Intraoperative pharmacologic opioid minimisation strategies and patient-centred outcomes after surgery: a scoping review.

BACKGROUND: Postoperative patient-centred outcome measures are essential to capture the patient's experience after surgery. Although a large number of pharmacologic opioid minimisation strategies (i.e. opioid alternatives) are used for patients undergoing surgery, it remains unclear which strategies are most promising in terms of patient-centred outcome improvements. This scoping review had two main objectives: (1) to map and describe evidence from clinical trials assessing the patient-centred effectiveness of pharmacologic intraoperative opioid minimisation strategies in adult surgical patients, and (2) to identify promising pharmacologic opioid minimisation strategies. METHODS: We searched MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL databases from inception to February 2023. We included trials investigating the use of opioid minimisation strategies in adult surgical patients and reporting at least one patient-centred outcome. Study screening and data extraction were conducted independently by at least two reviewers. RESULTS: Of 24,842 citations screened for eligibility, 2803 trials assessed the effectiveness of intraoperative opioid minimisation strategies. Of these, 457 trials (67,060 participants) met eligibility criteria, reporting at least one patient-centred outcome. In the 107 trials that included a patient-centred primary outcome, patient wellbeing was the most frequently used domain (55 trials). Based on aggregate findings, dexmedetomidine, systemic lidocaine, and COX-2 inhibitors were promising strategies, while paracetamol, ketamine, and gabapentinoids were less promising. Almost half of the trials (253 trials) did not report a protocol or registration number. CONCLUSIONS: Researchers should prioritise and include patient-centred outcomes in the assessment of opioid minimisation strategy effectiveness. We identified three potentially promising pharmacologic intraoperative opioid minimisation strategies that should be further assessed through systematic reviews and multicentre trials. Findings from our scoping review may be influenced by selective outcome reporting bias. STUDY REGISTRATION: OSF - https://osf.io/7kea3.

The Physician Anesthesia Workforce in Canada From 1996 to 2018: A Longitudinal Analysis of Health Administrative Data.

BACKGROUND: A robust anesthesia workforce is essential to the provision of safe surgical, obstetrical, and critical care but information describing the physician anesthesia workforce and volume of clinical services delivered in Canada is limited. This study examines the Canadian physician anesthesia workforce, exploring trends in physician characteristics and activity levels over time. Practice patterns of specialist anesthesiologists and family physician anesthetists (FPAs) working in urban and rural communities were of particular interest. METHODS: Physicians who provided anesthesia care between 1996 and 2018 were identified using health administrative data from the Canadian Institute of Health Information (CIHI). In addition, data from the Canadian Post-MD Education Registry (CAPER) were used to characterize physicians pursuing postgraduate anesthesia training (1996-2019). Descriptive analyses of physician demographics, training, location, specialty designations, and volume of clinical services were undertaken. RESULTS: Between 1996 and 2018, the anesthesia workforce grew 1.8-fold to 3681 physicians, including 536 FPAs. Over the same time, nerve block services increased 7-fold, and payments for other anesthesia services increased 5-fold. The average age of the anesthesiology workforce increased by 2.3 years and the annual retirement rate was 3%. The workforce has become more gender balanced but remains predominantly male (73% in 2018). The proportion of physicians who were trained internationally (about 30%; 38% in rural areas) remained stable (and higher than that in the overall physician workforce). FPAs provided most anesthesia care in rural Canada and their attrition rate was generally 2- to 3-fold higher than specialists. Physicians in the rural anesthesia workforce provided anesthesia services more intensively over time. Relatively few FPAs who left the anesthesia workforce entered full retirement and they instead contributed other medical services to their communities. CONCLUSIONS: This study provides foundational information regarding anesthesia workforce capacity over a 22-year period, including insights into demographics, locations of practice, and clinical volumes. The results do not quantify the gap between service capacity and need; however, they support the need for a national workforce strategy to achieve equitable access to sustainable anesthesia services in Canada, particularly for rural communities.

Postoperative outcomes for Indigenous Peoples in Canada: a systematic review.

