Systematic review and narrative synthesis of competency-based medical education in anaesthesia.

BACKGROUND: Competency-based medical education (CBME) addresses the accountability of postgraduate training programmes to graduate specialists capable of independent practice. METHODS: We undertook a systematic review and narrative synthesis of the published CBME literature in anaesthesia training programmes to identify current practices and areas requiring further exploration. RESULTS: We grouped the 23 studies that met our inclusion criteria into the following categories: demonstrating outcomes of CBME, developing a consensus on an achievable CBME curriculum, CBME curriculum framework, design and implementation of workplace-based assessment (WBA) tools, trainee self-assessment, perceptions of trainees and supervisors on WBA tools, and technological solutions for assessment and feedback. Included studies reported variable success in reaching consensus in competency outcome frameworks for sequenced progression and limited research on approaches to curriculum delivery, whilst the majority of studies focused on workplace assessment. Studies supported the use of entrustment scales, where assessors make a judgement on the extent to which the trainee can manage a case independently. While evidence supported the reliability of WBA tools, and predicted the numbers needed for high-stakes decisions, areas of concern related to factors influencing the value WBA tools in promoting trainee learning, and variable perceptions of their value in making decisions on progression. CONCLUSIONS: Evidence on outcomes of CBME was limited to acquisition of specific competencies during training. The large number of unanswered questions and the dearth of studies across the core components of CBME suggest that we need a collaborative approach to create the evidence required to implement CBME wisely and cost effectively, to have positive impacts on patients, trainees, and healthcare systems.

Oral medical assistance in dying (MAiD): informing practice to enhance utilization in Canada.

The legislation Bill C-14 legalized medical assistance in dying (MAiD) in Canada. After thorough assessments of eligibility by two clinicians, Bill C-14 allows for both intravenous-assisted death by a clinician (euthanasia) and prescription of oral medication for self-administration (assisted suicide). Nevertheless, since inception in June 2016, intravenous euthanasia is the main form of delivery of assisted death in Canada. The reasons why oral MAiD is underutilized in Canada are multifactorial. Currently, there is no consensus on either the medications or the protocols for oral administration, nor a comprehensive understanding of the potential side effects and complications associated with different regimens. The quality of evidence for optimal MAiD medications is low, so any suggested recommendations can only be informed by the global but generally anecdotal experience. The challenges for implementing oral MAiD in Canada include a need to enhance clinician comfort in prescribing oral medications as an alternative to intravenous administration. The goals for ideal oral MAiD medications are 100% effectiveness and minimal side effects, while ensuring that the needed dose is both palatable and deliverable in a tolerable oral volume. The Netherlands has the most experience worldwide and barbiturates have emerged as the most common, efficacious, and tolerable agents by patients. Based on this global experience and the over-arching goals for oral MAiD, we recommend the use of a secobarbital suspension combined with antiemetic prophylaxis.

Acquiring and maintaining point-of-care ultrasound (POCUS) competence for anesthesiologists.

PURPOSE: Point-of-care ultrasound (POCUS) involves the bedside use of ultrasound to answer specific diagnostic questions and to assess real-time physiologic responses to treatment. Although POCUS has become a well-established resource for emergency and critical care physicians, anesthesiologists are still working to obtain POCUS skills and to incorporate them into routine practice. This review defines the benefits of POCUS to anesthesia practice, identifies challenges to establishing POCUS in routine anesthesia care, and offers solutions to help guide its incorporation going forward. PRINCIPAL FINDINGS: Benefits to POCUS include improving the sensitivity and specificity of the physical examination and helping to guide patient treatment. The challenges to establishing POCUS as a standard in anesthesia practice include developing and maintaining competence. There is a need to develop standards of practice and a common language between specialties to facilitate training and create guidelines regarding patient management. CONCLUSIONS: Presently, our specialty requires consensus by expert stakeholders to address issues of competence, certification, development of standards and terminology, and the management of unexpected diagnoses. To promote POCUS competency in our discipline, we support its incorporation into anesthesiology curricula and training programs and the continuing professional development of POCUS-related activities at a national level.

