Lived experiences of transgender and nonbinary people in the perioperative context: a qualitative study.

BACKGROUND: Transgender and nonbinary (TNB) people experience obstacles that create barriers to accessing health care, including stigmatization and health inequities. Our intention was to describe the lived experiences of TNB patients and identify potential gaps in the education of health care professionals. METHODS: We conducted a qualitative descriptive study influenced by phenomenology by interviewing with TNB adults who underwent surgery in Canada within the previous 5 years. We recruited participants using purposeful and snowball sampling via online social networking sites. Audio recordings were transcribed. Two authors coded the transcripts and derived the themes. RESULTS: We interviewed 21 participants, with a median interview duration of 49 minutes. Participants described positive and negative health care encounters that led to stress, confusion, and feelings of vulnerability. Major themes included having to justify their need for health care in the face of structural discrimination; fear and previous traumatic experiences; community as a source of support and information; and the impact of interactions with health care professionals. INTERPRETATION: Participants detailed barriers to accessing care, struggled to participate in shared decision-making, and desired trauma-informed care principles; they described strength in community and positive interactions with health care professionals, although barriers to accessing gender-affirming care often overshadowed other aspects of the perioperative experience. Additional research, increased education for health care professionals, and policy changes are necessary to improve access to competent care for TNB people.

Perioperative Anesthesia-Related Complications and Risk Factors in Children: A Cross-Sectional Observation Study in Rwanda.

BACKGROUND: Despite an increasing awareness of the unmet burden of surgical conditions, information on perioperative complications in children remains limited especially in low-income countries such as Rwanda. The objective of this study was to estimate the prevalence of perioperative anesthesia-related adverse events and to explore potential risk factors associated with them among pediatric surgical patients in public referral hospitals in Rwanda. METHODS: Data were collected for all patients under 5 years of age undergoing surgery in 3 public referral hospitals in Rwanda from June to December 2015. Patient and family history, type of surgery, comorbidities, anesthesia technique, intraoperative adverse events and postoperative events in the postanesthesia care unit (PACU) were recorded. The incidence of perioperative adverse events was assessed and associated risk factors analyzed with univariate logistic regression. RESULTS: Of 354 patients enrolled in this study 11 children had a cardiac arrest. Six (1.7%) suffered an intraoperative cardiac arrest, 2 of whom (0.6%) died intraoperatively. In the PACU, 6 (1.8%) suffered a postoperative cardiac arrest, 5 of whom (1.5%) died in the PACU. One child had both an intraoperative cardiac arrest and then a cardiac arrest in PACU but survived. Eighty-nine children (25.1%) had an intraoperative adverse event, whereas 67 (20.6%) had an adverse event in PACU. A review of the cases where cardiac arrest or death occurred indicated that there were significant lapses in the expected standard of care. Age <1 week was associated with cardiac arrest or death. CONCLUSIONS: The rate of perioperative complications, including death, for children undergoing surgery in tertiary care hospitals in Rwanda was high. Quality improvement measures are needed to decrease this rate among surgical pediatric patients in this low resource setting.

An audit of the carbon footprint of travel for the Canadian Anesthesiologists' Society International Education Foundation partnerships.

PURPOSE: International partnerships have an important role in capacity building in global health, but frequently involve travel and its associated carbon footprint. The environmental impact of global health partnerships has not previously been quantified. METHODS: We conducted a retrospective internal audit of the environmental impact of air travel for the international education programs of the Canadian Anesthesiology Society's International Education Fund (CASIEF). We compiled a comprehensive list of volunteer travel routes and used the International Civil Aviation Organization Carbon Emissions Calculator, which considers travel distance, passenger numbers, and average operational data for optimized estimates. Comparisons were made with average Canadian household emissions and disability adjusted life years (DALYs) lost from climate change consequences. RESULTS: The total carbon dioxide emitted (CO2-e) for the Rwanda, Ethiopia, and Guyana CASIEF partnerships were 268.2, 60.7, and 52.0 tons, respectively. The DALYs cost of these programs combined is estimated to be as high as 1.1 years of life lost due to the effects of CO2-e. The mean daily carbon cost of the average Rwanda partnership was equivalent to daily emissions of 2.2 Canadians (or 383 Rwandans), for the Guyana partnership was equivalent to 1.6 Canadians (or 7.6 Guyanese people), and for the Ethiopia partnership was equivalent to 2.4 Canadians (or 252 Ethiopian people). CONCLUSIONS: Air travel from these CASIEF partnerships resulted in 380.9 tons CO2-e but also enabled 5,601 volunteer days-in-country since 2014. The estimated environmental cost needs to be balanced against the impact of the programs. Regardless, carbon-reduction remains a priority, whether by discouraging premium class travel, organizing longer trips to reduce daily emissions, prioritizing remote support and virtual education, or developing partnerships closer to home.

