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Introduction-Aim: Clinical reasoning in situations of uncertainty is a skill to be acquired from initial training. The aim of this study was to evaluate the clinical reasoning ability in a context of uncertainty of health science students using the Script Concordance Test (SCT)., Methods: This was a cross-sectional and descriptive study which included students in the third year of the National License in Anesthesia-Resuscitation, with their consent, and a panel of experts made up of ten members. The tool chosen was a TCS composed of 60 items which dealt with frequent and serious themes in general Anesthesia-Resuscitation., Results: We included 16 students. The average time to complete the test was 46.7 minutes±12.42 [95% CI; 37.81 -55.59] for experts and 54.38 minutes ±8.92 [95% CI; 49.62-59.13] for students. The average score obtained by the experts, reported out of 100, was 80.8±4.09 [95% CI; 77.90-83.75]. The average score of the students was 54.78±9.14 [95% CI; 49.91-59.65]., Conclusion: With the implementation of TCS as an assessment tool in health sciences, students demonstrated an increased capacity for reasoning in complex situations, as reflected in their average scores.

: Patient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the 'Helsinki Declaration on Patient Safety in Anaesthesiology'. In May/June 2020, ESA and EBA are celebrating the 10th anniversary of the Helsinki Declaration on Patient Safety in Anaesthesiology; a good opportunity to look back and forward evaluating what was achieved in the recent 10 years, and what needs to be done in the upcoming years. The Patient Safety and Quality Committee (PSQC) of ESA invited experts in their fields to contribute, and these experts addressed their topic in different ways; there are classical, narrative reviews, more systematic reviews, political statements, personal opinions and also original data presentation. With this publication we hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.

Background: Many hospitals have implemented surgical safety checklists based on the World Health Organization surgical safety checklist, which was associated with improved outcomes. However, the execution of the checklists is frequently incomplete. We reasoned that aviation-style computerized checklist displayed onto large, centrally located screen and operated by the anesthesia provider would improve the performance of surgical safety checklist., Methods: We performed a prospective before and after observational study to evaluate the effect of a computerized surgical safety checklist system on checklist performance. We created checklist software and translated our 4-part surgical safety checklist from wall poster into an aviation-style computerized format displayed onto a large, centrally located screen and operated by the anesthesia provider. Direct observers recorded performance of the first part of the surgical safety checklist that was initiated before anesthetic induction, including completion of each checklist item, provider participation and distraction level, resistance to use of the checklist, and the time required for checklist completion before and after checklist system implementation. We compared trends of the proportions of cases with 100% surgical safety checklist completion over time between pre- and postintervention periods and assessed for a jump at the start of intervention using segmented logistic regression model while controlling for potential confounding variables., Results: A total of 671 cases were observed before and 547 cases were observed after implementation of the computerized surgical safety checklist system. The proportion of cases in which all of the items of the surgical safety checklist were completed significantly increased from 2.1% to 86.3% after the computerized checklist system implementation (P < .001). Before computerized checklist system implementation, 488 of 671 (72.7%) cases had <75% of checklist items completed, whereas after a computerized checklist system implementation, only 3 of 547 (0.5%) cases had <75% of checklist items completed., Conclusions: The implementation of a computerized surgical safety checklist system resulted in an improvement in checklist performance.

Background: While increased surgical-provider volume has been associated with improved outcomes, research regarding volume-outcome relationships within high-volume institutions and the role of anaesthesiologists is limited. Further, the effect of anaesthesia-care-team composition remains understudied. This analysis aimed to identify the impact of anaesthesiologist and surgeon volume on adverse events after total joint arthroplasties., Methods: We retrospectively identified 40 437 patients who underwent total joint arthroplasties at a high-volume institution from 2005 to 2014. The main effects of interest were anaesthesiologist and surgeon volume and experience along with anaesthesia-care-team composition. Multivariable logistic regression models were used to evaluate three outcomes: any complication, cardiopulmonary complication, and length of stay (>5 days). Odds ratios (ORs) and 99.75% confidence intervals (CIs) were reported., Results: Across all three models, anaesthesiologist volume and experience, and anaesthesia-care-team composition were not significant predictors. Surgeon annual case volume >50 was associated with significantly reduced odds of any complication (annual case volume: 50-149; OR: 0.80; CI: 0.66-0.98) and prolonged length of stay (OR: 0.69; CI: 0.60-0.80). Surgeon experience >20 yr was associated with significantly reduced odds of prolonged length of stay (OR: 0.85; CI: 0.75-0.95)., Conclusions: Anaesthesiologist volume and experience, and anaesthesia-care-team composition did not impact the odds of an adverse outcome, although a higher surgeon volume was associated with decreased odds of complications and prolonged length of stay. Further study is necessary to determine if these findings can be extrapolated to less specialised, lower volume surgical settings., (Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Objective: The purposes of this study were to establish whether implementing a curriculum of perioperative point-of-care ultrasound (POCUS) of the heart and lungs for current in-training anesthesia residents during their required month of cardiac anesthesia was feasible and whether an evaluation tool would demonstrate improvement in the residents' baseline knowledge of POCUS., Design: Single-center, prospective, cohort, and observational study., Setting: A tertiary-care, university-affiliated hospital., Participants: The study comprised 16 anesthesia residents on their third postgraduate training year during their required cardiac anesthesia rotation., Interventions: The implementation of a curriculum to educate anesthesia residents in perioperative POCUS of the heart and lungs on patients undergoing elective cardiothoracic procedures that included both theoretical and practical approaches. A 21-question, multiple-choice, electronic-generated test was developed to gauge performance improvement from before ("pretest") to after ("posttest") the 4-week period., Measurements and Main Results: Of the 16 residents, 13 (81.3%) showed improved scores between the pretest and posttest periods after the 4-week rotation. The difference between pretest and posttest mean score was 5 (p = 0.001)., Conclusions: This study demonstrates that integrating a curriculum dedicated to perioperative POCUS of the heart and lungs as part of the goals and objectives during the rotation of cardiac anesthesia is feasible and that anesthesia residents who received the training proposed by the authors improved their cognitive and technical skills., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The International Federation of Nurse Anesthetists is calling for international collaboration to develop advanced nursing practice in anesthesia settings globally. However, international collaboration is challenging. Limited information is available about what process and factors specifically lead to a successful international collaboration partnership. This article aimed to describe a theoretical and empirical base that can be used to build and maintain long-term international partnerships. The Theoretical Framework of Developing International Partnerships was developed, which comprises seven interrelated concepts including partnerships, collaborations, environment, structure, process for collaborating, outcomes, and sustainability. It was used to guide an equitable horizontal collaboration partnership to develop anesthesia nursing care in local culture and context. Five major challenges were identified during the collaboration process. Sixty-six strategies were developed to facilitate collaboration using the theoretical framework. This work can inform others in establishing an international collaboration and partnership in advancing nursing knowledge and culturally congruent health care delivery.