Hospitalizations due to preventable adverse reactions-a systematic review.

PURPOSE: The study aimed to measure the percentage of preventable adverse drug reactions that lead to the hospitalization (PADRAd) and to explore the heterogeneity in its estimation through subgroup analysis of study characteristics. METHODS: Two investigators independently searched in electronic databases and related bibliography for prospective studies involving PADRAd. We excluded studies investigating medication errors and spontaneous and retrospective reporting. The primary outcome was PADRAd percentage. To explore the heterogeneity, we performed subgroup analysis based on study region, wards, age groups, adverse drug reaction (ADR) definitions, preventability assessment, ADR identification methods, study duration and sample size. We explored fatal PADRAd and causative drugs as a secondary outcome. We used the generic inverse variance method with random effect model to compute meta-analytic summary. RESULTS: Of the 68 full-text articles assessed, we included 22 studies. The mean PADRAd percentage was 45.11 % (95 % CI = 33.06-57.15; I 2 = 99 %). Studies including elderly (63.31 %) and all age groups (49.03 %) showed higher percentages than paediatric population (16.40 %). Studies examining all hospital populations showed higher percentages than specific wards. We observed high percentages in studies using Edwards and Aronson as an ADR definition and Hallas et al. as a preventability assessment tool. After age group adjustment, ADR detection methods did not show significant difference. The fatal PADRAd percentage was 1.58 % (95 % CI = -0.60 to 3.76; I 2 = 47 %). Paediatric and elderly studies showed a different causative drug pattern. CONCLUSION: Variation in PADRAd across the studies can be explained by difference in study populations and data collection methods. Extrapolation of preventable reactions should be carried out considering all these factors with caution.

EVALUATION OF ANTICOAGULANT EFFECT OF SULFATED POLYSACCHARIDE (SPS) FROM CODIUM DWARKENSE BORGESEN IN κ-CARRAGEENAN INDUCED HYPERCOAGULABLE STATE IN WISTAR ALBINO RATS.

Our aim of the present study was to evaluate the anticoagulant effect of sulfated polysaccharides (SPS) from Codium dwarkense Bergesen in ic-carrageenan induced hypercoagulable state in Wistar albino rats. 48 Wistar albino rats of either sex were randomly divided into 6 groups - disease control, active control, treatment lowmand high dose and preventive low and high dose. K-Carrageenan (3 mg/kg) single dose intravenously was given in rat tail vein at pre-decided time to produce hypercoagulable state. Baseline, 24, 48 and 72 hours duration blood samples were collected for PT, INR, aPTT, platelet count and fibrinogen level, FDP and D-Dimer measurements. At the end of experiment, animals were sacrificed for histopathology analysis of lung, liver and mesentery. Sulfated polysaccharide (SPS) significantly restored altered coagulation parameters (PT, INR, aPTI, platelet count and fibrinogen level) without affecting fibrinolytic parameters (FDP and D-Dimer). Administration of SPS both as a treatment and preventive therapy reduced the number of microthrombi along with less structural damage in histopathology of lung, liver and mesentery. Heparin served as active control and its administration significantly prolonged aPT' and restored PT. This study shows, anticoagulant activity of SPS extracted from Codium dwarkense Bergesen in Wistar albino rats.

The role of simulation in continuing medical education for acute care physicians: a systematic review.

