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.

High-fidelity simulation demonstrates the influence of anesthesiologists' age and years from residency on emergency cricothyroidotomy skills.

BACKGROUND: Age-related deterioration in both cognitive function and the capacity to control fine motor movements has been demonstrated in numerous studies. However, this decline has not been described with respect to complex clinical anesthesia skills. Cricothyroidotomy is an example of a complex, lifesaving procedure that requires competency in the domains of both cognitive processing and fine motor control. Proficiency in this skill is vital to minimize time to reestablish oxygenation during a "cannot intubate, cannot ventilate" scenario. In this prospective, controlled, single-blinded study, we tested the hypothesis that age affects the learning and performance of emergency percutaneous cricothyroidotomy in a high-fidelity simulated cannot intubate/cannot ventilate scenario. METHODS: Thirty-six staff anesthesiologists (19 aged younger than 45 years and 17 older than 45 years) managed a high-fidelity cannot intubate/cannot ventilate scenario in a high-fidelity simulator before and after a 1-hour standardized training session. The group division cutoff age of 45 years was based on the median age of our sample subject population before enrollment. The scenarios required the insertion of an emergency percutaneous cricothyroidotomy. We compared cricothyroidotomy skills in the older group with those in the younger group using procedural time, 5-point task-specific checklist score, and global rating scale score. Correlation based on age, years from residency, weekly clinical hours worked, previous continuing medical education in airway management, and previous simulation experience was also performed. RESULTS: In both prestandardization and poststandardization, age and years from residency correlated with procedural time, checklist scores, and global rating scores. Baseline, prestandardization variables were all better for the younger group, with a mean age of 37 years, compared with the older group, with a mean age of 58 years. Procedural time was 100 (72-128) seconds versus 152 (120-261) seconds. Checklist scores were 7.0 (6.1-8.0) versus 6.0 (4.8-8.0). Global rating scale scores were 22.0 (17.8-29.8) versus 17.5 (10.4-20.6). After the 1-hour standardized training session, the younger group continued to perform better than the older group with procedural time of 75 (66-91) seconds versus 87 (78-123) seconds, checklist scores of 10.0 (9.1-10.0) versus 9.0 (8.0-10.0), and global rating scale scores of 35.0 (32.1-35.0) versus 32.0 (29.0-33.8). Regression analysis was performed on the poststandardization data. Both age and years from residency independently affected procedural time, checklist scores, and global rating scale scores (all P < 0.05). CONCLUSIONS: Baseline proficiency with simulated emergency cricothyroidotomy is associated with age and years from residency. Despite standardized training, operator age and years from residency were associated with decreased proficiency. Further research should explore the potential of using age and years from residency as factors for implementing periodic continuing medical education.

Personalized oral debriefing versus standardized multimedia instruction after patient crisis simulation.

BACKGROUND: Simulation experience alone without debriefing is insufficient for learning. Standardized multimedia instruction has been shown to be useful in teaching surgical skills but has not been evaluated for use as an adjunct in crisis management training. Our primary purpose in this study was to determine whether standardized computer-based multimedia instruction is effective for learning, and whether the learning is retained 5 wk later. Our secondary purpose was to compare multimedia instruction to personalized video-assisted oral debriefing with an expert. METHODS: Thirty anesthesia residents were recruited to manage three different simulated resuscitation scenarios using a high-fidelity patient simulator. After the first scenario, subjects were randomized to either a computer-based multimedia tutorial or a personal debriefing of their performance with an expert and videotape review. After their respective teaching, subjects managed a similar posttest resuscitation scenario and a third retention test scenario 5 wk later. Performances were independently rated by two blinded expert assessors using a previously validated assessment system. RESULTS: Posttest (12.22 +/- 2.19, P = 0.009) and retention (12.80 +/- 1.77, P < 0.001) performances of nontechnical skills were significantly improved in the standardized multimedia instruction group compared with pretest (10.27 +/- 2.10). There were no significant differences in improvement between the two methods of instruction. CONCLUSION: Computer-based multimedia instruction is an effective method of teaching nontechnical skills in simulated crisis scenarios and may be as effective as personalized oral debriefing. Multimedia may be a valuable adjunct to centers when debriefing expertise is not available.

Fiberoptic oral intubation: the effect of model fidelity on training for transfer to patient care.