What We Already Know About This Topic: Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation., What This Article Tells Us That Is New: Failure to debrief after critical events is common among anesthesia trainees and likely anesthesia teams. Communication breakdowns are associated with a high rate of the failure to debrief., Background: Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation. The authors' objective was to understand barriers to debriefing, characterize quantifiable patterns and qualitative themes, and learn potential solutions through a mixed-methods study of actual critical events experienced by anesthesia personnel., Methods: At a large academic medical center, anesthesiology residents and a small number of attending anesthesiologists were audited and/or interviewed for the occurrence and patterns of debriefing after critical events during their recent shift, including operating room crises and disruptive behavior. Patterns of the events, including event locations and event types, were quantified. A comparison was done of the proportion of cases debriefed based on whether the event contained a critical communication breakdown. Qualitative analysis, using an abductive approach, was performed on the interviews to add insight to quantitative findings., Results: During a 1-yr period, 89 critical events were identified. The overall debriefing rate was 49% (44 of 89). Nearly half of events occurred outside the operating room. Events included crisis events (e.g., cardiac arrest, difficult airway requiring an urgent surgical airway), disruptive behavior, and critical communication breakdowns. Events containing critical communication breakdowns were strongly associated with not being debriefed (64.4% [29 of 45] not debriefed in events with a communication breakdown vs. 36.4% [16 of 44] not debriefed in cases without a communication breakdown; P = 0.008). Interview responses qualitatively demonstrated that lapses in communication were associated with enduring confusion that could inhibit or shape the content of discussions between involved providers., Conclusions: Despite the value of proximal debriefing to reducing provider burnout and improving wellness and learning, failure to debrief after critical events can be common among anesthesia trainees and perhaps anesthesia teams. Modifiable interpersonal factors, such as communication breakdowns, were associated with the failure to debrief.

Background: The use of cognitive aids, such as emergency manuals (EMs), improves team performance on critical steps during crisis events. In our large academic anesthesia practice, we sought to broadly implement an EM and subsequently evaluate team member performance on critical steps., Methods: We observed the phases of implementing an EM at a large academic anesthesia practice from 2013 to 2016, including the formation of the EM implementation team, identification of preferred EM characteristics, consideration of institution-specific factors, selection of the preferred EM, recognition of logistical barriers, and staff education. Utilization of the EM was tested in a regular clinical environment with all available resources using a standardized verbal simulation of 3 crisis events both preimplementation and 6 months postimplementation. Individual members of the anesthesia team were asked to verbalize interventions for specific crisis events over 60 seconds., Results: We introduced a customized version of the Stanford Emergency Manual on January 26, 2015. Fifty-nine total participants (equal proportion of anesthesiology attending physicians, resident physicians, certified registered nurse anesthetists, and student registered nurse anesthetist staff) were surveyed in the preimplementation phase and 60 in the 6-month postimplementation phase. In the postimplementation phase, a minority (41.7%) utilized the EM for the verbal-simulated crisis events. Those who used the EM performed better than those who did not (median 21.0 critical steps out of a possible 30 total steps [70.0%], interquartile range 19-25 vs 18.0 critical steps verbalized [60.0%], interquartile range 16-20; P < .001). Among all subjects, the median number of critical steps verbalized was 16 (53.3%) preimplementation and 19.5 critical steps (65.0%) postimplementation., Conclusions: Implementation of an EM in a large academic anesthesia practice is not without challenges. While full integration of the EM was not achieved 6 months after implementation, verbalization of critical steps on 3 simulated crisis events improved when the EM was utilized.

Background and Objectives: Advanced haptic simulators for neuraxial training are expensive, have a finite life, and are not patient specific. We sought to demonstrate the feasibility of developing a custom-made, low-cost, 3-dimensionally printed thoracic spine simulator model from patient computed tomographic scan data. This study assessed the model's practicality, efficiency as a teaching tool, and the transfer of skill set into patient care., Methods: A high-fidelity, patient-specific thoracic spine model was used for the study. Thirteen residents underwent a 1-hour 30-minute training session prior to performing thoracic epidural analgesia (TEA) on patients. We observed another group of 14 residents who were exposed to the traditional method of training during their regional anesthesia rotation for thoracic epidural placement. The TEA was placed for patients under the supervision of attending anesthesiologists, who were blinded to the composition of the study and control groups. As a primary outcome, data were collected on successful TEAs, which was defined as a TEA that provided full relief of sensation across the entire surgical area as assessed by both a pinprick and temperature test. Secondary outcomes included whether any assistance from the attending physician was required and failed epidurals., Results: A total of 27 residents completed the study (14 in the traditional training, 13 in the study group). We found that the residents who underwent training with the simulator had a significantly higher success rate (11 vs 4 successful epidural attempts, P = 0.002) as compared with the traditional training group. The control group also required significantly more assistance from the supervising anesthesiologist compared with the study group (5 vs 1 attempt requiring guidance). The number needed to treat (NNT) for the traditional training group was 1.58 patients over the study period with a 95% confidence interval of 1.55 to 1.61., Conclusions: By using patient-specific, 3-dimensionally printed, thoracic spine models, we demonstrated a significant improvement in clinical proficiency as compared with traditional teaching models.

