Patricia Houston

Nontechnical Skills in Anesthesia Crisis Management with Repeated Exposure to Simulation-based Education

Background:Critical incident reporting and observational studies have identified nontechnical skills that are vital to successful anesthesia crisis management. Examples of such skills include task management, team working, situation awareness, and decision making. These skills are not necessarily acquired through clinical experience and may need to be specifically taught. This study uses a high-fidelity patient simulator to assess the effect of repeated exposure to simulated anesthesia crises on the nontechnical skills of anesthesia residents. Methods:After institutional research board approval and informed consent, 20 anesthesia residents were recruited. Each resident was randomized to participate as the primary anesthesiologist in the management of three different simulated anesthesia crises using a high-fidelity patient simulator. After each session, videotaped footage was used to facilitate debriefing of their nontechnical skills. The videotapes were later reviewed by two expert blinded independent assessors who rated each residents nontechnical skills by using a previously validated and reliable marking system. Results:A significant improvement in the nontechnical skills of residents was demonstrated from their first to second session and from their first to third session (both P < 0.005). However from their second to third session, no significant improvement was observed. Interrater reliability between assessors was modest (single rater intraclass correlation = 0.53). Conclusion:A single exposure to anesthesia crises using a high-fidelity patient simulator can improve the nontechnical skills of anesthesia residents. However, an additional simulation session may confer little or no additional benefit.

Fiberoptic orotracheal intubation on anesthetized patients: Do manipulation skills learned on a simple model transfer into the operating room?

Background With increasing pressure to use operating room time efficiently, opportunities for residents to learn fiberoptic orotracheal intubation in the operating room have declined. The purpose of this study was to determine whether fiberoptic orotracheal intubation skills learned outside the operating room on a simple model could be transferred into the clinical setting. Methods First-year anesthesiology residents and first- and second-year internal medicine residents were recruited. Subjects were randomized to a didactic-teaching-only group (n = 12) or a model-training group (n = 12). The didactic-teaching group received a detailed lecture from an expert bronchoscopist. The model-training group was guided, by experts, through tasks performed on a simple model designed to refine fiberoptic manipulation skills. After the training session, subjects performed a fiberoptic orotracheal intubation on healthy, consenting, anesthetized, paralyzed female patients undergoing elective surgery with predicted “easy” laryngoscopic intubations. Two blinded anesthesiologists evaluated each subject. Results After the training session, the model group significantly outperformed the didactic group in the operating room when evaluated with a global rating scale (P < 0.01) and checklist (P < 0.05). Model-trained subjects completed the fiberoptic orotracheal intubation significantly faster than didactic-trained subjects (P < 0.01). Model-trained subjects were also more successful at achieving tracheal intubation than the didactic group (P < 0.005). Conclusion Fiberoptic orotracheal intubation skills training on a simple model is more effective than conventional didactic instruction for transfer to the clinical setting. Incorporating an extraoperative model into the training of fiberoptic orotracheal intubation may greatly reduce the time and pressures that accompany teaching this skill in the operating room.

Evaluation of patient simulator performance as an adjunct to the oral examination for senior anesthesia residents

Background: Patient simulators possess features for performance assessment. However, the concurrent validity and the “added value” of simulator-based examinations over traditional examinations have not been adequately addressed. The current study compared a simulator-based examination with an oral examination for assessing the management skills of senior anesthesia residents. Methods: Twenty senior anesthesia residents were assessed sequentially in resuscitation and trauma scenarios using two assessment modalities: an oral examination, followed by a simulator-based examination. Two independent examiners scored the performances with a previously validated global rating scale developed by the Anesthesia Oral Examination Board of the Royal College of Physicians and Surgeons of Canada. Different examiners were used to rate the oral and simulation performances. Results: Interrater reliability was good to excellent across scenarios and modalities: intraclass correlation coefficients ranged from 0.77 to 0.87. The within-scenario between-modality score correlations (concurrent validity) were moderate: r = 0.52 (resuscitation) and r = 0.53 (trauma) (P < 0.05). Forty percent of the average score variance was accounted for by the participants, and 30% was accounted for by the participant-by-modality interaction. Conclusions: Variance in participant scores suggests that the examination is able to perform as expected in terms of discriminating among test takers. The rather large participant-by-modality interaction, along with the pattern of correlations, suggests that an examinees performance varies based on the testing modality and a trainee who “knows how” in an oral examination may not necessarily be able to “show how” in a simulation laboratory. Simulation may therefore be considered a useful adjunct to the oral examination.

