Thomas Gale

Anaesthesia for neurosurgery in the sitting position.

The sitting position offers many advantages in terms of surgical access for posterior fossa and posterior cervical spine surgery. However, these advantages must be balanced against the risks which include venous and paradoxical arterial air embolism, cerebral and myocardial ischaemia secondary to hypotension, and complications of the positioning itself. These are largely in the domain of the neuroanaesthetist. In this paper, therefore, we will review the advantages, disadvantages and management of complications of the sitting position, from the neuroanaesthetists perspective.

Combined Femoral and Sciatic Nerve Block vs Combined Femoral and Periarticular Infiltration in Total Knee Arthroplasty: A Randomized Controlled Trial

This study tests the null hypothesis that there is no difference between sciatic nerve block (SNB) and periarticular anesthetic infiltration (PI) as adjuncts to femoral nerve blockade (FNB) in total knee arthroplasty in terms of postoperative opioid requirements. Fifty-two patients undergoing total knee arthroplasty were randomized to receive either (a) combined FNB-SNB or (b) combined FNB-PI. Average morphine consumption in the first 24 (20 vs 23 mg) and 48 hours (26 vs 33 mg) showed no significant difference. Visual Analogue Scale scores, knee flexion (60° vs 67.5°) and extension lag (0° vs 5°) were comparable. Anesthetic time, surgical time, and length of hospital stay (5.5 vs 6 days) were similar. This study showed no significant difference between the 2 groups. The PI offers a practical and potentially safer alternative to SNB.

Development of workplace-based assessments of non-technical skills in anaesthesia*

Non‐technical skills are recognised as crucial to good anaesthetic practice. We designed and evaluated a specialty‐specific tool to assess non‐technical aspects of trainee performance in theatre, based on a system previously found reliable in a recruitment setting. We compared inter‐rater agreement (multir‐ater kappa) for live assessments in theatre with that in a selection centre and a video‐based rater training exercise. Twenty‐seven trainees participated in the first in‐theatre assessment round and 40 in the second. Round‐ 1 scores had poor inter‐rater agreement (mean kappa = 0.20) and low reliability (generalisability coefficient G = 0.50). A subsequent assessor training exercise showed good inter‐rater agreement, (mean kappa = 0.79) but did not improve performance of the assessment tool when used in round 2 (mean kappa = 0.14, G = 0.42). Inter‐rater agreement in two selection centres (mean kappa = 0.61 and 0.69) exceeded that found in theatre. Assessment tools that perform reliably in controlled settings may not do so in the workplace.

Safety culture and the 5 steps to safer surgery: an intervention study

BACKGROUND Improvements in safety culture have been postulated as one of the mechanisms underlying the association between the introduction of the World Health Organisation (WHO) Surgical Safety Checklist with perioperative briefings and debriefings, and enhanced patient outcomes. The 5 Steps to Safer Surgery (5SSS) incorporates pre-list briefings, the three steps of the WHO Surgical Safety Checklist (SSC) and post-list debriefings in one framework. We aimed to identify any changes in safety culture associated with the introduction of the 5SSS in orthopaedic operating theatres. METHODS We assessed the safety culture in the elective orthopaedic theatres of a large UK teaching hospital before and after introduction of the 5SSS using a modified version of the Safety Attitude Questionnaire - Operating Room (SAQ-OR). Primary outcome measures were pre-post intervention changes in the six safety culture domains of the SAQ-OR. We also analysed changes in responses to two items regarding perioperative briefings. RESULTS The SAQ-OR survey response rate was 80% (60/75) at baseline and 74% (53/72) one yr later. There were significant improvements in both the reported frequency (P<0.001) and perceived importance (P=0.018) of briefings, and in five of the six safety culture domain scores (Working Conditions, Perceptions of Management, Job Satisfaction, Safety Climate and Teamwork Climate) of the SAQ-OR (P<0.001 in all cases). Scores in the sixth domain (Stress Recognition) decreased significantly (P=0.028). CONCLUSIONS Implementation of the 5SSS was associated with a significant improvement in the safety culture of elective orthopaedic operating theatres.

