Ultrastructural analysis of explanted CyPass microstents and correlation with clinical findings.

PURPOSE: The purpose of this study was to obtain insight into cellular processes after CyPass microstent implantation into the supraciliary space. With this knowledge, we expected to find some reason for surgical failure. METHODS: Nine CyPass microstents of 8 patients with primary open-angle glaucoma (n = 1), pseudoexfoliation glaucoma (n = 5), uveitic glaucoma (n = 1), and posttraumatic open-angle glaucoma (n = 1) were explanted due to recurrence of IOP elevation, corneal decompensation, or persistent hypotony. The explants were processed for light and transmission electron microscopy. RESULTS: Fibrotic material, consisting of collagen fibrils, microfibrils, pseudoexfoliation fibrils produced by activated fibroblasts, was detected in the stent lumen of 4/5 pseudoexfoliation glaucoma patients and also in posttraumatic open-angle glaucoma. Fibrotic material was also present on the outer surface and within fenestrations of the majority of stents. Complete absence of fibrotic reaction was noticed in 3 of 9 microstents. CONCLUSION: Although MIGS is known to be less invasive than conventional surgery, implants placed in the suprachoroidal space may be adversely affected by a fibrotic tissue reaction resulting in implant failure. Understanding mechanisms and risk factors leading to fibrotic scarring following antiglaucomatous surgery may help to develop novel strategies that improve surgical outcome.

A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist.

We implemented the World Health Organization surgical safety checklist at Auckland City Hospital from November 2007. We hypothesised that the checklist would reduce postoperative mortality and increase days alive and out of hospital, both measured to 90 postoperative days. We compared outcomes for cohorts who had surgery during 18-month periods before vs. after checklist implementation. We also analysed outcomes during 9 years that included these periods (July 2004-December 2013). We analysed 9475 patients in the 18-month period before the checklist and 10,589 afterwards. We analysed 57,577 patients who had surgery from 2004 to 2013. Mean number of days alive and out of hospital (95%CI) in the cohort after checklist implementation was 1.0 (0.4-1.6) days longer than in the cohort preceding implementation, p < 0.001. Ninety-day mortality was 395/9475 (4%) and 362/10,589 (3%) in the cohorts before and after checklist implementation, multivariable odds ratio (95%CI) 0.93 (0.80-1.09), p = 0.4. The cohort changes in these outcomes were indistinguishable from longer-term trends in mortality and days alive and out of hospital observed during 9 years, as determined by Bayesian changepoint analysis. Postoperative mortality to 90 days was 228/5686 (4.0%) for Maori and 2047/51,921 (3.9%) for non-Maori, multivariable odds ratio (95%CI) 0.85 (0.73-0.99), p = 0.04. Maori spent on average (95%CI) 1.1 (0.5-1.7) fewer days alive and out of hospital than non-Maori, p < 0.001. In conclusion, our patients experienced improving postoperative outcomes from 2004 to 2013, including the periods before and after implementation of the surgical checklist. Maori patients had worse outcomes than non-Maori.

Making robust assessments of specialist trainees' workplace performance.

BACKGROUND: Workplace-based assessments should provide a reliable measure of trainee performance, but have met with mixed success. We proposed that using an entrustability scale, where supervisors scored trainees on the level of supervision required for the case would improve the utility of compulsory mini-clinical evaluation exercise (CEX) assessments in a large anaesthesia training program. METHODS: We analysed mini-CEX scores from all Australian and New Zealand College of Anaesthetists trainees submitted to an online database over a 12-month period. Supervisors' scores were adjusted for the expected supervision requirement for the case for trainees at different stages of training. We used generalisability theory to determine score reliability. RESULTS: 7808 assessments were available for analysis. Supervision requirements decreased significantly (P < 0.05) with increased duration and level of training, supporting validity. We found moderate reliability (G > 0.7) with a feasible number of assessments. Adjusting scores against the expected supervision requirement considerably improved reliability, with G > 0.8 achieved with only nine assessments. Three per cent of trainees generated average mini-CEX scores below the expected standard. CONCLUSIONS: Using an entrustment scoring system, where supervisors score trainees on the level of supervision required, mini-CEX scores demonstrated moderate reliability within a feasible number of assessments, and evidence of validity. When scores were adjusted against an expected standard, underperforming trainees could be identified, and reliability much improved. Taken together with other evidence on trainee ability, the mini-CEX is of sufficient reliability for inclusion in high stakes decisions on trainee progression towards independent specialist practice.

Evaluating the ORSIM® simulator for assessment of anaesthetists' skills in flexible bronchoscopy: aspects of validity and reliability.

