Clinical triggers and vital signs influencing crisis acknowledgment and calls for help by anesthesiologists: A simulation-based observational study.

STUDY OBJECTIVE: In a perioperative emergency, anesthesiologists must acknowledge the unfolding crisis promptly, call for timely assistance, and avert patient harm. We aimed to identify vital signs and qualitative factors prompting crisis acknowledgment and to compare responses between observers and participants in simulation. DESIGN: Prospective, simulation-based, observational study. SETTING: An anesthesia crisis resource management course at a freestanding simulation center. SUBJECTS: Sixty attending anesthesiologists from a variety of practice settings. INTERVENTIONS: In each case, a primary anesthesiologist in charge (PAIC) managed a simulated patient undergoing a uniformly scripted sequence of perioperative anaphylaxis and called for help from another anesthesiologist when a crisis began. Anesthesiologist observers (AOs) viewed the case separately and recorded times of crisis onset. MEASUREMENTS: Simulation footage was reviewed by investigators for patient vital signs and participant behaviors at times of crisis acknowledgment, with the call for help as an explicit proxy for PAIC crisis acknowledgment. These factors were categorized, and group-level data were compared. RESULTS: Nineteen PAICs and 41 AOs were included. Clinicians acknowledged crises around a mean arterial pressure (MAP) of 65 mmHg and oxygen saturation of 94% as anaphylactic shock progressed. PAICs acknowledged crises at a higher respiratory rate than AOs (20 vs. 18 breaths/min, p = 0.038). Other vitals and timing of crisis acknowledgment did not differ between PAICs and AOs. Nearly half of all participants (45%) identified crises at MAP <65 mmHg. Timing of crisis acknowledgment varied widely (range: 421 s). CONCLUSIONS: Despite overall heterogeneity in clinical performance, anesthesiologists acknowledged crises per standard definitions of hypotension. Thresholds for crisis acknowledgment did not significantly differ between PAICs and AOs, suggesting minimal effect from active care responsibility. Many indicated crises at MAP <65 mmHg or after significant deterioration, risking failure-to-rescue events. We suggest that crisis management instruction should address triggers for requesting help.

Simulation-based Assessment to Reliably Identify Key Resident Performance Attributes.

BACKGROUND: Obtaining reliable and valid information on resident performance is critical to patient safety and training program improvement. The goals were to characterize important anesthesia resident performance gaps that are not typically evaluated, and to further validate scores from a multiscenario simulation-based assessment. METHODS: Seven high-fidelity scenarios reflecting core anesthesiology skills were administered to 51 first-year residents (CA-1s) and 16 third-year residents (CA-3s) from three residency programs. Twenty trained attending anesthesiologists rated resident performances using a seven-point behaviorally anchored rating scale for five domains: (1) formulate a clear plan, (2) modify the plan under changing conditions, (3) communicate effectively, (4) identify performance improvement opportunities, and (5) recognize limits. A second rater assessed 10% of encounters. Scores and variances for each domain, each scenario, and the total were compared. Low domain ratings (1, 2) were examined in detail. RESULTS: Interrater agreement was 0.76; reliability of the seven-scenario assessment was r = 0.70. CA-3s had a significantly higher average total score (4.9 ± 1.1 vs. 4.6 ± 1.1, P = 0.01, effect size = 0.33). CA-3s significantly outscored CA-1s for five of seven scenarios and domains 1, 2, and 3. CA-1s had a significantly higher proportion of worrisome ratings than CA-3s (chi-square = 24.1, P < 0.01, effect size = 1.50). Ninety-eight percent of residents rated the simulations more educational than an average day in the operating room. CONCLUSIONS: Sensitivity of the assessment to CA-1 versus CA-3 performance differences for most scenarios and domains supports validity. No differences, by experience level, were detected for two domains associated with reflective practice. Smaller score variances for CA-3s likely reflect a training effect; however, worrisome performance scores for both CA-1s and CA-3s suggest room for improvement.