The aging anesthesiologist: a narrative review and suggested strategies.

PURPOSE: To address an aging anesthesia workforce, we review the relevant changes and implications associated with age in order to stimulate discussion at the individual, local, and national levels regarding appropriate changes in practice aimed at protecting patient safety. PRINCIPAL FINDINGS: In a 2013 survey of Canadian Anesthesiologists, 22% were aged 55-64 yr, 7% were aged 65-74 yr, and 3% were older than 74 yr. Clinical abilities decline with age, making older anesthesiologists more likely than their younger colleagues to be associated with adverse patient events. Anesthesiologists older than 65 yr in Ontario, Quebec, and British Columbia had 50% more cases involving litigation and almost twice the number of cases involving severe patient injury compared with anesthesiologists younger than 51 yr of age. In the absence of overt deterioration in skills, decisions about reducing activities and retirement are left largely to individuals despite their limited ability to self-assess competence. This state of affairs may contribute to the increased incidence of adverse events and poor patient outcomes. CONCLUSIONS: Provincial regulatory bodies have peer assessment programs to evaluate physicians at random, following a complaint, and at certain ages, but all have limitations. Simulation has been used widely for training and assessment in the aviation industry as well as in automobile driving exams. Simulation can assess crisis recognition and management, which is crucial in anesthesiology and not well assessed by other methods, and could assist elderly anesthesiologists during the pre-retirement phase of their careers. A standardized schedule for winding down would have advantages for physicians, their department, and their patients. A suggested schedule might include no further on-call duties for those aged 60 yr and older, no further high-acuity cases for those aged 65 yr and older, and retirement from operating room (OR) clinical practice (with possible continuation of non-OR clinical or other non-clinical activities, if desired) at age 70 yr. These timelines could be extended with satisfactory performance in annual simulation sessions involving assessment and practice in crisis management.

Evolution of a research team: the patient partner perspective.

INTRODUCTION: Despite a movement toward the inclusion of patient partners or advisors as part of the research team in all funded studies, few publications have discussed patient engagement from the patient partners' perspective. METHODS: Qualitative interviews were conducted by independent qualitative researchers to collect and summarize the experiences and perspectives of the 16 Patient Partners (PPs) on the study team for PeRson EmPowered Asthma RElief (PREPARE), a large, pragmatic study of 1200 African American/Black (AA/B) and Hispanic/Latinx (H/L) adults with asthma. This study was funded by the Patient-Centered Outcomes Research Institute. RESULTS: This paper, authored by the PPs themselves, summarizes qualitative interview findings. The journey of the PREPARE PPs began with a desire to learn more about asthma and advocate for other individuals with asthma. Many challenges, including intimidation and lack of trust, were overcome as the research team prioritized building a comfortable environment in which PPs' lived experiences, opinions, and cultural beliefs are valued, and in which PP voices are centered and respected. Over time, the PPs gained confidence in expressing ideas and feedback, and in taking ownership of their role as valued members of the research team. The PP experience has had tremendous personal and professional impact on the PPs themselves, while also modeling a change in the way researchers and PPs relate to and partner with each other. CONCLUSION: The partnership between PPs and researchers in the PREPARE study has elevated the PP role from external advisors to integral and empowered members of a collective research team, and the partnership developed and evolved over time.

Patients and caregivers who have lived with a condition have an important and unique perspective researchers should consider. To this end, patients and caregivers have expanded their involvement in the design and conduct of clinical research, joining research teams and being engaged in the research process from start to finish. Researchers have reported on the positive impact that these "patient partners" or "patient advisors" have on research. But few papers report on the impact on the patient partners/advisors from being on a research team.Here we report the lived experiences of the 16 Patient Partners who served on the research team for a large study of 1200 African American/Black (AA/B) and Hispanic/Latinx (H/L) adults with asthma. These Patient Partners offered their input over 7 years, spanning from study design, study conduct, understanding results, to sharing results.To understand the Patient Partners' experiences, we conducted interviews asking about their journey on the research team. Motivations and reasons they became Patient Partners Initial experiences with the research team If and how over time, they became comfortable and developed confidence If and how the research team made them feel valued and respected The personal and professional impact of being a Patient Partner Their advice to researchers and fellow patients considering including or joining as Patient Partners or advisors By reporting the perspectives of these 16 Patient Partners, we hope to support continued movement toward broader and better inclusion of patients and caregivers on research teams.

