Where have all the pediatric anesthesiology fellows gone in the USA? Anesthesiology fellowship trends.

BACKGROUND: Recent consternation over the number of unfilled Pediatric Anesthesiology fellowship positions in the United States compelled us to assess the change in the ratio of Pediatric Anesthesiology fellows to the number of graduating anesthesiology residents over the 14-year period between 2008 and 2022. We also sought to report the total ratio of anesthesiology fellows to graduating residents and trends in the annual number of fellowship applicants relative to the number of Accreditation Council for Graduate Medical Education (ACGME)-accredited anesthesiology fellowship positions by specialty. METHODS: We used publicly available resources, including ACGME Data Resource Books, National Resident Matching Program (NRMP) data, San Francisco (SF) Match data, and American Board of Medical Specialties (ABMS) data, to determine the ratio of anesthesiology fellows to graduating anesthesiology residents and to compare the number of fellowship applicants to fellowship positions for Adult Cardiothoracic Anesthesiology, Critical Care Anesthesiology, Obstetric Anesthesiology, Pain Medicine and Pediatric Anesthesiology. RESULTS: Since 2008, the ratio of ACGME-accredited anesthesiology fellows to graduating residents increased from 0.36 in 2008 (2007 residency graduates) to 0.59 in 2022 (2021 residency graduates) and the ratio of Pediatric Anesthesiology fellows to graduating residents remained relatively stable from 0.10 to 0.11. The number of unmatched positions in Pediatric Anesthesiology increased from 17 in 2017 to 86 in 2023, and all ACGME-accredited fellowships had more positions available than applicants in 2023. CONCLUSION: In the USA, while the ratio of Pediatric Anesthesiology fellowship graduates to anesthesiology residency graduates remained relatively constant from 2008 to 2022, this is likely a lagging indicator that has not yet accounted for the recent decrease in fellowship applicants. These findings refute prior estimates for a surplus in Pediatric Anesthesia supply in the USA and have significant implications for the future.

The Effect of Novel Decision Support Tools on Technical and Non-Technical Performance of Teams in Managing Emergencies.

Cognitive aids have been shown to facilitate adherence to evidence-based guidelines and improve technical performance of teams when managing simulated critical events. Few studies have explored the effect of cognitive aids on non-technical skills, such as teamwork and communication. The current study sought to explore the effects of different decision support tools (DST), a type of cognitive aid, on the technical and non-technical performance of teams. The current study represents a randomized, blinded, control trial of the effects of three versions of an electronic DST on team performance during multiple simulations of perioperative emergencies. The DSTs included a version with only technical information, a version with only non-technical information and a version with both technical and non-technical information. The technical performance of teams was improved when they used the technical DST and the combined technical and non-technical DST when compared to memory alone. The technical performance of teams was significantly worse when using the non-technical DST. All three versions of the DST had a negligible effect on the non-technical performance of teams. The technical performance of teams in the current study was affected by different versions of a DST, yet there was no effect on the teams' non-technical performance. The use of a DST, including those that focused on non-technical information, did not impact the non-technical performance of the teams.

Hospitalization Patterns for Inpatient Pediatric Surgery and Procedures in California: 2000-2016.

BACKGROUND: We report hospitalization patterns from 2000 to 2016 for young children (ages 0-5 years old) in California who underwent 1 of the 20 most common inpatient procedures that required general anesthesia and evaluate the estimated probability of treatment at a tertiary care children's hospital (CH) by year. METHODS: We hypothesized that children ≤5 years old increasingly undergo care at tertiary care CHs for common inpatient surgeries or other procedures that require general anesthesia. Data from the California Office of Statewide Health Planning and Development dataset were used to determine procedure, patient age, year of procedure, and hospital name. Hospitals were designated as either tertiary care CHs, children's units within general hospitals (CUGHs), or general hospitals (GHs) based on the California Children's Services Provider List. A tertiary care CH was defined using the California Children's Services definition as a referral hospital that provides comprehensive, multidisciplinary, regionalized pediatric care to children from birth up to 21 years of age with a full range of medical and surgical care for severely ill children. We report the unadjusted percentage of patients treated at each hospital type and, after controlling for patient covariates and comorbidities, the estimated probability of undergoing care at a tertiary care CH from 2000 to 2016. RESULTS: There were 172,318 treatment episodes from 2000 to 2016. The estimated probability of undergoing care at a tertiary care CH increased from 63.4% (95% confidence interval [CI], 62.4%-64.4%) in 2000 to 78.3% (95% CI, 77.3%-79.4%) in 2016. CONCLUSIONS: Children ≤5 years old undergoing common inpatient procedures that require general anesthesia increasingly receive care at tertiary care CHs in California.