BACKGROUND: Substantial health inequities exist for Indigenous Peoples in Canada. The remote and distributed population of Canada presents unique challenges for access to and use of surgery. To date, the surgical outcome data for Indigenous Peoples in Canada have not been synthesized. METHODS: We searched 4 databases to identify studies comparing surgical outcomes and utilization rates of adults of First Nations, Inuit or Métis identity with non-Indigenous people in Canada. Independent reviewers completed all stages in duplicate. Our primary outcome was mortality; secondary outcomes included utilization rates of surgical procedures, complications and hospital length of stay. We performed meta-analysis of the primary outcome using random effects models. We assessed risk of bias using the ROBINS-I tool. RESULTS: Twenty-eight studies were reviewed involving 1 976 258 participants (10.2% Indigenous). No studies specifically addressed Inuit or Métis populations. Four studies, including 7 cohorts, contributed adjusted mortality data for 7135 participants (5.2% Indigenous); Indigenous Peoples had a 30% higher rate of death after surgery than non-Indigenous patients (pooled hazard ratio 1.30, 95% CI 1.09-1.54; I 2 = 81%). Complications were also higher for Indigenous Peoples, including infectious complications (adjusted OR 1.63, 95% CI 1.13-2.34) and pneumonia (OR 2.24, 95% CI 1.58-3.19). Rates of various surgical procedures were lower, including rates of renal transplant, joint replacement, cardiac surgery and cesarean delivery. INTERPRETATION: The currently available data on postoperative outcomes and surgery utilization rates for Indigenous Peoples in Canada are limited and of poor quality. Available data suggest that Indigenous Peoples have higher rates of death and adverse events after surgery, while also encountering barriers accessing surgical procedures. These findings suggest a need for substantial re-evaluation of surgical care for Indigenous Peoples in Canada to ensure equitable access and to improve outcomes. PROTOCOL REGISTRATION: PROSPERO-CRD42018098757.

Top ten priorities for anesthesia and perioperative research: a report from the Canadian Anesthesia Research Priority Setting Partnership.

PURPOSE: The purpose of the Canadian Anesthesia Research Priority Setting Partnership (CAR PSP) was to identify a top ten list of shared priorities for research in anesthesia and perioperative care in Canada. METHODS: We used the methods of the James Lind Alliance to involve patients, caregivers, healthcare professionals, and researchers in determining the research priorities in Canada. In a first survey, participants submitted questions that they want research to answer about anesthesia and perioperative care. We summarized those responses into a longlist of questions. We reviewed the literature to see if any of those questions were already answered. In a second survey, participants chose up to ten questions from the longlist that they thought were most important to be answered with research. From that list, the highest ranking questions were discussed and assigned a final rank at an in-person workshop. RESULTS: A total of 254 participants submitted 574 research suggestions that were then summarized into 49 questions. Those questions were checked against the literature to be sure they were not already adequately addressed, and in a second survey of those 49 questions, participants chose up to 10 that they thought were most important. A total of 233 participants submitted their priorities, which were then used to choose 24 questions for discussion at the final workshop. At the final workshop, 22 participants agreed on a top ten list of priorities. CONCLUSION: The CAR PSP top ten priorities reflect a wide variety of priorities captured by a broad spectrum of Canadians who receive and provide anesthesia care. The priorities are a tool to initiate and guide patient-oriented research in anesthesia and perioperative care.

RéSUMé: OBJECTIF: L'objectif du Partenariat canadien pour l'établissement des priorités de la recherche en anesthésie (CAR-PSP) était d'établir une liste des dix principales priorités pour la recherche sur les soins anesthésiques et périopératoires au Canada. MéTHODES: Nous avons utilisé la méthodologie de la James Lind Alliance pour impliquer des patients, des aidants, des professionnels de la santé et des chercheurs afin de déterminer quelles étaient les priorités en matière de recherche au Canada. Dans une première enquête, les participants ont envoyé des questions sur les soins anesthésiques et périopératoires auxquelles ils voulaient que la recherche réponde. Nous avons résumé ces envois par une liste exhaustive de questions. Nous avons passé en revue les publications pour voir s'il existait déjà des réponses à ces questions. Dans une deuxième étude, les participants ont choisi dans la liste jusqu'à dix questions qui leur semblaient les plus importantes et pour lesquelles la recherche devrait fournir des réponses. À partir de cette liste, les questions les mieux classées ont été discutées et un classement définitif leur a été attribué au cours d'un atelier où tous les participants étaient présents en personne. RéSULTATS: Au total, 254 participants ont envoyé 574 suggestions de recherche qui ont été résumées en 49 questions. La littérature a été examinée pour s'assurer que ces questions n'avaient pas déjà reçu des réponses adéquates, et dans une seconde étude, les participants ont choisi jusqu'à 10 questions qu'ils jugeaient les plus importantes parmi ces 49 questions. Au total, 233 participants ont communiqué leurs priorités qui ont alors servi à choisir 24 questions ouvertes pour la discussion dans un atelier final. Dans cet atelier, 22 participants se sont mis d'accord sur une liste des dix principales priorités. CONCLUSION: Les dix principales priorités du CAR-PSP sont le reflet d'un grand éventail de priorités venant de Canadiens de tous horizons qui reçoivent ou fournissent des soins d'anesthésie. Ces priorités sont un outil permettant d'entamer et de guider une recherche axée sur le patient dans le domaine des soins anesthésiques et périopératoires.

