic Anesthesiology.

Published scholarship in medical education (ME) began just over 50 years ago with the Journal of Medical Education. Before that time, fads, politics, and ideology rather than evidence guided much of medical educational decision-making. Currently, ME is a rapidly growing field of study with an increasing number of manuscripts, conferences, collaborative research efforts, and journals (ie, Academic Medicine, Medical Education, Medical Teacher, Teaching and Learning in Medicine, Journal of Graduate Medical Education) dedicated to reporting research and issues in ME despite the fact that medical education research (MER) is largely unfunded. In the field of anesthesiology, a new journal, Anesthesia and Analgesia Case Reports, publishes important teaching points or scientific observation related to anesthesiology education including case reports, educational interventions, and assessment methods. The Best Evidence Medical Education Collaboration (BEME, http://www.bemecollaboration.org) is an example of an attempt to disseminate best evidence to support ME, synthesize existing literature, and systematically inform our practice of ME. In light of this expansion, many have called for higher quality in MER, more rigorous and creative study designs, greater methodological rigor, and clear, meaningful outcomes in ME and MER. For these goals