Speeding the Detection of Vessel Cannulation: An In-Vitro Stimulation Study.

BACKGROUND: Some practitioners "prime" small IV angiocatheter needles with 0.9% sodium chloride-claiming this modification speeds visual detection of blood in the angiocatheter flash chamber on vessel cannulation. METHODS: We compared the time required for human blood to travel the length of saline-primed and saline-unprimed 24- and 22-gauge angiocatheter needles (Introcan Safety IV Catheter; B. Braun, Bethlehem, PA). A syringe pump (Medfusion 4000, Cary, NC) advanced each angiocatheter needle through the silicone membrane of an IV tubing "t-piece" (Microbore Extension Set, 5 Inch; Hospira, Lake Forest, IL) filled with freshly donated human blood. When the angiocatheter needle contacted the blood, an electrical circuit was completed, illuminating a light-emitting diode. We determined the time from light-emitting diode illumination to visual detection of blood in the flash chamber by video review. We tested 105 saline-primed angiocatheters and 105 unprimed angiocatheters in the 24- and 22-gauge angiocatheter sizes (420 catheters total). We analyzed the median time to visualize the flash using the nonparametric Wilcoxon rank sum test in R (http://www.R-project.org/). The Stanford University Administrative Panel on Human Subjects in Medical Research determined that this project did not meet the definition of human subjects research and did not require institutional review board oversight. RESULTS: In the 24-gauge angiocatheter group, the median (and interquartile range) time for blood to travel the length of the unprimed angiocatheter needle was 1.14 (0.61-1.47) seconds compared with 0.76 (0.41-1.20) seconds in the saline-primed group (P = 0.006). In the 22-gauge catheter group, the median (interquartile range) time for blood to travel the length of the unprimed angiocatheter needle was 1.80 (1.23-2.95) seconds compared with 1.46 (1.03-2.54) seconds in the saline-primed group (P = .046). CONCLUSIONS: These results support the notion that priming small angiocatheter needles, in particular 24-gauge catheters, with 0.9% sodium chloride may provide earlier detection of vessel cannulation than with the unprimed angiocatheter.

The Pediatric Anesthesiology Workforce: Projecting Supply and Trends 2015-2035.