Peripheral Nerve Blocks for Ambulatory Shoulder Surgery: A Population-based Cohort Study of Outcomes and Resource Utilization.

BACKGROUND: Nerve blocks improve early pain after ambulatory shoulder surgery; impact on postdischarge outcomes is poorly described. Our objective was to measure the association between nerve blocks and health system outcomes after ambulatory shoulder surgery. METHODS: We conducted a population-based cohort study using linked administrative data from 118 hospitals in Ontario, Canada. Adults having elective ambulatory shoulder surgery (open or arthroscopic) from April 1, 2009, to December 31, 2016, were included. After validation of physician billing codes to identify nerve blocks, we used multilevel, multivariable regression to estimate the association of nerve blocks with a composite of unplanned admissions, emergency department visits, readmissions or death within 7 days of surgery (primary outcome) and healthcare costs (secondary outcome). Neurology consultations and nerve conduction studies were measured as safety indicators. RESULTS: We included 59,644 patients; blocks were placed in 31,073 (52.1%). Billing codes accurately identified blocks (positive likelihood ratio 16.83, negative likelihood ratio 0.03). The composite outcome was not significantly different in patients with a block compared with those without (2,808 [9.0%] vs. 3,424 [12.0%]; adjusted odds ratio 0.96; 95% CI 0.89 to 1.03; P = 0.243). Healthcare costs were greater with a block (adjusted ratio of means 1.06; 95% CI 1.02 to 1.10; absolute increase $325; 95% CI $316 to $333; P = 0.005). Prespecified sensitivity analyses supported these results. Safety indicators were not different between groups. CONCLUSIONS: In ambulatory shoulder surgery, nerve blocks were not associated with a significant difference in adverse postoperative outcomes. Costs were statistically higher with a block, but this increase is not likely clinically relevant.

Issues postopératoires chez les Autochtones au Canada: revue systématique.

CONTEXTE: Il existe d'importantes iniquités en matière de santé chez les populations autochtones au Canada. La faible densité de la population canadienne et les populations en région éloignée posent un problème particulier à l'accès et à l'utilisation des soins chirurgicaux. Aucune synthèse des données sur les issues chirurgicales chez les Autochtones au Canada n'avait été publiée jusqu'à maintenant. MÉTHODES: Nous avons interrogé 4 bases de données pour recenser les études comparant les issues chirurgicales et les taux d'utilisation chez les adultes des Premières Nations, inuits et métis et chez les adultes non autochtones au Canada. Des évaluateurs indépendants ont réalisé toutes les étapes en parallèle. L'issue primaire était la mortalité; les issues secondaires comprenaient le taux d'utilisation des chirurgies, les complications et la durée du séjour à l'hôpital. Nous avons effectué une méta-analyse pour l'issue primaire à l'aide d'un modèle à effets aléatoires. Nous avons évalué les risques de biais à l'aide de l'outil ROBINS-I. RÉSULTATS: Vingt-huit études ont été analysées, pour un total de 1 976 258 participants (10,2 % d'Autochtones). Aucune étude ne portait précisément sur les populations inuites et métisses. Quatre études portant sur 7 cohortes ont fourni des données corrigées sur la mortalité pour 7135 participants (5,2 % d'Autochtones); les Autochtones présentaient un risque de décès après une intervention chirurgicale 30 % plus élevé que les patients non autochtones (rapport de risque combiné 1,30; IC à 95 % 1,09­1,54; I 2 = 81 %). Les complications étaient aussi plus fréquentes chez le premier groupe, notamment les infections (RC corrigé 1,63; IC à 95 % 1,13­2,34) et les pneumonies (RC 2,24; IC à 95 % 1,58­3,19). Les taux de différentes interventions chirurgicales étaient plus faibles, notamment pour les transplantations rénales, les arthroplasties, les chirurgies cardiaques et les accouchements par césarienne. INTERPRÉTATION: Les données disponibles sur les issues postopératoires et le taux d'utilisation de la chirurgie chez les Autochtones au Canada sont limitées et de faible qualité. Elles suggèrent que les Autochtones ont de plus hauts taux de décès et d'issues négatives postchirurgicales et qu'ils font face à des obstacles dans l'accès aux interventions chirurgicales. Ces conclusions indiquent qu'il y a un besoin de réévaluer en profondeur les soins chirurgicaux prodigués aux Autochtones au Canada pour leur assurer un accès équitable et améliorer les issues. NUMÉRO D'ENREGISTREMENT DU PROTOCOLE: PROSPERO-CRD42018098757.

