Steven K. Howard

Simulation-based training in anesthesia crisis resource management (ACRM): a decade of experience

Several gaps exist in the training of clinicians in health care domains, such as anesthesiology, that have the cognitive profile of complexity and dynamism. These features are shared with other industries such as commercial aviation. Training for cockpit crews on Crew Resource Management (CRM) emphasizes decision-making and teamwork principles. The authors created a simulation-based curriculum (ACRM) for anesthesiology based on principles of CRM in aviation. The training philosophy adapted to health care is one of training single-discipline crews to work in teams. The ACRM curriculum involves highly realistic simulation scenarios requiring complex decision making and interaction with multiple personnel. Scenarios are each followed by a detailed debriefing using videotapes of the simulation session. ACRM has been adopted at major health care institutions around the world. Special training for instructors is provided, especially concerning debriefing. The ACRM approach has been extended to a wide variety of other health care domains that involve complexity and dynamism, such as emergency and trauma medicine, intensive care, and cardiac arrest response teams. Simulation-based training based on CRM principles is expected to become routine in many health care settings in the coming decade.

The culture of safety: results of an organization-wide survey in 15 California hospitals

Objective: To understand fundamental attitudes towards patient safety culture and ways in which attitudes vary by hospital, job class, and clinical status. Design: Using a closed ended survey, respondents were questioned on 16 topics important to a culture of safety in health care or other industries plus demographic information. The survey was conducted by US mail (with an option to respond by Internet) over a 6 month period from April 2001 in three mailings. Setting: 15 hospitals participating in the California Patient Safety Consortium. Subjects: A sample of 6312 employees generally comprising all the hospital’s attending physicians, all the senior executives (defined as department head or above), and a 10% random sample of all other hospital personnel. The response rate was 47.4% overall, 62% excluding physicians. Where appropriate, responses were weighted to allow an accurate comparison between participating hospitals and job types and to correct for non-response. Main outcome measures: Frequency of responses suggesting an absence of safety culture (“problematic responses” to survey questions) and the frequency of “neutral” responses which might also imply a lack of safety culture. Responses to each question overall were recorded according to hospital, job class, and clinician status. Results: The mean overall problematic response was 18% and a further 18% of respondents gave neutral responses. Problematic responses varied widely between participating institutions. Clinicians, especially nurses, gave more problematic responses than non-clinicians, and front line workers gave more than senior managers. Conclusion: Safety culture may not be as strong as is desirable of a high reliability organization. The culture differed significantly, not only between hospitals, but also by clinical status and job class within individual institutions. The results provide the most complete available information on the attitudes and experiences of workers about safety culture in hospitals and ways in which perceptions of safety culture differ among hospitals and between types of personnel. Further research is needed to confirm these results and to determine how senior managers can successfully transmit their commitment to safety to the clinical workplace.

Time for a new paradigm in pediatric medical education: teaching neonatal resuscitation in a simulated delivery room environment.

Objectives. Acquisition and maintenance of the skills necessary for successful resuscitation of the neonate are typically accomplished by a combination of completion of standardized training courses using textbooks, videotape, and manikins together with active participation in the resuscitation of human neonates in the real delivery room. We developed a simulation-based training program in neonatal resuscitation (NeoSim) to bridge the gap between textbook and real life and to assess trainee satisfaction with the elements of this program. Methods. Thirty-eight subjects (physicians and nurses) participated in 1 of 9 full-day NeoSim programs combining didactic instruction with active, hands-on participation in intensive scenarios involving life-like neonatal and maternal manikins and real medical equipment. Subjects were asked to complete an extensive evaluation of all elements of the program on its conclusion. Results. The subjects expressed high levels of satisfaction with nearly all aspects of this novel program. Responses to open-ended questions were especially enthusiastic in describing the realistic nature of simulation-based training. The major limitation of the program was the lack of fidelity of the neonatal manikin to a human neonate. Conclusion. Realistic simulation-based training in neonatal resuscitation is possible using current technology, is well received by trainees, and offers benefits not inherent in traditional paradigms of medical education.