RéSUMé: OBJECTIF: Les partenariats internationaux jouent un rôle important dans le renforcement des capacités en santé mondiale, mais impliquent souvent des voyages et une empreinte carbone qui y est associée. L'impact environnemental des partenariats pour la santé mondiale n'a pas encore été quantifié. MéTHODE: Nous avons réalisé un audit interne rétrospectif de l'impact environnemental du transport aérien pour les programmes de formation internationale du Fonds d'éducation internationale de la Société canadienne des anesthésiologistes (FÉI SCA). Nous avons compilé une liste complète des itinéraires de voyage des bénévoles et utilisé le Calculateur d'émissions de carbone de l'Organisation de l'aviation civile internationale, qui prend en compte la distance parcourue, le nombre de passagers et les données opérationnelles moyennes pour des estimations optimisées. Des comparaisons ont été faites avec les émissions moyennes des ménages canadiens et les années de vie corrigées de l'incapacité (AVCI) perdues en raison des conséquences des changements climatiques. RéSULTATS: Le dioxyde de carbone total émis (CO2-e) dans le cadre des partenariats de la FÉI SCA avec le Rwanda, l'Éthiopie et le Guyana, étaient de 268,2, 60,7 et 52,0 tonnes, respectivement. Le coût combiné des AVCI de ces programmes est estimé à 1,1 année de vie perdue en raison des effets du CO2-e. Le coût quotidien moyen du carbone du partenariat moyen avec le Rwanda équivalait aux émissions quotidiennes de 2,2 Canadiens (ou 383 Rwandais); pour le partenariat avec le Guyana, cela équivalait à 1,6 Canadien (ou 7,6 Guyanais) et pour le partenariat avec l'Éthiopie, à 2,4 Canadiens (ou 252 Éthiopiens). CONCLUSION: Les voyages aériens des partenariats de la FÉI SCA ont entraîné la production de 380,9 tonnes de CO2-e mais ils ont également permis 5601 journées de bénévolat dans les pays partenaires depuis 2014. Le coût environnemental estimé doit être mis en perspective avec l'impact des programmes. Quoi qu'il en soit, la réduction des émissions de carbone reste une priorité, que ce soit en décourageant les voyages en première classe, en organisant des voyages plus longs pour réduire les émissions quotidiennes, en donnant la priorité à l'assistance à distance et à l'éducation virtuelle, ou en développant des partenariats plus près de chez soi.

A Prospective, Cohort Study of the Effect of Acute and Chronic Malnutrition on Length of Stay in Children Having Surgery in Rwanda.

BACKGROUND: Malnutrition is common in pediatric surgical patients, but there are little data from low-income countries that estimate the association of malnutrition with surgical outcomes. We aimed to determine the prevalence of malnutrition and its association with length of stay (LOS) among pediatric surgical patients in Kigali, Rwanda. METHODS: We conducted a prospective observational cohort study. We enrolled surgical patients between 1 month and 15 years of age. We measured the association of acute malnutrition (wasting) and chronic malnutrition (stunting) with postoperative LOS using log-gamma regression to account for the skewed LOS distribution. Adjustment was made for sex, age, elective versus emergency surgery, household income, and American Society of Anesthesiologists (ASA) classification. RESULTS: Of 593 children, 124 children (21.2%) had acute malnutrition (wasting) with 39 (6.6%) severely wasted. A total of 160 (26.9%) children had chronic malnutrition (stunting), with 81 (13.7%) severely stunted. Median (interquartile range [IQR]) LOS after surgery was 2 (1-5) days for children with mild/no wasting, 6 (2.5-12.5) days for children with moderate wasting, and 6 (2-15) days with severe wasting. Median (IQR) LOS after surgery was 2 (1-6) days for children with mild/no stunting, 3 (1-3) days for children with moderate stunting, and 5 (2.3-11.8) days with severe stunting malnutrition. After adjustment for confounders, the moderate wasting was associated with increased LOS, with ratio of means (RoM), 1.6; 95% confidence interval [CI], 1.3-2.0; P < .0001. Severe wasting was not associated with increased LOS (RoM, 1.3; 95% CI, 0.9-1.7; P = .12). Severe, but not moderate, stunting was associated with increased LOS (RoM, 1.9; 1.5-2.4; P < .0001). CONCLUSIONS: Malnutrition is prevalent in >20% of children presenting for surgery and associated with increased LOS after surgery, even after accounting for individual and family-level confounders. Although some aspects of malnutrition may relate to the surgical condition, severe malnutrition may represent a modifiable social risk factor that could be targeted to improve postoperative outcomes and resource use. Severely stunted children should be identified as at risk of having delayed recovery after surgery.

