Ankeet D. Udani

Crisis Resource Management

Crisis Resource Management (CRM) in health care, a term devised in the 1990s, can be summarized as articulation of the principles of individual and crew behavior in ordinary and crisis situations that focuses on the skills of dynamic decision-making, interpersonal behavior, and team management.

Preliminary Study of Ergonomic Behavior During Simulated Ultrasound-Guided Regional Anesthesia Using a Head-Mounted Display

A head‐mounted display provides continuous real‐time imaging within the practitioners visual field. We evaluated the feasibility of using head‐mounted display technology to improve ergonomics in ultrasound‐guided regional anesthesia in a simulated environment. Two anesthesiologists performed an equal number of ultrasound‐guided popliteal‐sciatic nerve blocks using the head‐mounted display on a porcine hindquarter, and an independent observer assessed each practitioners ergonomics (eg, head turning, arching, eye movements, and needle manipulation) and the overall block quality based on the injectate spread around the target nerve for each procedure. Both practitioners performed their procedures without directly viewing the ultrasound monitor, and neither practitioner showed poor ergonomic behavior. Head‐mounted display technology may offer potential advantages during ultrasound‐guided regional anesthesia.

Comparative-Effectiveness of Simulation-Based Deliberate Practice Versus Self-Guided Practice on Resident Anesthesiologists' Acquisition of Ultrasound-Guided Regional Anesthesia Skills.

Background and Objectives Simulation-based education strategies to teach regional anesthesia have been described, but their efficacy largely has been assumed. We designed this study to determine whether residents trained using the simulation-based strategy of deliberate practice show greater improvement of ultrasound-guided regional anesthesia (UGRA) skills than residents trained using self-guided practice in simulation. Methods Anesthesiology residents new to UGRA were randomized to participate in either simulation-based deliberate practice (intervention) or self-guided practice (control). Participants were recorded and assessed while performing simulated peripheral nerve blocks at baseline, immediately after the experimental condition, and 3 months after enrollment. Subject performance was scored from video by 2 blinded reviewers using a composite tool. The amount of time each participant spent in deliberate or self-guided practice was recorded. Results Twenty-eight participants completed the study. Both groups showed within-group improvement from baseline scores immediately after the curriculum and 3 months following study enrollment. There was no difference between groups in changed composite scores immediately after the curriculum (P = 0.461) and 3 months following study enrollment (P = 0.927) from baseline. The average time in minutes that subjects spent in simulation practice was 6.8 minutes for the control group compared with 48.5 minutes for the intervention group (P < 0.001). Conclusions In this comparative effectiveness study, there was no difference in acquisition and retention of skills in UGRA for novice residents taught by either simulation-based deliberate practice or self-guided practice. Both methods increased skill from baseline; however, self-guided practice required less time and faculty resources.

Upgrading a Social Media Strategy to Increase Twitter Engagement During the Spring Annual Meeting of the American Society of Regional Anesthesia and Pain Medicine

Abstract Microblogs known as “tweets” are a rapid, effective method of information dissemination in health care. Although several medical specialties have described their Twitter conference experiences, Twitter-related data in the fields of anesthesiology and pain medicine are sparse. We therefore analyzed the Twitter content of 2 consecutive spring meetings of the American Society of Regional Anesthesia and Pain Medicine using publicly available online transcripts. We also examined the potential contribution of a targeted social media campaign on Twitter engagement during the conferences. The original Twitter meeting content was largely scientific in nature and created by meeting attendees, the majority of whom were nontrainee physicians. Physician trainees, however, represent an important and increasing minority of Twitter contributors. Physicians not in attendance predominantly contributed via retweeting original content, particularly picture-containing tweets, and thus increased reach to nonattendees. A social media campaign prior to meetings may help increase the reach of conference-related Twitter discussion.

Evaluation of a Standardized Program for Training Practicing Anesthesiologists in Ultrasound-Guided Regional Anesthesia Skills

Practicing anesthesiologists have generally not received formal training in ultrasound‐guided perineural catheter insertion. We designed this study to determine the efficacy of a standardized teaching program in this population.

Using eye tracking technology to compare the effectiveness of malignant hyperthermia cognitive aid design

Background Malignant hyperthermia is a rare but potentially fatal complication of anesthesia, and several different cognitive aids designed to facilitate a timely and accurate response to this crisis currently exist. Eye tracking technology can measure voluntary and involuntary eye movements, gaze fixation within an area of interest, and speed of visual response and has been used to a limited extent in anesthesiology. Methods With eye tracking technology, we compared the accessibility of five malignant hyperthermia cognitive aids by collecting gaze data from twelve volunteer participants. Recordings were reviewed and annotated to measure the time required for participants to locate objects on the cognitive aid to provide an answer; cumulative time to answer was the primary outcome. Results For the primary outcome, there were differences detected between cumulative time to answer survival curves (P < 0.001). Participants demonstrated the shortest cumulative time to answer when viewing the Society for Pediatric Anesthesia (SPA) cognitive aid compared to four other publicly available cognitive aids for malignant hyperthermia, and this outcome was not influenced by the anesthesiologists’ years of experience. Conclusions This is the first study to utilize eye tracking technology in a comparative evaluation of cognitive aid design, and our experience suggests that there may be additional applications of eye tracking technology in healthcare and medical education. Potentially advantageous design features of the SPA cognitive aid include a single page, linear layout, and simple typescript with minimal use of single color blocking.