Situation Awareness in Anesthesiology

Situation awareness has primarily been confined to the aviation field. We believe that situation awareness is an equally important characteristic in the complex, dynamic, and risky field of anesthesiology. We describe three aspects of situations of which the decision maker must remain aware: subtle cues, evolving situations, and special knowledge elements. We provide examples of real or simulated anesthesia situations in which situation awareness is clearly involved in the provision of optimal patient care, and we map the elements of situation awareness onto a cognitive process model of the anesthesiologist. Finally, we consider how situation awareness can be further investigated and taught in this medical domain using anesthesia simulators and analyses of real cases. The study of situation awareness in anesthesiology may provide a good example of the wider application of the concept of situation awareness to nonaerospace environments.

Production pressure in the work environment. California anesthesiologists' attitudes and experiences.

BackgroundPressure to put efficiency, output, or continued production ahead of safety has caused catastrophic accidents in various industries. The authors assessed the attitudes and experiences of anesthesiologists concerning production pressure. MethodsA random, repeated-mailing survey was conducted among 647 members of the American Society of Anesthesiologists residing in California. Questions were asked about attitudes toward production pressure and other patient safety issues, frequency of occurrence of various operating room events, encounters with situations involving unsafe actions, and ratings of sources of production pressure. ResultsForty-seven percent of those sampled returned surveys. The demographics of the respondent population were largely similar to those of the population of anesthesiologists in California. There was no systematic difference between the respondents to the first versus the second mailing, reducing (but not eliminating) the possibility of self-selection blas. Nearly half (49%) of respondents had witnessed production pressure result in what they believed to be unsafe actions by an anesthesiologist. Such events included elective surgery in patients without adequate evaluation or with significant contraindications to surgery. Anesthesiologists felt pressures within themselves to work agreeably with surgeons, avoid delaying cases, and avoid litigation. They also reported overt pressure by surgeons to proceed with cases instead of canceling them, and to hasten anesthetic procedures. Some aspects of production pressure were perceived differently by those reimbursed by fee-for-service versus those paid by salary. ConclusionsProduction pressure from internal and external sources is a reality for many anesthesiologists and is perceived in some cases to have resulted in unsafe actions being performed.

Simulation Study of Rested Versus Sleep-deprived Anesthesiologists

Background Sleep deprivation causes physiologic and subjective sleepiness. Studies of fatigue effects on anesthesiologist performance have given equivocal results. The authors used a realistic simulation environment to study the effects of sleep deprivation on psychomotor and clinical performance, subjective and objective sleepiness, and mood. Methods Twelve anesthesia residents performed a 4-h anesthetic on a simulated patient the morning after two conditions of prior sleep: sleep-extended (EXT), in which subjects were allowed to arrive at work at 10:00 am for 4 consecutive days, thus allowing an increase in nocturnal sleep time, and total sleep deprivation (DEP), in which subjects were awake at least 25 h. Psychomotor testing was performed at specified periods throughout the night in the DEP condition and at matched times during the simulation session in both conditions. Three types of vigilance probes were presented to subjects at random intervals as well as two clinical events. Task analysis and scoring of alertness were performed retrospectively from videotape. Results In the EXT condition, subjects increased their sleep by more than 2 h from baseline (P = 0.0001). Psychomotor tests revealed progressive impairment of alertness, mood, and performance in the DEP condition over the course of the night and when compared with EXT during the experimental day. DEP subjects showed longer response latency to vigilance probes, although this was statistically significant for only one probe type. Task analysis showed no difference between conditions except that subjects “slept” more in the DEP condition. There was no significant difference in the cases’ clinical management between sleep conditions. Subjects in the DEP condition had lower alertness scores (P = 0.02), and subjects in the EXT condition showed little video evidence of sleepiness. Conclusions Psychomotor performance and mood were impaired while subjective sleepiness and sleepy behaviors increased during simulated patient care in the DEP condition. Clinical performance between conditions was similar.

Use of a fully simulated intensive care unit environment for critical event management training for internal medicine residents.

