Critical Appraisal of Anesthesiology Educational Research for 2020.

Background: This study reviews and appraises the articles published about anesthesiology education in 2020. The objective is to highlight high-quality evidence while showcasing articles with innovative ideas and high relevance to the practices of the anesthesiology education community. Methods: Three Ovid MEDLINE databases, Embase.com, ERIC, PsycINFO, and PubMed were searched, followed by a manual review of articles published in the highest impact factor journals in both the fields of anesthesiology and medical education. Abstracts were double screened, and quantitative articles were subsequently scored by 3 randomly assigned raters. Qualitative studies were scored by 2 raters. Two different rubrics were used for scoring quantitative and qualitative studies. In addition, reviewers rated each article on its overall quality to create an additional list of top articles based solely on the opinion of the reviewers. Results: A total of 2,491 citations were identified through the search criteria and the manual review. Of those, 61 articles met the inclusion criteria (57 quantitative and 4 qualitative). The top 12 quantitative papers and the top qualitative papers with the highest scores are reported and summarized. Conclusions: We found that teaching clinical procedures continues to be a topic of interest, with more studies of improved rigor identified. New trends in wellness studies and increasing attention to distance learning and technology-assisted instructional methods were additional topics covered over the year.

Critical Appraisal of Anesthesiology Educational Research for 2019.

Background: This study reviews and appraises the articles published about anesthesiology education in 2019. Through this critical appraisal, those interested in anesthesiology education are able to quickly review literature published during this year and explore innovative ways to improve education for all those involved in the practice of anesthesiology. Methods: Three Ovid MEDLINE databases, Embase.com, ERIC, and PsycINFO were searched followed by a manual review of articles published in the highest impact factor journals in both the fields of anesthesiology and medical education. Abstracts were double-screened and quantitative articles were subsequently scored by 3 randomly assigned raters. Qualitative studies were scored by 2 raters. Two different rubrics were used for scoring quantitative and qualitative studies; both allowed for scores ranging from 1 to 25. In addition, reviewers rated each article on its overall quality to create an additional list of top articles based solely on the opinion of the reviewers. Results: A total of 2374 unique citations were identified through the search criteria and the manual review. Of those, 70 articles met the inclusion criteria (62 quantitative and 8 qualitative). The top 12 quantitative papers and the top 2 qualitative papers with the highest scores were reported and summarized.Conclusions: This critical appraisal continues to be a useful tool for those working in anesthesiology education by highlighting the best research articles published over the year. Highlighting trends in medical education research in anesthesiology can help those in the field to think critically about the direction of this type of research.

Using Machine Learning to Evaluate Attending Feedback on Resident Performance.

BACKGROUND: High-quality and high-utility feedback allows for the development of improvement plans for trainees. The current manual assessment of the quality of this feedback is time consuming and subjective. We propose the use of machine learning to rapidly distinguish the quality of attending feedback on resident performance. METHODS: Using a preexisting databank of 1925 manually reviewed feedback comments from 4 anesthesiology residency programs, we trained machine learning models to predict whether comments contained 6 predefined feedback traits (actionable, behavior focused, detailed, negative feedback, professionalism/communication, and specific) and predict the utility score of the comment on a scale of 1-5. Comments with ≥4 feedback traits were classified as high-quality and comments with ≥4 utility scores were classified as high-utility; otherwise comments were considered low-quality or low-utility, respectively. We used RapidMiner Studio (RapidMiner, Inc, Boston, MA), a data science platform, to train, validate, and score performance of models. RESULTS: Models for predicting the presence of feedback traits had accuracies of 74.4%-82.2%. Predictions on utility category were 82.1% accurate, with 89.2% sensitivity, and 89.8% class precision for low-utility predictions. Predictions on quality category were 78.5% accurate, with 86.1% sensitivity, and 85.0% class precision for low-quality predictions. Fifteen to 20 hours were spent by a research assistant with no prior experience in machine learning to become familiar with software, create models, and review performance on predictions made. The program read data, applied models, and generated predictions within minutes. In contrast, a recent manual feedback scoring effort by an author took 15 hours to manually collate and score 200 comments during the course of 2 weeks. CONCLUSIONS: Harnessing the potential of machine learning allows for rapid assessment of attending feedback on resident performance. Using predictive models to rapidly screen for low-quality and low-utility feedback can aid programs in improving feedback provision, both globally and by individual faculty.