BACKGROUND: Developing expertise in flexible bronchoscopy is limited by inadequate opportunities to train on difficult airways. The new ORSIM bronchoscopy simulator aims to address this by creating virtual patients with difficult airways. This study aims to provide evidence on the validity and reliability of the ORSIM for assessment of subjects on both normal and abnormal airway simulations. METHODS: Novice, trainee, and expert subjects performed seven simulations of varying difficulty and scored the perceived difficulty for each. Time to completion was measured. Three blinded raters independently scored videos of each subject's performance. We measured inter-rater agreement and the difference in raters' scores between subject groups. RESULTS: We recruited 28 study subjects, generating 196 videos for analysis. Expert subjects consistently completed the scenarios faster than novices. Overall performance scores showed significant differences between subject groups (P<0.0001). Inter-rater reliability of scores was >0.8. CONCLUSIONS: Our results provide initial evidence on the validity and reliability of the ORSIM bronchoscopy simulator, supporting its potential value in training and assessment.

Improving team information sharing with a structured call-out in anaesthetic emergencies: a randomized controlled trial.

BACKGROUND: Sharing information with the team is critical in developing a shared mental model in an emergency, and fundamental to effective teamwork. We developed a structured call-out tool, encapsulated in the acronym 'SNAPPI': Stop; Notify; Assessment; Plan; Priorities; Invite ideas. We explored whether a video-based intervention could improve structured call-outs during simulated crises and if this would improve information sharing and medical management. METHODS: In a simulation-based randomized, blinded study, we evaluated the effect of the video-intervention teaching SNAPPI on scores for SNAPPI, information sharing, and medical management using baseline and follow-up crisis simulations. We assessed information sharing using a probe technique where nurses and technicians received unique, clinically relevant information probes before the simulation. Shared knowledge of probes was measured in a written, post-simulation test. We also scored sharing of diagnostic options with the team and medical management. RESULTS: Anaesthetists' scores for SNAPPI were significantly improved, as was the number of diagnostic options they shared. We found a non-significant trend to improve information-probe sharing and medical management in the intervention group, and across all simulations, a significant correlation between SNAPPI and information-probe sharing. Of note, only 27% of the clinically relevant information about the patient provided to the nurse and technician in the pre-simulation information probes was subsequently learnt by the anaesthetist. CONCLUSIONS: We developed a structured communication tool, SNAPPI, to improve information sharing between anaesthetists and their team, taught it using a video-based intervention, and provide initial evidence to support its value for improving communication in a crisis.

Can I leave the theatre? A key to more reliable workplace-based assessment.

BACKGROUND: The value of workplace-based assessments such as the mini-clinical evaluation exercise (mini-CEX), and clinicians' confidence and engagement in the process, has been constrained by low reliability and limited capacity to identify underperforming trainees. We proposed that changing the way supervisors make judgements about trainees would improve score reliability and identification of underperformers. Anaesthetists regularly make decisions about the level of trainee independence with a case, based on how closely they need to supervise them. We therefore used this as the basis for a new scoring system. METHODS: We analysed 338 mini-CEXs where supervisors scored trainees using the conventional system, and also scored trainee independence, based on the need for direct, or more distant, supervision. As supervisory requirements depend on case difficulty, we then compared the actual trainee independence score and the expected trainee independence score obtained externally. RESULTS: Compared with the conventional scoring system used in previous studies, reliability was very substantially improved using a system based on a trainee's level of independence with a case. Reliability improved further when this score was corrected for case difficulty. Furthermore, the new scoring system overcame the previously identified problem of assessor leniency and identified a number of trainees performing below expectations. CONCLUSIONS: Supervisors' judgements on trainee independence with a case, based on the need for direct or more distant supervision, can generate reliable scores of trainee ability without the need for an onerous number of assessments, identify trainees performing below expectations, and track trainee progress towards independent specialist practice.

Education in airway management.

In airway management, poor judgment, education and training are leading causes of patient morbidity and mortality. The traditional model of medical education, which relies on experiential learning in the clinical environment, is inconsistent and often inadequate. Curriculum change is underway in many medical organisations in an effort to correct these problems, and airway management is likely to be explicitly addressed as a clinical fundamental within any new anaesthetic curriculum. Competency-based medical education with regular assessment of clinical ability is likely to be introduced for all anaesthetists engaged in airway management. Essential clinical competencies need to be defined and improvements in training techniques can be expected based on medical education research. Practitioners need to understand their equipment and diversify their airway skills to cope with a variety of clinical presentations. Expertise stems from deliberate practice and a desire constantly to improve performance with a career-long commitment to education.

Standards for simulation in anaesthesia: creating confidence in the tools.

Simulation is an accepted part of training, assessment, and research in aviation, nuclear power, and the military. Confidence in results in these industries is underpinned by relatively comprehensive and widely accepted standards. In contrast, although there have been major advances in the technology and tools used for simulation in the healthcare industry over the last few decades, little work has been done in setting standards for simulation in healthcare. Standards are essential for achieving the full potential of simulation-based education, assessment, and research at all levels and specialities in healthcare. The absence of standards undermines confidence in the results of any simulation-based endeavour and increases the risk of negative learning. We propose a practical framework for setting standards for simulators for anaesthesia.

Investigation of trainee and specialist reactions to the mini-Clinical Evaluation Exercise in anaesthesia: implications for implementation.