Guideline for the Management of Postoperative Nausea and Vomiting

OBJECTIVE To provide recommendations for the management of postoperative nausea and vomiting (PONV), which may affect as many as 30% of patients. METHODS AND EVIDENCE: Medline, PubMed, and the Cochrane Database were searched for articles published in English from 1995 to 2007. Recognizing that we must work as a team to optimize the care of our patients perioperatively, this guideline was written in partnership with anaesthesiologists. OPTIONS The areas of clinical practice considered in formulating this guideline are prevention and prophylaxis, treatment, both medical and alternative, and patient education. OUTCOMES Implementation of this guideline should optimize the prevention of and prophylaxis against PONV and the prompt treatment of women who suffer from PONV following gynaecologic surgery. Increased awareness of options for management should help minimize the effects of PONV. BENEFITS, HARMS, AND COSTS PONV results not only in increased patient discomfort and dissatisfaction but also in increased costs related to length of hospital stay. Cost of medications to prevent and treat PONV must be weighed against improved surgical experience for the patient and decreased costs to the system. VALUES Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.

Audit of intensive care unit admissions from the operating room

An audit of 265 intensive care unit (ICU) admissions from the operating room was performed for the year 1991. In a quality assurance exercise we identified 34 unanticipated ICU admissions (UIAs) by a retrospective peer review of the medical charts. Of these UIAs, 16 were deemed predictable and seven preventable. Five of the seven potentially preventable UIAs were judged to have had inappropriate intravenous fluid management. This has prompted changes in our education programme. In an assessment of our resource management, we evaluated prospectively collected data on the Apache II scores on the day of admission, the incidence of ICU-specific interventions, length of stay in ICU, and outcomes. ICU-specific interventions were not initially required in 36% of admissions and these patients had a low risk (1.1%) of eventually requiring ICU-specific interventions. In comparison with patients requiring ICU-specific interventions, they had lower Apache II scores (10.2 vs 13.1), shorter ICU stays (medians of one vs two days), lower ICU mortality (0 vs 8.2%), P < 0.05, but hospital mortality was not different (7.4 vs 15.3%). This audit has prompted re-organisation of our intensive care services, so that patients not requiring ICU-specific interventions will be managed in an intermediate care area with nurse.patient ratios of 1:3 or 4, in comparison with 1:1 or 2 ratios in the intensive care area.RésuméUne vérification de 265 admissions dirigées de la salle d’opérations vers l’unité des soins intensifs (SI) a été réalisée pour l’année 1991. Lors d’un exercice d’apréciation de la qualité de l’acte médical, nous avons identifié 34 admissions aux SI non prévisibles lors d’une étude rétrospective de révision des dossiers médicaux. De ces admissions non anticipées, seize furent jugées prévisibles et sept évitables. Dans cinq des sept admissions considérées comme évitables, un déséquilibre liquidien était en cause. Ceci a provoqué des changements à notre programme d’enseignement. Dans l’évaluation de l’utilisation des ressources, nous avons évalué de façon prospective les données récoltées de scores Apache II le jour de l’admission, l’incidence des interventions spécifiques à une unité SI, la durée et le bilan du séjour aux SI. Des interventions spécifiques aux SI ne furent pas initialement requises dans 36% des admissions et ces malades avaient un faible taux de probabilité d’interventions spécifiques ultérieures. En comparaison avec des patients nécessitant ces interventions, ils avaient des scores Apache II plus bas (10,2 vs 13,1), des durées de séjour plus court (médiane 1 vs 2 jours), et un taux de mortalité aux SI favorable (0 vs 8,2%)P < 0,05, mais par contre une mortalité hospitalière non significativement différente (7,4 vs 15,3%). Cette vérification a nécessité une réorganisation de nos services de SI de sorte que les patients qui n’ont pas besoin d’intervention spécifiques aux SI sont traités dans des zones de soins intermédiates comportant un rapport nurse.patient de 1:3 ou 4, au lieu de 1:1 ou 2 dans une zone de SI.

Comparison of meperidine and pancuronium for the treatment of shivering after cardiac surgery