Critical Appraisal of Anesthesiology Educational Research for 2018.

BACKGROUND: Through a critical appraisal of the education research in anesthesiology, this article enables those interested in the field to read the high-quality articles for the past year and possibly implement these evidence-based interventions and concepts into practice. This study reviews and appraises all medical education studies published in 2018 in anesthesiology and summarizes the highest-rated articles evaluated. METHODS: Three Ovid MEDLINE databases, Embase.com, ERIC, PsycINFO, and PubMed were searched followed by a manual review of articles published in the highest impact factor journals in both the fields of anesthesiology and medical education. Abstracts were double-screened and quantitative articles subsequently scored by 3 randomly assigned raters. Qualitative studies were scored by 2 raters. Two different rubrics were used for scoring quantitative and qualitative studies, both allowed for scores ranging from 1 to 25. RESULTS: A total of 888 unique citations were identified through the search criteria. Of those, 39 articles met the inclusion criteria (36 quantitative and 3 qualitative). The top 11 quantitative papers and the top qualitative paper with the highest scores were reported and summarized. CONCLUSIONS: As the second article to critically review the literature available for education in anesthesiology, we are able to add to this annual series to help further disseminate the articles of the highest quality in anesthesiology education. Because this is only the second year, we can only report on initial suggestions of trends that we hope will help guide future research.

Family Comes First: A Pilot Study of the Incorporation of Social Support Into Resident Well-being.

BACKGROUND: Recent work has shown that understanding of work-related stress by family and friends is associated with increased resident well-being. However, it is often difficult for residents to communicate with their support persons (SPs), especially those who have minimal understanding of the medical field, regarding even the most basic functions of their role in the health care system. This study aimed to pilot test an innovative wellness event focusing on the social relatedness component of resident well-being. METHODS: The target population included 30 new residents at 2 anesthesiology residency programs and their SPs in 2017. The Family Anesthesia Experience (FAX) began with didactic presentations and a panel discussion about wellness topics. It concluded with a multifaceted simulation experience. Participants were surveyed before and after the event. Measures included SPs' understanding of residents' work and residents' stress, burnout, resilience, and social support levels. Student t tests, Mann-Whitney U tests, Wilcoxon signed-rank tests, and repeated measures analysis of variance were used to examine the impact of the event. RESULTS: Twenty-two (84.6%) of the 26 intervention clinical anesthesia year 1 residents who attended FAX completed the postevent surveys, and all intervention SPs (100%, n = 33) completed both pre-event and postevent surveys. The event was well received by the residents (100%) and their SPs (100%). Improvement in perceived understanding in the intervention SPs group (Pre: 1.44 ± 0.63, Post: 2.69 ± 0.33, P < .0001) was observed. Not all metrics of well-being for the residents achieved significance in change; however, decreased stress was observed compared with historical controls (Control: 1.91 ± 0.61, Intervention: 1.54 ± 0.42, P = .019). CONCLUSION: The event led to improved SPs' understanding of the role of an anesthesiology resident.

Do You Really Mean It? Assessing the Strength, Frequency, and Reliability of Applicant Commitment Statements During the Anesthesiology Residency Match.