BACKGROUND: A workforce analysis was conducted to predict whether the projected future supply of pediatric anesthesiologists is balanced with the requirements of the inpatient pediatric population. The specific aims of our analysis were to (1) project the number of pediatric anesthesiologists in the future workforce; (2) project pediatric anesthesiologist-to-pediatric population ratios (0-17 years); (3) project the mean number of inpatient pediatric procedures per pediatric anesthesiologist; and (4) evaluate the effect of alternative projections of individual variables on the model projections through 2035. METHODS: The future number of pediatric anesthesiologists is determined by the current supply, additions to the workforce, and departures from the workforce. We previously compiled a database of US pediatric anesthesiologists in the base year of 2015. The historical linear growth rate for pediatric anesthesiology fellowship positions was determined using the Accreditation Council for Graduate Medical Education Data Resource Books from 2002 to 2016. The future number of pediatric anesthesiologists in the workforce was projected given growth of pediatric anesthesiology fellowship positions at the historical linear growth rate, modeling that 75% of graduating fellows remain in the pediatric anesthesiology workforce, and anesthesiologists retire at the current mean retirement age of 64 years old. The baseline model projections were accompanied by age- and gender-adjusted anesthesiologist supply, and sensitivity analyses of potential variations in fellowship position growth, retirement, pediatric population, inpatient surgery, and market share to evaluate the effect of each model variable on the baseline model. The projected ratio of pediatric anesthesiologists to pediatric population was determined using the 2012 US Census pediatric population projections. The projected number of inpatient pediatric procedures per pediatric anesthesiologist was determined using the Kids' Inpatient Database historical data to project the future number of inpatient procedures (including out of operating room procedures). RESULTS: In 2015, there were 5.4 pediatric anesthesiologists per 100,000 pediatric population and a mean (±standard deviation [SD]) of 262 ±8 inpatient procedures per pediatric anesthesiologist. If historical trends continue, there will be an estimated 7.4 pediatric anesthesiologists per 100,000 pediatric population and a mean (±SD) 193 ±6 inpatient procedures per pediatric anesthesiologist in 2035. If pediatric anesthesiology fellowship positions plateau at 2015 levels, there will be an estimated 5.7 pediatric anesthesiologists per 100,000 pediatric population and a mean (±SD) 248 ±7 inpatient procedures per pediatric anesthesiologist in 2035. CONCLUSIONS: If historical trends continue, the growth in pediatric anesthesiologist supply may exceed the growth in both the pediatric population and inpatient procedures in the 20-year period from 2015 to 2035.

The Geographic Distribution of Pediatric Anesthesiologists Relative to the US Pediatric Population.

BACKGROUND: The geographic relationship between pediatric anesthesiologists and the pediatric population has potentially important clinical and policy implications. In the current study, we describe the geographic distribution of pediatric anesthesiologists relative to the US pediatric population (0-17 years) and a subset of the pediatric population (0-4 years). METHODS: The percentage of the US pediatric population that lives within different driving distances to the nearest pediatric anesthesiologist (0 to 25 miles, >25 to 50 miles, >50 to 100 miles, >100 to 250 miles, and >250 miles) was determined by creating concentric driving distance service areas surrounding pediatric anesthesiologist practice locations. US Census block groups were used to determine the sum pediatric population in each anesthesiologist driving distance service area. The pediatric anesthesiologist-to-pediatric population ratio was then determined for each of the 306 hospital referral regions (HRRs) in the United States and compared with ratios of other physician groups to the pediatric population. All geographic mapping and analysis was performed using ArcGIS Desktop 10.2.2 mapping software (Redlands, CA). RESULTS: A majority of the pediatric population (71.4%) lives within a 25-mile drive of a pediatric anesthesiologist; however, 10.2 million US children (0-17 years) live greater than 50 miles from the nearest pediatric anesthesiologist. More than 2.7 million children ages 0 to 4 years live greater than 50 miles from the nearest identified pediatric anesthesiologist. The median ratio of pediatric anesthesiologists to 100,000 pediatric population at the HRR level was 2.25 (interquartile range, 0-5.46). Pediatric anesthesiologist geographic distribution relative to the pediatric population by HRR is lower and less uniform than for all anesthesiologists, neonatologists, and pediatricians. CONCLUSIONS: A substantial proportion of the US pediatric population lives greater than 50 miles from the nearest pediatric anesthesiologist, and pediatric anesthesiologist-to-pediatric population ratios by HRR vary widely across the United States. These findings are important given that the new guidelines from the American College of Surgeons Children's Surgery Verification™ Quality Improvement Program state that pediatric anesthesiologists must care for a subset of pediatric patients. Because of the geographic distribution of pediatric anesthesiologists relative to the pediatric population, access to care by a pediatric anesthesiologist may not be feasible for all children, particularly for those with limited resources or in emergent situations.

Reporting of Perioperative Adverse Events by Pediatric Anesthesiologists at a Tertiary Children's Hospital: Targeted Interventions to Increase the Rate of Reporting.