Intravenous lidocaine does not reduce length of hospital stay following abdominal hysterectomy.

PURPOSE: Intravenous lidocaine given both intraoperatively and postoperatively decreases pain scores, reduces opioid consumption, and promotes faster return of bowel function following abdominal surgery. The purpose of this trial was to determine if intravenous lidocaine limited to the intraoperative period reduces length of hospital stay and improves functional recovery following abdominal hysterectomy. METHODS: Following Research Ethics Board approval and informed consent, women of American Society of Anesthesiologists' class I and II undergoing abdominal hysterectomy were assigned randomly to lidocaine and control groups. Lidocaine subjects received an intravenous bolus of 1.5 mg.kg(-1) followed by an infusion of 3 mg.kg(-1).hr(-1), while control subjects received matching placebo. Patients, anesthesiologists, and study personnel were blinded, and anesthesia and multimodal perioperative analgesia were standardized. The primary outcome of this trial was discharge from hospital on or before the second postoperative day (POD2). Additional criteria were assessed for secondary outcomes, i.e., discharge fitness on POD2, length of hospital stay, opioid use, numeric rating scores for pain, quality of recovery, and recovery of bowel function. RESULTS: Ninety of the 93 women who were recruited completed the study protocol. The characteristics of the patients in both groups were similar-lidocaine group (n = 44) and control group (n = 46)-and no difference was noted between groups in the numbers of women discharged from hospital on POD2 (10 lidocaine, 15 control; P = 0.295). Days to discharge fitness (P = 0.666) and length of hospital stay (P = 0.456) were also similar. Differences in opioid consumption, pain scores, and recovery were neither clinically nor statistically significant. CONCLUSION: Intraoperative administration of intravenous lidocaine did not reduce hospital stay or improve objective measures of analgesia and recovery following abdominal hysterectomy. This trial was registered at ClinicalTrials.gov (NCT00382499).

The Best and Worst Things Staff Report About Behavioral Training Workshops: a Large-Scale Evaluation.

A variable affecting the success of staff training programs conducted by behavior analysts is trainee acceptance of the training. This study constituted a large-scale evaluation of staff acceptance of behavioral training workshops. Over a 10-year period, 646 human service staff who participated in 132 workshops were questioned regarding the best and worst thing about the workshops. The most common staff comments concerning the best thing pertained to the training content, followed closely by trainer style and then trainee activities. There were far fewer comments regarding the worst thing, with most involving aspects of the physical environment in which training occurred. Implications of the results for practitioners are offered in terms of conducting workshop training in accordance with trainees' reported preferences. Emphasis is placed on ensuring training content is specific in nature as well as new and relevant for the trainees' work situation, providing frequent demonstrations and examples, and structuring repeated opportunities for active trainee responding.

No Less Worthy: Recommendations for Behavior Analysts Treating Adults with Intellectual and Developmental Disabilities with Dignity.

In this article, the authors offer recommendations for behavior analysts on how to treat adults with intellectual and developmental disabilities (IDD) with dignity. Initially, the importance of treating adults with disabilities with dignity is emphasized in terms of the impact on people with IDD, their family members, behavior analysts and other service providers, and the behavior analysis field in general. The recommendations are based primarily on the authors' professional and personal experiences along with similar experiences of others involved either personally or professionally in the disability field. The focus is on ways in which behavior analysts speak and behave that reflect dignity versus the lack thereof as perceived by others and, where relevant, consensus opinion within the professional field of IDD. Ways for behavior analysts to acquire and maintain awareness of manners of speaking and behaving that reflect dignity within the local settings in which they work are also provided.

Release method and anatomical hook location: effects on short-term mortality of angler-caught Acanthopagrus australis and Argyrosomus japonicus.