Shivering after cardiac surgery can produce adverse haemodynamic and metabolic sequelae. In this study, the metabolic effects of shivering and the efficacy of treatment with meperidine or pancuronium were studied, using a metabolic cart, in 61 patients who had undergone cardiac surgery. The patients received premedication with morphine, perphenazine and diazepam or lorazapam, and were anaesthetised with fentanyl or sufentanil and diazepam. Muscle relaxation was achieved with pancuronium. Patients were monitored with a radial arterial line, pulmonary artery catheter and oesophageal and urinary bladder temperature probes. Rewarming to an oesophageal temperature of 38° C was achieved before the termination of CPB and was maintained for a minimum of 15 min reperfusion time. Every 15 min after surgery, the patients’ temperature at three sites (pulmonary artery, oesophagus, bladder) and shivering scores were monitored. Hourly measurements were made of haemodynamic variables (MAP, PAOP, CVP, SVR, PVR, CI), carbon dioxide production, oxygen consumption and respiratory quotient. If the patient shivered, the measurements were recorded prior to drug treatment and repeated 30 min later following randomization to either: meperidine 0.25 mg · kg−1 (Group 1), meperidine 0.5 mg · kg−1 (Group 2) or pancuronium 0.06 mg · kg−1 intravenously (Group 3). Thirty-two patients shivered and mean VO2 and VCO2 values were greater in the shivering group than in the nonshivering patients (VO2 334.8 ±17.6 vs. 240.5 ± 8.8 ml · min−1; VCO2 238.8 ± 17.2 vs 199.2 ± 8.4 ml · min−1, P = 0.0001). Thirty minutes following treatment the mean VO2 in Group 3 was less (215.9 ± 24.3 ml · min−1) than in Groups 1 (295.9 ± 22.0 ml · min−1) and 2 (322.7 ± 21.0 ml · mint-1)(P < 0.01). It is concluded that drug treatment with meperidine is not as effective as pancuronium in alleviating the metabolic effects of shivering in these patients.RésuméLes frissons après une chirurgie cardiaque peuvent produire des effets métaboliques et hémodynamiques indésirables. Les effets métaboliques des frissons et l’efficacité du traitement avec mépéridine et pancuronium ont été étudiés à l’aide d’un appareillage metabolique chez 61 patients ayant subi une chirurgie cardiaque. Les patients étaient prémediqués avec morphine, perphénazine et diazepam ou lorazepam et étaient anesthésiés à l’aide de fentanyl ou sufentanil, diazepam, pancuronium et oxygène. Les patients étaient monitorisés à l’aide d’une canule artérielle radiale, un cathéter dans l’artére pulmonaire et de sondes de température oesophagienne et vésicale. On procédait à un réchauffement jusqu’à des températures oésophagiennes de 38° C avant l’arrêt de la circulation extra-corporelle (CEC) et ce réchauffement était maintenu pour un temps de perfusion minimum de 15 minutes. Dans la période post-opératoire, on notait la temperature du patient à trois sites (artere pulmonaire, oesophage, vessie) à toutes les 15 minutes et le pointage de frissonnement. On prenait des mesures horaires des variables hémodynamiques (MAP, PAOP, CVP, SVR, PVR, CI), de la production de dioxide de carbone, de la consommation d’oxygéne et du quotient respiratoire. Si le patient frissonnait, des mesures etaient prises avant le traitement médical et répétées trente minutes plus tard suite au traitement randomisé soit avec mépéridine 0,25 mg · kg−1 (groupe 1), mépéridine 0,5 mg · kg−1 (groupe 2) ou pancuronium 0,06 mg · kg−1 iv (groupe 3). Trente-deux patients ont frissonné et les valeurs moyennes de VO2 et de VCO2 étaient plus élevées chez les patients ayant frissonné que chez les patients n’ayant pas frissonné (VO2 334,8 ± 17,6 comparé á 240,5 ± 8,8 ml · min−; VCO2 238,8 ± 17,2 comparé à 199,2 ± 8,4 ml · min−1, P = 0,001). Trente minutes après le traitement, la VO2 moyenne dans le groupe 3 était moindre (215,9 ± 24,3 ml · min−1) que dans les groupes 1 (295,9 ± 22,0 ml · min−1) et 2 (332,7 ± 21,0 ml · min−1) (P < 0,01). Ladministration de meperidine pour le traitement medical du frisson chez ces patients n ’est pas aussi efficace que [’utilisation du pancuronium pour attenuer les ejfets métaboliques.

From Theory to Pamphlet: The 3Ws and an H Process for the Development of Meaningful Patient Education Resources

There is growing recognition of the importance of patient education given the prevalence and consequences of low health literacy in Canada and the USA. Research has shown that in addition to plain language, the use of theories of learning can contribute to the effectiveness of patient education resources, and as such, various guidelines and toolkits have been put together to help healthcare providers utilize these theories. Despite these efforts, this knowledge is not consistently applied in practice. To address this gap, we describe a new theory-based protocol, the “3Ws and an H,” that is designed to guide healthcare providers in the production of effective patient education resources. Adult learning theory underpins each step of the process, and by using the “3Ws and an H,” relevant theories are applied as the steps of the protocol are followed. To facilitate the adoption of this process, we describe it using a resource development project for survivors of endometrial cancer as an example.