BACKGROUND: Despite the critical nature of the residency interview process, few metrics have been shown to adequately predict applicant success in matching to a given program. While evaluating and ranking potential candidates, bias can occur when applicants make commitment statements to a program. Survey data show that pressure to demonstrate commitment leads applicants to express commitment to multiple institutions including telling >1 program that they will rank them #1. The primary purpose of this cross-sectional observational study is to evaluate the frequency of commitment statements from applicants to 5 anesthesiology departments during a single interview season, report how often each statement is associated with a successful match, and identify how frequently candidates incorrectly represented commitments to rank a program #1. METHODS: During the 2014 interview season, 5 participating anesthesiology programs collected written and verbal communications from applicants. Three residency program directors independently reviewed the statements to classify them into 1 of 3 categories; guaranteed commitment, high rank commitment, or strong interest. Each institution provided a deidentified rank list with associated commitment statements, biographical data, whether candidates were ranked-to-match, and if they successfully matched. RESULTS: Program directors consistently differentiated among strong interest, high rank, and guaranteed commitment statements with κ coefficients of 0.9 (95% CI, 0.8-0.9) or greater between any pair of reviewers. Overall, 35.8% of applicants (226/632) provided a statement demonstrating at least strong interest and 5.4% (34/632) gave guaranteed commitment statements. Guaranteed commitment statements resulted in a 95.7% match rate to that program in comparison to statements of high rank (25.6%), strong interest (14.6%), and those who provided no statement (5.9%). For those providing guaranteed commitment statements, it can be assumed that the 1 candidate (4.3%) who did not match incorrectly represented himself. Variables such as couples match, "R" positions, and not being ranked-to-match on both advanced and categorical rank lists were eliminated because they can result in a nonmatch despite truthfully ranking a program #1. CONCLUSIONS: Each level of commitment statement resulted in a progressively increased frequency of a successful match to the recipient program. Only 5.4% of applicants committed to rank a program #1, but these statements were very reliable. These data can help program directors interpret commitment statements and assist accurate evaluation of the interest of candidates throughout the match process.

Critical Appraisal of Anesthesiology Educational Research for 2017.

Background Critical appraisals provide a method for establishing the status of an area of study or evaluating the effectiveness of literature within it. The purpose of this study was to review and appraise studies published in 2017 on medical education in anesthesiology and to provide summaries of the highest-quality medical education research articles in the field. Methods Three Ovid MEDLINE databases, Embase.com, Education Resources Information Center (ERIC), and PsycINFO, were searched followed by a manual review of articles published in the highest impact factor journals in both the fields of anesthesiology and medical education. Abstracts were double-screened and quantitative articles subsequently scored by three randomly assigned raters. Qualitative studies were scored by two raters. Two different rubrics were used for scoring quantitative and qualitative studies, both allowed for scores ranging from 1-25. Results A total of 864 unique citations were identified through the search criteria. Of those, 62 articles met the inclusion criteria, with 59 quantitative and three qualitative. The top 10 papers with the highest scores were reported and summarized. Discussion As the first article to critically review the literature available for education in anesthesiology, we hope that this study will serve as the first manuscript in an annual series that will help individuals involved in anesthesiology education gain an understanding of the highest-quality research in the field. Once this process is repeated, trends can be tracked and serve as a resource to educators and researchers in anesthesiology for years to come.

Should Objective Structured Clinical Examinations Assist the Clinical Competency Committee in Assigning Anesthesiology Milestones Competency?

BACKGROUND: With the integration of Objective Structured Clinical Examinations into the Anesthesiology primary board certification process, residency programs may choose to implement Objective Structured Clinical Examinations for resident skill assessment. The aim of this study was to evaluate Objective Structured Clinical Examination-based milestone assessment and compare with Clinical Competency Committee milestone assessment that is based purely on clinical evaluations. METHODS: An annual Objective Structured Clinical Examination event was used to obtain milestone assessment of clinical anesthesia year 0-clinical anesthesia year 3 residents for selected milestones in patient care, professionalism, and interpersonal/communication skills. The Objective Structured Clinical Examination scenarios were different for each training level. The Clinical Competency Committee evaluated each resident semiannually based on clinical evaluations of resident performance. The Clinical Competency Committee milestone assessments from 2014 to 2016 that were recorded closest to the Objective Structured Clinical Examination event (±3 months) were compared to the Objective Structured Clinical Examination milestone assessments. A total of 35 residents were included in this analysis in 3 different training cohorts: A (graduates 2016, n = 12); B (graduates 2017, n = 10); and C (graduates 2018, n = 13). All residents participated in Objective Structured Clinical Examinations because their clinical anesthesia year 0 year and Clinical Competency Committee milestone data had been reported since December 2014. RESULTS: Both assessment techniques indicated a competency growth proportional to the length in training. Despite limited cumulative statistics in this study, average trends in the Objective Structured Clinical Examination-Clinical Competency Committee relationship indicated: (1) a good proportionality in reflecting competency growth; (2) a grade enhancement associated with Clinical Competency Committee assessment, dominated by evaluations of junior residents (clinical anesthesia year 0-clinical anesthesia year 1); and (3) an expectation bias in Clinical Competency Committee assessment, dominated by evaluation of senior residents (clinical anesthesia year 2-clinical anesthesia year 3). CONCLUSIONS: Our analysis confirms the compatibility of the 2 evaluation methods in reflecting longitudinal growth. The deviation of Objective Structured Clinical Examination assessments versus Clinical Competency Committee assessments suggests that Objective Structured Clinical Examinations may be providing additional or different information on resident performance. Educators might consider using both assessment methods to provide the most reliable and valid competency assessments during residency.

