Systematic review and narrative synthesis of competency-based medical education in anaesthesia.

BACKGROUND: Competency-based medical education (CBME) addresses the accountability of postgraduate training programmes to graduate specialists capable of independent practice. METHODS: We undertook a systematic review and narrative synthesis of the published CBME literature in anaesthesia training programmes to identify current practices and areas requiring further exploration. RESULTS: We grouped the 23 studies that met our inclusion criteria into the following categories: demonstrating outcomes of CBME, developing a consensus on an achievable CBME curriculum, CBME curriculum framework, design and implementation of workplace-based assessment (WBA) tools, trainee self-assessment, perceptions of trainees and supervisors on WBA tools, and technological solutions for assessment and feedback. Included studies reported variable success in reaching consensus in competency outcome frameworks for sequenced progression and limited research on approaches to curriculum delivery, whilst the majority of studies focused on workplace assessment. Studies supported the use of entrustment scales, where assessors make a judgement on the extent to which the trainee can manage a case independently. While evidence supported the reliability of WBA tools, and predicted the numbers needed for high-stakes decisions, areas of concern related to factors influencing the value WBA tools in promoting trainee learning, and variable perceptions of their value in making decisions on progression. CONCLUSIONS: Evidence on outcomes of CBME was limited to acquisition of specific competencies during training. The large number of unanswered questions and the dearth of studies across the core components of CBME suggest that we need a collaborative approach to create the evidence required to implement CBME wisely and cost effectively, to have positive impacts on patients, trainees, and healthcare systems.

Oral medical assistance in dying (MAiD): informing practice to enhance utilization in Canada.

The legislation Bill C-14 legalized medical assistance in dying (MAiD) in Canada. After thorough assessments of eligibility by two clinicians, Bill C-14 allows for both intravenous-assisted death by a clinician (euthanasia) and prescription of oral medication for self-administration (assisted suicide). Nevertheless, since inception in June 2016, intravenous euthanasia is the main form of delivery of assisted death in Canada. The reasons why oral MAiD is underutilized in Canada are multifactorial. Currently, there is no consensus on either the medications or the protocols for oral administration, nor a comprehensive understanding of the potential side effects and complications associated with different regimens. The quality of evidence for optimal MAiD medications is low, so any suggested recommendations can only be informed by the global but generally anecdotal experience. The challenges for implementing oral MAiD in Canada include a need to enhance clinician comfort in prescribing oral medications as an alternative to intravenous administration. The goals for ideal oral MAiD medications are 100% effectiveness and minimal side effects, while ensuring that the needed dose is both palatable and deliverable in a tolerable oral volume. The Netherlands has the most experience worldwide and barbiturates have emerged as the most common, efficacious, and tolerable agents by patients. Based on this global experience and the over-arching goals for oral MAiD, we recommend the use of a secobarbital suspension combined with antiemetic prophylaxis.

Acquiring and maintaining point-of-care ultrasound (POCUS) competence for anesthesiologists.

PURPOSE: Point-of-care ultrasound (POCUS) involves the bedside use of ultrasound to answer specific diagnostic questions and to assess real-time physiologic responses to treatment. Although POCUS has become a well-established resource for emergency and critical care physicians, anesthesiologists are still working to obtain POCUS skills and to incorporate them into routine practice. This review defines the benefits of POCUS to anesthesia practice, identifies challenges to establishing POCUS in routine anesthesia care, and offers solutions to help guide its incorporation going forward. PRINCIPAL FINDINGS: Benefits to POCUS include improving the sensitivity and specificity of the physical examination and helping to guide patient treatment. The challenges to establishing POCUS as a standard in anesthesia practice include developing and maintaining competence. There is a need to develop standards of practice and a common language between specialties to facilitate training and create guidelines regarding patient management. CONCLUSIONS: Presently, our specialty requires consensus by expert stakeholders to address issues of competence, certification, development of standards and terminology, and the management of unexpected diagnoses. To promote POCUS competency in our discipline, we support its incorporation into anesthesiology curricula and training programs and the continuing professional development of POCUS-related activities at a national level.

