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Introduction: Performance assessment and feedback are critical factors in successful medical simulation-based training. The Dynamic Haptic Robotic Trainer (DHRT) allows residents to practice ultrasound-guided needle insertions during simulated central venous catheterization (CVC) procedures while providing detailed feedback and assessment. A study was performed to examine the effectiveness of the DHRT in training the important skills of needle tip tracking and aspiration and how these skills impact procedural complications in simulated CVC., Methods: The DHRT data were collected for 163 residents at 2 hospitals for 6 simulated needle insertions. Users were given automated feedback on 5 performance metrics, which measure aspiration rate, arterial punctures, punctures through and through the vein, loss of access to the vein, and successful access to the vein. Aspiration rates and tip tracking rates were analyzed to determine their significance in preventing CVC complications and improving performance., Results: Tip tracking rates higher than 40% were 2.3 times more likely to result in successful venous access than rates less than 10%. Similarly, aspiration rates higher than 80% were 2.6 times more likely to result in successful venous access than rates less than 10%. Proper tip tracking and aspiration both reduced mechanical complications. Resident performance improved for all metrics except tip tracking., Conclusions: Proper tip tracking and aspiration both reduced complications and increased the likelihood of success. However, the skill of tip tracking was not effectively learned through practice without feedback. Therefore, ultrasound-guided needle-based procedures, including CVC, can be improved by providing specific feedback to users on their ultrasound usage to track needle insertions., Competing Interests: J.Z.M. and S.R.M. own equity in Medulate, which may have a future interest in this project. Company ownership has been reviewed by the university's individual conflict of interest committee and is currently being managed by the university. The other authors declare no conflict of interest., (Copyright © 2022 Society for Simulation in Healthcare.)

Background: Patients requiring percutaneous endoscopic gastrostomy (PEG) for amyotrophic lateral sclerosis (ALS) related dysphagia represent a clinical challenge. Diminished pulmonary function and aspiration risks can lead to anesthesia-related complications, and gastric displacement from hemidiaphragm elevation may preclude safe gastric access. This study reports the efficacy and outcomes of a dedicated anesthesia/surgery management protocol for ALS patients undergoing PEG., Methods: In 2013, a PEG placement protocol for ALS patients was developed emphasizing efficient pre-operative evaluation, rapidly metabolized anesthetic agents, and minimization of opioid use. Outcomes were analyzed retrospectively. Preoperative weight loss, pulmonary function tests, total analgesia, procedural time, and 90-day morbidity and mortality were recorded., Results: From 2013-2019, 67 ALS patients (mean age 65.3 years, 52.2% female) received a PEG under the protocol. Mean percentage weight loss 6 months before PEG was 9.3 ± 5.1% with 38.8% of patients meeting criteria for severe malnutrition. Mean anesthesia time (propofol induction to anesthesia emergence) was 34.5 ± 10.8 min and mean operative time (endoscope insertion to dressing placement) was 16.4 ± 8.2 min. Regional anesthesia with liposomal bupivacaine was performed in 76.1%. All attempts at PEG placement were successful. With a mean follow-up of 6.1 ± 6.8 months, all PEGs were functional and there were no surgical site complications. Thirty-day readmission rate was 7.0% and 90-day mortality was 22.4% (46.7% occurring within 30 days). Mean time from surgery to death was 8.8 ± 7.8 months., Conclusions: Protocols for optimizing PEG may help overcome challenges present in the ALS patient population. Despite patient comorbidities, protocol implementation and dedicated team members resulted in a high procedural success rate and low complication rate. Further study is warranted to optimize the timing of PEG placement in relation to ALS disease progression and determine the utility of regional anesthesia during PEG placement., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The COVID-19 pandemic presented challenges for simulation programs including American College of Surgeons Accredited Education Institutes and American Society of Anesthesiologists Simulation Education Network. American College of Surgeons Accredited Education Institutes and American Society of Anesthesiologists Simulation Education Network leadership were surveyed to identify opportunities to enhance patient safety through simulation., Methods: Between January and June 2021, surveys consisting of 3 targeted domains: (I) Changing practice; (II) Contributions and recognition; and (III) Moving ahead were distributed to 100 American College of Surgeons Accredited Education Institutes and 54 American Society of Anesthesiologists Simulation Education Network centers. Responses were combined and percent frequencies reported., Results: Ninety-six respondents, representing 51 (51%) American College of Surgeons Accredited Education Institutes, 17 (31.5%) American Society of Anesthesiologists Simulation Education Network, and 28 dually accredited centers, completed the survey. Change of practice. Although 20.3% of centers stayed fully operational at the COVID-19 onset, 82% of all centers closed: 32% were closed less than 3 months, 28% were closed 3 to 6 months, 8% were closed 7 to 9 months, and 32% remained closed as of June 6, 2021. Most impacted activities were large-group instruction and team training. Sixty-nine percent of programs converted in-person to virtual programs. Contributions. The top reported innovative contributions included policies (80%), curricula (80%), and scholarly work (74%), Moving ahead. The respondents' top concerns were returning to high-quality training to best address learners' deficiencies and re-engagement of re-directed training programs. When asked "How the American College of Surgeons/American Society of Anesthesiologists Programs could best assist your simulation center goals?" the top responses were "facilitate collaboration" and "publish best practices from this work.", Conclusion: The Pandemic presented multiple challenges and opportunities for simulation centers. Opportunities included collaboration between American College of Surgeons Accredited Education Institutes and the American Society of Anesthesiologists Simulation Education Network to identify best practices and resources needed to enhance patient safety through simulation., (Published by Elsevier Inc.)

