Development and Pilot Testing of a Programmatic System for Competency Assessment in US Anesthesiology Residency Training.

BACKGROUND: In 2018, a set of entrustable professional activities (EPAs) and procedural skills assessments were developed for anesthesiology training, but they did not assess all the Accreditation Council for Graduate Medical Education (ACGME) milestones. The aims of this study were to (1) remap the 2018 EPA and procedural skills assessments to the revised ACGME Anesthesiology Milestones 2.0, (2) develop new assessments that combined with the original assessments to create a system of assessment that addresses all level 1 to 4 milestones, and (3) provide evidence for the validity of the assessments. METHODS: Using a modified Delphi process, a panel of anesthesiology education experts remapped the original assessments developed in 2018 to the Anesthesiology Milestones 2.0 and developed new assessments to create a system that assessed all level 1 through 4 milestones. Following a 24-month pilot at 7 institutions, the number of EPA and procedural skill assessments and mean scores were computed at the end of the academic year. Milestone achievement and subcompetency data for assessments from a single institution were compared to scores assigned by the institution's clinical competency committee (CCC). RESULTS: New assessment development, 2 months of testing and feedback, and revisions resulted in 5 new EPAs, 11 nontechnical skills assessments (NTSAs), and 6 objective structured clinical examinations (OSCEs). Combined with the original 20 EPAs and procedural skills assessments, the new system of assessment addresses 99% of level 1 to 4 Anesthesiology Milestones 2.0. During the 24-month pilot, aggregate mean EPA and procedural skill scores significantly increased with year in training. System subcompetency scores correlated significantly with 15 of 23 (65.2%) corresponding CCC scores at a single institution, but 8 correlations (36.4%) were <30.0, illustrating poor correlation. CONCLUSIONS: A panel of experts developed a set of EPAs, procedural skill assessment, NTSAs, and OSCEs to form a programmatic system of assessment for anesthesiology residency training in the United States. The method used to develop and pilot test the assessments, the progression of assessment scores with time in training, and the correlation of assessment scores with CCC scoring of milestone achievement provide evidence for the validity of the assessments.

Recent advances in predicting, preventing, and managing postoperative delirium.

Postoperative delirium (POD) is a major public health problem associated with poor patient outcomes such as increased hospital lengths of stay, loss of functional independence, and higher mortality. Depending on the study, the reported incidence ranges from 5% to 65%, with the highest incidence in hip and cardiac surgery. Anesthesiologists should be familiar with the predisposing and precipitating factors of POD, particularly screening for preoperative cognitive impairment and frailty syndrome. Screening tools, for example, the Mini-Mental State Exam, Mini-Cog, 4 A's test for delirium screening, and Montreal Cognitive Assessment, can be used to assess for cognitive impairment and the Clinical Frailty Scale to assess for frailty syndrome. The Hospital Elder Life Program is the standard prevention protocol that is tried and tested in reducing the incidence of POD. Prehabilitation, lung protective strategies, pharmacologic agents such as ramelteon, a melatonin receptor agonist, glucocorticoids, dexmedetomidine, and non-pharmacologic agents, such as noise reduction strategies and the encouragement of nocturnal sleep, have all led to a decrease in the incidence of POD and are being studied for their efficacy. However, the data are inconclusive to date. Intraoperatively, preventing hypotension and blood pressure swings, ensuring adequate pain control and anesthetic depth, and using age-adjusted minimum alveolar concentration (MAC) titration reduce the incidence of POD. The incidence of POD using regional or general anesthesia is similar. In this narrative review, we will discuss the current understanding of the predictors, pathophysiology, prevention, and management of POD and identify areas of further research.

Rank and Match Outcomes of In-person and Virtual Anesthesiology Residency Interviews.

BACKGROUND: For the 2019-2020 interview season, the anesthesia residency program at Augusta University offered candidates a choice between in-person (IP) and video conference (VC) interviews to accommodate a greater number of qualified candidates. METHODS: The same applicant selection criteria were used for both interview types. However, we modified the informal interactions with residents, campus tours, and interview formats for VC interviews. We sought to compare the 2 methods by analyzing the respective costs, benefits, and match results. RESULTS: Of 159 candidates interviewed, we ranked 127 and matched with 12. The IP (n = 135) and VC (n = 24) groups were similar in gender distribution but not by the type of medical school, with more international medical graduates interviewing by VC than IP. There was no statistically significant difference between the 2 interview types for being ranked (81% of IP, 71% of VC) or matched (6% of IP, 17% of VC). US Medical Licensing Examination Step 1 and Step 2 scores and type of medical school did not affect the likelihood of being ranked or matched. Program costs per candidate were higher for the IP group ($431 for IP, $294 for VC). CONCLUSION: Our single-center study indicates that the interview type did not affect the likelihood of a candidate being ranked by or matched to our program. Further, VC interviews were more cost-effective and time-effective than IP interviews. Our findings suggest that VC interviews are a viable alternative and should be an option for residency interviews.

