John D. McAllister

Reliability and Validity of a Simulation-based Acute Care Skills Assessment for Medical Students and Residents

Background Medical students and residents are expected to be able to manage a variety of critical events after training, but many of these individuals have limited clinical experiences in the diagnosis and treatment of these conditions. Life-sized mannequins that model critical events can be used to evaluate the skills required to manage and treat acute medical conditions. The purpose of this study was to develop and test simulation exercises and associated scoring methods that could be used to evaluate the acute care skills of final-year medical students and first-year residents. Methods The authors developed and tested 10 simulated acute care situations that clinical faculty at a major medical school expects graduating physicians to be able to recognize and treat at the conclusion of training. Forty medical students and residents participated in the evaluation of the exercises. Four faculty members scored the students/residents. Results The reliability of the simulation scores was moderate and was most strongly influenced by the choice and number of simulated encounters. The validity of the simulation scores was supported through comparisons of students’/residents’ performances in relation to their clinical backgrounds and experience. Conclusion Acute care skills can be validly and reliably measured using a simulation technology. However, multiple simulated encounters, covering a broad domain, are needed to effectively and accurately estimate student/resident abilities in acute care settings.

Emergence behaviour in children: defining the incidence of excitement and agitation following anaesthesia

Background: Children display a variety of behaviour during anaesthetic recovery. The purpose of this study was to study the frequency and duration of emergence behaviour in children following anaesthesia and the factors that alter the incidence of various emergence behaviour following anaesthesia.

Consensus-Based Recommendations for Standardizing Terminology and Reporting Adverse Events for Emergency Department Procedural Sedation and Analgesia in Children

Children commonly require sedation and analgesia for procedures in the emergency department. Establishing accurate adverse event and complications rates from the available literature has been difficult because of the difficulty in aggregating results from previous studies that have used varied terminology to describe the same adverse events and outcomes. Further, serious adverse events occur infrequently, necessitating the study of large numbers of children to assess safety. These limitations prevent the establishment of a sufficiently large database on which evidence-based practice guidelines may be based. We assembled a panel of pediatric sedation researchers and experts to develop consensus-based recommendations for standardizing procedural sedation and analgesia terminology and reporting of adverse events. Our goal was to create a uniform reporting mechanism for future studies to facilitate the aggregation and comparison of results.

Acute care skills in anesthesia practice: a simulation-based resident performance assessment.

Background:A recurring initiative in graduate education is to find more effective methods to assess specialists’ skills. Life-sized simulators could be used to assess the more complex skills expected in specialty practice if a curriculum of relevant exercises were developed that could be simply and reliably scored. The purpose of this study was to develop simulation exercises and associated scoring methods and determine whether these scenarios could be used to evaluate acute anesthesia care skills. Methods:Twenty-eight residents (12 junior and 16 senior) managed three intraoperative and three postoperative simulation exercises. Trainees were required to make a diagnosis and intervention in a simulation encounter designed to recreate an acute perioperative complication. The videotaped performances were scored by six raters. Three raters used a checklist scoring system. Three faculty raters measured when trainees performed three key diagnostic or therapeutic actions during each 5-min scenario. These faculty also provided a global score using a 10-cm line with scores from 0 (unsatisfactory) to 10 (outstanding). The scenarios included (1) intraoperative myocardial ischemia, (2) postoperative anaphylaxis, (3) intraoperative pneumothorax, (4) postoperative cerebral hemorrhage with intracranial hypertension, (5) intraoperative ventricular tachycardia, and (6) postoperative respiratory failure. Results:The high correlation among all of the scoring systems and small variance among raters’ scores indicated that all of the scoring systems measured similar performance domains. Scenarios varied in their overall difficulty. Even though trainees who performed well on one exercise were likely to perform well in subsequent scenarios, the authors found that there were considerable differences in case difficulty. Conclusion:This study suggests that simulation can be used to measure more complex skills expected in specialty training. Similar to other studies that assess a broad content domain, multiple encounters are needed to estimate skill effectively and accurately.

Sedation and Anesthesia Protocols Used for Magnetic Resonance Imaging Studies in Infants: Provider and Pharmacologic Considerations

Most studies report the efficacy of only a single drug to achieve sedation in a broad age range of children. In clinical practice, a variety of sedative and anesthetic regimes are monitored by nurses and physicians. In this study we report the efficacy of a tiered approach to monitoring and sedation in infants. Two-hundred-fifty-eight infants who required magnetic resonance imaging (MRI) studies received either oral chloral hydrate (n = 102) or bolus doses of IV pentobarbital (n = 67) monitored by nurses or IV propofol infusion (n = 68) titrated by physicians. Fewer cardiorespiratory events were observed in the chloral hydrate group (2.9%) compared to pentobarbital (13.4%) and propofol groups (13.6%); P < 0.05, propofol versus chloral hydrate. Infants who received propofol were ready to begin MRI scanning earlier (mean 9.1 ± 6.7 min) than infants who received oral chloral hydrate (mean 23.5 ± 13.4 min; P < 0.05). The time to discharge was longest in the pentobarbital (mean 80.3 ± 39.2 min) and shortest in the propofol group (mean 53.9 ± 30.1 min; P < 0.05). Infants in the chloral hydrate group moved more frequently (22.5%) during MRI scanning (with four sedation failures of 102) compared to 12.2% in the pentobarbital group and 1.4% in the propofol group (P < 0.001).

