Laurence C. Torsher

The mayo high performance teamwork scale: reliability and validity for evaluating key crew resource management skills.

Purpose: To develop and evaluate a participant rating scale for assessing high performance teamwork skills in simulation medicine settings. Methods: In all, 107 participants in crisis resource management (CRM) training in a multidisciplinary medical simulation center generated 273 ratings of key CRM skills after participating in two or three simulation exercises. These data were analyzed using Rasch and traditional psychometric approaches to develop the 16-item Mayo High Performance Teamwork Scale (MHPTS). Sensitivity to change as a result CRM training was also evaluated. Results: The MHPTS showed satisfactory internal consistency and construct validity by Rasch (person reliability = 0.77; person separation = 1.85; item reliability = 0.96; item separation = 5.04) and traditional psychometric (Cronbach’s alpha = 0.85) indicators. The scale demonstrated sensitivity to change as a result of CRM training (pretraining mean = 21.44 versus first posttraining rating mean = 24.37; paired t = −4.15, P < 0.0001; first posttraining mean = 24.63 versus second posttraining mean = 26.83; paired t = −4.31 P < 0.0001). Conclusions: The MHPTS provides a brief, reliable, practical measure of CRM skills that can be used by participants in CRM training to reflect on and evaluate their performance as a team. Further evaluation of validity and appropriateness in other simulation and medical settings is desirable.

Risk of Patients With Severe Aortic Stenosis Undergoing Noncardiac Surgery

Aortic stenosis (AS) is a major risk factor for perioperative cardiac events in patients undergoing noncardiac surgery. We previously showed that selected patients with AS who were not candidates for, or refused, aortic valve replacement could undergo noncardiac surgery with acceptable risk. We extended our previous experience over a subsequent 5-year period by retrospectively analyzing the perioperative course of all patients with severe AS (aortic valve area index < 0.5 cm2/m2 or mean gradient > 50 mm Hg), determined with Doppler echocardiography or cardiac catheterization, who underwent noncardiac surgery. Nineteen patients underwent 28 surgical procedures: 22 elective and 6 emergency. The types of these procedures were 12 orthopedic, 6 intraabdominal, 4 vascular, 4 urologic, 1 otolaryngologic, and 1 thoracic. Mean age was 75 +/- 8 years. Of the 19 patients, 16 (84%) had > or = 1 symptom: dyspnea, angina, syncope, or presyncope. Mean left ventricular ejection fraction was 61 +/- 11%. The type of anesthesia was general in 26 procedures and continuous spinal in 2. Intraarterial monitoring of blood pressure was used in 20 of the 28 surgical procedures. Intraoperative hypotensive events were treated promptly, primarily with phenylephrine. In all cases the anesthesia team was aware of the severity of the AS and integrated this into the anesthetic plan. Two patients (elective operation in 1 and emergency in 1) had complicated postoperative courses and died. There were no other intraoperative or postoperative events in any of the other patients. Although aortic valve replacement remains the primary treatment for patients with severe AS, selected patients with severe AS, who are otherwise not candidates for aortic valve replacement, can undergo noncardiac surgery with acceptable risk when appropriate intraoperative and postoperative management is used.

Simulation education in anesthesia training: a case report of successful resuscitation of bupivacaine-induced cardiac arrest linked to recent simulation training.

Simulation training is rapidly becoming an integral element of the education curriculum of anesthesia residency programs. We report a case of successful resuscitation of bupivacaine-induced cardiac arrest treated with i.v. lipid emulsion by providers who had recently participated in simulation training involving a scenario nearly identical to this case. Upon debriefing, it was determined that the previous training influenced execution of the following steps: rapid problem recognition, prompt initiation of specific therapy in the setting of supportive advanced cardiac life support measures, and coordinated team efforts. Although the true cause of efficient resuscitation and ultimate recovery cannot be proven, the efficiency of the resuscitation process, including timely administration of lipid emulsion, is evidence that simulation may be useful for training providers to manage rare emergencies.

