Deven B. Chandra

Fiberoptic Oral Intubation : The Effect of Model Fidelity on Training for Transfer to Patient Care

Background:Previous studies have indicated that fiberoptic orotracheal intubation (FOI) skills can be learned outside the operating room. The purpose of this study was to determine which of two educational interventions allows learners to gain greater capacity for performing the procedure. Methods:Respiratory therapists were randomly assigned to a low-fidelity or high-fidelity training model group. The low-fidelity group was guided by experts, on a nonanatomic model designed to refine fiberoptic manipulation skills. The high-fidelity group practiced their skills on a computerized virtual reality bronchoscopy simulator. After training, subjects performed two consecutive FOIs on healthy, anesthetized patients with predicted “easy” intubations. Each subjects FOI was evaluated by blinded examiners, using a validated global rating scale and checklist. Success and time were also measured. Results:Data were analyzed using a two-way mixed design analysis of variance. There was no significant difference between the low-fidelity (n = 14) and high-fidelity (n = 14) model groups when compared with the global rating scale, checklist, time, and success at achieving tracheal intubation (all P = not significant). Second attempts in both groups were significantly better than first attempts (P < 0.001), and there was no interaction between “fidelity of training model” and “first versus second attempt” scores. Conclusions:There was no added benefit from training on a costly virtual reality model with respect to transfer of FOI skills to intraoperative patient care. Second attempts in both groups were significantly better than first attempts. Low-fidelity models for FOI training outside the operating room are an alternative for programs with budgetary constraints.

Personalized Oral Debriefing Versus Standardized Multimedia Instruction After Patient Crisis Simulation

BACKGROUND: Simulation experience alone without debriefing is insufficient for learning. Standardized multimedia instruction has been shown to be useful in teaching surgical skills but has not been evaluated for use as an adjunct in crisis management training. Our primary purpose in this study was to determine whether standardized computer-based multimedia instruction is effective for learning, and whether the learning is retained 5 wk later. Our secondary purpose was to compare multimedia instruction to personalized video-assisted oral debriefing with an expert. METHODS: Thirty anesthesia residents were recruited to manage three different simulated resuscitation scenarios using a high-fidelity patient simulator. After the first scenario, subjects were randomized to either a computer-based multimedia tutorial or a personal debriefing of their performance with an expert and videotape review. After their respective teaching, subjects managed a similar posttest resuscitation scenario and a third retention test scenario 5 wk later. Performances were independently rated by two blinded expert assessors using a previously validated assessment system. RESULTS: Posttest (12.22 ± 2.19, P = 0.009) and retention (12.80 ± 1.77, P < 0.001) performances of nontechnical skills were significantly improved in the standardized multimedia instruction group compared with pretest (10.27 ± 2.10). There were no significant differences in improvement between the two methods of instruction. CONCLUSION: Computer-based multimedia instruction is an effective method of teaching nontechnical skills in simulated crisis scenarios and may be as effective as personalized oral debriefing. Multimedia may be a valuable adjunct to centers when debriefing expertise is not available.

Cognitive aid for neonatal resuscitation: a prospective single-blinded randomized controlled trial

BACKGROUND Retention of skills and knowledge after neonatal resuscitation courses (NRP) is known to be problematic. The use of cognitive aids is mandatory in industries such as aviation, to avoid dependence on memory when decision-making in critical situations. We aimed to prospectively investigate the effect of a cognitive aid on the performance of simulated neonatal resuscitation. METHODS Thirty-two anaesthesia residents were recruited. The intervention group had a poster detailing the NRP algorithm and the control group did not. Video recordings of each of the performances were analysed using a previously validated checklist by a peer, an expert anaesthetist, and an expert neonatologist. RESULTS The median (IQR) checklist score in the control group [18.2 (15.0-20.5)] was not significantly different from that in the intervention group [20.3 (18.3-21.3)] (P=0.08). When evaluated by the neonatologist, none of the subjects correctly performed all life-saving interventions necessary to pass the checklist. A minority of the intervention group used the cognitive aid frequently. CONCLUSIONS Retention of skills after NRP training is poor. The infrequent use of the cognitive aid may be the reason that it did not improve performance. Further research is required to investigate whether cognitive aids can be useful if their use is incorporated into the NRP training.