Replicating an Educational OSCE Project for Skill Assessment of Junior Anesthesiology Residents at Multiple Institutions: A Qualitative Description.

BACKGROUND: Educational research projects are often developed and implemented at a single institution. However, the research project methods and results may not be generalizable and able to be replicated successfully at other institutions. The aim of this study was to investigate the process of replicating an effective educational Objective Structured Clinical Examination (OSCE) event at multiple other institutions. METHODS: An OSCE event was initially designed and implemented at the primary institution to assess the skill level of junior residents on the performance of basic anesthesia tasks. After the initial implementation, additional institutions were recruited to participate in a replication of this OSCE event at their own institutions. The primary institution provided the OSCE scenarios, assessment tools, rater training, and resident participant instructions. The participating secondary institutions' (n = 4) event managers obtained Institutional Review Board [IRB] approval, developed the event schedule, assigned faculty evaluators, and organized the simulation space at their own medical centers. The events were assessed by the secondary institutions' resident and faculty participants via an anonymous survey regarding the event's content and their perception of its educational value. RESULTS: We replicated a complex educational OSCE event, developed and implemented at 1 institution, at 4 other institutions. Resident participants (n = 60), participating faculty (n = 24), and event directors (n = 4) indicated a high level of appreciation for the OSCE event. CONCLUSION: Using a structured approach, educational OSCE events can be successfully replicated at multiple institutions. Organization of multi-institutional studies and collaborative efforts is complex. This study illustrates 1 example of how to successfully approach multi-institutional educational projects.

Results of a Flipped Classroom Teaching Approach in Anesthesiology Residents.

BACKGROUND: In a flipped classroom approach, learners view educational content prior to class and engage in active learning during didactic sessions. OBJECTIVE: We hypothesized that a flipped classroom improves knowledge acquisition and retention for residents compared to traditional lecture, and that residents prefer this approach. METHODS: We completed 2 iterations of a study in 2014 and 2015. Institutions were assigned to either flipped classroom or traditional lecture for 4 weekly sessions. The flipped classroom consisted of reviewing a 15-minute video, followed by 45-minute in-class interactive sessions with audience response questions, think-pair-share questions, and case discussions. The traditional lecture approach consisted of a 55-minute lecture given by faculty with 5 minutes for questions. Residents completed 3 knowledge tests (pretest, posttest, and 4-month retention) and surveys of their perceptions of the didactic sessions. A linear mixed model was used to compare the effect of both formats on knowledge acquisition and retention. RESULTS: Of 182 eligible postgraduate year 2 anesthesiology residents, 155 (85%) participated in the entire intervention, and 142 (78%) completed all tests. The flipped classroom approach improved knowledge retention after 4 months (adjusted mean = 6%; P = .014; d = 0.56), and residents preferred the flipped classroom (pre = 46%; post = 82%; P < .001). CONCLUSIONS: The flipped classroom approach to didactic education resulted in a small improvement in knowledge retention and was preferred by anesthesiology residents.

Enhancing Feedback on Professionalism and Communication Skills in Anesthesia Residency Programs.