A 1-week simulated internship course helps prepare medical students for transition to residency

Introduction: The transition from medical student to intern is inherently stressful, with potentially negative consequences for both interns and patients. Methods: We describe Internship Boot Camp, an innovative course specifically designed to prepare fourth-year medical students for the transition from medical school to internship. An intensive 1-week course, Internship Boot Camp has simulated, longitudinal patient-care scenarios that use high-fidelity medical simulation, standardized patients, procedural task trainers, and problem-based learning to help students apply their knowledge and develop a framework for response to the challenges they will face as interns. Results: In March 2007, 12 students participated in the course as an elective in their final year of medical school, and the other 28 students in their class did not. After beginning internship and 5 to 7 months after the completion of Internship Boot Camp, all 40 former students were asked to complete a blinded survey about their preparation for internship. The overall response rate for the survey was 80%. Of responders to an open-ended question about the aspects of medical school training that best prepared them for internship, 89% (8 of 9) of course participants listed “Internship Boot Camp.” The next highest response (“subinternship”) was given by 45% (9 of 20) of nonparticipants and 33% (3 of 9) of course participants. Discussion: Internship Boot Camp is a unique learning environment that is recalled by participants as the most helpful, of all components of their medical school education, in preparation for internship.

Designing and implementing a comprehensive learner-centered regional anesthesia curriculum.

Education experts have suggested that many doctors know what to teach, but few know how to teach.1 This statement stems from the fact that most physicians do not receive formal instruction in education theory or methodology during their own medical training. As a result, apprenticeship models of education have prevailed as the primary mode of teaching regional anesthesia to residents in-training for the past several decades. Limitations to this style of teaching include inconsistent learning experiences and limited case numbers. Recently, Richman et al2 demonstrated that a dedicated regional anesthesia rotation may increase the number of blocks performed by residents by concentrating their learning experiences into a focused period. Although this approach represents an educational step forward, most regional anesthesia curricula continue to revolve around an apprenticeship style of training. The Accreditation Council for Graduate Medical Education (ACGME) has also made attempts to improve resident education by implementing standardized education performance objectives (ie, competencies) and establishing minimum regional block numbers for anesthesia residents during the past decade (for complete explanation of ACGME competencies, see http://www.acgme.org/acWebsite/ home/home.asp). However, it has been estimated that 40% of residents lack adequate exposure or proficiency in peripheral nerve blockade. Finally, the introduction of ultrasound-guided regional anesthesia (UGRA) and the national spotlight on patient safety and quality care initiatives have introduced new challenges for regional anesthesia educators. In an effort to address these and many other concerns, we recently redesigned and implemented a new regional anesthesia curriculum within our institution. This curriculumVwhich describes a single institution’s approach to resident educationVis reviewed within this special article.

Simulation-based Assessment of the Management of Critical Events by Board-certified Anesthesiologists.

Background: We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods. Methods: A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant’s technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist. Results: Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance. Conclusions: Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.

Factors that influence the selection of sterile glove brand: A randomized controlled trial evaluating the performance and cost of gloves