BACKGROUND: Incident reporting systems (IRSs) are important patient safety tools for identifying risks and opportunities for improvement. A major IRS limitation is underreporting of incidents. Perioperative anesthesia IRSs have been established at multiple pediatric institutions and a national pediatric anesthesia IRS for perioperative serious adverse events (SAEs) is maintained by Wake Up Safe (WUS), a patient safety organization dedicated to pediatric anesthesia quality improvement. A confidential, electronic, perioperative IRS was instituted at our tertiary children's hospital, which is a WUS member. The primary study aim was to increase the rate of incident reporting by anesthesiologists at our institution through a series of interventions. The secondary aim was to characterize our reporting behavior relative to national practice by referencing SAE data from WUS. METHODS: Perioperative adverse events reported over a 71-month period (November 2010 to September 2016) were categorized and the monthly reporting rates determined. Effects of 6 interventions targeted to increase the reporting rate were analyzed using control charts. Intervention 5 involved interviewing pediatric anesthesiologists to ascertain incident reporting barriers and motivators. A key driver diagram was developed and used to guide an improvement initiative. Incidents that fulfilled WUS criteria for SAEs were identified and categorized. SAE reporting rates over a 27-month period for 12 WUS member institutions were determined. RESULTS: 2689 perioperative adverse events were noted in 1980 of 72,384 anesthetics. Mean monthly adverse event case rate was 273 (95% confidence interval, 250-297) per 10,000 anesthetics. A subgroup involving 54,469 cases had 529 SAEs in 440 anesthetics; a mean monthly SAE case rate of 80 (95% confidence interval, 69-91) per 10,000 anesthetics. Cardiac, respiratory, and airway events predominated. Relative to WUS peer members, our institution is a high-reporting outlier. The rate of incident reporting per 10,000 anesthetics was sustainably increased from 149 ± 35 to 387 ± 73 (mean ± SD) after implementing mandatory IRS data entry and Intervention 5 quality improvement initiative. Barriers to reporting included concern for punitive repercussions, feelings of incompetence, poor education about what constitutes an event, lack of feedback, and the perception that reporting had no value. These were addressed by IRS education, cultivation of a culture of safety where reporting is encouraged, reporter feedback, and better inclusion of anesthesiologists in patient safety work. CONCLUSIONS: Electronic mandatory IRS data entry and an initiative to understand and address reporting barriers and motivators were associated with sustained increases in the adverse event reporting rate. These strategies to minimize underreporting enhance IRS value for learning and may be generalizable.

Small-Volume Injections: Evaluation of Volume Administration Deviation From Intended Injection Volumes.

BACKGROUND: In the perioperative period, anesthesiologists and postanesthesia care unit (PACU) nurses routinely prepare and administer small-volume IV injections, yet the accuracy of delivered medication volumes in this setting has not been described. In this ex vivo study, we sought to characterize the degree to which small-volume injections (≤0.5 mL) deviated from the intended injection volumes among a group of pediatric anesthesiologists and pediatric postanesthesia care unit (PACU) nurses. We hypothesized that as the intended injection volumes decreased, the deviation from those intended injection volumes would increase. METHODS: Ten attending pediatric anesthesiologists and 10 pediatric PACU nurses each performed a series of 10 injections into a simulated patient IV setup. Practitioners used separate 1-mL tuberculin syringes with removable 18-gauge needles (Becton-Dickinson & Company, Franklin Lakes, NJ) to aspirate 5 different volumes (0.025, 0.05, 0.1, 0.25, and 0.5 mL) of 0.25 mM Lucifer Yellow (LY) fluorescent dye constituted in saline (Sigma Aldrich, St. Louis, MO) from a rubber-stoppered vial. Each participant then injected the specified volume of LY fluorescent dye via a 3-way stopcock into IV tubing with free-flowing 0.9% sodium chloride (10 mL/min). The injected volume of LY fluorescent dye and 0.9% sodium chloride then drained into a collection vial for laboratory analysis. Microplate fluorescence wavelength detection (Infinite M1000; Tecan, Mannedorf, Switzerland) was used to measure the fluorescence of the collected fluid. Administered injection volumes were calculated based on the fluorescence of the collected fluid using a calibration curve of known LY volumes and associated fluorescence.To determine whether deviation of the administered volumes from the intended injection volumes increased at lower injection volumes, we compared the proportional injection volume error (loge [administered volume/intended volume]) for each of the 5 injection volumes using a linear regression model. Analysis of variance was used to determine whether the absolute log proportional error differed by the intended injection volume. Interindividual and intraindividual deviation from the intended injection volume was also characterized. RESULTS: As the intended injection volumes decreased, the absolute log proportional injection volume error increased (analysis of variance, P < .0018). The exploratory analysis revealed no significant difference in the standard deviations of the log proportional errors for injection volumes between physicians and pediatric PACU nurses; however, the difference in absolute bias was significantly higher for nurses with a 2-sided significance of P = .03. CONCLUSIONS: Clinically significant dose variation occurs when injecting volumes ≤0.5 mL. Administering small volumes of medications may result in unintended medication administration errors.

