REMAP Periop: a randomised, embedded, multifactorial adaptive platform trial protocol for perioperative medicine to determine the optimal enhanced recovery pathway components in complex abdominal surgery patients within a US healthcare system.

INTRODUCTION: Implementation of enhanced recovery pathways (ERPs) has resulted in improved patient-centred outcomes and decreased costs. However, there is a lack of high-level evidence for many ERP elements. We have designed a randomised, embedded, multifactorial, adaptive platform perioperative medicine (REMAP Periop) trial to evaluate the effectiveness of several perioperative therapies for patients undergoing complex abdominal surgery as part of an ERP. This trial will begin with two domains: postoperative nausea/vomiting (PONV) prophylaxis and regional/neuraxial analgesia. Patients enrolled in the trial will be randomised to arms within both domains, with the possibility of adding additional domains in the future. METHODS AND ANALYSIS: In the PONV domain, patients are randomised to optimal versus supraoptimal prophylactic regimens. In the regional/neuraxial domain, patients are randomised to one of five different single-injection techniques/combination of techniques. The primary study endpoint is hospital-free days at 30 days, with additional domain-specific secondary endpoints of PONV incidence and postoperative opioid consumption. The efficacy of an intervention arm within a given domain will be evaluated at regular interim analyses using Bayesian statistical analysis. At the beginning of the trial, participants will have an equal probability of being allocated to any given intervention within a domain (ie, simple 1:1 randomisation), with response adaptive randomisation guiding changes to allocation ratios after interim analyses when applicable based on prespecified statistical triggers. Triggers met at interim analysis may also result in intervention dropping. ETHICS AND DISSEMINATION: The core protocol and domain-specific appendices were approved by the University of Pittsburgh Institutional Review Board. A waiver of informed consent was obtained for this trial. Trial results will be announced to the public and healthcare providers once prespecified statistical triggers of interest are reached as described in the core protocol, and the most favourable interventions will then be implemented as a standardised institutional protocol. TRIAL REGISTRATION NUMBER: NCT04606264.

A first look at the Accreditation Council for Graduate Medical Education anesthesiology milestones: implementation of self-evaluation in a large residency program.

STUDY OBJECTIVE: The objective was to determine if there is a correlation between resident postgraduate year (PGY) of training and self-evaluation of performance using the Accreditation Council for Graduate Medical Education milestones. DESIGN: Survey. SETTING: Residency program at a large academic center. PATIENTS: Residents and Faculty Clinical Competency Committee (CCC). INTERVENTIONS: None. MEASUREMENTS: Resident and CCC milestone scores. MAIN RESULTS: Correlation coefficients for average score for each milestone vs PGY level ranged from 0.80 for receiving and giving feedback to 0.95 for anesthetic choice and conduct. All milestones showed a relatively linear relationship with PGY of training, and none were found to be consistently reached very late or very early in training. When examining variation across the scores for the individual residents, the distributions for PGY-2 and -3 appeared to be wider than those for PGY-1 and -4. The intraclass correlation coefficients ranged from 0.718 to 0.928. CONCLUSIONS: There was a remarkable degree of consistency in the relationship between level of training and resident self-assessment score for every milestone, as well as strong agreement between the resident and CCC faculty scores. Examination of the variance in the scores, when interpreted in light of our particular training program's characteristics, suggests that the milestones accurately reflect the progression in skill across the residency. In addition, given the concordance between the self-evaluation scores and the CCC faculty scores, self-evaluation may be a reasonable starting point as programs begin the daunting task of determining scores for each of the 25 milestones as part of the biannual evaluation process.

Simulation in the operating room.

Simulation has become a significant training tool in the operating room (OR). It can be used in both simple task training and complex scenarios. The challenge for simulation in the OR is how to translate that which is learned, and perceived to beneficial, into behavioral change and improved patient outcomes. Simulation in the developing world is progressing, but is still hampered by a shortage of material, personnel funding.

Use of social media resources by applicants during the residency selection process.

BACKGROUND: The attitudes of residency applicants regarding social media resources and how these resources affect their decisions during residency selection have not been well-studied. The objective of this study was to evaluate the use of electronic and social media resources by residency applicants and the impact of these resources on their residency selection decisions. METHODS: Interviewees at our anesthesiology residency program during the 2012-2013 interview cycle were surveyed anonymously regarding their use of electronic and social media resources. RESULTS: On a scale from 1 to 5 (1=not at all important, 5=very important), social media resources were given a ranking of 3 (2-3) (median [25%-75%]) for importance for gathering residency program information. Our Facebook page was accessed by 47% of respondents. Thirty-seven percent did so before applying and 58% did so after applying but before interviewing. The Facebook page was useful to 12% when deciding whether to apply to our program, 25% when deciding whether to interview, and 29% when deciding where to rank our program on their rank order list. Participants who responded that our Facebook page was useful in three domains (applying, interviewing, and ranking) credited it for increasing the likelihood that they applied to, interviewed at, and preferentially ranked our program. CONCLUSIONS: Social media resources serve a valuable role for residency applicants. Applicants who accessed our program's Facebook page reported that it made them more likely to apply to our program, interview at our program, and that it increased the position of our program on their rank order lists.

Financial Implications of Different Interpretations of ACGME Anesthesiology Program Requirements for Rotations in the Operating Room.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) standards for resident education in anesthesiology mandate required rotations including rotations inside the operating room (OR). When residents complete rotations outside the OR, other providers must be used to maintain the OR's clinical productivity. OBJECTIVE: WE QUANTIFIED AND COMPARED THE COSTS OF REPLACING RESIDENTS BY USING TWO DIFFERENT WORKING PATTERNS THAT ARE COMPLIANT WITH THE ACGME ANESTHESIOLOGY PROGRAM REQUIREMENTS: (1) the minimum amount of time in the OR, and (2) working the maximum amount of time permitted in the OR. METHODS: We calculated resident replacement costs over a 36-month residency period in both a minimum and maximum OR time model. We used a range of Certified Registered Nurse Anesthetist (CRNA) pay scales determined by a local market analysis for cost comparisons. RESULTS: Depending on CRNA pay rates, the cost differentials to replace a resident in the OR between the minimum and maximum OR time models ranged from $236,000 to $581,876, assuming a 50-hour resident work week, and $373,400 to $931,001, assuming an 80-hour resident work week. This cost was per resident over the entire 3 years of their residency. CONCLUSIONS: Varying the amount of time residents work in the OR (as allowed under ACGME program requirements) has significant financial implications over a 36-month anesthesiology residency. The larger the residency, the more significant will be the impact on the department and sponsoring institution.

What is an anesthesiology resident worth?

STUDY OBJECTIVE: To determine the cost of replacing an anesthesiology resident with a certified registered nurse anesthetist (CRNA) for equal operating room (OR) work. DESIGN: Retrospective financial analysis. SETTING: Academic anesthesiology department. PARTICIPANTS: Clinical anesthesia (CA)-1 through CA-3 residents. MEASUREMENTS: Cost of replacing anesthesiology residents with CRNAs for equal OR work was determined. MAIN RESULTS: The cost of replacing one anesthesiology resident with a CRNA for the same number of OR hours ranged from $9,940.32 to $43,300 per month ($106,241.68 to $432,937.50 per yr). Numbers varied depending on the CRNA pay scale and whether the calculations were based on the number of OR hours worked at our residency program or OR hours worked in a maximum duty hour model. CONCLUSIONS: A CRNA is paid substantially more per OR hour worked, at all pay levels, than an anesthesiology resident.