High-fidelity simulation demonstrates the influence of anesthesiologists' age and years from residency on emergency cricothyroidotomy skills.

BACKGROUND:Age-related deterioration in both cognitive function and the capacity to control fine motor movements has been demonstrated in numerous studies. However, this decline has not been described with respect to complex clinical anesthesia skills. Cricothyroidotomy is an example of a complex, lifesaving procedure that requires competency in the domains of both cognitive processing and fine motor control. Proficiency in this skill is vital to minimize time to reestablish oxygenation during a “cannot intubate, cannot ventilate” scenario. In this prospective, controlled, single-blinded study, we tested the hypothesis that age affects the learning and performance of emergency percutaneous cricothyroidotomy in a high-fidelity simulated cannot intubate/cannot ventilate scenario. METHODS:Thirty-six staff anesthesiologists (19 aged younger than 45 years and 17 older than 45 years) managed a high-fidelity cannot intubate/cannot ventilate scenario in a high-fidelity simulator before and after a 1-hour standardized training session. The group division cutoff age of 45 years was based on the median age of our sample subject population before enrollment. The scenarios required the insertion of an emergency percutaneous cricothyroidotomy. We compared cricothyroidotomy skills in the older group with those in the younger group using procedural time, 5-point task-specific checklist score, and global rating scale score. Correlation based on age, years from residency, weekly clinical hours worked, previous continuing medical education in airway management, and previous simulation experience was also performed. RESULTS:In both prestandardization and poststandardization, age and years from residency correlated with procedural time, checklist scores, and global rating scores. Baseline, prestandardization variables were all better for the younger group, with a mean age of 37 years, compared with the older group, with a mean age of 58 years. Procedural time was 100 (72–128) seconds versus 152 (120–261) seconds. Checklist scores were 7.0 (6.1–8.0) versus 6.0 (4.8–8.0). Global rating scale scores were 22.0 (17.8–29.8) versus 17.5 (10.4–20.6). After the 1-hour standardized training session, the younger group continued to perform better than the older group with procedural time of 75 (66–91) seconds versus 87 (78–123) seconds, checklist scores of 10.0 (9.1–10.0) versus 9.0 (8.0–10.0), and global rating scale scores of 35.0 (32.1–35.0) versus 32.0 (29.0–33.8). Regression analysis was performed on the poststandardization data. Both age and years from residency independently affected procedural time, checklist scores, and global rating scale scores (all P < 0.05). CONCLUSIONS:Baseline proficiency with simulated emergency cricothyroidotomy is associated with age and years from residency. Despite standardized training, operator age and years from residency were associated with decreased proficiency. Further research should explore the potential of using age and years from residency as factors for implementing periodic continuing medical education.

An Assessment Tool for Brachial Plexus Regional Anesthesia Performance: Establishing Construct Validity and Reliability

Background and Objectives: Technical proficiency in regional anesthesia is often determined subjectively through in-training evaluations. Objective assessment tools improve these evaluations by providing criteria for measurement. However, any evaluation instrument needs to be valid and reliable before it is adopted into a curriculum. The purpose of this study is to determine the validity and reliability of a devised assessment of residents performing an interscalene brachial plexus block (ISB). Methods: In this prospective study, 10 junior trainees and 10 senior trainees were videotaped performing an ISB. Junior trainees were defined as in their first year of anesthetic training and had performed less than 10 ISBs independently. Senior trainees had completed at least 1 year of anesthesia training and had performed greater than 10 ISBs independently. Two blinded expert raters independently evaluated the performance of the ISB using a checklist and global rating scale. Construct validity was established if the assessments were able to reliably discriminate between different levels of training. Results: Senior trainees performed an ISB significantly better than junior trainees when assessed using the global rating scale (P < .05) and checklist (P < .001). The overall interrater reliability for the global rating scores was excellent (r = 0.85, P < .05) and was good for the checklist scores (r = 0.74, P < .05). Conclusions: Both assessment modalities were valid, in that they reliably discriminated between different levels of training. Objective measures of technical skills are feasible, timely, and improve the validity and reliability of competency assessments.