A national curriculum in anesthesia: rationale, development, implementation, and implications

In 2010, the Specialty Committee of the Royal College of Physicians and Surgeons of Canada (RCPSC) approved the use of the National Postgraduate Medical Education Curriculum in Anesthesia as a companion to the description of the Role of Medical Expert in the Objectives of Training Requirements (OTRs). The National Curriculum in Anesthesia represents the first of its kind in postgraduate medicine in Canada and will be a model for other national curricula moving forward. A collective consensus was reached amongst the Association of Canadian University Departments of Anesthesia (ACUDA) program directors and the RCPSC Specialty and Examination Boards that the time had come for a national curriculum. Ironically, the concept of developing a national curriculum in anesthesia was not new. The first efforts at developing a national curriculum in anesthesia began in 1971. A committee was established through the University Departments of Anesthesia (now known as ACUDA) to build a curriculum that would align curriculum objectives to specialist national exam criteria. In their commentary in 1974, Green et al. articulated the same rationale as is the impetus for the current project. Several sound reasons exist to create the standardized national curriculum. Over time, residents have found it more difficult to prepare for national examinations given the increasing overlap with other specialty disciplines in medicine and general surgery. Furthermore, the Examination Board did not have a well-defined curriculum around which to define the examination. With 17 different curricula driving one national exam, there was no assurance that anesthesia residents in all centres were being exposed to the specific elements of the medical expert competencies. With the growing demands of social accountability, there is increased pressure for programs to adapt to meet the challenges of aging populations, continuing change in health care systems, and complex work environments. While all postgraduate residency anesthesia programs were based on OTRs set out by the RCPSC and were all well developed prior to the National Curriculum in Anesthesia, there remained a gap in standardized curricular content to prepare residents for a standardized national exam in anesthesia. The introduction of competencies and the development of training models outside of the traditional apprenticeship approach to medical education were creating gaps for postgraduate medical educators in terms of matching objectives to assessment and learning strategies. The development of the recent National Curriculum in Anesthesia is a milestone in narrowing this gap.

Chest compressions performed by ED staff: a randomized cross-over simulation study on the floor and on a stretcher.

BACKGROUND Multiple factors may contribute to the observed survival variability following in-hospital cardiopulmonary resuscitation (CPR). While in-hospital CPR is most often performed on patients lying on a bed or stretcher, CPR training uses primarily manikins placed on the floor. We analyzed the quality of external chest compressions (ECC) in simulated cardiac arrest scenarios occurring both on a stretcher and on the floor. METHODS Prospective cross-over simulation study enrolling ED nurses and nurses aides as part of an annual evaluation. Simulated CPR was performed in the 2 rescuer-mode for 2 min, both kneeling on the floor, and standing beside a knee high stretcher. The order of position was randomized. ECC parameters were compared. RESULTS ED nurses (n=48) and nurses aides (n=26) performed 128 scenarios. Mean ECC depth was 32 ± 13 mm on the floor and 27 ± 11 mm on a stretcher (∆: 5 mm, 95%CI [3-7], P<.001). Participants last trained within a year (n=17) developed deeper ECCs than their colleagues (n=47) in both positions (floor: 39 ± 12 mm vs stretcher: 34 ± 11 mm (p=0.016) for those trained within the year, and floor: 29 ± 12 mm vs stretcher: 24 ± 10 mm (P<.001) for those trained over a year ago). CONCLUSIONS The quality of chest compressions performed by ED staff was below 2005 guideline standards, with decreased ECC depth during CPR on a stretcher. Annual refresher courses should be implemented in the ED, with a focus on obtaining required ECC depth while standing next to a stretcher.

Water, water everywhere, but not a drop in sight: the impact of drug shortages on Canadian anesthesia care

A 38-yr-old mother of three presents for a laparoscopic appendectomy for acute appendicitis. She is a non-smoker and has a history of motion sickness. Her attending anesthesiologist advises her that she is at high risk for postoperative nausea and vomiting and that the most commonly used intravenous antiemetics are currently unavailable. The patient develops intractable vomiting in the postoperative care unit and requires three days of hospitalization as a result of a gastrointestinal hemorrhage secondary to a Mallory-Weiss type esophageal injury. Both the anesthesiologist and the patient are upset over the outcome of the anesthetic care. Although this is a fictitious case, in April of 2012, this type of scenario was very possible in institutions across Canada. In the survey of Canadian anesthesiologists reported by Hall et al. in this issue of the Journal, 53 (20.6%) of the 258 respondents during April 15 to June 4, 2012 noted a shortage of antiemetic agents. Shortages of anesthetic agents have been reported to cause life-threatening illness. During the 2010 propofol shortage in the United States, contamination of propofol single-use vials used inappropriately for multiple patients led to an outbreak of hepatitis C infection and the need for approximately 40,000 patients to be tested for potential infection. The global pharmaceutical market is valued in excess of US