BACKGROUND: Despite its importance, training faculty to provide feedback to residents remains challenging. We hypothesized that, overall, at 4 institutions, a faculty development program on providing feedback on professionalism and communication skills would lead to (1) an improvement in the quantity, quality, and utility of feedback and (2) an increase in feedback containing negative/constructive feedback and pertaining to professionalism/communication. As secondary analyses, we explored these outcomes at the individual institutions. METHODS: In this prospective cohort study (October 2013 to July 2014), we implemented a video-based educational program on feedback at 4 institutions. Feedback records from 3 months before to 3 months after the intervention were rated for quality (0-5), utility (0-5), and whether they had negative/constructive feedback and/or were related to professionalism/communication. Feedback records during the preintervention, intervention, and postintervention periods were compared using the Kruskal-Wallis and χ tests. Data are reported as median (interquartile range) or proportion/percentage. RESULTS: A total of 1926 feedback records were rated. The institutions overall did not have a significant difference in feedback quantity (preintervention: 855/3046 [28.1%]; postintervention: 896/3327 [26.9%]; odds ratio: 1.06; 95% confidence interval, 0.95-1.18; P = .31), feedback quality (preintervention: 2 [1-4]; intervention: 2 [1-4]; postintervention: 2 [1-4]; P = .90), feedback utility (preintervention: 1 [1-3]; intervention: 2 [1-3]; postintervention: 1 [1-2]; P = .61), or percentage of feedback records containing negative/constructive feedback (preintervention: 27%; intervention: 32%; postintervention: 25%; P = .12) or related to professionalism/communication (preintervention: 23%; intervention: 33%; postintervention: 24%; P = .03). Institution 1 had a significant difference in feedback quality (preintervention: 2 [1-3]; intervention: 3 [2-4]; postintervention: 3 [2-4]; P = .001) and utility (preintervention: 1 [1-3]; intervention: 2 [1-3]; postintervention: 2 [1-4]; P = .008). Institution 3 had a significant difference in the percentage of feedback records containing negative/constructive feedback (preintervention: 16%; intervention: 28%; postintervention: 17%; P = .02). Institution 2 had a significant difference in the percentage of feedback records related to professionalism/communication (preintervention: 26%; intervention: 57%; postintervention: 31%; P < .001). CONCLUSIONS: We detected no overall changes but did detect different changes at each institution despite the identical intervention. The intervention may be more effective with new faculty and/or smaller discussion sessions. Future steps include refining the rating system, exploring ways to sustain changes, and investigating other factors contributing to feedback quality and utility.

Ultrasound Skill and Application of Knowledge Assessment using an Innovative OSCE Competition-Based Simulation Approach.

BACKGROUND: Despite Point-of Care Ultrasound (PoC US) rapidly becoming an important tool in perioperative medicine structured education, PoC US is currently rarely integrated into the anesthesiology residency curriculum. The aim of this project was to assess the current ultrasound skills of anesthesiology residents at one institution and evaluate the needs for development of a formal ultrasound curriculum. METHODS: A event containing 6 different OSCE PoC US stations was developed with following stations: vascular, peripheral nerve block, lung ultrasound, transthoracic echocardiography (TTE) human model, pathologic TTE (simulator), and inferior vena cava (IVC) evaluation (simulator). The ability to obtain an US image or to interpret the US information was evaluated using a checklist and global rating scale. After IRB approval, anesthesiology residents participated in this event (n=30; PGY 2-4). RESULTS: All residents were able to identify vascular structures and demonstrated sufficient ultrasound skill for lung anatomy IVC assessment. The lowest scores were observed for performing and interpreting TTE. There were no differences in resident ultrasound skills for all OSCE stations except minor differences between PGY 2 and PGY 4 in TTE pathology station. While more advanced residents had more clinical exposure to ultrasound for procedures and point-of-care diagnosis, we did not find growth in ultrasound skill level. Despite performing sufficient ultrasound guided peripheral nerve blocks, PGY 4 residents were not able to consistently identify common nerve block targets. CONCLUSIONS: Our findings indicate that exposure and clinical use of ultrasound for procedures and point-of-care diagnosis is not sufficient for developing competency in PoC US and that a formal curriculum throughout the entire anesthesiology residency is needed to ensure PoC US competency.

Systemic-to-pulmonary artery pressure ratio as a predictor of patient outcome following liver transplantation.