A clinical tool to predict adverse behaviour in children at the induction of anesthesia.

PURPOSE: To develop and validate a parent questionnaire to aid in predicting which children are likely to exhibit significant adverse behaviour at anesthetic induction. METHODS: Parents of 209 children, ages two to 13 yr, completed a brief questionnaire prior (13 items) to their child's anesthetic induction for surgery. The questionnaire included content drawn from both the literature and clinical experience. Results from the questionnaire were compared with the Induction Compliance Checklist (ICC), a validated tool to measure adverse behaviour at induction. Analyses assessing the correlation between each of the items and the total questionnaire score and between each item and the ICC score resulted in three items being removed from the questionnaire because they provided no predictive power. The association between the resulting ten-item parent questionnaire and the ICC was re-assessed using correlation. Hierarchical regression was used to evaluate the added value of our tool compared with the modified Yale Preoperative Anxiety Scale (mYPAS) in the prediction of ICC scores. RESULTS: The Cronbach's alpha reliability coefficient for the ten-item parent questionnaire was 0.73. The Pearson product-moment correlation between the ten-item questionnaire and the ICC was 0.34 (P < 0.001) for all children and 0.38 (P < 0.001) for children not preoperatively sedated. Values represent medium effect sizes for the new questionnaire's predictive power. The parent questionnaire provided added value relative to the mYPAS in terms of correlation with the ICC. CONCLUSION: Adverse behaviour at anesthesia induction is significantly predicted by our new parent questionnaire. Further refinement may improve predictive power beyond the observed medium effect size.

Effectiveness of dexmedetomidine during surgery under general anaesthesia on patient-centred outcomes: a systematic review and Bayesian meta-analysis protocol.

INTRODUCTION: Dexmedetomidine is a promising pharmaceutical strategy to minimise opioid use during surgery. Despite its growing use, it is uncertain whether dexmedetomidine can improve patient-centred outcomes such as quality of recovery and pain. METHODS AND ANALYSIS: We will conduct a systematic review and meta-analysis following the recommendations of the Cochrane Handbook for Systematic Reviews. We will search MEDLINE, Embase, CENTRAL, Web of Science and CINAHL approximately in October 2023. We will include randomised controlled trials evaluating the impact of systemic intraoperative dexmedetomidine on patient-centred outcomes. Patient-centred outcome definition will be based on the consensus definition established by the Standardised Endpoints in Perioperative Medicine initiative (StEP-COMPAC). Our primary outcome will be the quality of recovery after surgery. Our secondary outcomes will be patient well-being, function, health-related quality of life, life impact, multidimensional assessment of postoperative acute pain, chronic pain, persistent postoperative opioid use, opioid-related adverse events, hospital length of stay and adverse events. Two reviewers will independently screen and identify trials and extract data. We will evaluate the risk of bias of trials using the Cochrane Risk of Bias Tool (RoB 2.0). We will synthesise data using a random effects Bayesian model framework, estimating the probability of achieving a benefit and its clinical significance. We will assess statistical heterogeneity with the tau-squared and explore sources of heterogeneity with meta-regression. We have involved patient partners, clinicians, methodologists, and key partner organisations in the development of this protocol, and we plan to continue this collaboration throughout all phases of this systematic review. ETHICS AND DISSEMINATION: Our systematic review does not require research ethics approval. It will help inform current clinical practice guidelines and guide development of future randomised controlled trials. The results will be disseminated in open-access peer-reviewed journals, presented at conferences and shared among collaborators and networks. PROSPERO REGISTRATION NUMBER: CRD42023439896.