OBJECTIVES: We systematically reviewed the effectiveness of simulation-based education, targeting independently practicing qualified physicians in acute care specialties. We also describe how simulation is used for performance assessment in this population. DATA SOURCES: Data source included: DataMEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL Database of Controlled Trials, and National Health Service Economic Evaluation Database. The last date of search was January 31, 2013. STUDY SELECTION: All original research describing simulation-based education for independently practicing physicians in anesthesiology, critical care, and emergency medicine was reviewed. DATA EXTRACTION: Data analysis was performed in duplicate with further review by a third author in cases of disagreement until consensus was reached. Data extraction was focused on effectiveness according to Kirkpatrick's model. For simulation-based performance assessment, tool characteristics and sources of validity evidence were also collated. DATA SYNTHESIS: Of 39 studies identified, 30 studies focused on the effectiveness of simulation-based education and nine studies evaluated the validity of simulation-based assessment. Thirteen studies (30%) targeted the lower levels of Kirkpatrick's hierarchy with reliance on self-reporting. Simulation was unanimously described as a positive learning experience with perceived impact on clinical practice. Of the 17 remaining studies, 10 used a single group or "no intervention comparison group" design. The majority (n = 17; 44%) were able to demonstrate both immediate and sustained improvements in educational outcomes. Nine studies reported the psychometric properties of simulation-based performance assessment as their sole objective. These predominantly recruited independent practitioners as a convenience sample to establish whether the tool could discriminate between experienced and inexperienced operators and concentrated on a single aspect of validity evidence. CONCLUSIONS: Simulation is perceived as a positive learning experience with limited evidence to support improved learning. Future research should focus on the optimal modality and frequency of exposure, quality of assessment tools and on the impact of simulation-based education beyond the individuals toward improved patient care.

Within-team debriefing versus instructor-led debriefing for simulation-based education: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of an interprofessional within-team debriefing with that of an instructor-led debriefing on team performance during a simulated crisis. BACKGROUND: Although instructor-led simulation debriefing is considered the "gold standard" in team-based simulation education, cost and logistics are limiting factors for its implementation. Within-team debriefing, led by the individuals of the team itself rather than an external instructor, has the potential to address these limitations. METHODS: One hundred twenty subjects were grouped into 40 operating room teams consisting of 1 anesthesia trainee, 1 surgical trainee, and 1 staff circulating operating room nurse. All teams managed a simulated crisis scenario (pretest). Teams were then randomized to either a within-team debriefing group or an instructor-led debriefing group. In the within-team debriefing group, the teams reviewed the video of their scenario by themselves. The teams in the instructor-led debriefing group reviewed their scenario guided by a trained instructor. Immediately after debriefing, all teams managed a different intraoperative crisis scenario (posttest). All sessions were videotaped. Blinded expert examiners used the validated Team Emergency Assessment Measure scale to assess crisis resource management performance of all teams in random order. RESULT: Team performance significantly improved from pretest to posttest (P = 0.008) regardless of the type of debriefing. There was no significant difference in the degree of improvement between within-team debriefing and instructor-led debriefing (P = 0.52). CONCLUSIONS: Within-team debriefing results in measurable improvements in team performance in simulated crisis scenarios. This form of debriefing may be as effective as instructor-led team debriefing, which could improve resource utilization and feasibility of team-based simulation (NCT01067378).

Review article: simulation: a means to address and improve patient safety.

PURPOSE: The purpose of this article is to review the role of technical and nontechnical skills in routine and crisis situations. We discuss the role of different simulation modalities in addressing these skills and competencies to enhance patient safety. PRINCIPAL FINDINGS: Human and system errors are a recognized cause of significant morbidity and mortality. Technical skills encompass the medical and procedural knowledge required for patient care, while nontechnical skills are behaviour-based and include task management, situation awareness, teamwork, decision-making, and leadership. Both sets of skills are required to improve patient safety. Healthcare simulation can provide an opportunity to practice technical and nontechnical skills in a patient-safe environment. More specifically, these skills are most required in dynamic and crisis situations, which may best be practiced in a simulated patient setting. CONCLUSION: Healthcare simulation is a valuable tool to improve patient safety. Simulation-based education can focus on the necessary technical and nontechnical skills to enhance patient safety. Simulation-based research can serve as a means to identify gaps in current practice, test different solutions, and show improved practice patterns by studying performance in a setting that does not compromise patient safety.

The difficult airway with recommendations for management--part 2--the anticipated difficult airway.

BACKGROUND: Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway. METHODS: To review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned. PRINCIPAL FINDINGS: Previously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician's experience, must also be considered in deciding the appropriate strategy. CONCLUSIONS: With an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.

The difficult airway with recommendations for management--part 1--difficult tracheal intubation encountered in an unconscious/induced patient.