Validation of the Lusaka Formula: A Novel Formula for Weight Estimation in Children Presenting for Surgery in Zambia.

BACKGROUND: In children, the use of actual weight or predicted weight from various estimation methods is essential to reduce harm associated with dosing errors. This study aimed to validate the new locally derived Lusaka formula on an independent cohort of children undergoing surgery at the University Teaching Hospital in Lusaka, Zambia, to compare the Lusaka formula's performance to commonly used weight prediction tools and to assess the nutritional status of this population. METHODS: The Lusaka formula (weight = [age in months/2] + 3.5 if under 1 year; weight = 2×[age in years] + 7 if older than 1 year) was derived from a previously published data set. We aimed to validate this formula in a new data set. Weights, heights, and ages of 330 children up to 14 years were measured before surgery. Accuracy was examined by comparing the (1) mean percentage error and (2) the percentage of actual weights that fell between 10% and 20% of the estimated weight for the Lusaka formula, and for other existing tools. World Health Organization (WHO) growth charts, mid upper arm circumference (MUAC), and body mass index (BMI) were used to assess nutritional status. RESULTS: The Lusaka formula had similar precision to the Broselow tape: 160 (48.5%) vs 158 (51.6%) children were within 10% of the estimated weight, 241 (73.0%) vs 245 (79.5%) children were within 20% of the estimated weight. The Lusaka formula slightly underestimated weight (mean bias, -0.5 kg) in contrast to all other predictive tools, which overestimated on average. Twenty-two percent of children had moderate or severe chronic malnutrition (stunting) and 4.7% of children had moderate or severe acute malnutrition (wasting). CONCLUSIONS: The Lusaka formula is comparable to, or better than, other age-based weight prediction tools in children presenting for surgery at the University Teaching Hospital in Lusaka, Zambia, and has the advantage that it covers a wider age range than tools with comparable accuracy. In this population, commonly used aged-based prediction tools significantly overestimate weights.

Burnout Syndrome Among Anesthesia Providers Working in Public Hospitals in Rwanda: A Cross-Sectional Survey.

BACKGROUND: Many studies address anesthesia provider burnout in high-income countries; however, there is a paucity of data on burnout for anesthesia providers in low-income countries (LICs). Our objectives were (1) to evaluate the prevalence of burnout among anesthesia providers in Rwandan hospitals and (2) to determine factors associated with burnout among anesthesia providers in Rwandan hospitals. METHODS: A questionnaire was sent to selected Rwandan anesthesia providers working in public hospitals. The questionnaire assessed burnout using the Maslach Burnout Inventory Human Services Survey, a validated 22-item survey used to measure burnout among health professionals. Sociodemographic and work-related factors found to be associated with burnout were also assessed using logistic regression in a Bayesian framework to estimate odds ratios (OR) and associated credible intervals (CrIs). RESULTS: Surveys were distributed to 137 Rwandan anesthesia providers; 99 (72.3%) were returned. Sixty-six (67%) respondents were nonphysician anesthesia providers. Burnout was present in 26 of 99 (26.3%) participants (95% confidence interval [CI], 17.9-36.1). When considering weakly informative priors, we found a 99% probability that not having the right team (OR, 5.36%; 95 CrI, 1.34-23.53) and the frequency of seeing patients with negative outcomes such as death or permanent disability (OR, 9.62; 95% CrI, 2.48-42.84) were associated with burnout. CONCLUSIONS: In a cross-sectional survey of anesthesia providers in Rwanda, more than a quarter of respondents met the criteria for burnout. Lacking the right team and seeing negative outcomes were associated with higher burnout rate. These identified factors should be addressed to prevent the negative consequences of burnout, such as poor patient outcomes.