Intraoperative pharmacologic opioid minimisation strategies and patient-centred outcomes after surgery: a scoping review protocol.

INTRODUCTION: For close to a century opioid administration has been a standard of care to complement anaesthesia during surgery. Considering the worldwide opioid epidemic, this practice is now being challenged and there is a growing use of systemic pharmacological opioid minimising strategies. Our aim is to conduct a scoping review that will examine clinical trials that have evaluated the impact of intraoperative opioid minimisation strategies on patient-centred outcomes and identify promising strategies. METHODS AND ANALYSIS: Our scoping review will follow the framework developed by Arksey and O'Malley. We will search MEDLINE, Embase, CENTRAL, Web of Science and CINAHL from their inception approximately in March 2023. We will include randomised controlled trials, assessing the impact of systemic intraoperative pharmacologic opioid minimisation strategies on patient-centred outcomes. We define an opioid minimisation strategy as any non-opioid drug with antinociceptive properties administered during the intraoperative period. Patient-centred outcomes will be defined and classified based on the consensus definitions established by the Standardised Endpoints in Perioperative Medicine initiative (StEP-COMPAC group) and informed by knowledge users and patient partners. We will use a coproduction approach involving interested parties. Our multidisciplinary team includes knowledge users, patient partners, methodologists and knowledge user organisations. Knowledge users will provide input on methods, outcomes, clinical significance of findings, implementation and feasibility. Patient partners will participate in assessing the relevance of our design, methods and outcomes and help to facilitate evidence translation. We will provide a thorough description of available clinical trials, compare their reported patient-centred outcome measures with established recommendations and identify promising strategies. ETHICS AND DISSEMINATION: Ethics approval is not required for the review. Our scoping review will inform future research including clinical trials and systematic reviews through identification of important intraoperative interventions. Results will be disseminated through a peer-reviewed publication, presentation at conferences and through our network of knowledge user collaborators. REGISTRATION: Open Science Foundation (currently embargoed).

Postoperative outcomes for Nunavut Inuit at a Canadian quaternary care centre: a retrospective cohort study.

BACKGROUND: Structural aspects of health care systems, such as limited access to specialized surgical and perioperative care, can negatively affect the outcomes and resource use of patients undergoing elective and emergency surgical procedures. The aim of this study was to compare postoperative outcomes of Nunavut Inuit and non-Inuit patients at a Canadian quaternary care centre. METHODS: We conducted a retrospective cohort study involving adult (age ≥ 18 yr) patients undergoing inpatient surgery from 2011 to 2018 at The Ottawa Hospital, the quaternary referral hospital for the Qikiqtaaluk Region of Nunavut. The study was designed and conducted in collaboration with Nunavut Tunngavik Incorporated. The primary outcome was a composite of in-hospital death or complications.Secondary outcomes included postoperative length of stay in hospital, adverse discharge disposition, readmissions within 30 days and total hospitalization costs. RESULTS: A total of 98 701 episodes of inpatient surgical care occurred among patients aged 18 to 104 years; 928 (0.9%) of these involved Nunavut Inuit, and 97 773 involved non-Inuit patients. Death or postoperative complication occurred more often among Nunavut Inuit than non-Inuit patients (159 [17.2%] v. 15 691 [16.1%]), which was significantly different after adjustment for age, sex, surgical specialty, risk and urgency (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.03-1.51). This association was most pronounced in cases of cancer (OR 1.63, 95% CI 1.03-2.58) and elective surgery (OR 1.58, 95% CI 1.20-2.10). Adjusted rates of readmission, adverse discharge disposition, length of stay and total costs were significantly higher for Nunavut Inuit. INTERPRETATION: Nunavut Inuit had a 25% relative increase in their odds of morbidity and death after surgery at a major quaternary care hospital in Canada compared with non-Inuit patients, while also having higher rates of other adverse outcomes and resource use. An examination of perioperative systems involving patients, Inuit leadership, health care providers and governments is required to address these differences in health outcomes.

DECOLONIZING CANCER CARE IN CANADA.