Preliminary Experience Using Eye-Tracking Technology to Differentiate Novice and Expert Image Interpretation for Ultrasound-Guided Regional Anesthesia

Objective measures are needed to guide the novices pathway to expertise. Within and outside medicine, eye tracking has been used for both training and assessment. We designed this study to test the hypothesis that eye tracking may differentiate novices from experts in static image interpretation for ultrasound (US)‐guided regional anesthesia.

Sepsis in the Operating Room: A Simulation Case for Perioperative Providers

Introduction Sepsis should be included in the differential of any patient with unexplained organ dysfunction, whether or not an obvious infection is initially detected. Perioperative providers frequently care for patients with sepsis. This simulation case challenges participants to recognize and manage a presentation of postoperative sepsis, providing an opportunity to discuss the rationale behind sepsis management during debriefing. Methods Assuming the role of an anesthesia provider, the participant takes over the care of a 62-year-old female who has just undergone cystoscopy and is extubated in the operating room (OR). The participant receives a brief handoff from the outgoing anesthesiologist while the patient awaits a postanesthesia care unit slot. The case has been uneventful, aside from intermittent hypotension responsive to IV fluids and boluses of phenylephrine. Within minutes of the handoff, the patient becomes somnolent and hypotensive. Efforts to treat hypotension eventually precipitate hypoxemia. Trainees must recognize and manage this cardiopulmonary decompensation. The scenario benefits from an OR simulation environment containing an anesthetic ventilator, anesthesia drugs and equipment, and a mannequin on an OR table. Results Twelve residents completed the simulation scenario. Formal feedback was collected via email questionnaire from faculty instructors within 30 days of teaching each session. Discussion Sepsis presents a diagnostic dilemma in part because no single diagnostic test rules the syndrome in or out. Multiple operational definitions of sepsis in the academic literature add to the confusion for clinicians. Our case simulation challenges perioperative providers to make a timely diagnosis and initiate appropriate treatment of sepsis.

Perioperative enhancement for CHD patients

We applaud Wernovsky et al for sharing what we strongly support as excellent guidelines for standardised testing and coordinated surveillance of patients with complex CHD. In the United States of America, there are currently more adults than children living with CHD, and projections indicate that this population will continue to grow. CHD patients have improved life expectancy, higher healthcare utilisation rates, and increasingly require elective or emergent non-cardiac surgical, radiological, obstetric, and/or procedural care under anaesthesia. These patients have a higher risk of mortality compared with patients without CHD, and consequently carry with them lifetime complex medical and social issues that require multidisciplinary care. Therefore, a perioperative care plan including consultation with an anaesthesiologist, discussion of unique patient characteristics that portend risk, anaesthetic technique, appropriate testing, and procedure location should be included in the “roadmap” for each patient. This type of patient-centred, interdisciplinary, coordinated care at our institution is implemented by the Perioperative Enhancement Team, whose projects to date have addressed patients with anaemia, diabetes, malnutrition, senior health, and chronic pain. Motivated by the recommendations of Wernovsky et al, Perioperative Enhancement Team will now go forward to develop a programme to address the unique and important perioperative challenges of patients with CHD.

Development and Testing of a Curriculum for Teaching Informed Consent forSpinal Anesthesia to Anesthesiology Residents

Introduction: Properly obtaining informed consent for spinal anesthesia is a skill expected of anesthesiology residents. The goals of the study were to 1) use a Delphi method to develop a curriculum for teaching informed consent for spinal anesthesia, and a checklist of required elements; 2) determine which elements of the informed consent process were most frequently missed prior to the curriculum; 3) quantify if this curriculum improved performance of correctly obtaining informed consent from a standardized patient; and 4) measure retention of learning as measured by how residents performed on actual patients. Methods: Performance on obtaining informed consent was tested with an 11-item checklist on a standardized patient before and after completing the curriculum. Resident performance on their next three patients scheduled to have spinal anesthesia was evaluated at the bedside using the same checklist. Results: At baseline before completing the curriculum 18 anesthesia residents (39% female) with a mean 6.29 months (SD 3.59, median 6.5, 25th-75th quartile range 4.25-9.75) of residency completed and 11.39 prior spinals (SD 13.1, median 13.14, 25th-75th quartile range 3-14) successfully performed 47% (SD 20%, median 45%, 25th-75th quartile range 36-41%) of the 11 required elements. The 3 most commonly missed elements were: “Teach back: Ask the patient to repeat key items in discussion” (0% correct), “Connect, Introduce, Communicate, Ask permission, Respond, Exit” (6%), and “Have the patient verbally agree with the consent forms (17%).” 7 residents completed the written materials and video curriculum and significantly increased their performance to successfully complete 90% of the required elements on a standardized patient, and 86% on actual patients 1-5 days later (P<0.01). 11 other residents completed the written materials and video curriculum supplemented with a 1:1 session with a faculty and significantly increased the percentage of properly completed elements to 97% on the standardized patient, and to 88% on actual patients (P<0.01). Conclusions: The curriculum developed increased performance on how well informed consent was obtained by junior anesthesia residents on an 11 item checklist and may be used by training programs to teach and evaluate their residents.