Fibreoptic airway training: correlation of simulator performance and clinical skill.

Purpose: Simulation centres, where trainees can practise technical procedures on models of varying fidelity, provide a training option that allows them to acquire skills in a controlled environment prior to clinical performance. It has been proposed that the time to complete a simulator task may translate to proficiency in the clinical setting. The objective of this study was to determine whether time to complete a simulator task translates to clinical fibreoptic manipulation (FOM) performance.Methods: Thirty registered respiratory therapists at a teaching hospital were recruited as subjects for a single-blinded randomized trial. Subjects were randomized to training on either a low fidelity (n=15) or high fidelity (n=15) model. After training, each subject was tested for the time required to complete a specific task on his/her respective model. Subjects then performed a fibreoptic orotracheal intubation (FOI) on healthy, consenting, and anesthetised patients requiring intubation for elective surgery. Performance was measured independently by blinded examiners using a checklist and global rating scale (GRS); and time was measured from insertion of the fibreoptic scope to visualization of the carina. Data were analyzed using Spearman rank order correlation coefficients.Results: There was no correlation between the time to complete a task on either the high or low fidelity simulators, and the clinical FOI performance as assessed by a checklist, GRS, and time to complete the FOM (allP=NS).Conclusion: These results suggest that simulator-based, task-orientated time measurement may not be a good indicator of FOI performance in the clinical setting.RésuméObjectif: Les centres de simulation, où les stagiaires peuvent s’exercer à réaliser des gestes techniques sur des modèles d’une fidélité variable, constituent une alternative de formation qui leur permet d’acquérir des compétences dans un environnement contrôlé et ce, avant de travailler dans un environnement clinique. Il a été suggéré que le temps nécessaire à compléter une tâche dans un simulateur pourrait refléter l’aptitude dans un contexte clinique. L’objectif de cette étude était de déterminer si le temps utilisé pour compléter une tâche dans un simulateur se traduisait en performance de manipulation fibroscopique (FOM) clinique.Méthode: Trente inhalothérapeutes certifiés oeuvrant dans un hôpital universitaire ont été recrutés pour participer à cette étude randomisée en simple aveugle. Les sujets ont été randomisés à s’entraîner soit avec un modèle peu fidèle (n=15) ou très fidèle (n=15). Après la formation, chaque sujet a été testé par rapport au temps requis pour compléter une tâche spécifique sur son modèle respectif. Les sujets ont ensuite réalisé une intubation orotrachéale par fibroscopie (FOI) sur des patients sains, consen-tants et anesthésiés nécessitant une intubation pour une chirurgie élective. La performance a été mesurée de façon indépendante par des examinateurs en aveugle à l’aide d’une liste de contrôle et une échelle d’évaluation générale (GRS); le laps de temps écoulé entre l’insertion du fibroscope et la visualisation de la carène a été mesuré. Les données ont été analysées à l’aide des coefficients de corrélation des rangs de Spearman.Résultats: Il n’y a pas eu de corrélation entre le temps nécessaire à compléter une tâche sur les simulateurs, qu’ils soient très fidèles ou peu fidèles, et la performance d’intubation par fibroscopie telle que mesurée par une liste de contrôle, le GRS, et le temps pour effectuer la FOM (tous P=NS).Conclusion: Ces résultats suggèrent que le chronométrage basé sur simulateur et centré sur la tâche ne constitue pas un bon indice de la performance de FOI dans un contexte clinique.

Management of simulated oxygen supply failure : Is there a gap in the curriculum?