Postoperative outcomes for Indigenous Peoples in Canada: a systematic review.

BACKGROUND: Substantial health inequities exist for Indigenous Peoples in Canada. The remote and distributed population of Canada presents unique challenges for access to and use of surgery. To date, the surgical outcome data for Indigenous Peoples in Canada have not been synthesized. METHODS: We searched 4 databases to identify studies comparing surgical outcomes and utilization rates of adults of First Nations, Inuit or Métis identity with non-Indigenous people in Canada. Independent reviewers completed all stages in duplicate. Our primary outcome was mortality; secondary outcomes included utilization rates of surgical procedures, complications and hospital length of stay. We performed meta-analysis of the primary outcome using random effects models. We assessed risk of bias using the ROBINS-I tool. RESULTS: Twenty-eight studies were reviewed involving 1 976 258 participants (10.2% Indigenous). No studies specifically addressed Inuit or Métis populations. Four studies, including 7 cohorts, contributed adjusted mortality data for 7135 participants (5.2% Indigenous); Indigenous Peoples had a 30% higher rate of death after surgery than non-Indigenous patients (pooled hazard ratio 1.30, 95% CI 1.09-1.54; I 2 = 81%). Complications were also higher for Indigenous Peoples, including infectious complications (adjusted OR 1.63, 95% CI 1.13-2.34) and pneumonia (OR 2.24, 95% CI 1.58-3.19). Rates of various surgical procedures were lower, including rates of renal transplant, joint replacement, cardiac surgery and cesarean delivery. INTERPRETATION: The currently available data on postoperative outcomes and surgery utilization rates for Indigenous Peoples in Canada are limited and of poor quality. Available data suggest that Indigenous Peoples have higher rates of death and adverse events after surgery, while also encountering barriers accessing surgical procedures. These findings suggest a need for substantial re-evaluation of surgical care for Indigenous Peoples in Canada to ensure equitable access and to improve outcomes. PROTOCOL REGISTRATION: PROSPERO-CRD42018098757.

Not a "first world problem"-Care of the anesthetist in East and Southern Africa.

Burnout and related concepts such as resilience, wellness, and taking care of healthcare professionals have become increasingly prevalent in the medical literature. Most of the work in this area comes from high-income countries, with the remainder from upper-middle-income countries, and very little from lower-middle-income or low-income countries. Sub-Saharan Africa is particularly poorly represented in this body of literature. Anglo-American concepts are often applied to different jurisdictions without consideration of cultural and societal differences. However, anesthesia providers in this region have unique challenges, with both the highest burden of "surgical" disease in the world and the least resources, both in terms of human resources for health and in terms of essential drugs and equipment. The effect of burnout on healthcare systems is also likely to be very different with the current human resources for the health crisis in East and Central Africa. According to the Joint Learning Initiative Managing for Performance framework, the three essential factors for building a workforce to effectively support a healthcare system are coverage, competence, and motivation. Current efforts to build capacity in anesthesia in East and Southern Africa focus largely on coverage and competence, but neglect motivation at the risk of failing to support a sustainable workforce. In this paper, we include a review of the relevant literature, as well as draw from personal experience living and working in East and Southern Africa, to describe the unique issues surrounding burnout, resilience, and wellness in this region.

A Cross-Sectional Survey to Determine the Prevalence of Burnout Syndrome Among Anesthesia Providers in Zambian Hospitals.