The Dynamic Haptic Robotic Trainer (DHRT) was developed to minimize the up to 39% of adverse effects experienced by patients during Central Venous Catheterization (CVC) by standardizing CVC training, and provide automated assessments of performance. Specifically, this system was developed to replace manikin trainers that only simulate one patient anatomy and require a trained preceptor to evaluate the trainees' performance. While the DHRT system provides automated feedback, the utility of this system with real-world scenarios and expertise has yet to be thoroughly investigated. Thus, the current study was developed to determine the validity of the current objective assessment metrics incorporated in the DHRT system through expert interviews. The main findings from this study are that experts do agree on perceptions of patient case difficulty, and that characterizations of patient case difficulty is based on anatomical characteristics, multiple needle insertions, and prior catheterization., Competing Interests: Company ownership has been reviewed by the University’s Individual Conflict of Interest Committee and is currently being managed by the University.

Acute adrenal insufficiency is a rare but potentially life-threatening event during the perioperative period. The usual manifestations of an acute adrenal crisis can mimic common postoperative complications and a high index of suspicion is required for the diagnosis. Early diagnosis and prompt treatment can be lifesaving. We present the case of a 65-year-old man who, after a partial nephrectomy, developed acute adrenal insufficiency, which remained undiagnosed in the postoperative period, eventually leading to cardiac arrest. This case highlights the need for perioperative physicians to have a watchful eye for diagnosing and treating this uncommon yet lethal condition.

The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.