BACKGROUND: The mini-Clinical Evaluation Exercise (mini-CEX) is a workplace-based assessment which may be useful in anaesthesia training. However, its value depends on how supervisors use it with their trainees. This study analyses experience with the mini-CEX after its introduction into anaesthesia departments in our institution. METHODS: We conducted surveys, focus groups, and interviews with trainees and specialists. Data were recorded, transcribed, and entered into NVivo 8. Themes were identified and data coded into these themes. RESULTS: We identified six themes: assessor factors included skills needed to perform the assessments, influences on scoring decisions, and effects on the specialist-trainee relationship; trainee factors related to impact on trainee performance and value at the different training levels; teaching and learning included the effect of focused observation on structuring workplace learning; feedback described how the mini-CEX changed feedback and what was considered useful; mini-CEX process included implementation, initiation of assessments and case selection; and use in assessment included comparisons with existing assessments and the ability to identify poor performers. CONCLUSIONS: Mini-CEX formalized the supervisory relationship, promoting educational interactions. During the observation period, trainees took responsibility for decisions, and specialists learnt more about their abilities. The structured format broadened the scope of feedback and made it easier to address performance gaps. We identified factors that facilitated or hindered implementation, or limited effective feedback and the ability to address poor performance. From this analysis, we propose strategies for the implementation of mini-CEX, and recommendations for assessor training to improve the quality and value of the assessments.

Mini-clinical evaluation exercise in anaesthesia training.

BACKGROUND: The Mini-Clinical Evaluation Exercise (Mini-CEX) is a workplace-based assessment tool of potential value in anaesthesia to assess and improve clinical performance. Its reliability and positive educational impact have been reported in other specialities, but not, to date, in anaesthesia. In this study, we evaluated the psychometric characteristics, logistics of application, and impact on the quality of supervision of the Mini-CEX in anaesthesia training. METHODS: A Mini-CEX encounter consisted of a single specialist anaesthetist observing a trainee over a defined period of time, completing an online Mini-CEX form with the trainee, and providing written and verbal feedback. We sought trainee and supervisor perspectives on its value and ease of use and used Generalizability Theory to estimate reliability. RESULTS: We collected 331 assessments from 61 trainees and 58 assessors. Survey responses strongly supported the positive effect of the Mini-CEX on feedback, its relative feasibility, and acceptance as a potential assessment tool. In this cohort, we found variable assessor stringency and low trainee variation. However, a feasible sample of cases and assessors would produce sufficiently precise scores to decide that performance was satisfactory for each trainee with 95% confidence. To generate scores that could discriminate sufficiently between trainees to allow ranking, a much larger sample of cases would be needed. CONCLUSIONS: The Mini-CEX in anaesthesia has strengths and weaknesses. Strengths include: its perceived very positive educational impact and its relative feasibility. Variable assessor stringency means that large numbers of assessors are required to produce reliable scores.

The impact of trained assistance on error rates in anaesthesia: a simulation-based randomised controlled trial.

Trained assistance for the anaesthetist appears likely to improve safety in anaesthesia. However, there are few objective data to support this assumption, and the requirement for a trained assistant is not universally enforced. We applied a simulation-based model developed in previous work to test the hypothesis that the presence of a trained assistant reduces error in anaesthesia. Ten randomly selected anaesthetists, five trained anaesthetic technicians and five theatre nurses without training in anaesthesia participated in two simulated emergencies, with anaesthetists working alternately with a technician or a nurse. The mean (SD) error rate per scenario was 4.75 (2.9). There were significantly fewer errors in the technician group than the nurse group (33 vs 62, p = 0.01) and this difference remained significant when errors were weighted for severity. This provides objective evidence supporting the requirement for trained assistance to the anaesthetist, and furthermore, demonstrates that a simulation-based model can provide rigorous evidence on safety interventions in anaesthesia.

A simulation design for research evaluating safety innovations in anaesthesia*.

SUMMARY: It is notoriously difficult to obtain evidence from clinical randomised controlled trials for safety innovations in healthcare. We have developed a research design using simulation for the evaluation of safety initiatives in anaesthesia. We used a standard and a modified scenario in a human-patient simulator, involving a potentially life-threatening problem requiring prompt attention--either a cardiac arrest or a failure in oxygen supply. The modified scenarios involved distractions such as loud music, a demanding and uncooperative surgeon, telephone calls and frequent questions from a medical student. Twenty anaesthetics were administered by 10 anaesthetists. A mean (SD) of 11.3 (2.8) errors per anaesthetic were identified in the oxygen failure scenarios, compared with 8.0 (3.4) in the cardiac arrest scenarios (ANOVA: p = 0.04). The difference between the combined standard scenarios and the combined modified scenarios was not significant. The mean rate of errors overall was 9.7 per simulation, with a pooled SD of 4.46, so in future studies 21 subjects would provide 80% statistical power to show a reduction in error rate of 30% from baseline with p