In this study we evaluated, in our residency program, the understanding and management of a simulated oxygen pipeline failure. Performances of 20 residents were evaluated by 2 raters. Fourth-year residents did not perform better than second-year residents (P = NS). The majority of the participants either did not have the knowledge to change the oxygen cylinder or did not attempt to change the oxygen, even after prompting. We conclude that the delegation of gas machine maintenance to perioperative personnel, such as respiratory therapists and technicians, may have created a new gap in knowledge and resulted in inadequate training.

Mental practice: a simple tool to enhance team-based trauma resuscitation

INTRODUCTION Effective trauma resuscitation requires the coordinated efforts of an interdisciplinary team. Mental practice (MP) is defined as the mental rehearsal of activity in the absence of gross muscular movements and has been demonstrated to enhance acquiring technical and procedural skills. The role of MP to promote nontechnical, team-based skills for trauma has yet to be investigated. METHODS We randomized anaesthesiology, emergency medicine, and surgery residents to two-member teams randomly assigned to either an MP or control group. The MP group engaged in 20 minutes of MP, and the control group received 20 minutes of Advanced Trauma Life Support (ATLS) training. All teams then participated in a high-fidelity simulated adult trauma resuscitation and received debriefing on communication, leadership, and teamwork. Two blinded raters independently scored video recordings of the simulated resuscitations using the Mayo High Performance Teamwork Scale (MHPTS), a validated team-based behavioural rating scale. The Mann-Whitney U-test was used to assess for between-group differences. RESULTS Seventy-eight residents provided informed written consent and were recruited. The MP group outperformed the control group with significant effect on teamwork behaviour as assessed using the MHPTS: r=0.67, p<0.01. CONCLUSIONS MP leads to improvement in team-based skills compared to traditional simulation-based trauma instruction. We feel that MP may be a useful and inexpensive tool for improving nontechnical skills instruction effectiveness for team-based trauma care.

Audio spectrum and sound pressure levels vary between pulse oximeters

PurposeThe variable-pitch pulse oximeter is an important intraoperative patient monitor. Our ability to hear its auditory signal depends on its acoustical properties and our hearing. This study quantitatively describes the audio spectrum and sound pressure levels of the monitoring tones produced by five variable-pitch pulse oximeters.MethodsWe compared the Datex-Ohmeda Capnomac Ultima, Hewlett-Packard M1166A, Datex-Engstrom AS/3, Ohmeda Biox 3700, and Datex-Ohmeda 3800 oximeters. Three machines of each of the five models were assessed for sound pressure levels (using a precision sound level meter) and audio spectrum (using a hanning windowed fast Fourier transform of three beats at saturations of 99%, 90%, and 85%).ResultsThe widest range of sound pressure levels was produced by the Hewlett-Packard M1166A (46.5 ± 1.74 dB to 76.9 ± 2.77 dB). The loudest model was the Datex-Engstrom AS/3 (89.2 ± 5.36 dB). Three oximeters, when set to the lower ranges of their volume settings, were indistinguishable from background operating room noise. Each model produced sounds with different audio spectra. Although each model produced a fundamental tone with multiple harmonic overtones, the number of harmonics varied with each model; from three harmonic tones on the Hewlett-Packard M1166A, to 12 on the Ohmeda Biox 3700. There were variations between models, and individual machines of the same model with respect to the fundamental tone associated with a given saturation.ConclusionThere is considerable variance in the sound pressure and audio spectrum of commercially-available pulse oximeters. Further studies are warranted in order to establish standards.RésuméObjectifLe sphygmo-oxymètre à tonalité variable est un moniteur peropératoire important. Notre capacité à entendre son signal sonore dépend de ses propriétés acoustiques et de notre audition. Notre étude quantitative décrit le spectre audible et les niveaux de pression sonore des tonalités de monitorage produites par cinq sphygmo-oxymètres à tonalité variable.MéthodeNous avons comparé les oxymètres suivants: Datex-Ohmeda Capnomac Ultima, Hewlett-Packard M1166A, Datex-Engstrom AS/3, Ohmeda Biox 3700 et Datex-Ohmeda 3800. Trois appareils de chaque modèle ont été évalués pour les niveaux de pression sonore avec un sonomètre de précision, et pour le spectre audible en utilisant une transformée de Fourier à fenêtre Hanning de trois battements à des saturations de 99 %, 90 % et 85 %.RésultatsLa plus grande étendue de niveaux sonores a été produite par le Hewlett-Packard M1166A (46,5 ± 1,74 dB à 76,9 ± 2,77 dB). Le Datex-Engstrom AS/3 a produit la plus haute intensité sonore (89,2 ± 5,36 dB). Trois oxymètres, dont les paramètres de volume étaient fixés à de bas niveaux, ne pouvaient être entendus dans le bruit de la salle ďopération. Chaque modèle a produit des sons au spectre audible différent ayant un son fondamental et de multiples partiels harmoniques. Mais le nombre ďharmoniques variait selon le modèle, allant de trois pour le Hewlett-Packard M1166A à 12 pour le Ohmeda Biox 3700. Il y avait des variations entre les modèles et entre les appareils ďun même modèle quant au son fondamental associé à une saturation donnée.ConclusionIl y a une grande variation de pression sonore et de spectre audible pour les sphygmo-oxymètres offerts sur le marché. Il reste maintenant à fixer des normes.