Intraosseous vascular access is a time-tested procedure that is reemerging in popularity. This is primarily a result of the emphasis on intraosseous access in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Advanced Cardiac Life Support. Modern intraosseous insertion devices are easy to learn and use, suggesting the possibility of use beyond the resuscitation setting. We present a case series of recent intraosseous insertions for a variety of indications by anesthesiologists at our institution to demonstrate the potential utility of this alternative access technique., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Laryngeal tubes (LT) are often used as rescue airway devices. Among prehospital medical personnel, the success rates are high and significantly faster compared to an endotracheal tube (ETT). Therefore, LTs are increasingly used in the prehospital setting. The exchange of an LT for an ETT may often be desirable. Two fiberoptic bronchoscope-facilitated techniques have been described to exchange an LT for an ETT: an intraluminal technique using an Aintree intubating catheter and an extraluminal technique using a nasal route alongside the LT. In this randomized cross-over mannequin study, we compared the intraluminal with the extraluminal exchange technique. The primary outcome was time to achieve an effective airway through an ETT. We hypothesized that the intraluminal technique would be significantly faster., Methods: Thirty anesthesia providers were recruited to the study. Each participant attempted both techniques in an intubation simulation model. The tube exchange time was recorded from picking up the fiberoptic bronchoscope until confirmation of ventilation with the ETT., Results: Four participants in each group had a failed attempt at intubation. Time to establish an endotracheal intubation was significantly shorter with the intraluminal technique vs the extraluminal technique (77.5 vs 140 seconds; P=.03)., Conclusion: Based on the results of our study, we suggest that the intraluminal technique may be a suitable alternative for a fiberoptic-guided rapid exchange of an LT for an ETT to establish an effective airway in a challenging situation., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Observations of cardiopulmonary arrests (CPAs) reveal concerning patterns when clinicians identify a problem, (e.g. loss of pulse) but do not immediately initiate appropriate therapy (e.g. compressions) resulting in delays in life saving therapy., Methods: We hypothesized that when individuals utilized specific, short, easy-to-state action phrases stating an observation followed by an associated intervention, there would be a higher likelihood that appropriate action would immediately occur. Phase I: A retrospective analysis of residents in simulated CPAs measured what proportion verbalized "There's no pulse", statements and/or actions that followed and whether "Action-Linked Phrases" were associated with faster initiation of compressions. Phase II: Two prospective, quasi-experimental studies evaluated if teaching three Action-Linked Phrases for Basic Life Support (BLS) courses or six Action-Linked Phrases for Advanced Cardiovascular Life Support (ACLS) courses was associated with increased use of these phrases., Results: Phase I: 62% (42/68) of residents verbalized "there's no pulse" during initial assessment of a pulseless patient, and only 16/42 (38%) followed that by stating "start compressions". Residents verbalizing this Action-Linked Phrase started compressions sooner than others: (30s [IQR:19-42] vs. 150 [IQR:51-242], p < 0.001). Phase II: In BLS courses, the three Action-Linked Phrases were used more frequently in the intervention group: (226/270 [84%] vs. 14/195 [7%]; p < 0.001). In ACLS courses, the six Action-Linked Phrases were uttered more often in the intervention group: (43% [157/368] vs. 23% [46/201], p < 0.001)., Conclusions: Action-Linked Phrases innately used by residents in simulated CPAs were associated with faster initiation of compressions. Action-Linked Phrases were verbalized more frequently if taught as part of a regular BLS or ACLS course. This simple, easy to teach, and easy to implement technique holds promise for impacting cardiac arrest teams' performance of key actions., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Simulation-based medical education is growing in use and popularity in various settings and specialties. A literature review yields scant information about the use of simulation-based medical education in neurology, however. The specialty of neurology presents an interesting challenge to the field of simulation-based medical education because of the inability of even the most advanced mannequins to mimic a focal neurologic deficit. The authors present simulator protocols for status epilepticus and acute stroke that use a high-fidelity mannequin despite its inability to mimic a focal neurologic deficit. These protocols are used in the training of third- and fourth-year medical students during their neurology clerkship at Penn State College of Medicine. The authors also provide a review of the pertinent literature.

Purpose: The purpose of this study was to assess the effectiveness of high-fidelity simulation for teaching root cause analysis (RCA) in graduate medical education., Methods: Thirty clinical anesthesiology-1 through clinical anesthesiology-3 residents were randomly assigned to 2 groups: group A participants received a 10-minute lecture on RCA and participated in a simulation exercise where a medical error occurs, and group B participants received the 10-minute lecture on RCA only. Participants completed baseline, postintervention, and 6-month follow-up assessments, and they were evaluated on their attitude toward as well as understanding of RCA and "systems-based" care., Results: All 30 residents completed the surveys. Baseline attitudes and knowledge scores were similar between groups. Postintervention knowledge scores were also similar between groups; however, group B was significantly more skeptical (P < .001) about the use of RCA and "systems improvement" strategies. Six months later, group A demonstrated retained knowledge scores and unchanged attitude, whereas group B demonstrated significantly worse knowledge scores (P  =  .001) as well as continued skepticism toward a systems-based approach (P < .001) to medical error reduction., Conclusion: High-fidelity simulation in conjunction with focused didactics is an effective strategy for teaching RCA and systems theory in graduate medical education. Our findings also suggest that there is greater retention of knowledge and increased positive attitude toward systems improvement when focused didactics are coupled with a high-fidelity simulation exercise.