Cancer incidence and mortality among Indigenous peoples of Canada (First Nations, Inuit, and Métis) continue to rise in contrast to non-Indigenous Canadians, and Indigenous peoples are at higher risk of cancers associated with known modifiable risk factors. Jurisdictional and administrative challenges have hindered high quality cancer care for Indigenous peoples since the country's inception, and different Indigenous populations face these challenges under similar yet non-identical circumstances. Collaborative initiatives under Indigenous leadership have drawn attention to specific issues such as screening, funding, and culturally appropriate care, and have identified resources necessary to address these problems. The Canadian Partnership Against Cancer and their collaborators have committed significant resources to Indigenous cancer programs with locally and regionally determined leadership and priorities. In the context of broader global movements against systemic racism and inequity, decolonization of cancer care demands critical analysis of the existing cancer systems and restructuring under Indigenous leadership with multidisciplinary collaboration.

Factors influencing the choice of anesthetic technique for primary hip and knee arthroplasty.

Despite evidence in the literature, continuing wide variation exists in anesthetic technique for primary joint arthroplasties. Recent evidence suggests that neuraxial anesthesia has advantages over general anesthesia in terms of mortality, major morbidity and healthcare utilization. Yet, despite the proposed benefits, utilization of these two techniques varies greatly across geographical locations, with general anesthesia being most common for total hip arthroplasty (THA) and total knee arthroplasty (TKA) in parts of the world. We uncover some factors that promote or hinder the use of neuraxial anesthesia in THA and TKA. Healthcare professionals should be familiarized with the evidence for neuraxial anesthesia, and unbiased educational material should be developed for patients regarding anesthetic options for THA and TKA in order to promote best practice.

Novice performance of ultrasound-guided needling skills: effect of a needle guidance system.

BACKGROUND AND OBJECTIVES: Ultrasound-guided needle placement is a widely used technical skill that can be challenging to learn. The SonixGPS is a novel ultrasound needle-tracking system that has the potential to improve performance over traditional ultrasound systems. The objective of our study was to determine if the use of the SonixGPS ultrasound system improves performance of novice practitioners in ultrasound-guided needle placement compared with conventional ultrasound in the out-of-plane approach on a simulation model. METHODS: Twenty-six medical students without previous ultrasound experience were randomized into 2 groups. Each group performed 30 simulated ultrasound nerve blocks on a porcine meat tissue simulation (phantom) model. Both groups used the SonixGPS ultrasound; however, the study group had the needle-tracking system activated, whereas the control group did not. The participants were assessed for success rate, technical aspects of block performance, and certain behaviors that could compromise the quality of the block. Learning curves were developed to assess competence. RESULTS: The needle guidance group reached competence more often. This group had fewer attempts and quality-compromising behaviors than did those using conventional ultrasound. CONCLUSIONS: Use of the SonixGPS ultrasound needle guidance system improves the performance of technical needling skills of novice trainees in an ex vivo model. The place of this technology in the wider education of ultrasound-guided regional anesthesia remains to be established.

A valid and reliable assessment tool for remote simulation-based ultrasound-guided regional anesthesia.

BACKGROUND AND OBJECTIVES: The purpose of this study was to establish construct and concurrent validity and interrater reliability of an assessment tool for ultrasound-guided regional anesthesia (UGRA) performance on a high-fidelity simulation model. METHODS: Twenty participants were evaluated using a Checklist and Global Rating Scale designed for assessing any UGRA block. The participants performed an ultrasound-guided supraclavicular brachial plexus block on both a patient and a simulator. Evaluations were completed in-person by an expert and remotely by a blinded expert using video recordings. Using previous number of blocks performed as an indication of expertise, participants were divided into Novice (n = 8) and Experienced (n = 12) groups. Construct validity was assessed through the tool's reliable on-site and remote discrimination of Novice and Experienced anesthetists. Concurrent validity was established by comparisons of patient versus simulator scoring. Finally, interrater reliability was determined by comparing the scores of on-site and off-site evaluators. RESULTS: The Global Rating Scale was able to differentiate Novice from Experienced anesthetists both by on-site and remote assessment on a patient and simulation model. The Checklist was unable to discern the 2 groups on a simulation model remotely and was marginally significant with on-site scoring. CONCLUSIONS: This is the first study to demonstrate the validity and reliability of a Global Rating Scale assessment tool for use in UGRA simulation training. Although the checklist may require further refinement, the Global Rating Scale can be used for remote and on-site assessment of UGRA skills.