The Ability of Military Critical Care Air Transport Members to Visually Estimate Percent Systolic Pressure Variation.

INTRODUCTION: Inappropriate fluid management during patient transport may lead to casualty morbidity. Percent systolic pressure variation (%SPV) is one of several technologies that perform a dynamic assessment of fluid responsiveness (FT-DYN). Trained anesthesia providers can visually estimate and use %SPV to limit the incidence of erroneous volume management decisions to 1-4%. However, the accuracy of visually estimated %SPV by other specialties is unknown. The aim of this article is to determine the accuracy of estimated %SPV and the incidence of erroneous volume management decisions for Critical Care Air Transport (CCAT) team members before and after training to visually estimate and utilize %SPV. MATERIAL AND METHODS: In one sitting, CCAT team providers received didactics defining %SPV and indicators of fluid responsiveness and treatment with %SPV ≤7 and ≥14.5 defining a fluid nonresponsive and responsive patient, respectively; they were then shown ten 45-second training arterial waveforms on a simulated Propaq M portable monitor's screen. Study subjects were asked to visually estimate %SPV for each arterial waveform and queried whether they would treat with a fluid bolus. After each training simulation, they were told the true %SPV. Seven days post-training, the subjects were shown a different set of ten 45-second testing simulations and asked to estimate %SPV and choose to treat, or not. Nonparametric limits of agreement for differences between true and estimated %SPV were analyzed using Bland-Altman graphs. In addition, three errors were defined: (1) %SPV visual estimate errors that would label a volume responsive patient as nonresponsive, or vice versa; (2) incorrect treatment decisions based on estimated %SPV (algorithm application errors); and (3) incorrect treatment decisions based on true %SPV (clinically significant treatment errors). For the training and testing simulations, these error rates were compared between, and within, provider groups. RESULTS: Sixty-one physicians (MDs), 64 registered nurses (RNs), and 53 respiratory technicians (RTs) participated in the study. For testing simulations, the incidence and 95% CI for %SPV estimate errors with sufficient magnitude to result in a treatment error were 1.4% (0.5%, 3.2%), 1.6% (0.6%, 3.4%), and 4.1% (2.2%, 6.9%) for MDs, RNs, and RTs, respectively. However, clinically significant treatment errors were statistically more common for all provider types, occurring at a rate of 7%, 10%, and 23% (all P < .05). Finally, students did not show clinically relevant reductions in their errors between training and testing simulations. CONCLUSIONS: Although most practitioners correctly visually estimated %SPV and all students completed the training in interpreting and applying %SPV, all groups persisted in making clinically significant treatment errors with moderate to high frequency. This suggests that the treatment errors were more often driven by misapplying FT-DYN algorithms rather than by inaccurate visual estimation of %SPV. Furthermore, these errors were not responsive to training, suggesting that a decision-making cognitive aid may improve CCAT teams' ability to apply FT-DYN technologies.

Predicting Success: Does Performance on the Anesthesia Knowledge Test - 6 (AKT-6) correlate with the American Board of Anesthesiology (ABA) Licensing Exam first-time pass rate?

BACKGROUND: We sought to determine the relationship between residents' Anesthesia Knowledge Test 6 (AKT-6) scores and their first-time success/failure on the American Board of Anesthesiology written licensing examination. Reliable early identification of residents at risk for failing the ABA exam would be an invaluable screening tool for program leadership and facilitate timely remediation for struggling residents. METHODS: Program directors were invited to submit anonymous data regarding their residents' performance on the AKT-6 and their subsequent first-time success/failure on the American Board of Anesthesiology written licensing examination. RESULTS: Eight residency programs responded with AKT6 percentile scores and ABA part 1 first-time pass/fail status from 306 residents spanning 2004-2011. Of these, 292 also included AKT6% correct scores. AKT-6 performance was significantly better for trainees who went on to pass the ABA exam on their first attempt compared to those who failed. Trainees who scored at or below the 4(th) percentile (or answered ≤42% of questions correctly) failed the ABA exam while all those scoring above the 84(th) percentile (or answered >68% of questions correctly) passed. A Mantel-Haenszel common odds ratio estimate revealed significantly increased odds of failure below the thresholds of AKT-6 scores ≤ 36(th) percentile (≤56% correct). CONCLUSIONS: Observations from this work help to validate educators' use of AKT-6 exam performance as a marker for likelihood of success/failure on the ABA written licensing exam. Our analysis, based on data from eight training programs, yielded definitive cut points for ABA exam failure and passing. ROC analysis of our data supports a recommendation for educators to intervene with trainees scoring at or below the 36(th) percentile or 56% correct on AKT-6 testing. Our results likely require confirmation in a larger subset of anesthesiology residency programs.