While standardized examinations and data from simulators and phantom models can assess knowledge and manual skills for ultrasound, an Objective Structured Clinical Examination (OSCE) could assess workflow understanding. We recruited 8 experts to develop an OSCE to assess workflow understanding in perioperative ultrasound. The experts used a binary grading system to score 19 graduating anesthesia residents at 6 stations. Overall average performance was 86.2%, and 3 stations had an acceptable internal reliability (Kuder-Richardson formula 20 coefficient >0.5). After refinement, this OSCE can be combined with standardized examinations and data from simulators and phantom models to assess proficiency in ultrasound.

Background: When workload is low, anesthesia providers may perform non-patient care activities of a clinical, educational, or personal nature. Data are limited on the incidence or impact of distractions on actual care. We examined the prevalence of self-initiated nonclinical distractions and their effects on anesthesia workload, vigilance, and the occurrence of nonroutine events., Methods: In 319 qualifying cases in an academic medical center using a Web-based electronic medical chart, a trained observer recorded video and performed behavioral task analysis. Participant workload and response to a vigilance (alarm) light were randomly measured. Postoperatively, participants were interviewed to elicit possible nonroutine events. Two anesthesiologists reviewed each event to evaluate their association with distractions., Results: At least one self-initiated distraction was observed in 171 cases (54%), largely during maintenance. Distractions accounted for 2% of case time and lasted 2.3 s (median). The most common distraction was personal internet use. Distractions were more common in longer cases but were not affected by case type or American Society of Anesthesiologists physical status. Workload ratings were significantly lower during distraction-containing case periods and vigilance latencies were significantly longer in cases without any distractions. Three distractions were temporally associated with, but did not cause, events., Conclusions: Both nurse anesthetists and residents performed potentially distracting tasks of a personal and/or educational nature in a majority of cases. Self-initiated distractions were rarely associated with events. This study suggests that anesthesia professionals using sound judgment can self-manage nonclinical activities. Future efforts should focus on eliminating more cognitively absorbing and less escapable distractions, as well as training in distraction management.

We conducted a retrospective case review to determine if the presence of an Accreditation Council for Graduate Medical Education (ACGME) fellowship-trained pediatric anesthesiologist improves efficiency during pediatric tonsillectomies and adenotonsillectomies in hospitals that do not have dedicated pediatric operating rooms and, if so, to determine which specific anesthesia practices might account for such a difference. We reviewed the charts of all patients aged 12 years and younger who had undergone a tonsillectomy or adenotonsillectomy from Jan. 1, 2008, through Aug. 1, 2013, at San Francisco General Hospital. A total of 75 cases met our eligibility criteria. We compiled information on patient demographics, surgical time, anesthesia time, and anesthesia practices. Our primary study outcome was the amount of anesthesia-controlled time (ACT), which is the sum of time spent in induction and emergence. Cases were grouped according to whether the operation was staffed by an ACGME fellowship-trained pediatric anesthesiologist or a general anesthesiologist. Data were analyzed for 1 pediatric anesthesiologist and 23 general anesthesiologists. We found that ACT was significantly shorter during the cases staffed by the ACGME fellowship-trained pediatric anesthesiologist, although there were no major differences in anesthesia practices between the types of anesthesiologist. We suggest that staffing pediatric tonsillectomy operations with a fellowship-trained pediatric anesthesiologist may be an effective strategy for increasing operating room efficiency.

Background: Educators in anesthesia have an obligation to ensure that fellowship programs are training anesthesiologists to meet the highest standards of performance in clinical and academic practice. The objective of this survey was to characterize the perspectives of graduates of Canadian core fellowship programs in pediatric anesthesia (during a ten-year period starting in 2003) on the adequacies and inadequacies of fellowship training., Methods: We conducted an electronic survey of graduates from eight departments of pediatric anesthesia in Canada who completed one-year core fellowship training in pediatric anesthesia from 2003 to 2013. A novel survey design was implemented, and the content and structure of the design were tested before distribution. Data were collected on respondents' demographics, details of training and practice settings, perceived self-efficacy in subspecialty practices, research experience, and perspectives on one-year core fellowship training in pediatric anesthesia. Descriptive statistics and 95% confidence intervals were determined., Results: The survey was sent to 132 anesthesiologists who completed core fellowship training in pediatric anesthesia in Canada. Sixty-five (49%) completed and eligible surveys were received. Most of the anesthesiologists surveyed perceived that 12 months of core fellowship training are sufficient to acquire the knowledge and critical skills needed to practice pediatric anesthesia. Subspecialty areas most frequently perceived to require improved training included pediatric cardiac anesthesia, chronic pain medicine, and regional anesthesia., Conclusions: This survey reports perceived deficiencies in domains of pediatric anesthesia fellowship training. These findings should help guide the future development of core and advanced fellowship training programs in pediatric anesthesia.

