A modern roadmap for the use of simulation in regional anesthesiology training.

PURPOSE OF REVIEW: A variety of educational modalities are used to teach regional anesthesia. Simulation is an educational tool that facilitates hands-on learning in a well tolerated, reproducible environment, eliminating potential harm to patients during the process of learning. Available literature and expert consensus statements support customizing simulation programs according to the level of training and experience of the learners. RECENT FINDINGS: Simulation is useful for learners of all levels of expertise, though the application and frequency of simulation must be adapted to meet the learners' objectives. SUMMARY: This review presents recommendations for the use of simulation for residents, fellows, practicing anesthesiologists without formal training in regional anesthesia, and practicing anesthesiologists with regional anesthesia expertise. Passports and portfolio programs that include simulation can be used to verify training. Virtual applications of simulation are growing, expanding the scope of regional anesthesia simulation and increasing access to lower resource areas.

Developing a Real-Time Electroencephalogram-Guided Anesthesia-Management Curriculum for Educating Residents: A Single-Center Randomized Controlled Trial.

BACKGROUND: Different anesthetic drugs and patient factors yield unique electroencephalogram (EEG) patterns. Yet, it is unclear how best to teach trainees to interpret EEG time series data and the corresponding spectral information for intraoperative anesthetic titration, or what effect this might have on outcomes. METHODS: We developed an electronic learning curriculum (ELC) that covered EEG spectrogram interpretation and its use in anesthetic titration. Anesthesiology residents at a single academic center were randomized to receive this ELC and given spectrogram monitors for intraoperative use versus standard residency curriculum alone without intraoperative spectrogram monitors. We hypothesized that this intervention would result in lower inhaled anesthetic administration (measured by age-adjusted total minimal alveolar concentration [MAC] fraction and age-adjusted minimal alveolar concentration [aaMAC]) to patients ≥60 old during the postintervention period (the primary study outcome). To study this effect and to determine whether the 2 groups were administering similar anesthetic doses pre- versus postintervention, we compared aaMAC between control versus intervention group residents both before and after the intervention. To measure efficacy in the postintervention period, we included only those cases in the intervention group when the monitor was actually used. Multivariable linear mixed-effects modeling was performed for aaMAC fraction and hospital length of stay (LOS; a non-prespecified secondary outcome), with a random effect for individual resident. A multivariable linear mixed-effects model was also used in a sensitivity analysis to determine if there was a group (intervention versus control group) by time period (post- versus preintervention) interaction for aaMAC. Resident EEG knowledge difference (a prespecified secondary outcome) was compared with a 2-sided 2-group paired t test. RESULTS: Postintervention, there was no significant aaMAC difference in patients cared for by the ELC group (n = 159 patients) versus control group (N = 325 patients; aaMAC difference = -0.03; 95% confidence interval [CI], -0.09 to 0.03; P =.32). In a multivariable mixed model, the interaction of time period (post- versus preintervention) and group (intervention versus control) led to a nonsignificant reduction of -0.05 aaMAC (95% CI, -0.11 to 0.01; P = .102). ELC group residents (N = 19) showed a greater increase in EEG knowledge test scores than control residents (N = 20) from before to after the ELC intervention (6-point increase; 95% CI, 3.50-8.88; P < .001). Patients cared for by the ELC group versus control group had a reduced hospital LOS (median, 2.48 vs 3.86 days, respectively; P = .024). CONCLUSIONS: Although there was no effect on mean aaMAC, these results demonstrate that this EEG-ELC intervention increased resident knowledge and raise the possibility that it may reduce hospital LOS.

A Pilot Project Using Eye-Tracking Technology to Design a Standardised Anaesthesia Workspace.

OBJECTIVE: Maximising safe handoff procedures ensures patient safety. Anaesthesiology practices have primarily focused on developing better communication tools. However, these tools tend to ignore the physical layout of the anaesthesia workspace itself. Standardising the anaesthesia workspace has the potential to improve patient safety. The design process should incorporate end user feedback and objective data. METHODS: This pilot project aims to design a standardised anaesthesia workspace using eye-tracking technology at a single university-affiliated Veterans Affairs hospital. Twelve practising anaesthesiologists observed a series of images representing five clinical scenarios. Each of these had a question prompting them to look for certain items commonly found in the anaesthesia workspace. Using eye-tracking technology, the gaze data of participants were recorded. These data were used to generate heat maps of the specific areas of interest in the workspace that received the most fixation counts. RESULTS: The laryngoscope and propofol had the highest percentages of gaze fixations on the left-hand side of the workstation, in closest proximity to the anaesthesiologist. Atropine, although the highest percentage of gaze fixations (33%) placed it on the right-hand side of the workstation, also had 25% of gaze fixations centred over the anaesthesia cart. CONCLUSION: Gaze fixation analyses showed that anaesthesiologists identified locations for the laryngoscope and propofol within easy reach and emergency medications further away. Because eye tracking can provide objective data to influence the design process, it may be useful when developing standardised anaesthesia workspace templates for individual practices.