One field and 3 aquaria experiments were done to quantify the short-term mortality of yellowfin bream Acanthopagrus australis and mulloway Argyrosomus japonicus after being angled and subjected to 3 general handling treatments. Anglers were supplied with identical J-type hooks and asked to handle hooked fish by either (1) physically removing the hook or (2) cutting the line (5 cm from the mouth of the fish) and leaving the hook in. Some hooked A. japonicus were subjected to a third handling treatment where the line was cut underwater without exposing the fish to air. Technical and biological data were collected before all fish were released into sea cages and monitored for 5 d. Control fish were seined and similarly caged and monitored. Concentrations of plasma glucose and cortisol were collected from a sample of fish on the first and last day of the experiments. Significant predictors of mortality for both species involved the presence of blood at the mouth and an interaction between anatomical hook location and hook removal. A. australis and A. japonicus that had their ingested hooks removed experienced the greatest mortalities (87.5 and 72.7%, respectively). Typically, these fish suffered damage to their oesophagus, stomach wall and vital organs. Mortality rates of A. australis and A. japonicus were significantly decreased to 1.7 and 16%, respectively, when they were released with their lines cut, with some of these fish free of hooks after 5 d. In contrast, few mortalities occurred in either species when the hooks were removed or the lines cut on mouth-hooked fish or in A. japonicus when it was released with no air exposure. For A. australis, the field- and aquaria-based experiments provided comparable results in terms of identifying treatment-specific effects, but there were potential biases in rates of hook ingestion. Irrespective of the treatment of fish, all experiments caused physiological changes measured as elevations in either plasma cortisol or glucose. We concluded that anglers should cut the line from hook-ingested A. australis and A. japonicus, but remove the hook from mouth-hooked individuals to prevent subsequent ingestion. Further research is required to examine the longer-term consequences of these handling practices on fish health.

Effects of reactivity to observations on staff performance.

We examined reactivity of staff behavior to observations of their work performance. After training 2 job coaches to reduce completion of break activities for supported workers, we evaluated job-coach behavior using both conspicuous and inconspicuous observations. Results indicated that both coaches completed none of the activities when observations were conspicuous but most of the activities when observations were inconspicuous. Subsequently, job coaches were taught to self-record their performances, and their completion of activities remained low with inconspicuous observations. Implications of reactivity are discussed for investigations that target staff behavior.

Maintaining Staff Performance Following a Training Intervention: Suggestions from a 30-Year Case Example.

A frequent challenge encountered by behavior analysts in human service agencies is maintaining effects of their training interventions with agency staff. A case example is provided to illustrate how effects of a staff training intervention initiated by a behavior analyst maintained for an extended period in a center-based program for adolescents and adults with severe disabilities. The process involved the behavior analyst working closely with the program supervisor and a professional staff member in a collaborative team approach to increase involvement of center participants in functional (vs. nonfunctional) educational tasks. Initially, the team jointly developed an intervention to increase staffs' provision of functional tasks. The behavior analyst subsequently worked with the team members regarding how to implement the intervention by training their staff and providing feedback. The two team members then continued providing feedback during their respective supervisor tenures without continued presence of the behavior analyst. Results indicated that initial increases in participant involvement in functional tasks maintained during follow-up observations encompassing 30 years. Normative comparisons also showed that the levels were well above the level of functional task involvement in other center-based programs across that time period. Results are discussed regarding recommendations for behavior analysts to use a collaborative team approach with supervisors indigenous to an agency to help maintain staff behavior targeted for change by the behavior analysts.

Evaluating and increasing in-home leisure activity among adults with severe disabilities in supported independent living.

Observations were conducted of the in-home leisure activity of three adults with severe disabilities in three supported independent living (SIL) sites. Results indicated a lack of leisure engagement. Potentially preferred, typical leisure activities were then identified by consulting lists of common leisure activities, surveying adults in surrounding communities, and interviewing support staff and family members. Next, in-home staffs were trained to provide the identified leisure activities in a repeated, paired-choice manner. Results indicated increased leisure engagement for each participant when staff provided leisure choices along with brief prompting. Social validation surveys suggested the choice procedures were well received by the staff and participants. Comparison observations of nine adults in other SIL arrangements in two states indicated the low levels of engagement initially observed in the three target homes may be quite common among people with severe disabilities in SIL. Results are discussed regarding use of behavioral procedures to evaluate and improve aspects of quality of life in SIL. Future research needs noted focus on how to impact staff performance and consumer lifestyles in residential settings in which supervision is infrequent.

Enhancing job-site training of supported workers with autism: a reemphasis on simulation.