Background: European health systems depend increasingly on the services of health professionals who obtained their primary medical qualification from other countries. There has been a significant increase recently in fully qualified specialist doctors arriving from the European Union to provide short term or longer-term solutions to health human resources needs in the UK National Health System. These doctors often take up senior consultant positions. As a result, the NHS has had to learn to deal with both expatriation and repatriation of EU doctors as a constant dynamic characteristic of its own ability to deliver services. We conducted a qualitative study to explore the acclimatisation experience of EU doctors with qualifications in anaesthesia arriving in the United Kingdom to take up clinical employment in the NHS. The question we ask is: how do specialty registered anaesthetists who trained in other European countries experience the process of acclimatisation to practice in the United Kingdom in a large hospital in London?, Methods: We did individual interviews with non-UK, EU-qualified doctors with Certification of Completion of specialty Training who were registered with the General Medical Council in the UK and could practice in the NHS as specialist anaesthetists. The doctors were all interviewed whilst working in a large NHS teaching hospital in London, UK. We analysed qualitative data from interview transcripts to identity themes and patterns regarding senior doctor's acclimatisation to the British system., Results: Acclimatisation conceived of as transfer of clinical expertise was problematic for doctors who felt they lacked the right kind of support. Doctors sought different opportunities to share wider perspectives on care deriving from their previous experience., Conclusions: Hospital conceptions of acclimatisation as a highly individual process can offer an idealized view of clinical work and learning in the new system. Socio-cultural theories suggest we create regular learning opportunities for international staff to critically reflect on practice with local staff to acclimatise more effectively.

Background: Anesthesiologists face increasing pressure to demonstrate the value of the care they provide, whether locally or nationally through public reporting and payor requirements. In this article, we describe the current state of performance measurement in anesthesia care at the national level and highlight gaps and opportunities in performance measurement for anesthesiologists., Methods: We evaluated all endorsed performance measures in the National Quality Forum (NQF), the clearinghouse for all federal performance measures, and classified all measures as follows: (1) anesthesia-specific; (2) surgery-specific; (3) jointly attributable; or (4) other. We used NQF-provided descriptors to characterize measures in terms of (1) structure, process, outcome, or efficiency; (2) patients, disease, and events targeted; (3) procedural specialty; (4) reporting eligibility; (5) measures stewards; and (6) timing in the care stream., Results: Of the 637 endorsed performance measures, few (6, 1.0%) were anesthesia-specific. An additional 39 measures (6.1%) were surgery-specific, and 67 others (10.5%) were jointly attributable. "Anesthesia-specific" measures addressed preoperative antibiotic timing (n = 4), normothermia (n = 1), and protocol use for the placement of central venous catheter (n = 1). Jointly attributable measures included outcome measures (n = 49/67, 73.1%), which were weighted toward mortality alone (n = 24) and cardiac surgery (n = 14). Other jointly attributable measures addressed orthopedic surgery (n = 4), general surgical oncologic resections (n = 12), or nonspecified surgeries (n = 15), but none specifically addressed anesthesia care outside the operating room such as for endoscopy. Only 4 measures were eligible for value-based purchasing. No named anesthesiology professional groups were among measure stewards, but surgical professional groups (n = 33/67, 47%) were frequent measure stewards., Conclusions: Few NQF performance measures are specific to anesthesia practice, and none of these appears to demonstrate the value of anesthesia care or differentiate high-quality providers. To demonstrate their role in patient-centered, outcome-driven care, anesthesiologists may consider actively partnering in jointly attributable or team-based reporting. Future measures may incorporate surgical procedures not proportionally represented, as well as procedural and sedation care provided in nonoperating room settings.

Background: As a specialty, anesthesiology has relatively low research productivity. Prior studies indicate that junior faculty development programs favorably affect academic performance. We therefore initiated a junior faculty development program and hypothesized that most (>50%) new junior faculty would take <50 nonclinical days to achieve a primary program goal (e.g., investigation or publication), and <5 nonclinical days to achieve a secondary program goal (e.g., teaching or nonclinical service)., Methods: Twenty new junior faculty participated in the 2-year program which had a goal-oriented structure and was supported by nonclinical time, formally assigned mentors, and a didactic curriculum. Goal productivity equaled the number of program goals accomplished divided by the amount of nonclinical time received. Primary goal productivity was expressed as primary goals accomplished per 50 nonclinical days. Secondary goal productivity was expressed as secondary goals accomplished per 5 nonclinical days., Results: Median primary goal productivity was 0.45 primary goals per 50 nonclinical days (25th-75th interquartile range = 0.00-0.73). Contrary to our hypothesis, most new junior faculty needed >50 nonclinical days to achieve a primary goal (17/20, P = 0.0026). Median secondary goal productivity was 0.57 secondary goals per 5 nonclinical days (25th-75th interquartile range = 0.38-0.77). Contrary to our hypothesis, most new junior faculty needed >5 nonclinical days to accomplish a secondary goal (18/20, P = 0.0004). It was not clear that the faculty development program increased program goal productivity., Conclusions: Even with structured developmental support, most new junior anesthesia faculty needed >50 nonclinical days to achieve a primary (traditional academic) goal and >5 nonclinical days to achieve a secondary goal. Currently, most new anesthesia faculty are not productive in traditional academic activities (research). They are more productive in activities related to clinical care, education, and patient care systems management.