BACKGROUND: Burnout is a psychological syndrome that results from chronic exposure to job stress. It is defined by a triad of emotional exhaustion, depersonalization, and reduced personal accomplishment. In research, mostly from high-income countries, burnout is common in health care professionals, especially in anesthesiologists. Burnout can negatively impact patient safety, the physical and mental health of the anesthetist, and institutional efficiency. However, data on burnout for anesthesia providers in low- and middle-income countries are poorly described. This study sought to determine the prevalence of burnout syndrome among all anesthesia providers (physician and nonphysician) working in Zambian hospitals and to determine which sociodemographic and occupational factors were associated with burnout. METHODS: A questionnaire was sent to all Zambian anesthesia providers working in private and public hospitals. The questionnaire assessed burnout using the Maslach Burnout Inventory Human Services Survey, a validated 22-item survey widely used to measure burnout among health professionals. Sociodemographic and occupational factors postulated to be associated with burnout were also assessed. RESULTS: Surveys were distributed to all 184 anesthesia providers in Zambia; 160 were returned. This resulted in a response rate representing 87% of all anesthesia providers in the country. Eighty-six percentage of respondents were nonphysician anesthesia providers. Burnout was present in 51.3% (95% confidence interval [CI], 43.2-59.2) of participants. Logistic regression analysis revealed that "not having the right team to carry out work to an appropriate standard" (odds ratio, 2.91, 95% CI, 1.33-6.39; P = .008), and "being a nonphysician" (odds ratio, 3.4, 95% CI, 1.25-12.34; P = .019) were significantly associated with burnout in this population. CONCLUSIONS: In a cross-sectional survey of anesthesia providers in Zambia, >50% of the respondents met the criteria for burnout. The risk was particularly high among nonphysician providers who typically work in isolated rural practice. Efforts to decrease burnout rates through policy and educational initiatives to increase the quantity and quality of training for anesthesia providers should be considered.

Retention and Migration of Rwandan Anesthesiologists: A Qualitative Study.

BACKGROUND: Health care professional migration continues to challenge countries where the lack of surgical and anesthesia specialists results in being unable to address the global burden of surgical disease in their populations. Medical migration is particularly damaging to health care systems that are just beginning to scale up capacity building of human resources for health. Anesthesiologists are scarce in low-resource settings. Defining reasons why anesthesiologists leave their country of training through in-depth interviews may provide guidance to policy makers and academic organizations on how to retain valuable health professionals. METHODS: There were 24 anesthesiologists eligible to participate in this qualitative interview study, 15 of whom are currently practicing in Rwanda and 9 had left the country. From the eligible group, interviews were conducted with 13 currently practicing in Rwanda and 2 who had left to practice elsewhere. In-depth interviews of approximately 60 minutes were used to define themes influencing retention and migration among anesthesiologists in Rwanda. Interviews were conducted using a semistructured guide and continued until theoretical sufficiency was reached. Thematic analysis was done by 4 members of the research team using open coding to inductively identify themes. RESULTS: Interpretation of results used the framework categorizing themes into push, pull, stick, and stay to describe factors that influence migration, or the potential for migration, of anesthesiologists in Rwanda. While adequate salary is essential to retention of anesthesiologists in Rwanda, other factors such as lack of equipment and medication for safe anesthesia, isolation, and demoralization are strong push factors. Conversely, a rich academic life and optimism for the future encourage anesthesiologists to stay. CONCLUSIONS: Our study suggests that better clinical resources and equipment, a more supportive community of practice, and advocacy by mentors and academic partners could encourage more staff anesthesiologists to stay and work in Rwanda.

Four early warning scores predict mortality in emergency surgical patients at University Teaching Hospital, Lusaka: a prospective observational study.

PURPOSE: The value of early warning scoring systems has been established in high-income countries. There is little evidence for their use in low-resource settings. We aimed to compare existing early warning scores to predict 30-day mortality. METHODS: University Teaching Hospital is a tertiary center in Lusaka, Zambia. Adult surgical patients, excluding obstetrics, admitted for > 24 hr were included in this prospective observational study. On days 1 to 3 of admission, we collected data on patient demographics, heart rate, blood pressure, oxygen saturation, oxygen administration, temperature, consciousness level, and mobility. Two-, three-, and 30-day mortality were recorded with their associated variables analyzed using area under receiver operating curves (AUROC) for the National Early Warning Score (NEWS); the Modified Early Warning Score (MEWS); a modified Hypotension, Oxygen Saturation, Temperature, ECG, Loss of Independence (mHOTEL) score; and the Tachypnea, Oxygen saturation, Temperature, Alertness, Loss of Independence (TOTAL) score. RESULTS: Data were available for 254 patients from March 2017 to July 2017. Eighteen (7.5%) patients died at 30 days. The four early warning scores were found to be predictive of 30-day mortality: MEWS (AUROC, 0.76; 95% confidence interval [CI], 0.63 to 0.88; P < 0.001), NEWS (AUROC 0.805; 95% CI, 0.688 to 0.92; P < 0.001), mHOTEL (AUROC 0.759; 95% CI, 0.63 to 0.89, P < 0.001), and TOTAL (AUROC 0.782; 95% CI, 0.66 to 0.90; P < 0.001). CONCLUSIONS: We validated four scoring systems in predicting mortality in a Zambian surgical population. Further work is required to assess if implementation of these scoring systems can improve outcomes.