This article traces the history of anesthesiology's role in simulation from Resusci Anne and Sim One to the use of simulation today for introducing new products and techniques to otherwise fully trained, practicing physicians. The article also describes the latest efforts of the American Society of Anesthesiologists (ASA) to promote simulation-based instruction. The article focuses in particular on the activities of the ASA Committee on Simulation Education. Many predict that simulation-based teaching will generate the next revolution in health care education. The ASA is hoping to capitalize on anesthesiology's long involvement and leadership in simulation-based health care education to help bring about this revolution.

Unlabelled: Given in clinically relevant large doses to rats, mu-opioids produce limbic system hypermetabolism and histopathology. This investigation extends these observations, in both rats and humans, for the short-acting drug remifentanil, which allows more precise control and assessment of the effects of duration of opioid exposure. We performed two series of experiments: one in rats for neuropathologic effects and the second in humans for neurometabolic effects. Fifty mechanically ventilated rats received saline solution or remifentanil 20-160 microg x kg(-1) x min(-1) for 3 h, followed by neuropathologic evaluation 7 days later. Four volunteers underwent induction of anesthesia and endotracheal intubation with propofol and rocuronium administration followed by remifentanil infusion at 1-3 microg x kg(-1) x min(-1) with positron emission tomography evaluation of cerebral metabolic rate for glucose. In rats, dose-related electroencephalogram activation was evident and 19 of 40 remifentanil-treated rats showed brain damage, primarily in the limbic system (P < 0.01). In humans, cerebral metabolic rate for glucose in the temporal lobe increased from 6.29 +/- 0.32 to 7.68 +/- 1.05 mg x 100 g(-1) x min(-1) (P < 0.05). These data indicate that prolonged large-dose remifentanil infusion is neurotoxic in rats with congruent metabolic effects with brief infusion in humans and suggest that some adverse effects reported in rats may be clinically relevant., Implications: This study demonstrates dose-related remifentanil neurotoxicity in physiologically controlled rats with congruent brain metabolic effects in four humans undergoing positron emission tomography evaluation during brief large-dose remifentanil anesthesia. These data suggest that some adverse effects reported in rats may be clinically relevant.

Many medical disciplines participate in the acute care of hemodynamically unstable patients. At WVU we have many opportunities for multidisciplinary critical care group instruction in our simulation facility. The main educational goals of this session are the recognition and management of a pulmonary artery catheter that is coiled in the right ventricle. Recognition of waveforms and identification of catheter malposition are a priority in our critical care education programs. We present the scenario using the METI model C manikin with system 5.5 software. The target audiences for this scenario at WVU include junior house staff from assorted disciplines, masters level physician assistant students, and medical students during the second and fourth years of training. This scenario has also been included in a critical care medicine CME course for a variety of health care practitioners. We present a variety of the manufacturer's pre-packaged hemodynamic instability scenarios. Standard man awake or relaxed with the hypotension-hemorrhage scenario is described in detail. The focus is on catheter misplacement rather than on disease state. Despite prior preparation from lecture with slides, textbook review, ordemonstration without patient context, most students do not recognize a right ventricular waveform when it is simulated in the context of a patient care scenario. Debriefing occurs immediately in the simulation laboratory and includes a review of typical waveform and pressure transitions as the catheter passes from the introducer to the wedge position. Measurement of cardiac output is demonstrated. A variety of electronic resources are suggested for further self-study and more complete review of invasive monitoring principles and techniques. Students over the past 4 years have had an overwhelmingly positive response to this simulation experience.

Study Objectives: To evaluate the cerebral vascular effects of cis-atracurium and rocuronium given after thiopental induction of anesthesia., Design: Randomized, single-blinded study., Setting: University-affiliated hospital., Patients: 39 adult ASA physical status I and II patients undergoing nonintracranial procedures., Interventions: Patients received intravenously (IV), either saline placebo, cis-atracurium, or rocuronium after induction of general anesthesia with thiopental sodium., Measurements: The right middle cerebral artery was insonated using a pulsed-wave range-gated transcranial Doppler, and data were recorded at preinduction, immediately postinduction, at injection of the study drug, and at 15-second intervals for 3 minutes thereafter. The variables recorded for each subject included the systolic, diastolic, and mean flow velocity, as well as pulsality index, systolic, diastolic, and mean arterial blood pressure (MAP), and end-tidal carbon dioxide concentration., Main Results: No significant differences between the groups were present in the postanesthetic induction maximal or minimal mean flow velocity., Conclusions: cis-Atracurium and rocuronium, administered after thiopental, do not produce clinically relevant changes in cerebral blood flow velocity.