Background: Our goal in this study was to test the relationship between speaking up--i.e., questioning, correcting, or clarifying a current procedure--and technical team performance in anesthesia. Hypothesis 1: team members' higher levels of speaking up are related to higher levels of technical team performance. Hypothesis 2: team members will react to speaking up by either clarifying their procedure or initiating a procedural change. Hypothesis 3: higher levels of speaking up during an earlier phase of teamwork will be related to higher levels of speaking up during a later phase., Methods: This prospective observational study involved 2-person ad hoc anesthesia teams performing simulated inductions of general anesthesia with minor nonroutine events (e.g., bradycardia) in a large teaching hospital. Subjects were registered anesthesia nurses and residents. Each team consisted of 1 nurse and 1 resident. Synchronized video and vital parameter recordings were obtained. Two trained observers blinded to the hypotheses coded speaking up and further team communication and coordination behavior on the basis of 12 distinct categories. All teamwork measures were quantified as percentage of total time spent on the respective teamwork category. Two experienced staff anesthesiologists blinded to the hypotheses evaluated technical team performance using a Delphi-validated rating checklist. Hypotheses 1 and 3 were tested using linear regression with residents' and nurses' levels of speaking up as 2 separate predictor variables. Hypothesis 2 was analyzed using lag sequential analysis, resulting in Z values representing the extent to which the observed value for a conditional transition significantly differs from its unconditional value., Results: Thirty-one nurses and 31 residents participated. Technical team performance could be predicted by the level of speaking up from nurses (R(2) = 0.18, P = 0.017) but not from residents (R(2) = 0.19, P = 0.053); this result supports Hypothesis 1 for nurses. Supporting Hypothesis 2, residents reacted to speaking up with clarifying the procedure by providing information (Z = 18.08, P < 0.001), initiating procedural change by giving instructions (Z = 4.74, P < 0.001) and team member monitoring (Z = 3, P = 0.0013). Likewise, nurses reacted with clarifying the procedure by providing or evaluating information (Z = 16.09, P < 0.001; Z = 3.72, P < 0.001) and initiating procedural change by providing assistance (Z = 0.57, P < 0.001). Indicating a trend for Hypothesis 3, nurses' level of speaking up before intubation predicted their level of speaking up during intubation (R(2) = 0.15, P = 0.034), although this did not reach the Bonferroni-corrected significance level of P = 0.025. No respective relationship was found for residents (R(2) = 0.15, P = 0.096)., Conclusions: This study provides empirical evidence and shows mechanisms for the positive relationship between speaking-up behavior and technical team performance.

Background: In this article some definitions of competency and professionalism will be discussed, and an overview of existing methods that assess competency and professionalism in anaesthesia resident doctors (residents) is provided. In addition, we will discuss how progression to professionalism, education in anaesthesiology and other medical specialties may be improved using the adult skill acquisition model. The goal of this paper is to refine the definitions of professionalism and competency, and to propose a new approach to medical education., Context: The terms professionalism and competency are both used in the context of education, sometimes interchangeably, adding to the confusion surrounding their definitions and application. Competency, from our point of view, is the ability to perform a certain task required for a work situation. Professionalism includes competencies in addition to the specific behaviours required to successfully perform in a certain specialty. Areas in which progress in medical education may be achieved include: resident selection; teaching and testing of programs (e-education); better use of simulation for skills assessment; and teaching and assessment of non-technical skills during residency. Medical schools and teaching hospitals should work continuously on creating and maintaining a high level of professional culture., Implications: Medical knowledge, manual skills and non-technical skills should be used for the assessment of professionalism in medical specialties. The necessity to improve on the quality of medical care calls for changes in medical education., (© Blackwell Publishing Ltd 2012.)

Background: The potential for catastrophe resulting from anesthetic equipment failure and the failure of training programs to adequately prepare residents to detect and manage equipment failure prompted the Israel Board of Anesthesiologists to include simulation-based testing in the Objective Structured Clinical Evaluation component of the Israeli Board Examination in Anesthesiology., Methods: We used simulation-based scenarios to measure the performance of residents while (a) checking the anesthesia machine before the first morning case, (b) checking the anesthesia machine between cases, (c) managing an oxygen pipeline failure, and (d) managing an expiratory valve failure., Results: During board examination, 3 of 28 examinees failed to correctly check at least 70% of the items on the anesthesia machine checkout list before the first morning case and 3 of 30 failed to correctly check 70% of the items between cases. Although all examinees recognized inadequate oxygen cylinder pressure and a malfunctioning valve, 1 of 31 examinees failed to open the O(2) cylinder, 6 of 31 did not disconnect the anesthesia machine from the central oxygen supply, 14 of 31 could not explain how to minimize the use of oxygen, 2 of 30 failed to find the faulty valve, and 15 of 30 could not give the correct differential diagnosis., Conclusions: During simulation-based board examination most senior anesthesia residents became aware of equipment failures but many failed to correctly diagnosis and manage the failure.

Background: Calls for reform to postgraduate medical training structures in the UK have included suggestions that training should foster excellence and not simply ensure competence., Methods: We conducted a modified Delphi-type survey starting with an e-mail request to specialist anaesthetists involved in education, asking them to identify the attributes of an excellent anaesthetist. In focused group interviews, their coded and categorized responses were ranked, and suggestions were made for incorporation into anaesthesia education. We also compared the findings with currently available professional and educational guidance., Results: Our expert group strongly expressed the view that while superior knowledge and skills, associated with exceptional performance in clinical work, were fundamental to the excellent practitioner, they were not sufficient in themselves. A group of attributes that were personal qualities and functions of personality were also considered essential. The defining characteristic of excellence was, perhaps, the continuing urge to seek challenges and learn from them. Other high-ranking characteristics included clinical skills, interest in teaching, conscientiousness, innovation/originality, communication skills, and good relationships with patients. Knowledge for its own sake (personal involvement in research) was not rated highly, but applied knowledge was judged to underlie many of the most important categories., Conclusions: The achievement of excellence in anaesthesia is likely to depend on the successful interplay of individuals' personal qualities and the environment in which they work. Thus, not only trainees but also educational supervisors, heads of departments, and those responsible for organizing training systems all have a part to play in the encouragement of excellence.