The Current Landscape of US Pediatric Anesthesiologists: Demographic Characteristics and Geographic Distribution.

BACKGROUND: There is no comprehensive database of pediatric anesthesiologists, their demographic characteristics, or geographic location in the United States. METHODS: We endeavored to create a comprehensive database of pediatric anesthesiologists by merging individuals identified as US pediatric anesthesiologists by the American Board of Anesthesiology, National Provider Identifier registry, Healthgrades.com database, and the Society for Pediatric Anesthesia membership list as of November 5, 2015. Professorial rank was accessed via the Association of American Medical Colleges and other online sources. Descriptive statistics characterized pediatric anesthesiologists' demographics. Pediatric anesthesiologists' locations at the city and state level were geocoded and mapped with the use of ArcGIS Desktop 10.1 mapping software (Redlands, CA). RESULTS: We identified 4048 pediatric anesthesiologists in the United States, which is approximately 8.8% of the physician anesthesiology workforce (n = 46,000). The median age of pediatric anesthesiologists was 49 years (interquartile range, 40-57 years), and the majority (56.4%) were men. Approximately two-thirds of identified pediatric anesthesiologists were subspecialty board certified in pediatric anesthesiology, and 33% of pediatric anesthesiologists had an identified academic affiliation. There is substantial heterogeneity in the geographic distribution of pediatric anesthesiologists by state and US Census Division with urban clustering. CONCLUSIONS: This description of pediatric anesthesiologists' demographic characteristics and geographic distribution fills an important gap in our understanding of pediatric anesthesia systems of care.

Hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission.

BACKGROUND: We have recently shown that intraoperative bacterial transmission to patient IV stopcock sets is associated with increased patient mortality. In this study, we hypothesized that bacterial contamination of anesthesia provider hands before patient contact is a risk factor for direct intraoperative bacterial transmission. METHODS: Dartmouth-Hitchcock Medical Center is a tertiary care and level 1 trauma center with 400 inpatient beds and 28 operating suites. The first and second operative cases in each of 92 operating rooms were randomly selected for analysis. Eighty-two paired samples were analyzed. Ten pairs of cases were excluded because of broken or missing sampling protocol and lost samples. We identified cases of intraoperative bacterial transmission to the patient IV stopcock set and the anesthesia environment (adjustable pressure-limiting valve and agent dial) in each operating room pair by using a previously validated protocol. We then used biotype analysis to compare these transmitted organisms to those organisms isolated from the hands of anesthesia providers obtained before the start of each case. Provider-origin transmission was defined as potential pathogens isolated in the patient stopcock set or environment that had an identical biotype to the same organism isolated from hands of providers. We also assessed the efficacy of the current intraoperative cleaning protocol by evaluating isolated potential pathogens identified at the start of case 2. Poor intraoperative cleaning was defined as 1 or more potential pathogens found in the anesthesia environment at the start of case 2 that were not there at the beginning of case 1. We collected clinical and epidemiological data on all the cases to identify risk factors for contamination. RESULTS: One hundred sixty-four cases (82 case pairs) were studied. We identified intraoperative bacterial transmission to the IV stopcock set in 11.5 % (19/164) of cases, 47% (9/19) of which were of provider origin. We identified intraoperative bacterial transmission to the anesthesia environment in 89% (146/164) of cases, 12% (17/146) of which were of provider origin. The number of rooms that an attending anesthesiologist supervised simultaneously, the age of the patient, and patient discharge from the operating room to an intensive care unit were independent predictors of bacterial transmission events not directly linked to providers. CONCLUSION: The contaminated hands of anesthesia providers serve as a significant source of patient environmental and stopcock set contamination in the operating room. Additional sources of intraoperative bacterial transmission, including postoperative environmental cleaning practices, should be further studied.