Continuous-flow delivery of nitrous oxide and oxygen: A safe and cost-effective technique for inhalation analgesia and sedation of pediatric patients

Nitrous oxide (N2O) safely and rapidly alleviates the pain and distress of minor procedures in the emergency department (ED). We have found self-administration in children does not consistently achieve acceptable analgesia and sedation. The equipment generally available for ED use is designed for adults and delivers 50% N2O through a demand valve that requires an inspiratory effort of -3 to -5 cm of water to activate gas flow. This is difficult for young children who are crying, have more shallow respirations than adults, or cannot follow instructions. In collaboration with the Departments of Anesthesiology, Dentistry, and Respiratory Therapy, we constructed a continuous-flow system for delivering N2O and oxygen (O2). The following is a description of the components, assembly, and use of a continuous-flow machine that safely and inexpensively delivers N2O and O2 to children.

An acute care skills evaluation for graduating medical students: a pilot study using clinical simulation

Purpose  This investigation aimed to explore the measurement properties of scores from a patient simulator exercise.

A simulation-based acute skills performance assessment for anesthesia training.

In an earlier study, trained raters provided reliable scores for a simulation-based anesthesia acute care skill assessment. In this study, we used this acute care skill evaluation to measure the performance of student nurse anesthetists and resident physician trainees. The performance of these trainees was analyzed to provide data about acute care skill acquisition during training. Group comparisons provided information about the validity of the simulated exercises. A set of six simulation-based acute care exercises was used to evaluate 43 anesthesia trainees (28 residents [12 junior and 16 senior] and 15 student nurse anesthetists). Six raters scored the participants on each exercise using either a detailed checklist, key-action items, or a global rating. Trainees with the most education and clinical experience (i.e., senior residents) received higher scores on the simulation scenarios, providing some evidence to support the validity of the multi-scenario assessment. Trainees varied markedly in ability depending on the content of the exercise. In general, anesthesia providers demonstrated similar aptitude in managing each of the six simulated events. Most participants effectively managed ventricular tachycardia, but postoperative events such as anaphylaxis and stroke were more difficult for all trainees to promptly recognize and treat. Training programs could use a simulation-based multiple encounter evaluation to measure provider skill in acute care.

Pediatric laryngeal dimensions: an age-based analysis.

BACKGROUND: In children, the cricoid is considered the narrowest portion of the “funnel-shaped” airway. Growth and development lead to a transition to the more cylindrical adult airway. A number of airway decisions in pediatric airway practice are based on this transition from the pediatric to the adult airway. Our primary aim in this study was to measure airway dimensions in children of various ages. The measures of the glottis and cricoid regions were used to determine whether a transition from the funnel-shaped pediatric airway to the cylindrical adult airway could be identified based on images obtained from video bronchoscopy. METHODS: One hundred thirty-five children (ASA physical status 1 or 2) aged 6 mo to 13 yr were enrolled for measurement of laryngeal dimensions, including cross-sectional area (G-CSA), anteroposterior and transverse diameters at the level of the glottis and the cricoid (C-CSA), using the video bronchoscopic technique under general anesthesia. RESULTS: Of the 135 children enrolled in the study, seven patients were excluded from the analysis mainly because of poor image quality. Of the 128 children studied (79 boys and 49 girls), mean values (±standard deviation) for the demographic data were age 5.9 (±3.3) yr, height 113.5 (±22.2) cm and weight 23.5 (±13) kg. Overall, the mean C-CSA was larger than the G-CSA (48.9 ± 15.5 mm2 vs 30 ± 16.5 mm2, respectively). This relationship was maintained throughout the study population starting from 6 mo of age (P < 0.001, r = 0.45, power = 1). The mean ratio for C-CSA: G-CSA was 2.1 ± 1.2. There was a positive correlation between G- and the C-CSA versus age (r = 0.36, P < 0.001; r = 0.27, P = 0.001, respectively), height (r = 0.34, P < 0.001; r = 0.29, P < 0.001, respectively), and weight (r = 0.35, P < 0.001; r = 0.25, P = 0.003, respectively). No significant gender differences in the mean values of the studied variables were observed. CONCLUSION: In this study of infants and children, the glottis rather than cricoid was the narrowest portion of the pediatric airway. Similar to adults, the pediatric airway is more cylindrical than funnel shaped based on these video bronchoscopic images. Further studies are needed to determine whether these static airway measurements in anesthetized and paralyzed children reflect the dynamic characteristics of the glottis and cricoid in children.

Midazolam with ketamine: Who benefits?☆

[Kennedy RM, McAllister JD. Midazolam with ketamine: who benefits? Ann Emerg Med . March 2000;35:297-299.].