Anaesthesiology, which includes anaesthesia, perioperative care, intensive care medicine, pain therapy and emergency medicine, has always participated in systematic attempts to improve patient safety. Anaesthesiologists have a unique, cross-specialty opportunity to influence the safety and quality of patient care. Past achievements have allowed our specialty a perception that it has become safe, but there should be no room for complacency when there is more to be done. Increasingly older and sicker patients, more complex surgical interventions, more pressure on throughput, new drugs and devices and simple chance all pose hazards in the work of anaesthesiologists. In response to this increasingly difficult and complex working environment, the European Board of Anaesthesiology (EBA), in cooperation with the European Society of Anaesthesiology (ESA), has produced a blueprint for patient safety in anaesthesiology. This document, to be known as the Helsinki Declaration on Patient Safety in Anaesthesiology, was endorsed by these two bodies together with the World Health Organization (WHO), the World Federation of Societies of Anaesthesiologists (WFSA), and the European Patients' Federation (EPF) at the Euroanaesthesia meeting in Helsinki in June 2010. The Declaration represents a shared European view of that which is worthy, achievable, and needed to improve patient safety in anaesthesiology in 2010. The Declaration recommends practical steps that all anaesthesiologists who are not already using them can successfully include in their own clinical practice. In parallel, EBA and ESA have launched a joint patient safety task-force in order to put these recommendations into practice. It is planned to review this Declaration document regularly.

Medicine involves specific practical expertise as well as more general context-independent medical knowledge. This raises the question, what is the nature of the expertise involved? Is there a model of clinical judgement or understanding that can accommodate both elements? This paper begins with a summary of a published account of the kinds of situation-specific skill found in anaesthesia. It authors claim that such skills are often neglected because of a prejudice in favour of the 'technical rationality' exemplified in evidence-based medicine but they do not themselves offer a general account of the relation of practical expertise and general medical knowledge. The philosopher Hubert Dreyfus provides one model of the relation of general knowledge to situation-specific skilled coping. He claims that the former logically depends on the latter and provides two arguments, which I articulate in the second section, for this. But he mars those arguments by building in the further assumption that such situation-specific responses must be understood as concept-free and thus mindless. That assumption is held in place by three arguments all of which I criticize in the next section to give a unified account of clinical judgement as both practical and conceptually structured and thus justified in the face of a prejudice in favour of 'technical rationality'.

Recent trends in medical training have tended to focus on competence, in the sense of adequate performance, rather than excellence. This article reviews published literature and relevant concepts relating to excellence and professionalism from within anaesthesia, from medicine more generally and from outside the profession. A number of conceptual frameworks are presented that could be adapted for the promotion of excellence, and some of the necessary prerequisites for this promotion discussed.

A key aspect of the practice of anaesthesia is the ability to perform practical procedures efficiently and safely. Decreased working hours during training, an increasing focus on patient safety, and greater accountability have resulted in a paradigm shift in medical education. The resulting international trend towards competency-based training demands robust methods of evaluation of all domains of learning. The assessment of procedural skills in anaesthesia is poor compared with other domains of learning and has fallen behind surgical fields. Logbooks and procedure lists are best suited to providing information regarding likely opportunities within training programmes. Retrospective global scoring and direct observation without specific criteria are unreliable. The current best evidence for a gold standard for assessment of procedural skills in anaesthesia consists of a combination of previously validated checklists and global rating scales, used prospectively by a trained observer, for a procedure performed in an actual patient. Future research should include core assessment parameters to ensure methodological rigor and facilitate robust comparisons with other studies: (i) reliability, (ii) validity, (iii) feasibility, (iv) cost-effectiveness, and (v) comprehensiveness with varying levels of difficulty. Simulation may become a key part of the future of formative and summative skills assessment in anaesthesia; however, research is required to develop and test simulators that are realistic enough to be suitable for use in high-stakes evaluation.

Background: Research into adverse events in hospitalized patients suggests that a significant number are preventable. The purpose of this randomized, controlled study was to determine if simulation-based debriefing improved performance of practicing anaesthetists managing high-fidelity simulation scenarios., Methods: The anaesthetists were randomly allocated to Group A: simulation debriefing; Group B: home study; and Group C: no intervention and secondary randomization to one of two scenarios. Six to nine months later, subjects returned to manage the alternate scenario. Facilitators blinded to study group allocation completed the performance checklists (dichotomously scored checklist, DSC) and Global Rating Scale of Performance (GRS). Two non-expert raters were trained, and assessed all videotaped performances., Results: Interim analysis indicated no difference between Groups B and C which were merged into one group. Seventy-four subjects were recruited, with 58 complete data sets available. There was no significant effect of group on pre-test scores. A significant improvement was seen between pre- and post-tests on the DSC in debriefed subjects (pre-test 66.8%, post-test 70.3%; F(1,57)=4.18, P=0.046). Both groups showed significant improvement in the GRS over time (F(1,57)=5.94, P=0.018), but no significant difference between the groups., Conclusions: We found a modest improvement in performance on a DSC in the debriefed group and overall improvement in both control and debriefed groups using a GRS. Whether this improvement translates into clinical practice has yet to be determined.