AIM: To assess the value of the mean systemic-to-pulmonary artery pressure (MAP/mPAP) ratio for predicting outcomes following orthotopic liver transplant (OLT). METHODS: A retrospective data analysis was performed and data (mean arterial blood pressure, mean pulmonary artery pressure and Cardiac Index) were collected at several points during OLT. Outcomes evaluated were duration of postoperative endotracheal intubation [ET; minutes after intensive care unit (ICU) arrival], length of ICU stay, total hospitalization and frequency of immediate postoperative complications. A total of 91 patients were included in the data analysis. Based on the intraoperative course of the MAP/mPAP ratio, 2 hemodynamic responses were identified: Group 1 (MAP/mPAP ratio increase during anhepatic period with postreperfusion recovery, n = 66); and Group 2 (MAP/mPAP ratio with no change during anhepatic period or decreased without recovery, n = 25). RESULTS: The main finding was that the lack of increased MAP/mPAP ratio in the anhepatic period was associated with: (1) longer intubation times; and (2) prolonged ICU stays and total hospitalization time, when compared to patients with an increase in MAP/mPAP ratio during the anhepatic period. CONCLUSION: The data from this retrospective study should raise awareness to the mean systemic to pulmonary artery pressure ratio as a potential indicator for poor outcome after OLT. Further prospective studies are needed for validation.

Cognitive aid use improves transition of care by graduating medical students during a simulated crisis.

BACKGROUND: Residents are expected to have transition of care (ToC) skills upon entering graduate medical education. It is unclear whether experience and training during medical school is adequate. OBJECTIVE: The aim of the project was to assess: 1) graduating medical students' ability to perform ToC in a crisis situation, and 2) whether using a cognitive aid improves the ToC quality. METHODS: The authors developed simulation scenarios for rapid response teams and a cognitive aid to assist in the ToC during crisis situations. Graduating medical students were enrolled and randomly divided into teams of three students, randomly assigned into one of two groups: teams using a cognitive aid for ToC (CA), or not using a cognitive aid (nCA). In the scenario, teams respond to a deteriorating patient and then transfer care to the next provider after stabilization. Three faculty reviewed the recording to assess completeness of the ToC and the overall quality. A completeness score was expressed as a fraction of the maximum score. Statistical analysis was performed using a t-test and Mann-Whitney U test. RESULTS: A total of 112 senior medical students participated: CA n=19, nCA n=17. The completeness score of the ToC and overall quality improved when using the cognitive aid (completeness score: CA 0.80±0.06 vs. nCA 0.52±0.07, p<0.01; ToC quality: CA 3.16±0.65 vs. nCA 1.92±0.56, p<0.01). Participants' rating of knowledge and comfort with the ToC process increased after the simulation. CONCLUSION: The completeness of information transfer during the ToC process by graduating medical students improved by using a cognitive aid in a simulated patient crisis.

A Competitive Objective Structured Clinical Examination Event to Generate an Objective Assessment of Anesthesiology Resident Skills Development.

Residency programs are charged with teaching, assessing, and documenting resident competency for a multitude of skills throughout the course of residency training. An innovative, competition-based objective structured clinical examination event was designed in our department to objectively assess the skill level of anesthesiology residents. After conducting the identical event for 2 years in postgraduate year 1 (PGY1) and postgraduate year 2 (PGY2) residents, we tested the hypothesis that the event can provide adequate standardization to appropriately document progression in technical and nontechnical skills. Twenty-one residents participated in both events during their PGY1 and PGY2 years: n = 10, 2012/2013, n = 11, 2013/2014. The PGY1 participants in 2012 were retested in 2013 (as PGY2 residents) during an identical event, and their performance was compared as a group and on an individual level. The PGY1 residents in 2013 did the same in 2014. Four workstations were analyzed to determine whether improvement in performance occurred between the PGY1 and the PGY2 years: (1) preoperative assessment, (2) operating room anesthesia station checkout, (3) peripheral IV and endotracheal tube placement, and (4) transfer of care in the postanesthesia care unit. The performances of PGY1 and PGY2 residents were compared. The assessments were performed by anesthesiology faculty using checklists, time to complete task, and Likert scale ratings. Data analysis showed improved technical anesthesia skills (operating room setup, peripheral IV, and endotracheal tube placement) and more complete anesthesia-related information management in the preoperative assessment and postoperative transition of care in the postanesthesia care unit in PGY2 residents compared with the PGY1 performance of the same residents. The described event is a valuable tool for objective assessment of multiple anesthesia skills and possible milestones during residency.