Management of inpatient emergencies (including “codes”) in teaching hospitals is often the responsibility of trainees in internal medicine. In such settings, successful implementation of therapeutic plans requires a technically competent leader who is able to coordinate the entire team’s effort. Leadership requires acquiring and interpreting patient information, choosing and prioritizing tasks to be accomplished, assigning them to specific individuals, and repeatedly reevaluating the results of therapy. Most residencies do not offer systematic training in crisis management leadership beyond limited portions of advanced cardiac life support certification. Crisis management skills are important in other medical fields, and specialized simulation-based curricula have been used in these settings for some time (1– 6). Members of our group pioneered the development of crisis-management and teamwork training for anesthesiologists based in part on the curriculum of Crew Resource Management (CRM) taught in commercial aviation. In the 1980s, research in aviation demonstrated that a large proportion of aircraft accidents were linked to failures on the part of crews with appropriate technical skills to manage their resources effectively (7). In an effort to address the shortcomings of decision-making and teamwork skills of cockpit crews, airlines in the United States joined with NASA and the U.S. military in establishing CRM training (8). Similarly, in health care, many accidents seemed due to nontechnical aspects of the work of individuals, teams, and systems. Thus, by analogy to the aviation curriculum, the Anesthesia Crisis Resource Management (ACRM) course developed in 1990 emphasizes nontechnical skills of decision making and team and resource management (2, 9) (Table 1). A textbook on the principles of CRM in anesthesiology (with content highly applicable to critical care) has been available since 1994 (2). The decision-making components of critical care deal with cognition in highly dynamic environments that differ from those encountered in the outpatient clinic or the wards. In such environments, diagnosis, monitoring, and therapy are completely interleaved and iterated rapidly, often including hands-on implementation by an integrated team rather than simply writing orders for later execution. In these dynamic settings, issues of allocation of attention, use of redundant information, and repeated situational reevaluation are paramount. The team and resource management components deal with the ability to translate the knowledge of what needs to be done into effective team activity in the complex and ill-structured real world of an intensive care unit (ICU) or ward emergency response team. Here, issues of leadership and followership are important, combined with the communication skills needed to create effective teamwork. Being able to identify, mobilize, and use the technical, human, and organizational resources of the ICU and the hospital is crucial. CRM-based simulation training for anesthesiologists and other medical specialties has spread widely since 1990, being adopted most notably at Stanford and Harvard in the United States and at a number of centers around the world, including centers in the United Kingdom, Australia, New Zealand, Switzerland, Denmark, and Germany (6, 10–16). The ACRM-like approach has been codified, and specialized instructor training programs are offered by the initial centers of excellence (4, 17). Other approaches to applying CRM to health care also have been described, such as Team Oriented Medical Simulation (18, 19). To date, a simulation-based crisis management curriculum has not been offered to internal medicine house staff in the intensive care setting. We describe the initial evaluation of a crisis management curriculum that has been taught during our medical surgical ICU rotation for the past 2 yrs. The major goal of the course is to combine didactic teaching with an experience representing what a practitioner might encounter in a real medical setting. Four elements were essential: a) providing a reasonable replica of both the human aspects and physical environment surrounding medical emergencies; b) presenting “cases” that challenge both the medical and nontechnical skills of trainees; c) allowing residents to experience managing the cases themselves without direction from an expert attending; and d) providing participants with detailed review of their performance, using self-critique by the individuals involved, their peer group, and expert instructors. The title of the course is Improving Management of Patient Emergency Situations (IMPES). *See also p. 2553. From the Department of Anesthesia, Stanford University Medical Center, Stanford, CA, and the Department of Anesthesia, VA Palo Alto Health Care System, Palo Alto, CA. Copyright

Use of cognitive aids in a simulated anesthetic crisis.

We evaluated empirically the extent to which the use of a cognitive aid during a high-fidelity simulation of a malignant hyperthermia (MH) event facilitated the correct and prompt treatment of MH. We reviewed the management of 48 simulated adult MH scenarios; 24 involving CA 1 and 24 involving CA 2 residents. In the CA 1 group, 19 of the 24 teams (79%) used a cognitive aid, but only 8 of the 19 teams used it frequently or extensively. In the CA 2 group, 18 of the 23 teams (78%) used a cognitive aid but only 6 of them used it frequently or extensively. The frequency of cognitive aid use correlated significantly with the MH treatment score for the CA 1 group (Spearman r = 0.59, P < 0.01) and CA 2 group (Spearman r = 0.68, P < 0.001). The teams that performed the best in treating MH used a cognitive aid extensively throughout the simulation. Although the effect was less pronounced in the more experienced CA 2 cohort, there was still a strong correlation between performance and cognitive aid use. We were able to show a strong correlation between the use of a cognitive aid and the correct treatment of MH.