BACKGROUND: Previous studies have indicated that fiberoptic orotracheal intubation (FOI) skills can be learned outside the operating room. The purpose of this study was to determine which of two educational interventions allows learners to gain greater capacity for performing the procedure. METHODS: Respiratory therapists were randomly assigned to a low-fidelity or high-fidelity training model group. The low-fidelity group was guided by experts, on a nonanatomic model designed to refine fiberoptic manipulation skills. The high-fidelity group practiced their skills on a computerized virtual reality bronchoscopy simulator. After training, subjects performed two consecutive FOIs on healthy, anesthetized patients with predicted "easy" intubations. Each subject's FOI was evaluated by blinded examiners, using a validated global rating scale and checklist. Success and time were also measured. RESULTS: Data were analyzed using a two-way mixed design analysis of variance. There was no significant difference between the low-fidelity (n = 14) and high-fidelity (n = 14) model groups when compared with the global rating scale, checklist, time, and success at achieving tracheal intubation (all P = not significant). Second attempts in both groups were significantly better than first attempts (P < 0.001), and there was no interaction between "fidelity of training model" and "first versus second attempt" scores. CONCLUSIONS: There was no added benefit from training on a costly virtual reality model with respect to transfer of FOI skills to intraoperative patient care. Second attempts in both groups were significantly better than first attempts. Low-fidelity models for FOI training outside the operating room are an alternative for programs with budgetary constraints.

An assessment tool for brachial plexus regional anesthesia performance: establishing construct validity and reliability.

BACKGROUND AND OBJECTIVES: Technical proficiency in regional anesthesia is often determined subjectively through in-training evaluations. Objective assessment tools improve these evaluations by providing criteria for measurement. However, any evaluation instrument needs to be valid and reliable before it is adopted into a curriculum. The purpose of this study is to determine the validity and reliability of a devised assessment of residents performing an interscalene brachial plexus block (ISB). METHODS: In this prospective study, 10 junior trainees and 10 senior trainees were videotaped performing an ISB. Junior trainees were defined as in their first year of anesthetic training and had performed less than 10 ISBs independently. Senior trainees had completed at least 1 year of anesthesia training and had performed greater than 10 ISBs independently. Two blinded expert raters independently evaluated the performance of the ISB using a checklist and global rating scale. Construct validity was established if the assessments were able to reliably discriminate between different levels of training. RESULTS: Senior trainees performed an ISB significantly better than junior trainees when assessed using the global rating scale (P < .05) and checklist (P < .001). The overall interrater reliability for the global rating scores was excellent (r = 0.85, P < .05) and was good for the checklist scores (r = 0.74, P < .05). CONCLUSIONS: Both assessment modalities were valid, in that they reliably discriminated between different levels of training. Objective measures of technical skills are feasible, timely, and improve the validity and reliability of competency assessments.

Management of simulated oxygen supply failure: is there a gap in the curriculum?

In this study we evaluated, in our residency program, the understanding and management of a simulated oxygen pipeline failure. Performances of 20 residents were evaluated by 2 raters. Fourth-year residents did not perform better than second-year residents (P = NS). The majority of the participants either did not have the knowledge to change the oxygen cylinder or did not attempt to change the oxygen, even after prompting. We conclude that the delegation of gas machine maintenance to perioperative personnel, such as respiratory therapists and technicians, may have created a new gap in knowledge and resulted in inadequate training.

Fibreoptic airway training: correlation of simulator performance and clinical skill.

PURPOSE: Simulation centres, where trainees can practise technical procedures on models of varying fidelity, provide a training option that allows them to acquire skills in a controlled environment prior to clinical performance. It has been proposed that the time to complete a simulator task may translate to proficiency in the clinical setting. The objective of this study was to determine whether time to complete a simulator task translates to clinical fibreoptic manipulation (FOM) performance. METHODS: Thirty registered respiratory therapists at a teaching hospital were recruited as subjects for a single-blinded randomized trial. Subjects were randomized to training on either a low fidelity (n = 15) or high fidelity (n = 15) model. After training, each subject was tested for the time required to complete a specific task on his/her respective model. Subjects then performed a fibreoptic orotracheal intubation (FOI) on healthy, consenting, and anesthetised patients requiring intubation for elective surgery. Performance was measured independently by blinded examiners using a checklist and global rating scale (GRS); and time was measured from insertion of the fibreoptic scope to visualization of the carina. Data were analyzed using Spearman rank order correlation coefficients. RESULTS: There was no correlation between the time to complete a task on either the high or low fidelity simulators, and the clinical FOI performance as assessed by a checklist, GRS, and time to complete the FOM (all P = NS). CONCLUSION: These results suggest that simulator-based, task-orientated time measurement may not be a good indicator of FOI performance in the clinical setting.