Anaesthetic machine checking guidelines : have we improved our practice?

Background and objectives This study follows up an initial audit in 1992 indicating that anaesthetic machine checking practices were often incomplete. The aims were to ascertain if there has been any improvement during this period with special reference to the latest guidelines. Methods Following the Association of Anaesthetists of Great Britain and Ireland machine checking guidelines, a structured questionnaire, was used to interview 41 anaesthetists in the South West region on one particular day. Results Despite 80% of subjects stating that they had read the latest guidelines recently, only one undertook a complete check and 39/41 (95%) performed partial checks (omitting one or more steps in the guidelines). Steps most commonly omitted were additional monitoring, ventilator function, availability of an alternative means of ventilation and function of ancillary equipment such as laryngoscopes. Only 5/41 subjects performed any check between cases. Several of these checks have been introduced in the 2004 guidelines. Conclusions Although there has been a significant increase in the proportion of anaesthetists undertaking machine checks since 1992 (P = 0.0007), we conclude that machine checking guidelines are still poorly followed, with checks specific to the latest guidelines most likely to be omitted.

A study to assess the influence of interprofessional point of care simulation training on safety culture in the operating theatre environment of a university teaching hospital

ABSTRACT Interprofessional point of care or in situ simulation is used as a training tool in our operating theatre directorate with the aim of improving crisis behaviours. This study aimed to assess the impact of interprofessional point of care simulation on the safety culture of operating theatres. A validated Safety Attitude Questionnaire was administered to staff members before each simulation scenario and then re-administered to the same staff members after 6–12 months. Pre- and post-training Safety Attitude Questionnaire—Operating Room (SAQ-OR) scores were compared using paired sample t-tests. Analysis revealed a statistically significant perceived improvement in both safety (p < 0.001) and teamwork (p = 0.013) climate scores (components of safety culture) 6–12 months after interprofessional simulation training. A growing body of literature suggests that a positive safety culture is associated with improved patient outcomes. Our study supports the implementation of point of care simulation as a useful intervention to improve safety culture in theatres.

The impact of large scale licensing examinations in highly developed countries: a systematic review

BackgroundTo investigate the existing evidence base for the validity of large-scale licensing examinations including their impact.MethodsSystematic review against a validity framework exploring: Embase (Ovid Medline); Medline (EBSCO); PubMed; Wiley Online; ScienceDirect; and PsychINFO from 2005 to April 2015. All papers were included when they discussed national or large regional (State level) examinations for clinical professionals, linked to examinations in early careers or near the point of graduation, and where success was required to subsequently be able to practice. Using a standardized data extraction form, two independent reviewers extracted study characteristics, with the rest of the team resolving any disagreement. A validity framework was used as developed by the American Educational Research Association, American Psychological Association, and National Council on Measurement in Education to evaluate each paper’s evidence to support or refute the validity of national licensing examinations.Results24 published articles provided evidence of validity across the five domains of the validity framework. Most papers (n = 22) provided evidence of national licensing examinations relationships to other variables and their consequential validity. Overall there was evidence that those who do well on earlier or on subsequent examinations also do well on national testing. There is a correlation between NLE performance and some patient outcomes and rates of complaints, but no causal evidence has been established.ConclusionsThe debate around licensure examinations is strong on opinion but weak on validity evidence. This is especially true of the wider claims that licensure examinations improve patient safety and practitioner competence.