Hospitalizations due to preventable adverse reactions-a systematic review.

PURPOSE: The study aimed to measure the percentage of preventable adverse drug reactions that lead to the hospitalization (PADRAd) and to explore the heterogeneity in its estimation through subgroup analysis of study characteristics. METHODS: Two investigators independently searched in electronic databases and related bibliography for prospective studies involving PADRAd. We excluded studies investigating medication errors and spontaneous and retrospective reporting. The primary outcome was PADRAd percentage. To explore the heterogeneity, we performed subgroup analysis based on study region, wards, age groups, adverse drug reaction (ADR) definitions, preventability assessment, ADR identification methods, study duration and sample size. We explored fatal PADRAd and causative drugs as a secondary outcome. We used the generic inverse variance method with random effect model to compute meta-analytic summary. RESULTS: Of the 68 full-text articles assessed, we included 22 studies. The mean PADRAd percentage was 45.11 % (95 % CI = 33.06-57.15; I 2 = 99 %). Studies including elderly (63.31 %) and all age groups (49.03 %) showed higher percentages than paediatric population (16.40 %). Studies examining all hospital populations showed higher percentages than specific wards. We observed high percentages in studies using Edwards and Aronson as an ADR definition and Hallas et al. as a preventability assessment tool. After age group adjustment, ADR detection methods did not show significant difference. The fatal PADRAd percentage was 1.58 % (95 % CI = -0.60 to 3.76; I 2 = 47 %). Paediatric and elderly studies showed a different causative drug pattern. CONCLUSION: Variation in PADRAd across the studies can be explained by difference in study populations and data collection methods. Extrapolation of preventable reactions should be carried out considering all these factors with caution.

EVALUATION OF ANTICOAGULANT EFFECT OF SULFATED POLYSACCHARIDE (SPS) FROM CODIUM DWARKENSE BORGESEN IN κ-CARRAGEENAN INDUCED HYPERCOAGULABLE STATE IN WISTAR ALBINO RATS.

Our aim of the present study was to evaluate the anticoagulant effect of sulfated polysaccharides (SPS) from Codium dwarkense Bergesen in ic-carrageenan induced hypercoagulable state in Wistar albino rats. 48 Wistar albino rats of either sex were randomly divided into 6 groups - disease control, active control, treatment lowmand high dose and preventive low and high dose. K-Carrageenan (3 mg/kg) single dose intravenously was given in rat tail vein at pre-decided time to produce hypercoagulable state. Baseline, 24, 48 and 72 hours duration blood samples were collected for PT, INR, aPTT, platelet count and fibrinogen level, FDP and D-Dimer measurements. At the end of experiment, animals were sacrificed for histopathology analysis of lung, liver and mesentery. Sulfated polysaccharide (SPS) significantly restored altered coagulation parameters (PT, INR, aPTI, platelet count and fibrinogen level) without affecting fibrinolytic parameters (FDP and D-Dimer). Administration of SPS both as a treatment and preventive therapy reduced the number of microthrombi along with less structural damage in histopathology of lung, liver and mesentery. Heparin served as active control and its administration significantly prolonged aPT' and restored PT. This study shows, anticoagulant activity of SPS extracted from Codium dwarkense Bergesen in Wistar albino rats.

The role of simulation in continuing medical education for acute care physicians: a systematic review.