Cognitive aids with roles defined (CARD) for obstetrical crises: a multisite before-and-after cohort study.

PURPOSE: Patient outcome during an obstetrical emergency depends on prompt coordination of an interprofessional team. The cognitive aids with roles defined (CARD) is a cognitive aid that addresses the issue of teamwork in crisis management. This study evaluated the clinical impact of implementing the CARD cognitive aid during emergency Cesarean deliveries. METHODS: We conducted a prospective before-and-after cohort trial at the maternity units of two Canadian academic hospital campuses. Both sites received didactic online training regarding teamwork during crises, which involved training on using CARD for the "CARD" campus (intervention) and no mention of CARD at the "no CARD" campus (control). The primary outcome was the total time to delivery after the call for an emergency Cesarean delivery. Secondary outcomes included specific intervals of time within the time to delivery and clinical outcomes for both the babies and mothers. RESULTS: We analyzed data from 267 eligible emergency Cesarean deliveries that occurred between January 11 2014 and December 31 2017. The use of CARD did not significantly change the median [interquartile range] time to delivery of the baby during an emergency Cesarean delivery from the pre-intervention to the post-intervention time period (17 [12-28] vs 15 [13-20], respectively; median difference, 2; 95% confidence interval, -1 to 5; P = 0.36). The clinical outcomes for the baby or the mother and other secondary outcomes also did not change. CONCLUSIONS: The CARD cognitive aid did not significantly improve time-based or clinical maternal and neonatal outcomes of emergency Cesarean delivery at our academic maternity unit.

RéSUMé: OBJECTIF: Les devenirs des patientes pendant les urgences obstétricales dépendent de la coordination rapide d'une équipe interprofessionnelle. Le système CARD (Cognitive Aids with Roles Defined) est un outil de soutien cognitif qui est centré sur le travail d'équipe dans la gestion de crise. Cette étude a évalué l'impact clinique de la mise en œuvre d'un système CARD pendant les accouchements par césarienne d'urgence. MéTHODE: Nous avons réalisé une étude de cohorte prospective avant / après dans les services de maternité de deux campus hospitaliers universitaires canadiens. Les deux sites ont eu accès à une formation didactique en ligne portant sur le travail d'équipe pendant les crises; dans le campus « CARD ¼ (groupe intervention), une formation sur l'utilisation du système CARD a été incluse, alors qu'aucune mention du système n'a été faite dans le campus « sans CARD ¼ (groupe témoin). Le critère d'évaluation principal était le délai total jusqu'à l'accouchement après l'appel pour un accouchement par césarienne d'urgence. Les critères secondaires comprenaient les intervalles spécifiques de temps jusqu'à l'accouchement et les pronostics cliniques des bébés et de leurs mères. RéSULTATS: Nous avons analysé les données de 267 accouchements par césarienne d'urgence éligibles survenus entre le 11 janvier 2014 et le 31 décembre 2017. L'utilisation du système CARD n'a pas modifié de manière significative le délai médian [écart interquartile] jusqu'à l'accouchement du bébé pendant un accouchement par césarienne d'urgence tel que mesuré entre le moment pré-intervention et le moment post-intervention (17 [12­28] vs 15 [13­20], respectivement; différence médiane, 2; intervalle de confiance 95 %, −1 à 5; P = 0,36). Les pronostics cliniques des bébés et des mères et les autres critères d'évaluation secondaires n'ont pas non plus été modifiés. CONCLUSION: Le système CARD n'a pas amélioré de façon significative les pronostics maternels et néonatals fondés sur le temps ou la clinique en cas d'accouchement par césarienne d'urgence dans notre service de maternité universitaire.