Fatigue in anesthesia: implications and strategies for patient and provider safety.

HEALTHCARE delivery takes place 24 h a day, 7 days a week, and is colloquially termed a “24/7” operation. Anesthesia providers are required to deliver critical around-the-clock care to a variety of patients. This parallels the situation in many other domains that provide such services, e.g., transportation, law enforcement, communications, fire fighting, technology, manufacturing, and the military. Even “convenience” industries (e.g., gas stations and grocery stores) now provide uninterrupted access. These continuous operational demands present unique physiologic challenges to the humans who are called on to provide safe operations within these systems. Human physiologic design dictates circadian patterns of alertness and performance and includes a vital need for sleep. Human requirements for sleep and a stable circadian clock can be, and often are, in direct opposition to the societal demand for continuous operations. Recently, patient safety has taken center stage in health care. The Institute of Medicine’s report “To Err Is Human: Building a Safer Health System,” revealed that medical errors contribute to many hospital deaths and serious adverse events. The response to this report was widespread and included the Quality Interagency Coordination Task Force’s response to the President of the United States, “Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact.” 2 This report listed more than 100 action items to be undertaken by federal agencies to improve quality and reduce medical errors. One action promised by the Agency for Healthcare Research and Quality was “the development and dissemination of evidence-based, best safety practices to provider organizations.” In addition to the multiple recommendations to improve patient safety, the report from the Agency for Healthcare Research and Quality included a review chapter on sleep, fatigue,# and medical errors.** There is evidence that the issue of fatigue in health care is coming to prominence on a national level. In April 2001, Public Citizen (a consumer and health advocacy group) and a consortium of interested parties petitioned the Occupational Safety and Health Administration to implement new regulations on resident work hours (table 1). The primary intent of the regulations is to provide more humane working conditions, which the petitioners declare will result in a better standard of care for all patients. Also, the Patient and Physician Safety and Protection Act of 2001, which would limit resident physician work hours, was introduced in Congress. Recently, the Accreditation Council on Graduate Medical Education, the accrediting organization for residency training programs in the United States, has approved common program requirements for resident duty and rest hours that will take effect in July 2003.†† This article is accompanied by an Editorial View. Please see: Lydic R: Fact and fantasy about sleep and anesthesiology. ANESTHESIOLOGY 2002; 97:1050–1.

Trauma training in simulation: translating skills from SIM time to real time.

BACKGROUND : Training surgical residents to manage critically injured patients in a timely fashion presents a significant challenge. Simulation may have a role in this educational process, but only if it can be demonstrated that skills learned in a simulated environment translate into enhanced performance in real-life trauma situations. METHODS : A five-part, scenario-based trauma curriculum was developed specifically for this study. Midlevel surgical residents were randomized to receiving this curriculum in didactic lecture (LEC) fashion or with the use of a human performance simulator (HPS). A written learning objectives test was administered at the completion of the training. The first four major trauma resuscitations performed by each participating resident were captured on videotape in the emergency department and graded by two experienced judges blinded to the method of training. The assessment tool used by the judges included an evaluation of both initial trauma evaluation or treatment skills (part I) and crisis management skills (part II) as well as an overall score (poor/fail, adequate, or excellent). RESULTS : The two groups of residents received almost identical scores on the posttraining written test. Average SIM and LEC scores for part I were also similar between the two groups. However, SIM-trained residents received higher overall scores and higher scores for part II crisis management skills compared with the LEC group, which was most evident in the scores received for the teamwork category (p = 0.04). CONCLUSIONS : A trauma curriculum incorporating simulation shows promise in developing crisis management skills that are essential for evaluation of critically injured patients.