Currently recommended practice in supported work emphasizes training job skills to workers with severe disabilities while on the job. Early behavioral research indicated that skills needed in natural environments could also be trained in simulated settings. We compared job-site plus simulation training for teaching job skills to supported workers with autism to provision of training exclusively on the job. Job-site training occurred in a small publishing company during the regular work routine, and simulation training occurred in an adult education site for people with severe disabilities. Two pairs of workers received training on two job skills; one skill was trained at the job site and the other was trained using job-site plus simulation training. Results indicated that for 3 of the 4 comparisons, job-site plus simulation training resulted in a higher level of skill or more rapid skill acquisition than did job-site-only training. Results suggested that job-site training, the assumed best practice for teaching vocational skills, is likely to be more effective if supplemented with simulation training. Directions for future research include expanding applications of behavioral technologies to other aspects of the current support paradigm.

Familiarizing New Staff for Working with Adults with Severe Disabilities: a Case for Relationship Building.

In human service agencies, situations exist at various times in which consumers are not familiar with the staff who work with them. We evaluated effects of familiar versus unfamiliar staff working with two men with severe disabilities in a vocational program. Results indicated both participants displayed more compliance with familiar staff relative to unfamiliar staff and one exhibited more on-task (one was near ceiling levels with both staff). Subsequently, a familiarization process was conducted with four new staff before working with four men with severe disabilities that involved spending time with a participant in a preferred activity and phasing in to the participant's routine. Each staff worked with one participant after being familiarized and concurrently with another without being familiarized. In all but one case, participant compliance was greater with the familiarized staff. Except when on-task was near ceiling levels, it also was higher with the familiarized staff. Additionally, results offered some support for the existence of a good relationship between familiarized staff and participants in terms of more participant happiness indices than with unfamiliar staff and, to a smaller degree, less unhappiness indices and problem behavior. Implications for practitioners are discussed, including being aware of potential problems when unfamiliar staff work with adults with severe disabilities and considering familiarizing new staff prior to working with individuals. Discussion also addresses how more attention could be directed to relationship development from a practitioner and research perspective.

Improving staff performance through clinician application of outcome management.

In two studies, three clinicians were assisted in using an outcome management approach to supervision for improving the work performance of their staff assistants. Using vocal and written instructions, feedback, and modeling, each clinician was assisted in specifying an area of staff performance (or consumer activity related to staff performance) to improve, developing and implementing a performance monitoring system, training staff in the targeted performances using performance- and competency-based training, and providing on-the-job supportive and corrective feedback. In Study 1, a senior job coach was assisted in using the outcome management steps to improve prompting procedures of three staff job coaches working with supported workers with autism in a community job. Correct prompting improved for all three job coaches following implementation of the outcome management process by the senior job coach. In Study 2, two teachers in two adult education classrooms were assisted in using the process to improve the degree to which their assistants involved students with severe disabilities in meal-preparation activities. Student participation in the activities increased in both classrooms when the teachers implemented the outcome management steps. In both studies, improved performances maintained for at least a 14-week period. Results are discussed in regard to working with supervisors as representing one step in promoting the adoption of research-based supervisory strategies within human service organizations.

An enriched teaching program for reducing resistance and indices of unhappiness among individuals with profound multiple disabilities.

We evaluated an enriched teaching program for reducing resistance and indices of unhappiness displayed by 3 individuals with profound multiple disabilities during teaching sessions. The program involved presentation of preferred activities before, during, and after each teaching session, discontinuation of identified nonpreferred activities, and a brief break and preferred activity following occurrence of resistance. Implementation of the enriched teaching program was accompanied by reductions in resistance and indices of unhappiness for each participant. Results also indicated no negative impact of the program on participant performance of the teaching steps or staff teaching proficiency. Staff questionnaire responses provided a degree of social validation for the observed changes in that staff reported the participants liked the enriched teaching program more than the traditional teaching process. Directions for future research discussed include identifying critical aspects of the overall program and the potential relation between teaching proficiency and the program's enrichment effectiveness.

Postoperative pain management in patients with chronic pain syndromes.

The problems encountered when heavily medicated patients with chronic pain syndromes present for surgery are discussed in a case study. A management plan is proposed. The attending anesthesiologist, the acute and chronic pain service, the surgeon, the nursing staff, the patient and their significant others must be involved from the beginning.

Observational assessment of toy preferences among young children with disabilities in inclusive settings. Efficiency analysis and comparison with staff opinion.