Simulation-based assessment in anesthesia: an international multicentre validation study.

PURPOSE: Simulated clinical events provide a means to evaluate a practitioner's performance in a standardized manner for all candidates that are tested. We sought to provide evidence for the validity of simulation-based assessment tools in simulated pediatric anesthesia emergencies. METHODS: Nine centres in two countries recruited subjects to participate in simulated operating room events. Participants ranged in anesthesia experience from junior residents to staff anesthesiologists. Performances were video recorded for review and scored by specially trained, blinded, expert raters. The rating tools consisted of scenario-specific checklists and a global rating scale that allowed the rater to make a judgement about the subject's performance, and by extension, preparedness for independent practice. The reliability of the tools was classified as "substantial" (intraclass correlation coefficients ranged from 0.84 to 0.96 for the checklists and from 0.85 to 0.94 for the global rating scale). RESULTS: Three-hundred and ninety-one simulation encounters were analysed. Senior trainees and staff significantly out-performed junior trainees (P = 0.04 and P < 0.001 respectively). The effect size of grade (junior vs senior trainee vs staff) on performance was classified as "medium" (partial η2 = 0.06). Performance deficits were observed across all grades of anesthesiologist, particularly in two of the scenarios. CONCLUSIONS: This study supports the validity of our simulation-based anesthesiologist assessment tools in several domains of validity. We also describe some residual challenges regarding the validity of our tools, some notes of caution in terms of the intended consequences of their use, and identify opportunities for further research.

Strengthening the Anesthesia Workforce in Low- and Middle-Income Countries.

The majority of the world's population lacks access to safe, timely, and affordable surgical care. Although there is a health workforce crisis across the board in the poorest countries in the world, anesthesia is disproportionally affected. This article explores some of the key issues that must be tackled to strengthen the anesthesia workforce in low- and lower-middle-income countries. First, we need to increase the overall number of safe anesthesia providers to match a huge burden of disease, particularly in the poorest countries in the world and in remote and rural areas. Through using a task-sharing model, an increase is required in both nonphysician anesthesia providers and anesthesia specialists. Second, there is a need to improve and support the competency of anesthesia providers overall. It is important to include a broad base of knowledge, skills, and attitudes required to manage complex and high-risk patients and to lead improvements in the quality of care. Third, there needs to be a concerted effort to encourage interprofessional skills and the aspects of working and learning together with colleagues in a complex surgical ecosystem. Finally, there has to be a focus on developing a workforce that is resilient to burnout and the challenges of an overwhelming clinical burden and very restricted resources. This is essential for anesthesia providers to stay healthy and effective and necessary to reduce the inevitable loss of human resources through migration and cessation of professional practice. It is vital to realize that all of these issues need to be tackled simultaneously, and none neglected, if a sustainable and scalable solution is to be achieved.

Newborn Resuscitation Skills in Health Care Providers at a Zambian Tertiary Center, and Comparison to World Health Organization Standards.