Multifaceted remediation program: experience of a residency program to rescue residents who failed the American Board of Anesthesiology basic examination.

PROBLEM: Passing the American Board of Anesthesiology (ABA) basic examination is required to progress through anesthesiology training in USA. Failing the test may be related to medical knowledge gaps, presence of negative psychosocial factors, and/or individual approaches to learning. This article describes the experience of development and implementation of a multifaceted remediation program (MRP) in residents who failed the ABA basic test. INTERVENTION: This is a retrospective analysis of four cases of residents who failed the ABA basic test between 2016 and 2017. The MRP is described. Pedagogical diagnosis, objectives, teaching strategies and assessment, and their constructive alignment are presented. Information regarding test performance is also presented. CONTEXT: This study involves accredited anesthesiology residency program in USA. Outcomes: Four subjects (11% of program residents) failed the ABA basic test. Superficial approach to learning was observed in 100% of cases. The total possible number of participants was 4. The actual number of participants was 4, and the response rate was 100%. Four residents fell under 10th percentile on the first attempt, and 100% passed the test on the second attempt. There was 38% improvement in the number of failed keywords between the two attempts. LESSONS LEARNED: Implementation of the MRP developed at our institution is successful to remediate anesthesiology residents who fail the ABA basic examination. We learned that the deep analysis of learning approaches, psychosocial factors, and medical knowledge gaps can be used to develop a remediation program based on the constructive alignment between objectives, curriculum, and assessment.

Developing Modules to Train Anesthesiology Residents & Medical Students in a Lung Isolation Technique.

BACKGROUND: One-lung ventilation (OLV) can be accomplished by using ether a double-lumen endotracheal tube (DLT) or a bronchial blocker. Patient factors, surgical requirements and the anesthesiologist's expertise influence technique choice. Bronchial blockers are in general less traumatic, safer to place, and suitable in a wider variety of scenarios than DLTs, but require greater technical skill. We designed a study to determine whether trainees can achieve OLV using a bronchial blocker on completion of a 4-week multimodal training module. METHODS: Anesthesia residents and medical students took part in didactic (lecture and video) and clinical simulation training. During simulation training, participants practiced placing a bronchial blocker under supervision until they performed the technique satisfactorily. Trainees could then practice independently as often as they wished. A skills check was performed during the supervised and after the independent practice; feedback was provided. For more advanced learners, practical clinical training was continued in the operating room. Assessments data (test scores and skills checks) were analyzed using the t-test. RESULTS: Difference between pre-test and post-test scores (didactics) was statistically significant (p=0.02) as was the number of skills checks items satisfactorily demonstrated by the 14 participants on the first supervised attempt and the last independent practice (simulation; p<0.01). All eight who performed one-lung isolation in the operating room were technically proficient in achieving adequate OLV to the satisfaction of the supervising attending anesthesiologist. CONCLUSIONS: This multimodal standardized teaching module which incorporates didactics, simulation training, and, for more advanced trainees, practical clinical experience, improves trainees' knowledge and skills in bronchial blocker placement and OLV.

Left Ventricular Outflow Tract Area Measurements by Planimetry Using Two-Dimensional Simultaneous Orthogonal Plane Imaging During Transesophageal Echocardiography.