Rising to the challenge: acute stress appraisals and selection centre performance in applicants to postgraduate specialty training in anaesthesia

The ability to work under pressure is a vital non-technical skill for doctors working in acute medical specialties. Individuals who evaluate potentially stressful situations as challenging rather than threatening may perform better under pressure and be more resilient to stress and burnout. Training programme recruitment processes provide an important opportunity to examine applicants’ reactions to acute stress. In the context of multi-station selection centres for recruitment to anaesthesia training programmes, we investigated the factors influencing candidates’ pre-station challenge/threat evaluations and the extent to which their evaluations predicted subsequent station performance. Candidates evaluated the perceived stress of upcoming stations using a measure of challenge/threat evaluation—the cognitive appraisal ratio (CAR)—and consented to release their demographic details and station scores. Using regression analyses we determined which candidate and station factors predicted variation in the CAR and whether, after accounting for these factors, the CAR predicted candidate performance in the station. The CAR was affected by the nature of the station and candidate gender, but not age, ethnicity, country of training or clinical experience. Candidates perceived stations involving work related tasks as more threatening. After controlling for candidates’ demographic and professional profiles, the CAR significantly predicted station performance: ‘challenge’ evaluations were associated with better performance, though the effect was weak. Our selection centre model can help recruit prospective anaesthetists who are able to rise to the challenge of performing in stressful situations but results do not support the direct use of challenge/threat data for recruitment decisions.

The International Landscape of Medical Licensing Examinations: A Typology Derived From a Systematic Review

Background: National licensing examinations (NLEs) are large-scale examinations usually taken by medical doctors close to the point of graduation from medical school. Where NLEs are used, success is usually required to obtain a license for full practice. Approaches to national licensing, and the evidence that supports their use, varies significantly across the globe. This paper aims to develop a typology of NLEs, based on candidacy, to explore the implications of different examination types for workforce planning. Methods: A systematic review of the published literature and medical licensing body websites, an electronic survey of all medical licensing bodies in highly developed nations, and a survey of medical regulators. Results: The evidence gleaned through this systematic review highlights four approaches to NLEs: where graduating medical students wishing to practice in their national jurisdiction must pass a national licensing exam before they are granted a license to practice; where all prospective doctors, whether from the national jurisdiction or international medical graduates, are required to pass a national licensing exam in order to practice within that jurisdiction; where international medical graduates are required to pass a licensing exam if their qualifications are not acknowledged to be comparable with those students from the national jurisdiction; and where there are no NLEs in operation. This typology facilitates comparison across systems and highlights the implications of different licensing systems for workforce planning. Conclusion: The issue of national licensing cannot be viewed in isolation from workforce planning; future research on the efficacy of national licensing systems to drive up standards should be integrated with research on the implications of such systems for the mobility of doctors to cross borders.

Health Worker Focused Distributed Simulation for Improving Capability of Health Systems in Liberia.

Introduction The main goal of this study was to produce an adaptable learning platform using virtual learning and distributed simulation, which can be used to train health care workers, across a wide geographical area, key safety messages regarding infection prevention control (IPC). Methods A situationally responsive agile methodology, Scrum, was used to develop a distributed simulation module using short 1-week iterations and continuous synchronous plus asynchronous communication including end users and IPC experts. The module contained content related to standard IPC precautions (including handwashing techniques) and was structured into 3 distinct sections related to donning, doffing, and hazard perception training. Outcome Using Scrum methodology, we were able to link concepts applied to best practices in simulation-based medical education (deliberate practice, continuous feedback, self-assessment, and exposure to uncommon events), pedagogic principles related to adult learning (clear goals, contextual awareness, motivational features), and key learning outcomes regarding IPC, as a rapid response initiative to the Ebola outbreak in West Africa. Gamification approach has been used to map learning mechanics to enhance user engagement. Conclusions The developed IPC module demonstrates how high-frequency, low-fidelity simulations can be rapidly designed using scrum-based agile methodology. Analytics incorporated into the tool can help demonstrate improved confidence and competence of health care workers who are treating patients within an Ebola virus disease outbreak region. These concepts could be used in a range of evolving disasters where rapid development and communication of key learning messages are required.