PurposeTo determine whether glove use modifies tactile and psychomotor performance of health care providers when compared with no glove use and to evaluate factors that influence the selection of sterile glove brand.MethodsForty-two anesthesia providers (nine anesthesiologists, seven nurse anesthetists, 20 residents, six student nurse anesthetists) enrolled in and completed this cross-over randomized trial from May 2010 until August 2011. Participants underwent standardized psychomotor testing while wearing five different types of protective gloves. Assessments of psychomotor performance included tactile, fine motor/dexterity, and hand-eye coordination tests. Subjective ratings of glove comfort and performance were reported at the completion of each glove trial. The manufacturer’s suggested retail price was collected for each glove tested.ResultsThere were statistically significant differences in touch sensitivity for all nerve distributions, with all glove types resulting in less sensitivity than a bare hand. When compared with the non-sterile glove, only the thickest glove tested (Ansell Perry Orthopaedic) was found to have less touch sensitivity. Fine motor dexterity testing revealed no statistically significant differences in time to completion amongst glove types or bare handed performance. In hand-eye coordination testing across treatment conditions, the thickest glove tested (Ansell Perry® Orthopaedic) was the only glove to show a statistically significant difference from a bare hand. There were statistically significant differences in glove comfort ratings across glove types, with latex-free, powder-free (Cardinal Esteem®), and latex powder-free (Mölnlycke-Biogel®) rated highest; however, there were no statistically significant differences in subjective performance ratings across glove types.ConclusionsGiven the observed similarities in touch sensitivity and psychomotor performance associated with five different glove types, our results suggest that subjective provider preferences, such as glove comfort, should be balanced against material costs.RésuméObjectifDéterminer si l’utilisation de gants modifiait la performance tactile et psychomotrice des professionnels de la santé par rapport à une performance à mains nues, et évaluer les facteurs influençant le choix d’une marque de gants stériles.MéthodeQuarante-deux professionnels des soins en anesthésie (neuf anesthésiologistes, sept infirmiers anesthésistes, 20 résidents, six étudiants infirmiers anesthésistes) ont participé à cette étude randomisée croisée entre mai 2010 et août 2011. Les participants ont été soumis à des tests psychomoteurs standardisés en portant cinq différents types de gants de protection. L’évaluation de la performance psychomotrice a été réalisée à l’aide de tests tactiles, de motricité fine / dextérité, et de coordination main-œil. Des notes subjectives portant sur le confort et la performance des gants ont été données par les participants à la fin de chaque test de gants. Le prix de vente suggéré du fabricant a été noté pour chaque marque de gant testée.RésultatsDes différences statistiquement significatives ont été notées au niveau de la sensibilité du toucher pour toutes les distributions nerveuses, tous les types de gants entraînant une sensibilité moindre que la main nue. Par rapport aux gants non stériles, seuls les gants les plus épais testés (Ansell Perry Orthopaedic) ont été démontrés comme possédant une sensibilité moindre au toucher. Le test de dextérité et de motricité fine n’a révélé aucune différence statistiquement significative au niveau du temps mis pour compléter le test entre les types de gants et la performance à main nue. Au niveau de la coordination main-œil pour plusieurs conditions de traitement, les gants les plus épais (Ansell Perry® Orthopaedic) étaient les seuls à afficher une différence statistiquement significative par rapport à la main nue. Des différences statistiquement significatives sont apparues dans les notes en matière de confort des gants, les gants sans latex et sans poudre (Cardinal Esteem®) et les gants sans poudre en latex (Mölnlycke-Biogel®) recevant les meilleures notes; toutefois, aucune différence statistiquement significative en matière de notes subjectives de performance n’a été notée entre les différents types de gants.ConclusionÉtant donné les similitudes observées en matière de sensibilité du toucher et de performance psychomotrice entre les cinq différents types de gants, nos résultats suggèrent que les préférences subjectives du professionnel d’anesthésie, telles que le confort des gants, devraient être évaluées en gardant à l’esprit les coûts matériels.

An innovative team collaboration assessment tool for a quality improvement curriculum.

The success of quality improvement (QI) initiatives is significantly dependent on the effective functioning of the team responsible for the project. To our knowledge, there is no published literature on performance-based team assessment tools in the context of a QI curriculum. This study demonstrates the validity, feasibility, and acceptability of an objective structured clinical examination station designed to assess competency in teamwork at the completion of a QI curriculum taught in a graduate medical education program. Further research with multiple teams and during a longer period will be needed to better understand the psychometric properties and predictive validity of the teamwork objective structured clinical examination station. (Am J Med Qual 2009;24:6-11)

Postoperative confusion and basilar artery stroke

IntroductionNon-focal postoperative mental status changes can be challenging.MethodsSingle patient case report and medical literature review.ResultsWe describe a 67-year-old male who was admitted for radical cystectomy and ileal conduiturinary diversion. General anesthesia was uneventful and the patient remained hemodynamically stable throughout the procedure. At the end of the procedure, the patients tracheal was extubated. Initially, he was arousable, able to move all extremities, and answer questions appropriately. Over the next 2 hours, his mental status waxed and waned and respirations became irregular. An emergent head computed tomogram without contrast revealed a hyperdense basilar artery consistent with acute thrombosis. Vascular radiology intervention occurred approximately 9 hours after the onset of symptoms, but there was no improvement in the patients neurological status and the subsequently died.ConclusionAlthough nonfocal postoperative mental status changes are common and often secondary to benign etiologies, they may herald more significant pathology, including stroke. Patients with postoperative mental status changes should be evaluated carefully to identify like-threatening and treatable etiologies. Recent advance in the acute care of stroke such as thrombolysis and angioplasty, can improve outcome if instituted promptly.

Simulation in Anesthesiology

The specialty of anesthesiology has been at the forefront of healthcare simulation from its development and early applications to pioneering simulation for residency training requirements and maintenance of specialty board status. As such, the specialty of anesthesiology has a rich and mature experience with simulation. In this chapter we will explore the application of simulation to the field of anesthesiology with regard to training, assessment, and maintenance of competence. Given the specialty’s extensive experience, much of the chapter will be devoted to the “art” of simulation with a detailed discussion of scenario, course, and curricular development.