BACKGROUND: Birth asphyxia is a leading cause of early neonatal death. In 2013, 32% of neonatal deaths in Zambia were attributable to birth asphyxia and trauma. Basic, timely interventions are key to improving outcomes. However, data from the World Health Organization suggest that resuscitation is often not initiated, or is conducted suboptimally. Currently, there are little data on the quality of newborn resuscitation in the context of a tertiary center in a lower-middle income country. We aimed to measure the competencies of clinical practitioners responsible for newborn resuscitation. METHODS: This observational study was conducted over 5 months in Zambia. Health care professionals were recruited from anesthesia, pediatrics, and midwifery. Newborn skills and knowledge were examined using the following: (1) multiple-choice questions; (2) a ventilation skills test; and (3) 2 low-medium fidelity simulation scenarios. Participant demographics including previous resuscitation training and a self-efficacy rating score were noted. The primary outcome examined performance scores in a simulated scenario, which assessed the care of a newborn that failed to respond to basic interventions. Secondary outcome measures included apnea times after delivery and performance in the other assessments. RESULTS: Seventy-eight participants were enrolled into the study (13 physician anesthesiology residents, 13 pediatric residents, and 52 midwives). A significant difference in interprofessional performance was observed when examining checklist scores for the unresponsive newborn simulated scenario (P = .006). The median (quartiles) checklist score (out of 18) was 14.0 (13.0-14.75) for the anesthesiologists, 11.0 (8.5-12.3) for the pediatricians, and 10.8 (8.3-13.9) for the midwives. A score of 14 or more was required to pass the scenario. There was no significant difference in performance between participants with and without previous newborn resuscitation training (P = .246). The median (quartiles) apnea time after delivery was significantly different between all groups (P = .01) with anesthetic and pediatric residents performing similarly, 61 (37-97) and 63 (42.5-97.5) seconds, respectively. The midwifery participants displayed a significantly longer apnea time, 93.5 (66.3-129) seconds. Self-efficacy rating scores displayed no correlation between confidence level and the primary outcome, Spearman coefficient 0.06 (P = .55). CONCLUSIONS: Newborn resuscitation skills among health care professionals are varied. Midwives lead the majority of deliveries with anesthesiologists and pediatricians only being present at operative or high-risk births. It is therefore common that midwifery practitioners will initiate resuscitation. Despite this, midwives perform poorly when compared to anesthesia and pediatric residents. To address this discrepancy, a multidisciplinary, simulation-based newborn resuscitation program should be considered with continual clinical reenforcement of best practice.

Observations of the hidden curriculum on a paediatrics tertiary care clinical teaching unit.

OBJECTIVE: The hidden curriculum is a set of influences that function at the level of organizational structure and culture which fall outside the formal curriculum, and are often unarticulated or unexplored. Learning associated with the hidden curriculum may have negative consequences on trainee educational development. The study goal was to examine how aspects of the hidden curriculum were enacted during ward rounds on a tertiary care general paediatrics clinical teaching unit (CTU). METHODS: We conducted an ethnographic case study on a CTU of a tertiary care paediatric hospital and observed interactions between medical students, residents and attending staff on rounds. Detailed field notes were collected and inductive analysis was used to inform descriptions and identify themes regarding the hidden curriculum. RESULTS: Twenty-two hours of observation were performed. Two major themes emerged: the hierarchical nature of team dynamics and engagement mediated by perceptions of relevance of the rotation. The hierarchical nature of team dynamics reflected the reinforcement of the rules of rank and 'who to respect'; it contained three subthemes including 'rules of the game', positioning and questioning order. Engagement mediated by perceptions of relevance of the rotation concerned the finding that active participation and attentiveness during rounds varied by home discipline. CONCLUSIONS: We were able to identify representations of the hidden curriculum during observations on a tertiary care paediatric CTU. Interest appears to be a determinant in student level of engagement and observed hierarchies have the potential to impact this engagement either positively or negatively.

Challenging Authority During an Emergency-the Effect of a Teaching Intervention.

OBJECTIVES: Previous research has shown that residents were unable to effectively challenge a superior's wrong decision during a crisis situation, a problem that can contribute to preventable mortality. We aimed to assess whether a teaching intervention enabled residents to effectively challenge clearly wrong clinical decisions made by their staff. SUBJECTS AND INTERVENTION: Following ethics board approval, second year residents were randomized to a teaching intervention targeting cognitive skills needed to challenge a superior's decision, or a control group receiving general crisis management instruction. Two weeks later, subjects participated in a simulated crisis that presented them with opportunities to challenge clearly wrong decisions in a can't-intubate-can't-ventilate scenario. It was only disclosed that the staff was a confederate during the debriefing. Performances were video recorded and assessed by two raters blinded to group allocation using the modified Advocacy-Inquiry Score. MEASUREMENTS AND MAIN RESULTS: Fifty residents completed the study. The interrater reliability of the modified Advocacy-Inquiry Scores (intraclass correlation coefficient = 0.87) was excellent. The median (interquartile range) best modified Advocacy-Inquiry Score was significantly better in the intervention group 5.0 (4.50-5.62 [4-6]) than in the control group 3.5 (3.0-4.75 [3-6]) (p < 0.001). CONCLUSIONS: A short targeted teaching intervention was effective in significantly improving residents' ability to challenge a wrong decision by a superior. This suggests that residents are not given the proper tools to challenge authority during a life-threatening crisis situation. This educational gap can have significant implications for patients' safety.