OBJECTIVES: We systematically reviewed the effectiveness of simulation-based education, targeting independently practicing qualified physicians in acute care specialties. We also describe how simulation is used for performance assessment in this population. DATA SOURCES: Data source included: DataMEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL Database of Controlled Trials, and National Health Service Economic Evaluation Database. The last date of search was January 31, 2013. STUDY SELECTION: All original research describing simulation-based education for independently practicing physicians in anesthesiology, critical care, and emergency medicine was reviewed. DATA EXTRACTION: Data analysis was performed in duplicate with further review by a third author in cases of disagreement until consensus was reached. Data extraction was focused on effectiveness according to Kirkpatrick's model. For simulation-based performance assessment, tool characteristics and sources of validity evidence were also collated. DATA SYNTHESIS: Of 39 studies identified, 30 studies focused on the effectiveness of simulation-based education and nine studies evaluated the validity of simulation-based assessment. Thirteen studies (30%) targeted the lower levels of Kirkpatrick's hierarchy with reliance on self-reporting. Simulation was unanimously described as a positive learning experience with perceived impact on clinical practice. Of the 17 remaining studies, 10 used a single group or "no intervention comparison group" design. The majority (n = 17; 44%) were able to demonstrate both immediate and sustained improvements in educational outcomes. Nine studies reported the psychometric properties of simulation-based performance assessment as their sole objective. These predominantly recruited independent practitioners as a convenience sample to establish whether the tool could discriminate between experienced and inexperienced operators and concentrated on a single aspect of validity evidence. CONCLUSIONS: Simulation is perceived as a positive learning experience with limited evidence to support improved learning. Future research should focus on the optimal modality and frequency of exposure, quality of assessment tools and on the impact of simulation-based education beyond the individuals toward improved patient care.

Residents' reluctance to challenge negative hierarchy in the operating room: a qualitative study.

PURPOSE: Our aim was to clarify how hierarchy influences residents' reluctance to challenge authority with respect to clearly erroneous medical decision-making. METHODS: After research ethics approval, we recruited 44 anesthesia residents for a high-fidelity simulation scenario at two Ontario universities. During the scenario, an actor, whom the residents were told was an actual new staff anesthesiologist at their university, asked the trainees to give blood to a Jehovah's Witness in contradiction to the patient's explicitly stated wishes. Following the case, the trainees were debriefed and were interviewed for 30-40 min. The interviews were audio recorded and transcribed verbatim, and the text was coded using a qualitative approach informed by grounded theory. RESULTS: Qualitative analysis of the participants' interviews yielded rich descriptive accounts of hierarchical influences often characterized by fear and intimidation. Residents spoke about their coping strategies, which included adaptability, avoiding conflict, using inquiry as a method for patient advocacy, and relying on a diffusion of responsibility within the larger operating room team. CONCLUSIONS: Study results showed that hierarchy played a dominant role in the functioning of the operating room. Participants spoke of both the positive and negative effects of such a hierarchical learning environment. The majority of participants described a negative perception of hierarchy as the norm, and they employed many coping strategies. This study provides insight into how a negative hierarchical culture can adversely impact patient safety, resident learning, and team functioning. We propose a theoretical model to describe challenging authority in this context.

Transesophageal echocardiography simulation is an effective tool in teaching psychomotor skills to novice echocardiographers.

BACKGROUND: Performance of transesophageal echocardiography (TEE) requires the psychomotor ability to obtain interpretable echocardiographic images. The purpose of this study was to determine the effectiveness of a simulation-based curriculum in which a TEE simulator is used to teach the psychomotor skills to novice echocardiographers and to compare instructor-guided with self-directed online delivery of the curriculum. METHODS: After institutional review board approval, subjects inexperienced in TEE completed an online review of TEE material prior to a baseline pre-test of TEE psychomotor skills using the simulator. Subjects were randomized to two groups. The first group received an instructor-guided lesson of TEE psychomotor skills with the simulator. The second group received a self-directed slide presentation of TEE psychomotor skills with the simulator. Both lessons delivered identical information. Following their respective training sessions, all subjects performed a post-test of their TEE psychomotor skills using the simulator. Two assessors rated the TEE performances using a validated scoring system for acquisition of images. RESULTS: Pre-test TEE simulator scores were similar between the two instruction groups (9.0 vs 5.0; P = 0.28). The scores in both groups improved significantly following training, regardless of the method of instruction (P < 0.0001). The improvement in scores (post-test scores minus pre-test scores) did not differ significantly between instruction groups (12.5 vs 14.5; P = 0.55). There was strong inter-rater reliability between assessors (α = 0.98; 95% confidence interval [CI]: 0.97 to 0.99). CONCLUSIONS: High-fidelity TEE simulators are an effective training adjunct for the acquisition of basic TEE psychomotor skills. There was no difference in improvement between the different modalities of instruction. Further research will examine the need for a faculty resource for a curriculum in which a simulator is used as an adjunct.