The global approach to resuscitation has changed dramatically in the past year. The groundwork for these changes began a decade ago with the development of the Utstein guidelines for uniform reporting of critical events. Consistency in data collection was necessary to enable evidence-based review and comparison of current practice. Resuscitation protocols have been significantly altered based upon these data. Basic life support (BLS) protocols have been simplified. Early access to electrical cardioversion is the key to survival. Mobilization of AED technology in the community is essential. Several issues were identified as crucial to future improvement of resuscitation statistics. Prevention strategies should be developed for high-risk patients. There is a need to identify cases in which resuscitation should not be started. Enhancement of educational methods to improve performance and retention of skills is key. Finally, the roadblocks for performance of ethical prospective research must be minimized.

Unlabelled: In previous studies, large-dose fentanyl produced electrographic seizure activity and histologically evident brain damage. We assessed whether fentanyl-induced brain damage is attenuated by using anticonvulsant drugs. Using halothane/nitrous oxide anesthesia, 40 Sprague-Dawley rats underwent tracheal intubation, arterial and venous cannulation, and insertion of biparietal electroencephalogram electrodes and a rectal temperature probe. Halothane was discontinued. The dose of IV fentanyl shown previously to cause maximal brain damage was given to all animals and N(2)O was discontinued. Control rats were given fentanyl only. Rats in the three study groups also received midazolam, phenytoin, or N(2)O/naloxone. After characteristic seizure activity began with fentanyl loading the study drug was started. After a 2-h infusion, wounds were closed, and animals recovered overnight and underwent cerebral perfusion-fixation. Neuropathologic alterations were ranked on a scale of 0-5 for both neuronal death (0 = normal, 5 = more than 75% neuronal death) and for malacia. Significantly fewer rats in the N(2)O/Naloxone, Phenytoin, and Midazolam Groups sustained any brain damage compared with controls. Protection against opioid neurotoxicity is achieved with midazolam, naloxone, and phenytoin. If opioid neurotoxicity is clinically relevant, a small change in anesthetic practice might reduce any potential neurologic morbidity., Implications: Narcotics in large doses can cause brain damage in rats. This brain damage is attenuated by a narcotic antagonist, a sedative, and an antiepileptic drug.

Nitric oxide (NO) derived from the inducible isoform of NO synthase (iNOS) is an inflammatory product implicated both in secondary damage and in recovery from brain injury. To address the role of iNOS in experimental traumatic brain injury (TBI), we used 2 paradigms in 2 species. In a model of controlled cortical impact (CCI) with secondary hypoxemia, rats were treated with vehicle or with 1 of 2 iNOS inhibitors (aminoguanidine and L-N-iminoethyl-lysine), administered by Alzet pump for 5 days and 1. 5 days after injury, respectively. In a model of CCI, knockout mice lacking the iNOS gene (iNOS(-/-)) were compared with wild-type (iNOS(+/+)) mice. Functional outcome (motor and cognitive) during the first 20 days after injury, and histopathology at 21 days, were assessed in both studies. Treatment of rats with either of the iNOS inhibitors after TBI significantly exacerbated deficits in cognitive performance, as assessed by Morris water maze (MWM) and increased neuron loss in vulnerable regions (CA3 and CA1) of hippocampus. Uninjured iNOS(+/+) and iNOS(-/-) mice performed equally well in both motor and cognitive tasks. However, after TBI, iNOS(-/-) mice showed markedly worse performance in the MWM task than iNOS(+/+) mice. A beneficial role for iNOS in TBI is supported.