Numerous investigations have demonstrated means of assessing preferences among students and adults with disabilities. In contrast, there has been little attention on preference identification among young children. We evaluated a preference assessment with 7 toddlers and preschoolers with disabilities in inclusive programs. First, identification of toy-play preferences was compared across three assessments that varied in amount of toy-play behavior sampled and time required for implementation (5-, 10-, and 15-session assessments). Second, results of the assessments were compared to staff opinion. Results indicated the most efficient assessment identified preferences that generally were consistent with preferences identified with the less time-efficient assessments. Results also indicated staff reports did not consistently indicate which toys were played with most frequently. Overall, results demonstrate an efficient means of determining preferences among young children with disabilities in inclusive settings. Results also suggest that staff opinion should not be relied on exclusively to determine preferences.

Increasing toy play among toddlers with multiple disabilities in an inclusive classroom: a more-to-less, child-directed intervention continuum.

We evaluated a more-to-less, child-directed continuum of interventions to increase toy play among toddlers with multiple disabilities in an inclusive classroom. In keeping with recommended practices in early intervention, all procedures were conducted within the toddlers' classroom. Following initial observations of three toddlers (under 3 years of age) that indicated toy play was less frequent than that of their typically developing peers, preference assessments were conducted of selected toys. The toddlers were then provided with repeated choices of preferred toys in a child-directed manner. Two of the toddlers subsequently received staff prompts and praise for toy play, representing a less child-directed (i.e., more staff-directed) intervention component, in addition to choices of preferred toys. Overall, toy play as well as nonprompted toy play increased for one toddler during the former condition and for two toddlers during the latter condition. For two of the toddlers, toy play increased to a level commensurate with that of their classmates who did not have disabilities. Small increases also occurred in the number of toys played with by each toddler. Results are discussed in terms of how intervention procedures can be applied along a more- to less-child-directed continuum based on individual child responsiveness to respective procedures. Areas for future research discussed include applying the continuum with other child behaviors, including more advanced toy play.

Evaluation of a shared-work program for reducing assistance provided to supported workers with severe multiple disabilities.

Concern has been expressed recently regarding the need to enhance the performance of individuals with highly significant disabilities in community-based, supported jobs. We evaluated a shared-work program for reducing job coach assistance provided to three workers with severe multiple disabilities in a publishing company. Following systematic observations of the assistance provided as each worker worked on entire job tasks, steps comprising the tasks were then re-assigned across workers. The re-assignment involved assigning each worker only those task steps for which the respective worker received the least amount of assistance (e.g., re-assigning steps that a worker could not complete due to physical disabilities), and ensuring the entire tasks were still completed by combining steps performed by all three workers. The shared-work program was accompanied by reductions in job coach assistance provided to each worker. Work productivity of the supported workers initially decreased but then increased to a level equivalent to the higher ranges of baseline productivity. These results suggested that the shared-work program appears to represent a viable means of enhancing supported work performance of people with severe multiple disabilities in some types of community jobs. Future research needs discussed focus on evaluating shared-work approaches with other jobs, and developing additional community work models specifically for people with highly significant disabilities.

Increasing pretend toy play of toddlers with disabilities in an inclusive setting.

UNLABELLED: We evaluated a program for increasing pretend toy play of 2-year-old children with disabilities in an inclusive classroom. Classroom personnel implemented the program, which involved choices of classroom centers containing toys that tend to occasion pretend play in toddlers without disabilities, along with prompting and praise. Increases occurred in independent pretend-play rates among all 5 participating toddlers. Results are discussed regarding the importance of promoting toy play of very young children with disabilities that is similar to the type of play of their nondisabled peers, and the need to identify critical program components that are applicable in inclusive settings. DESCRIPTORS: pretend play, young children with disabilities

Improving day-treatment services for adults with severe disabilities: a norm-referenced application of outcome management.

We evaluated an outcome management program for working with staff to improve the performance of adults with severe disabilities in a congregate day-treatment setting. Initially, observations were conducted of student task involvement and staff distribution of teaching interactions across students in four program sites. Using recent normative data to establish objective goals for student performance, management intervention was warranted in two of the sites. A six-step outcome management program was then implemented in the two sites. The program involved defining desired student and staff outcomes, systematic monitoring of the outcomes, staff training, and supportive and corrective feedback. The outcome management program was accompanied by increases in student on-task behavior and staff distribution of teaching interactions in both sites. The increases brought the levels of on-task behavior above the normative average; on-task behavior was maintained above the baseline average for over 1 year in both sites. These results are discussed in terms of the benefits of relying on normative data for objectively evaluating and improving service delivery systems. Discussion of future research needs focuses on applying the outcome management program to other settings and services for people with disabilities.