Competence by Design: The Role of High-Stakes Examinations in a Competence Based Medical Education System.

Competency based medical education is developed utilizing a program of assessment that ideally supports learners to reflect on their knowledge and skills, allows them to exercise a growth mindset that prepares them for coaching and eventual lifelong learning, and can support important progression and certification decisions. Examinations can serve as an important anchor to that program of assessment, particularly when considering their strength as an independent, third-party assessment with evidence that they can predict future physician performance and patient outcomes. This paper describes the aims of the Royal College of Physicians and Surgeons of Canada's ("the Royal College") certification examinations, their future role, and how they relate to the Competence by Design model, particularly as the culture of workplace assessment and the evidence for validity evolves. For example, high-stakes examinations are stressful to candidates and focus learners on exam preparation rather than clinical learning opportunities, particularly when they should be developing greater autonomy. In response, the Royal College moved the written examination earlier in training and created an exam quality review, by a specialist uninvolved in development, to review the exam for clarity and relevance. While learners are likely to continue to focus on the examination as an important hurdle to overcome, they will be preparing earlier in training, allowing them the opportunity to be more present and refine their knowledge when discussing clinical cases with supervisors in the Transition to Practice phase. The quality review process better aligns the exam to clinical practice and can improve the educational impact of the examination preparation process.

Competence By Design: a transformational national model of time-variable competency-based postgraduate medical education.

Postgraduate medical education is an essential societal enterprise that prepares highly skilled physicians for the health workforce. In recent years, PGME systems have been criticized worldwide for problems with variable graduate abilities, concerns about patient safety, and issues with teaching and assessment methods. In response, competency based medical education approaches, with an emphasis on graduate outcomes, have been proposed as the direction for 21st century health profession education. However, there are few published models of large-scale implementation of these approaches. We describe the rationale and design for a national, time-variable competency-based multi-specialty system for postgraduate medical education called Competence by Design. Fourteen innovations were bundled to create this new system, using the Van Melle Core Components of competency based medical education as the basis for the transformation. The successful execution of this transformational training system shows competency based medical education can be implemented at scale. The lessons learned in the early implementation of Competence by Design can inform competency based medical education innovation efforts across professions worldwide.

Within-team debriefing versus instructor-led debriefing for simulation-based education: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of an interprofessional within-team debriefing with that of an instructor-led debriefing on team performance during a simulated crisis. BACKGROUND: Although instructor-led simulation debriefing is considered the "gold standard" in team-based simulation education, cost and logistics are limiting factors for its implementation. Within-team debriefing, led by the individuals of the team itself rather than an external instructor, has the potential to address these limitations. METHODS: One hundred twenty subjects were grouped into 40 operating room teams consisting of 1 anesthesia trainee, 1 surgical trainee, and 1 staff circulating operating room nurse. All teams managed a simulated crisis scenario (pretest). Teams were then randomized to either a within-team debriefing group or an instructor-led debriefing group. In the within-team debriefing group, the teams reviewed the video of their scenario by themselves. The teams in the instructor-led debriefing group reviewed their scenario guided by a trained instructor. Immediately after debriefing, all teams managed a different intraoperative crisis scenario (posttest). All sessions were videotaped. Blinded expert examiners used the validated Team Emergency Assessment Measure scale to assess crisis resource management performance of all teams in random order. RESULT: Team performance significantly improved from pretest to posttest (P = 0.008) regardless of the type of debriefing. There was no significant difference in the degree of improvement between within-team debriefing and instructor-led debriefing (P = 0.52). CONCLUSIONS: Within-team debriefing results in measurable improvements in team performance in simulated crisis scenarios. This form of debriefing may be as effective as instructor-led team debriefing, which could improve resource utilization and feasibility of team-based simulation (NCT01067378).