Objective: To measure quinolinic acid, a macrophage-derived neurotoxin, in the cerebrospinal fluid (CSF) of children after traumatic brain injury (TBI) and to correlate CSF quinolinic acid concentrations to clinically important variables., Design: A prospective, observational study., Setting: The pediatric intensive care unit in Children's Hospital of Pittsburgh, a tertiary care, university-based children's hospital., Patients: Seventeen critically ill children following severe TBI (Glasgow Coma Scale score <8) whose care required the placement of an intraventricular catheter for continuous drainage of CSF., Interventions: None., Measurements and Main Results: Patients ranged in age from 2 mos to 16 yrs (mean 6.0 yrs). CSF was collected immediately on placement of the ventricular catheter and daily thereafter. Quinolinic acid concentration was measured by gas chromatography/mass spectroscopy in 69 samples (4.0 +/- 0.4 [SEM] samples per patient). CSF quinolinic acid concentration progressively increased after injury (p = .034, multivariate analysis) and was increased in nonsurvivors vs. survivors (p = .002, multivariate analysis). CSF quinolinic acid concentration was not associated with age. Although overall CSF quinolinic acid concentration was not associated with shaken injury (p = .16, multivariate analysis), infants suffering with shaken infant syndrome had increased admission CSF quinolinic acid concentrations compared with children with accidental mechanisms of injury (p = .027, Mann-Whitney Rank Sum test)., Conclusions: A large and progressive increase in the macrophage-derived neurotoxin quinolinic acid is seen following severe TBI in children. The increase is strongly associated with increased mortality. Increased CSF quinolinic acid concentration on admission in children with shaken infant syndrome could reflect a delay in presentation to medical attention or age-related differences in quinolinic acid production. These findings raise the possibility that quinolinic acid may play a role in secondary injury after TBI in children and suggest an interaction between inflammatory and excitotoxic mechanisms of injury following TBI.

We tested the hypothesis that quinolinic acid, a tryptophan-derived N-methyl-D-aspartate agonist produced by macrophages and microglia, would be increased in CSF after severe traumatic brain injury (TBI) in humans, and that this increase would be associated with outcome. We also sought to determine whether therapeutic hypothermia reduced CSF quinolinic acid after injury. Samples of CSF (n = 230) were collected from ventricular catheters in 39 patients (16 to 73 years old) during the first week after TBI, (Glasgow Coma Scale [GCS] < 8). As part of an ongoing study, patients were randomized within 6 hours after injury to either hypothermia (32 degrees C) or normothermia (37 degrees C) treatments for 24 hours. Otherwise, patients received standard neurointensive care. Quinolinic acid was measured by mass spectrometry. Univariate and multivariate analyses were used to compare CSF quinolinic acid concentrations with age, gender, GCS, time after injury, mortality, and treatment (hypothermia versus normothermia). Quinolinic acid concentration in CSF increased maximally to 463 +/- 128 nmol/L (mean +/- SEM) at 72 to 83 hours after TBI. Normal values for quinolinic acid concentration in CSF are less than 50 nmol/L. Quinolinic acid concentration was increased 5- to 50-fold in many patients. There was a powerful association between time after TBI and increased quinolinic acid (P < 0.00001), and quinolinic acid was higher in patients who died than in survivors (P = 0.003). Age, gender, GCS, and treatment (32 degrees C versus 37 degrees C) did not correlate with CSF quinolinic acid. These data reveal a large increase in quinolinic acid concentration in CSF after TBI in humans and raise the possibility that this macrophage-derived excitotoxin may contribute to secondary damage.

As public concern for quality control of medical care at the beginning of this century forced regulations on medical licensing of physicians, the forces of change in health care are again substantial, this time driven by concerns for cost and access. Our experience at the University of Pittsburgh Medical Center leads us to believe that well-trained physician extenders will play a valuable role in improving efficiency and effectiveness in the care of critically ill patients. We have developed a method for training and supervision. Graded practice supervision, with physician-led professional review, is considered a reasonable goal. We propose that the appropriate degree of supervision in any given area can be determined by: a) careful development of training programs; b) careful assessment of the individual's practice with the target patient population; and c) application of a review process that is sensitive in that population. Issues surrounding the independent practice and reimbursement of acute care nurse practitioners (ACNPs) are not resolved. These issues should be addressed by joint position statements that are based on objective documentation of the safe, effective performance of ACNPs, and on the incorporation of routine performance measurements with continued medical or joint evaluation of the quality review system. Guidelines regarding the evolving roles of ACNPs should be established by professional associations and state or national boards of both nursing and medical practice. Critical care physician and nursing leaders should lead such initiatives.