BACKGROUND: Previously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group's mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered. METHODS: Nineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria. CONCLUSIONS: The clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative "Plan B" technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, "cannot intubate, cannot oxygenate" situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.

Review article: new directions in medical education related to anesthesiology and perioperative medicine.

PURPOSE: We aim to provide a broad overview of current key issues in anesthesiology education to encourage both "clinician teachers" and "clinician educators" in academic health centres to consider how medical educational theory can inform their own practice. PRINCIPAL FINDINGS: Evolving contextual issues, such as work-hour reform and the patient safety movement, necessitate innovative approaches to anesthesiology education. There is a substantial amount of relevant literature from other disciplines, such as sociology, psychology, and human factors research, using methodologies that are often unfamiliar to most clinicians. Recurring themes include the increasing use of simulation-based education, the importance of faculty development, challenges in teaching and assessing the non-medical expert roles, and the promise of team training and interprofessional education. Interdisciplinary collaborations are likely key to answering pressing questions in anesthesiology education, and a greater understanding of qualitative and mixed methods research will allow a broader range of questions to be answered. Simulation offers the opportunity to learn from failures without exposing patients to risk and brings the challenge of integrating innovations into existing curricula. Interprofessional education allows learning in the teams that will work together; even so, it needs to be prioritized to overcome logistical barriers. The challenges of introducing a competency-based curriculum have resulted in hybrid systems where elements of competency-based medical education have been combined with traditional apprenticeship curricula. The value of faculty development to encourage even simple measures, such as establishing learning objectives and discussing these with trainees, cannot be over-emphasized. Key issues in assessment include the need to evaluate multiple levels of performance in a cohesive system of assessment and the need to identify the unintended consequences of assessment. CONCLUSIONS: We have identified a number of key themes and challenges for anesthesiology education. This discussion will continue in greater depth in individual articles in this issue so as to promote further interest in a growing body of literature that is relevant to anesthesiology education.

Review article: leading the future: guiding two predominant paradigm shifts in medical education through scholarship.

PURPOSE: The purpose of this article is to consolidate some of the key concepts about scholarship in education related to the specialty of anesthesiology. We frame the discussion on two paradigm shifts in medical education, i.e., competency-based education and lifelong learning, and the scholarly approaches to lead these paradigm shifts in anesthesiology. PRINCIPAL FINDINGS: Conventional medical education is being challenged by a shift from time-based education to competency-based education. This potential shift will also create a continuous need to foster a culture of lifelong learning in contrast with the traditional compartmentalized model of undergraduate, postgraduate, and continuing medical education. The specialty of anesthesia has the capacity to lead these changes by enhancing scholarship in education locally and nationally. The promotion of scholarship in education necessitates the creation of infrastructure and accountability frameworks to show return on investment. High-quality scholarship in medical education requires a solid rationale and, ultimately, a demonstrable benefit to patient care. CONCLUSION: Accountability of lifelong learning to established competency frameworks seems inevitable. Anesthesiology is one of only a few specialties that can truly protect faculty from clinical responsibilities in favour of scholarship pursuits. With appropriate support for scholarship in education, anesthesiologists have an opportunity to lead these paradigm shifts.

An experiential teaching session on the anesthesia machine check improves resident performance.

PURPOSE: A preoperative machine check is imperative, yet machine faults are missed despite experience. We hypothesized that a simulation training session would improve junior residents' ability to perform a machine check beyond the level of final year residents who received only didactic training. METHODS: In 2005, an experiential machine check training session was introduced into residency training at the postgraduate year 1 (PGY-1) level. Three weeks later, the simulation residents were asked to perform a machine check and detect ten preset faults. The control group consisted of PGY-5 residents who had received a didactic anesthesia machine lecture during their residency; these control residents were asked to perform the same machine check as the simulation residents. Data were collected from 2005 to 2008 with each cohort of incoming PGY-1 residents and graduating PGY-5 residents. When the first group of PGY-1 residents became PGY-5 residents in 2009, they were invited to return for a retention test. In all tests, the number of faults detected was recorded, and the machine check was evaluated using a checklist. RESULTS: Thirty-seven simulation residents and 27 control residents participated in the study. Simulation residents had significantly higher checklist scores than the control residents, and they identified more machine faults (both P < 0.001). Twenty-one simulation residents repeated the study in their senior year, and they continued to achieve higher checklist scores and identify more machine faults than the control residents (both P < 0.001). CONCLUSION: Our results suggest that an experiential training session allowed junior residents to achieve skills superior to those of senior colleagues after a five-year residency. This training was retained for two to four years as they continued to outperform their comparative controls.