Review article: simulation: a means to address and improve patient safety.

PURPOSE: The purpose of this article is to review the role of technical and nontechnical skills in routine and crisis situations. We discuss the role of different simulation modalities in addressing these skills and competencies to enhance patient safety. PRINCIPAL FINDINGS: Human and system errors are a recognized cause of significant morbidity and mortality. Technical skills encompass the medical and procedural knowledge required for patient care, while nontechnical skills are behaviour-based and include task management, situation awareness, teamwork, decision-making, and leadership. Both sets of skills are required to improve patient safety. Healthcare simulation can provide an opportunity to practice technical and nontechnical skills in a patient-safe environment. More specifically, these skills are most required in dynamic and crisis situations, which may best be practiced in a simulated patient setting. CONCLUSION: Healthcare simulation is a valuable tool to improve patient safety. Simulation-based education can focus on the necessary technical and nontechnical skills to enhance patient safety. Simulation-based research can serve as a means to identify gaps in current practice, test different solutions, and show improved practice patterns by studying performance in a setting that does not compromise patient safety.

"GIOSAT": a tool to assess CanMEDS competencies during simulated crises.

PURPOSE: Our objective was to develop and evaluate a Generic Integrated Objective Structured Assessment Tool (GIOSAT) to integrate Medical Expert and intrinsic (non-medical expert) CanMEDS competencies with non-technical skills for crisis simulation. METHODS: An assessment tool was designed and piloted using two pediatric anesthesia scenarios (laryngospasm and hyperkalemia). Following revision of the tool, we used previously recorded videos of anesthesia residents (n = 50) who managed one of two intraoperative advanced cardiac life support (ACLS) scenarios (ventricular tachycardia or ventricular fibrillation). Four independent trained raters, blinded to the residents' level of training, analyzed the video recordings using the GIOSAT scale. Inter-rater reliability was calculated using intraclass correlations (ICCs) for single raters (single measure) and the average of the four raters (average measure), and construct validity was investigated by correlating GIOSAT scores with postgraduate year of residency (PGY). RESULTS: Total GIOSAT scores for the ACLS scenarios had single measure ICCs of 0.62 and average measure ICCs of 0.85. Inter-rater reliability was substantial for both Medical Expert and intrinsic competencies (single measure ICCs 0.69 and 0.62, respectively; average measure ICCs 0.90 and 0.82, respectively). We found significant correlations between PGY level and total GIOSAT score (r = 0.36; P = 0.011) and between PGY level and Medical Expert competencies (r = 0.42; P = 0.003); however, correlations were not found between PGY level and intrinsic CanMEDS competencies (r = 0.24; P = 0.09). CONCLUSION: Inter-rater reliability of the total GIOSAT scores using four trained raters was substantial. Significant correlation between PGY and (i) total GIOSAT score and (ii) Medical Expert competencies supports construct validity. Evidence of validity was not obtained for intrinsic CanMEDS competencies.

The difficult airway with recommendations for management--part 2--the anticipated difficult airway.

BACKGROUND: Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway. METHODS: To review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned. PRINCIPAL FINDINGS: Previously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician's experience, must also be considered in deciding the appropriate strategy. CONCLUSIONS: With an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.

The difficult airway with recommendations for management--part 1--difficult tracheal intubation encountered in an unconscious/induced patient.

BACKGROUND: Previously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group's mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered. METHODS: Nineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria. CONCLUSIONS: The clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative "Plan B" technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, "cannot intubate, cannot oxygenate" situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.