We conducted a retrospective survey to investigate if the grade of anaesthetist was a significant factor in determining outcome after day surgery in a district general hospital. All day surgery procedures performed between 1996 and 2006 were included except those under surgically administered local anaesthetic. The outcome measures assessed were unplanned admissions and symptoms reported after discharge. The overall admission rate was 2.6%, the admission rate for anaesthetic-related reasons was 1.5%, and 49% of patients reported some symptoms after discharge. Over the period studied the admission rate fell from 4.2% to 2.0%, admissions for anaesthetic-related reasons fell from 3.0% to 0.7% and reported symptoms fell from 67% to 37%. Consultants anaesthetists were associated with the lowest unplanned admission rate (consultants 2.3%, staff grade and associate specialists 3.1%, and trainees 3.3%), the lowest admission rate for anaesthetic reasons (consultants 1.2%, staff and associate specialists 2.0%, and trainees 1.8%), lower than expected specialty-weighted admissions and the lowest number of reported symptoms (consultants 47.3%, staff grade and associate specialists 52.6%, trainees 49.0%) (p < 0.001). We conclude that there was an improvement in outcome over the period of study and that the grade of anaesthetist is associated with outcome after day surgery.

Background: The effect of resident training in anaesthesiology on operating room (OR) economics is an issue of debate. Comparisons of anaesthesia process times between residents and consultants might be systematically skewed by interactions of anaesthesia technique and patient factors., Methods: In this prospective, observational study, we analysed anaesthesia process times in 599 cases performed for four different surgical services in a University hospital. The following factors were recorded for each case and used in multivariate analyses of process times: age, American Society of Anesthesiologist (ASA) status, BMI, emergency status, the educational level of the anaesthetist, and the anaesthesia technique., Results: In the non-adjusted comparison, only for two of seven anaesthetic techniques did resident cases have statistically significant longer induction times than consultant cases: general anaesthesia with placement of a central venous catheter [mean (sd) anaesthesia time for resident cases 38.2 (17.0) vs 22.3 (10.0) min for consultant cases, P=0.001] and general anaesthesia with a laryngeal mask airway [resident cases 11.3 (5.5) vs consultant cases 7.3 (5.0) min, P=0.003]. Anaesthetic technique had the greatest effect on anaesthesia induction time. Educational level of the anaesthetist and age of the patients had small, but significant effects., Conclusions: Anaesthesia cases performed by residents have in some, but not in all, anaesthesia techniques increased process times compared with cases performed by consultants. This limits a possible negative impact on OR economics by resident education. Patient-based factors including ASA status, BMI, and emergency status have minimal or no effect on anaesthesia process times.

Background: Despite a growing recognition of the role of human error in anaesthesia, it remains unclear what should be done to mitigate its effects. We addressed this issue by using task analysis to create a systematic description of the behaviours that are involved during anaesthesia, which can be used as a framework for promoting good practice and highlight areas of concern., Methods: The task steps involved in preparing and delivering anaesthesia were identified using hierarchical task analysis (HTA). The systematic human error reduction and prediction approach (SHERPA) was then used to identify potential human errors at each task step and suggest ways of preventing these errors., Results: The number and type of behaviours involved vary according to the 'phase' of anaesthesia, with tasks in the induction room, including induction of anaesthesia itself, being the most demanding. Errors during preoperative planning and perioperative maintenance could be avoided by measures to support information handling and decision-making. Errors during machine checking, induction, and emergence could be reduced by streamlining or automating task steps, or by making changes to the physical design of the work environment., Conclusions: We have demonstrated the value of task analysis in improving anaesthetic practice. Task analysis facilitates the identification of relevant human factors issues and suggests ways in which these issues can be addressed. The output of the task analysis will be of use in focusing future interventions and research in this area.

A monitoring system for cardiac surgery has been in use at Papworth Hospital for 10 years. We wished to determine whether this system would have detected an increase in deaths associated with a single practitioner, whether a poorly performing doctor or a serial killer such as Dr Harold Shipman, whose activities went undetected in the absence of a monitoring system for nearly a quarter of a century. Random extra deaths were artificially introduced into the practice of a surgeon and an anaesthetist in a way that broadly reproduced Shipman's pattern. The standard monitoring system was then used to analyse the hypothetical data thus generated. Using the current standard monitoring, the excess deaths would have been detected in less than 10 months. Suspicions would have been raised even earlier. Robust local quality monitoring of risk-adjusted outcomes is possible and, in our opinion, essential.

In this study, we aimed to construct, validate, and apply an instrument for assessing resident performance at outpatient preanesthesia consultation (PAC). A focus group and a Delphi panel of experts defined component items of a typical outpatient PAC, which could be used as indicators of competence. Items were incorporated in a checklist, which was further validated in a sample of consultations performed by board-certified anesthesiologists. The resulting instrument contained 37 items, grouped into five domains (physician-patient relationship, medical history, physical examination, patient education, and preanesthesia records), with high construct validity, high discriminant validity, moderate internal consistency, and high probability of inter-raters agreement. The instrument was applied to evaluate the performance of seven first-year residents at 317 consecutive PAC. Data were analyzed by constructing exponentially weighted moving average charts for domain and total scores. Statistically significant differing levels of performance could be consistently detected. Applying exponentially weighted moving average charts to the sequential analysis of the developed checklist scores can reliably assess resident performance at the devised criteria. The Preanesthesia Consultation Scoring Checklist is a potentially useful instrument for both formative and summative assessment of residents during their training in processes involved in outpatient preanesthesia evaluation.