Looking in the mirror: self-debriefing versus instructor debriefing for simulated crises.

OBJECTIVE: To examine the effectiveness of self-debriefing as compared to instructor debriefing in the change of nontechnical skills performance of anesthesiology residents. DESIGN: Prospective, randomized, controlled study. SETTING: A university hospital simulation center. SUBJECTS: : Fifty anesthesiology residents. INTERVENTIONS: Subjects were instructed in the principles of nontechnical skills for crisis management. Subsequently, each resident participated in a high-fidelity simulated anesthesia crisis scenario (pretest). Participants were randomized to either a video-assisted self-debriefing or instructor debriefing. In the self-debriefing group, subjects reviewed their pretest scenario by themselves, guided by the Anesthetists' Non-Technical Skills scale. The instructor debriefing group reviewed their pretest scenario guided by an expert instructor also using the Anesthetists' Non-Technical Skills scale as a framework. Immediately following their respective debriefings, subjects managed a second simulated crisis (post-test). MEASUREMENTS AND MAIN RESULTS: After all data were collected, two blinded experts independently rated videos of all performances in a random order using the Anesthetists' Non-Technical Skills scale. Performance significantly improved from pretest to post-test (p < .01) regardless of the type of debriefing received. There was no significant difference in the degree of improvement between self-debriefing and instructor debriefing (p = .58). CONCLUSIONS: Nontechnical skills for crisis resource management improved with training, as measured by the Anesthetists' Non-Technical Skills scale. Crisis resource management can be taught, with measurable improvements. Effective teaching of nontechnical skills can be achieved through formative self-assessment even when instructors are not available.

Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac surgery.

BACKGROUND: Simulation-based training is useful in improving physicians' skills. However, no randomized controlled trials have been able to demonstrate the effects of simulation teaching in real-life patient care. This study aimed to determine whether simulation-based training or an interactive seminar resulted in better patient care during weaning from cardiopulmonary bypass (CPB)-a high stakes clinical setting. METHODS: This study was conducted as a prospective, single-blinded, randomized controlled trial. After institutional research board approval, 20 anesthesiology trainees, postgraduate year 4 or higher, inexperienced in CPB weaning, and 60 patients scheduled for elective coronary artery bypass grafting were recruited. Each trainee received a teaching syllabus for CPB weaning 1 week before attempting to wean a patient from CPB (pretest). One week later, each trainee received a 2-h training session with either high-fidelity simulation-based training or a 2-h interactive seminar. Each trainee then weaned patients from CPB within 2 weeks (posttest) and 5 weeks (retention test) from the intervention. Clinical performance was measured using the validated Anesthesiologists' Nontechnical Skills Global Rating Scale and a checklist of expected clinical actions. RESULTS: Pretest Global Rating Scale and checklist performances were similar. The simulation group scored significantly higher than the seminar group at both posttest (Global Rating Scale [mean +/- standard error]: 14.3 +/- 0.41 vs. 11.8 +/- 0.41, P < 0.001; checklist: 89.9 +/- 3.0% vs. 75.4 +/- 3.0%, P = 0.003) and retention test (Global Rating Scale: 14.1 +/- 0.41 vs. 11.7 +/- 0.41, P < 0.001; checklist: 93.2 +/- 2.4% vs. 77.0 +/- 2.4%, P < 0.001). CONCLUSION: Skills required to wean a patient from CPB can be acquired through simulation-based training. Compared with traditional interactive seminars, simulation-based training leads to improved performance in patient care by senior trainees in anesthesiology.