Individualized remediation during fellowship training.

The Accreditation Council for Graduate Medical Education requires medical training programs to monitor, track, and formally document a fellow's performance. If deficiencies are found, programs are expected to prepare and implement an effective plan of action for improvement and to ensure that graduates acquire the personal and professional attributes of an independent physician. We revised our evaluation policy and instituted a remediation protocol in 2008. Since that time, 130 pediatric anesthesia fellows have graduated. Seven fellows (5%) underwent departmental formal consultation for deficient behavior or poor performance. Of these 7 fellows, 4 underwent an individualized remediation program (IRP). A formal performance review and written contract, with specifically identified problems and general themes, recommendations for time-based successful behaviors, and clearly identified consequences for unsuccessful behaviors, was initiated for each fellow undergoing an IRP. All fellows who participated in this program completed their subspecialty training in pediatric anesthesia, and all eligible fellows have successfully achieved their subspecialty board certification. Our approach has the advantage of multimodality, time-based daily evaluations, and group discussions in the context of a Clinical Competency Committee. Utilization of an IRP as a metric for progress has features similar to effective cognitive behavioral therapy contracts and has ensured that our graduates are held to clearly delineated and specified skills and behaviors that allow them to work independently in the field of pediatric anesthesiology.

Anesthesiologist- and System-Related Risk Factors for Risk-Adjusted Pediatric Anesthesia-Related Cardiac Arrest.

BACKGROUND: Pediatric anesthesia-related cardiac arrest (ARCA) is an uncommon but potentially preventable adverse event. Infants and children with more severe underlying disease are at highest risk. We aimed to identify system- and anesthesiologist-related risk factors for ARCA. METHODS: We analyzed a prospectively collected patient cohort data set of anesthetics administered from 2000 to 2011 to children at a large tertiary pediatric hospital. Pre-procedure systemic disease level was characterized by ASA physical status (ASA-PS). Two reviewers independently reviewed cardiac arrests and categorized their anesthesia relatedness. Factors associated with ARCA in the univariate analyses were identified for reevaluation after adjustment for patient age and ASA-PS. RESULTS: Cardiac arrest occurred in 142 of 276,209 anesthetics (incidence 5.1/10,000 anesthetics); 72 (2.6/10,000 anesthetics) were classified as anesthesia-related. In the univariate analyses, risk of ARCA was much higher in cardiac patients and for anesthesiologists with lower annual caseload and/or fewer annual days delivering anesthetics (all P < 0.001). Anesthesiologists with the highest academic rank and years of experience also had higher odds of ARCA (P = 0.02). After risk adjustment for ASA-PS ≥ III and age ≤ 6 months, however, the association with lower annual days delivering anesthetics remained (P = 0.03), but the other factors were no longer significant. CONCLUSIONS: Case-mix explained most associations between higher risk of pediatric ARCA and anesthesiologist-related variables at our institution, but the association with fewer annual days delivering anesthetics remained. Our findings highlight the need for rigorous adjustment for patient risk factors in anesthesia patient safety studies.

Using medical simulation to teach crisis resource management and decision-making skills to otolaryngology housestaff.

OBJECTIVES: Develop a course to use in situ high-fidelity medical simulation (HFS) in an actual operating room (OR) to (1) teach teamwork and crisis resource management (CRM) skills simultaneously to otolaryngology and anesthesia trainees and OR nurses and (2) provide decision-making experience to ear, nose, and throat residents and OR teams in simulated high-risk, low-frequency airway emergencies. STUDY DESIGN: A simulation-based, in situ CRM course was developed to teach airway management and CRM in the OR. Upon completion of each course, the participants were surveyed using questions with (1-5) scale answers. SETTING: The simulated clinical scenarios took place in the intensive care unit and OR at Children's Hospital Boston. SUBJECTS AND METHODS: The participants consisted of pediatric otolaryngology fellows, otolaryngology residents, anesthesiology residents, fellows, and certified registered nurse anesthetists as well as OR nurses. Fifty-nine individuals participated in 9 simulation-based courses given between October 2008 and May 2010. The team members participated together in 3 simulated medical crises that centered on airway and anesthesia issues. Each simulated crisis was followed by a structured debriefing session conducted by trained debriefers. Embedded within the course were didactics on CRM principles. RESULTS: The participants' responses on the survey included General Course Organization, Realism, Debriefing, and Relevance to Future Practice. Ninety percent of the responses were favorable or very favorable. CONCLUSION: Using a newly developed, in situ HFS-based course, clinical decision-making skills and teamwork can be effectively taught concurrently to members of an OR team.