Background: Expert professional practice in any field is known to rely on both explicit (formal) and tacit (personal) forms of knowledge. Current anaesthetic training programmes appear to favour explicit knowledge and measurable competencies. We aimed to describe and explore the way different types of knowledge are learned and used in anaesthetic practice., Method: Qualitative approach using non-participant observation of, and semi-structured interviews with, anaesthetic staff in two English hospitals., Results: The development of expertise in anaesthesia rests on the ability to reconcile and interpret many sources of knowledge--clinical, social, electronic, and experiential--and formal theoretical learning. Experts have mastered technical skills but are also able to understand the dynamic and uncertain condition of the anaesthetized patient and respond to changes in it. This expertise is acquired by working with colleagues, and, importantly, by working independently, to develop personal routines. Routines mark the successful incorporation of new knowledge but also function as a defence against the inherent uncertainty of anaesthetic practice. The habits seen in experts' routines are preferred ways of working chosen from a larger repertoire of techniques which can also be mobilized as changing circumstances demand., Conclusions: Opportunities for developing expertise are linked to the independent development of personal routines. Evidence-based approaches to professional practice may obscure the role played by the interpretation of knowledge. We suggest that the restriction of apprenticeship-style training threatens the acquisition of anaesthetic expertise as defined in this paper.

Objective: To explore the acquisition of knowledge in anaesthetic practice using qualitative methods., Methods: An ethnographic study examining the nature of expertise in anaesthesia in one English hospital. The study used qualitative research methods, including observation of anaesthetic practice and interviews with members of the anaesthetic team. An integral part of the study was a process of feedback to the anaesthetic team including presenting observational data and conducting debriefing interviews with individual team members., Results: The study highlights the continued importance of the clinical apprenticeship in passing on knowledge, but also emphasizes the central role of practising independently in the acquisition of skills. Anaesthetists who participated in debriefing interviews or read observational transcripts found the experience valuable for thinking about their own practice., Discussion: One suggestion arising from the use of qualitative methods in this setting is that the type of detailed, systematic observation and data recording used in this study could be beneficial in the training and, possibly, appraisal of anaesthetists. This novel and innovative application of qualitative methods in anaesthesia is described and discussed with a view to broadening the debate about specialist training.

Fatigue has been implicated in the occurrence of critical incidents. Using a driving simulator to assess vigilance, we investigated the effect of sleep disruption on the ability of anaesthetists to maintain vigilance after a night on-call. Following an undisturbed night of sleep, subjects demonstrated a significant improvement in their vigilance scores. Subjects failed to demonstrate this following a disturbed night. The timing of disturbance had a bearing on performance. Subjects' performance was worse if their sleep had been disturbed in the first third of the night. The effect of sleep disruption on vigilance has implications for patient safety during anaesthesia.

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.

Background: There is increasing emphasis on performance-based assessment of clinical competence. The High Fidelity Patient Simulator (HPS) may be useful for assessment of clinical practice in anaesthesia, but needs formal evaluation of validity, reliability, feasibility and effect on learning. We set out to assess the reliability of a global rating scale for scoring simulator performance in crisis management., Methods: Using a global rating scale, three judges independently rated videotapes of anaesthetists in simulated crises in the operating theatre. Five anaesthetists then independently rated subsets of these videotapes., Results: There was good agreement between raters for medical management, behavioural attributes and overall performance. Agreement was high for both the initial judges and the five additional raters., Conclusions: Using a global scale to assess simulator performance, we found good inter-rater reliability for scoring performance in a crisis. We estimate that two judges should provide a reliable assessment. High fidelity simulation should be studied further for assessing clinical performance.

Four observers estimated the weight and height of 38 patients who were lying covered on operating theatre trolleys. Regression analysis of the results was performed for each observer. The results showed marked variation in ability to assess these characteristics accurately.

Cusum analysis is a statistical technique to distinguish deviations from an acceptable failure rate. The progress of anaesthetic trainees learning four practical procedures (obstetric extradural anaesthesia, spinal anaesthesia, central venous cannulation and arterial cannulation) was monitored from their first attempt using cusum analysis. Suitable acceptable and unacceptable failure rates for each procedure were chosen by consultant anaesthetists. For obstetric extradural anaesthesia, four trainees eventually achieved acceptable failure rates (5%) and the number of attempts required to demonstrate this statistically ranged from 29 to 185; three trainees had an unacceptable failure rate (10%) and five trainees had inconclusive records. For spinal anaesthesia, two trainees achieved an acceptable failure rate (10%) and the number of attempts required to demonstrate this statistically ranged from 39 to 67; two trainees had an unacceptable failure rate (20%) and four trainees had inconclusive records. One trainee demonstrated statistically an acceptable failure rate in arterial cannulation (20%) after 14 attempts and four trainees had inconclusive records. Two records of central venous cannulation were inconclusive. Some records showed variable failure rates which were sometimes associated with lack of practice or a change in technique. Cusum analysis can be used to monitor training in practical procedures and as a continuous audit of quality of clinical practice.

Audiologists and speech-language pathologists who participate in or perform procedures on patients who have been medicated for sedation or topical anesthesia should appreciate the complex factors which may expose their patients to risk or harm. Administration of medications to achieve a desired patient state is a medical procedure requiring physician or dentist prescription, physician or dentist approval on the conditions of administration and monitoring, and physician or dentist availability for provision of emergency care that may be required. For these reasons, audiologists and speech-language pathologists should address issues of scope of practice as defined by state licensing boards and institutional regulatory committees, professional liability, and patient and practitioner safety before engaging in procedures on individuals medicated for sedation or topical anesthesia. These issues should be defined in specific, written protocols that the audiologist and speech-language pathologist develop in collaboration with physicians, dentists, and other medical professionals who are responsible for patient care. The protocols should specify responsibility for each aspect of care and limit procedures to professional settings with immediate access to emergency medical care. In all instances, both in development of written protocols and in actual professional practice, the comfort and safety of the patient must be paramount.