A Smartphone-based Decision Support Tool Improves Test Performance Concerning Application of the Guidelines for Managing Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy.

BACKGROUND: The American Society of Regional Anesthesia and Pain Medicine (ASRA) consensus statement on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy is the standard for evaluation and management of these patients. The authors hypothesized that an electronic decision support tool (eDST) would improve test performance compared with native physician behavior concerning the application of this guideline. METHODS: Anesthesiology trainees and faculty at 8 institutions participated in a prospective, randomized trial in which they completed a 20-question test involving clinical scenarios related to the ASRA guidelines. The eDST group completed the test using an iOS app programmed to contain decision logic and content of the ASRA guidelines. The control group completed the test by using any resource in addition to the app. A generalized linear mixed-effects model was used to examine the effect of the intervention. RESULTS: After obtaining institutional review board's approval and informed consent, 259 participants were enrolled and randomized (eDST = 122; control = 137). The mean score was 92.4 ± 6.6% in the eDST group and 68.0 ± 15.8% in the control group (P < 0.001). eDST use increased the odds of selecting correct answers (7.8; 95% CI, 5.7 to 10.7). Most control group participants (63%) used some cognitive aid during the test, and they scored higher than those who tested from memory alone (76 ± 15% vs. 57 ± 18%, P < 0.001). There was no difference in time to completion of the test (P = 0.15) and no effect of training level (P = 0.56). CONCLUSIONS: eDST use improved application of the ASRA guidelines compared with the native clinician behavior in a testing environment.

Objective Assessment of Anesthesiology Resident Skills Using an Innovative Competition-Based Simulation Approach.

Residency programs are charged with teaching, assessing, and documenting resident competency for a multitude of skills. Documentation of competency requires demonstrating specific milestones mandated by the Accreditation Council for Graduate Medical Education. Our department designed an innovative, competition-based approach to objectively assess the skill level of postgraduate year 1 residents in performing basic anesthesia-related tasks after 1 month of anesthesiology training. We launched an "Olympic" event to assess requisite skills in an environment of friendly competition. A simulation format was chosen to allow standardized objective assessment of the resident's skill level at an early stage of training, with possible identification of and intervention for skills needing improvement. Our experience may serve as a template for other programs and specialties developing processes for assessing and documenting improvement in skill and competency over the course of residency training.

The impact of exposure to liver transplantation anesthesia on the ability to treat intraoperative hyperkalemia: a simulation experience.

The objective of this study was to assess whether resident exposure to liver transplantation anesthesia results in improved patient care during a simulated critical care scenario. Our hypothesis was that anesthesia residents exposed to liver transplantation anesthesia care would be able to identify and treat a simulated hyperkalemic crisis after reperfusion more appropriately than residents who have not been involved in liver transplantation anesthesia care. Participation in liver transplantation anesthesia is not a mandatory component of the curriculum of anesthesiology training programs in the United States. It is unclear whether exposure to liver transplantation anesthesia is beneficial for skill set development. A high-fidelity human patient simulation scenario was developed. Times for administration of epinephrine, calcium chloride, and secondary hyperkalemia treatment were recorded. A total of 25 residents with similar training levels participated: 13 residents had previous liver transplantation experience (OLT), whereas 12 residents had not been previously exposed to liver transplantations (non-OLT). The OLT group performed better in recognizing and treating the hyperkalemic crisis than the non-OLT group. Pharmacologic therapy for hyperkalemia was given earlier (OLT 53.3 ± 27.0 seconds versus non-OLT 148 ± 104.1 seconds; P < 0.01) and hemodynamics restored quicker (OLT 87.9 ± 24.9 seconds versus non-OLT 219.9 ± 87.1 seconds; P < 0.01). Simulation-based assessment of clinical skills is a useful tool for evaluating anesthesia resident performance during an intraoperative crisis situation related to liver transplantations. Previous liver transplantation experience improves the anesthesia resident's ability to recognize and treat hyperkalemic cardiac arrest.