Setting standards for simulation in anesthesia: the role of safety criteria in accreditation standards.

PurposeIn this article, we describe a critical event which occurred in a simulation centre, and we also review possible safety issues for participants and staff involved in medical simulation training.Principal findingsThe authors report an incident with the potential of harming trainees and staff which occurred during a full-scale simulation. The episode raised the question of training safety in simulation centres. In this instance, the computer program controlling the mannequin enabled a continuous and non-regulated outflow of carbon dioxide which led to an intense reaction in the soda lime canister. The absorbent canister became too hot to be touched (a temperature probe, later placed in the centre of the front canister, measured 53°C). All activities involving the mannequin and anesthesia machine were stopped immediately.ConclusionsSimulation in healthcare is a valuable educational tool to train for a variety of clinical encounters in a safe environment without harming a patient. Due to technological progress and the use of authentic equipment recreating near real environments, simulation training has become exceedingly realistic. The Society for Simulation in Healthcare (SSH) has published revised accreditation standards for simulation centres which incorporate training safety sub-criteria to address and manage. By highlighting recommendations of other high-risk industries on this issue, SSH proposes a possible approach to enhance safety in medical simulation.RésuméObjectifDans cet article, nous décrivons un événement critique survenu dans un centre de simulation et passons en revue des questions de sécurité potentielles pour les participants et le personnel prenant part à la formation en simulation médicale.Constatations principalesLes auteurs rapportent un incident survenu pendant une simulation à grande échelle qui aurait pu potentiellement blesser les personnes en formation et le personnel. Cet épisode a soulevé la question de la sécurité de la formation dans les centres de simulation. Dans le cas présenté ici, le programme informatique contrôlant le mannequin a permis le débit continu et non régulé de dioxyde de carbone, ce qui a entraîné une réaction intense dans le réservoir de chaux sodée. Le réservoir absorbant est devenu trop chaud pour pouvoir être manipulé (par la suite, un thermomètre placé au centre du réservoir frontal a mesuré une température de 53°C). Toutes les activités impliquant le mannequin et la machine d’anesthésie ont été immédiatement interrompues.ConclusionLa simulation est un outil éducatif précieux en soins de santé; il permet de former le personnel à plusieurs situations cliniques dans un environnement sécuritaire et sans mettre en péril un patient. En raison des progrès technologiques et de l’utilisation d’équipement authentique recréant des environnements quasi réels, la formation en simulation est devenue très réaliste. La Société pour la simulation en soins de santé (Society for Simulation in Healthcare – SSH) a publié des normes d’agrément révisées destinées aux centres de simulation; ces normes intègrent des sous-critères de sécurité de la formation qui doivent être pris en compte. En mettant en exergue les recommandations d’autres industries à haut risque concernant cette question, la SSH propose une approche possible afin d’améliorer la sécurité en simulation médicale.