Tools for Assessing the Performance of Pediatric Perioperative Teams During Simulated Crises: A Psychometric Analysis of Clinician Raters' Scores.

INTRODUCTION: The pediatric perioperative setting is a dynamic clinical environment where multidisciplinary interprofessional teams interact to deliver complex care to patients. This environment requires clinical teams to possess high levels of complex technical and nontechnical skills. For perioperative teams to identify and maintain clinical competency, well-developed and easy-to-use measures of competency are needed. METHODS: Tools for measuring the technical and nontechnical performance of perioperative teams were developed and/or identified, and a group of raters were trained to use the instruments. The trained raters used the tools to assess pediatric teams managing simulated emergencies. A psychometric analysis of the trained raters' scores using the different instruments was performed and the agreement between the trained raters' scores and a reference score was determined. RESULTS: Five raters were trained and scored 96 recordings of perioperative teams managing simulated emergencies. Scores from both technical skills assessment tools demonstrated significant reliability within and between ratings with the scenario-specific performance checklist tool demonstrating greater interrater agreement than scores from the global rating scale. Scores from both technical skills assessment tools correlated well with the other and with the reference standard scores. Scores from the Team Emergency Assessment Measure nontechnical assessment tool were more reliable within and between raters and correlated better with the reference standard than scores from the BARS tool. CONCLUSIONS: The clinicians trained in this study were able to use the technical performance assessment tools with reliable results that correlated well with reference scores. There was more variability between the raters' scores and less correlation with the reference standard when the raters used the nontechnical assessment tools. The global rating scale used in this study was able to measure the performance of teams across a variety of scenarios and may be generalizable for assessing teams in other clinical scenarios. The Team Emergency Assessment Measure tool demonstrated reliable measures when used to assess interprofessional perioperative teams in this study.

Stopcock lumen contamination does not reflect the full burden of bacterial intravenous tubing contamination: analysis using a novel injection port.

BACKGROUND: Prior clinical studies have used injection port lumen culture as a marker of intravenous (IV) fluid system contamination. We hypothesized that culturing injected saline (effluent) is a more sensitive method of detecting IV fluid system bacterial contamination than lumen culture. To test this hypothesis, we compared the incidence of lumen contamination with effluent contamination in a simulated setting. We also measured the effect of a novel injection port protective device (Port Guide; Matrix Tooling, Inc, Wood Dale, IL) on contamination. METHODS: In this ex vivo study, 33 providers performed 5 injections of 1 mL sterile saline into each of 4 injection port designs: (1) stopcock, (2) stopcock with Port Guide, (3) stopcock with disinfectable needleless closed connector (DNCC), and (4) stopcock with DNCC and Port Guide. The primary outcome was the rate of effluent contamination with simultaneously contaminated injection port lumen. RESULTS: Bacterial organisms were recovered from the effluent in 17 of the 132 injection ports evaluated. Of those 17 injection ports with contaminated effluent, 4 injection port lumens were simultaneously contaminated (24%). Additionally, use of the stopcock with Port Guide significantly reduced effluent contamination. CONCLUSION: Effluent culture is a more sensitive marker of IV fluid system contamination than injection port lumen culture. A novel protective device on the stopcock (Port Guide) significantly reduced IV fluid system bacterial contamination.