OBJECTIVE: Calculations of the left ventricular outflow tract (LVOT) area are typically based on the assumption that the LVOT is circular. This study was conducted to determine whether simultaneous orthogonal plane imaging with tilt during two-dimensional (2D) transesophageal echocardiography provided more accurate measurements of the LVOT area than the standard method. DESIGN: The authors prospectively measured the LVOT area in 2D by (1) the standard calculation based on the diameter as viewed on the long axis, and (2) a direct measurement using planimetry of the short axis, in consecutive patients presenting for elective surgery. The authors validated the planimetric technique by obtaining three-dimensional (3D) measurements in a subset of the subjects. SETTING: An academic medical center. PARTICIPANTS: Adult surgical patients with no evidence of aortic stenosis. INTERVENTIONS: Transesophageal images were acquired by anesthesiologists certified by the National Board of Echocardiography. MEASUREMENTS AND MAIN RESULTS: Image acquisition and assessment were performed in the operating room and found to be adequate for analysis in 52 of 55 subjects. Simultaneous orthogonal plane imaging with tilt enabled long- and short-axis visualization of the LVOT. The authors found that the standard method underestimated the area by 0.78 cm(2) compared to the direct method (2D planimetry) when measured at the same beat at a similar point in the cardiac cycle. Moreover, 2D planimetry measurements were comparable to 3D planimetry measurements in the last 20 study subjects (R(2) = 0.88, p<0.0001). CONCLUSIONS: This study suggested that 2D planimetry may be more accurate than 2D diameter-based calculations.

The Feasibility of Simultaneous Orthogonal Plane Imaging with Tilt for Short-Axis Evaluation of the Pulmonic Valve by Transesophageal Echocardiography.

Simultaneous orthogonal plane imaging with tilt enables the display of two 2D, real-time images and the evaluation of structures that cannot be seen by conventional single-plane transesophageal echocardiographic (TEE) imaging. After a step-wise examination protocol, we used simultaneous orthogonal plane imaging to obtain the short-axis view of the pulmonic valve (PV) and assessed flow in both images simultaneously using color Doppler imaging in 100 consecutive patients undergoing intraoperative TEE. Our goals were to assess the ability of this technique to visualize all 3 leaflets of the PV, assess feasibility of planimetry to measure valve area, and assess flow using color Doppler imaging. All study images were obtained by anesthesiologists who are diplomates in Advanced Perioperative Transesophageal Echocardiography. All 3 leaflets of the PV were successfully visualized in the short-axis view in 65% of cases, 2 leaflets were visualized in 32% of cases, and only 1 leaflet could be imaged in 3%. The flow across the valve could be evaluated using color Doppler imaging in all cases. Planimetry for valve area was possible when all 3 leaflets were seen. It is important to inspect the PV during a routine TEE examination; however, the orientation of the PV in respect to the esophagus makes this evaluation challenging. We present a simple protocol to evaluate the PV in long-axis and short-axis views simultaneously that can potentially help evaluate for pathologies involving the PV.

Inferior vena cava diameter (IVCD) measured with transesophageal echocardiography (TEE) can be used to derive the central venous pressure (CVP) in anesthetized mechanically ventilated patients.

BACKGROUND: Estimation of right atrial pressure (RAP) from variations in the diameter of the inferior vena cava (IVC) during the respiratory cycle using transthoracic echocardiography (TTE) is used routinely to calculate pulmonary artery systolic pressure, adding to right ventricular systolic pressure (RVSP) from the jet velocity of tricuspid regurgitation. Using transesophageal echocardiography (TEE) we sought to determine if the inferior vena cava diameter (IVCD) could be used to derive the central venous pressure (CVP) in anesthetized, mechanically ventilated patients. METHODS: The IVCD was measured in its long axis (bicaval view) at the cavo-atrial junction using TEE and ECG synchronization (to coincide with the end of the T-wave) in 95 anesthetized, mechanically ventilated patients undergoing elective cardiac surgery. Each patient received a pulmonary artery catheter (PAC) that allowed for continuous monitoring of the CVP. Three independent readers were assigned to document the IVCD and the CVP. Statistical analysis was performed using bivariate correlation, variance (ANOVA), linear regression, Bland-Altman and Passing-Bablock analysis of agreement. RESULTS: The IVCD measured in millimeters at the cavo-atrial junction showed a positive correlation with the CVP (n = 95, r = 0.860, P < 0.0001, r(2)= 0.737, P < 0.0001). The linear regression equation [CVPc = (IVCD-4.004/0.751] was prospectively tested in a cohort of 12 anesthetized, mechanically ventilated patients under various hemodynamic conditions with a good correlation between the mean CVP (CVPm) and the calculated CVP (CVPc) (r = 0.923, P < 0.0001, r(2)= 0.851, P < 0.0001). CONCLUSION: The TEE measured IVCD at the cavo-atrial junction showed a statistically significant correlation with the mean CVP. Using an equation derived from linear regression analysis, a reliable CVP can be estimated from the IVCD.