Using eye tracking technology to compare the effectiveness of malignant hyperthermia cognitive aid design.

BACKGROUND: Malignant hyperthermia is a rare but potentially fatal complication of anesthesia, and several different cognitive aids designed to facilitate a timely and accurate response to this crisis currently exist. Eye tracking technology can measure voluntary and involuntary eye movements, gaze fixation within an area of interest, and speed of visual response and has been used to a limited extent in anesthesiology. METHODS: With eye tracking technology, we compared the accessibility of five malignant hyperthermia cognitive aids by collecting gaze data from twelve volunteer participants. Recordings were reviewed and annotated to measure the time required for participants to locate objects on the cognitive aid to provide an answer; cumulative time to answer was the primary outcome. RESULTS: For the primary outcome, there were differences detected between cumulative time to answer survival curves (P < 0.001). Participants demonstrated the shortest cumulative time to answer when viewing the Society for Pediatric Anesthesia (SPA) cognitive aid compared to four other publicly available cognitive aids for malignant hyperthermia, and this outcome was not influenced by the anesthesiologists' years of experience. CONCLUSIONS: This is the first study to utilize eye tracking technology in a comparative evaluation of cognitive aid design, and our experience suggests that there may be additional applications of eye tracking technology in healthcare and medical education. Potentially advantageous design features of the SPA cognitive aid include a single page, linear layout, and simple typescript with minimal use of single color blocking.

Preliminary Experience Using Eye-Tracking Technology to Differentiate Novice and Expert Image Interpretation for Ultrasound-Guided Regional Anesthesia.

OBJECTIVES: Objective measures are needed to guide the novice's pathway to expertise. Within and outside medicine, eye tracking has been used for both training and assessment. We designed this study to test the hypothesis that eye tracking may differentiate novices from experts in static image interpretation for ultrasound (US)-guided regional anesthesia. METHODS: We recruited novice anesthesiology residents and regional anesthesiology experts. Participants wore eye-tracking glasses, were shown 5 sonograms of US-guided regional anesthesia, and were asked a series of anatomy-based questions related to each image while their eye movements were recorded. The answer to each question was a location on the sonogram, defined as the area of interest (AOI). The primary outcome was the total gaze time in the AOI (seconds). Secondary outcomes were the total gaze time outside the AOI (seconds), total time to answer (seconds), and time to first fixation on the AOI (seconds). RESULTS: Five novices and 5 experts completed the study. Although the gaze time (mean ± SD) in the AOI was not different between groups (7 ± 4 seconds for novices and 7 ± 3 seconds for experts; P = .150), the gaze time outside the AOI was greater for novices (75 ± 18 versus 44 ± 4 seconds for experts; P = .005). The total time to answer and total time to first fixation in the AOI were both shorter for experts. CONCLUSIONS: Experts in US-guided regional anesthesia take less time to identify sonoanatomy and spend less unfocused time away from a target compared to novices. Eye tracking is a potentially useful tool to differentiate novices from experts in the domain of US image interpretation.

Upgrading a Social Media Strategy to Increase Twitter Engagement During the Spring Annual Meeting of the American Society of Regional Anesthesia and Pain Medicine.

Microblogs known as "tweets" are a rapid, effective method of information dissemination in health care. Although several medical specialties have described their Twitter conference experiences, Twitter-related data in the fields of anesthesiology and pain medicine are sparse. We therefore analyzed the Twitter content of 2 consecutive spring meetings of the American Society of Regional Anesthesia and Pain Medicine using publicly available online transcripts. We also examined the potential contribution of a targeted social media campaign on Twitter engagement during the conferences. The original Twitter meeting content was largely scientific in nature and created by meeting attendees, the majority of whom were nontrainee physicians. Physician trainees, however, represent an important and increasing minority of Twitter contributors. Physicians not in attendance predominantly contributed via retweeting original content, particularly picture-containing tweets, and thus increased reach to nonattendees. A social media campaign prior to meetings may help increase the reach of conference-related Twitter discussion.

Sepsis in the Operating Room: A Simulation Case for Perioperative Providers.

INTRODUCTION: Sepsis should be included in the differential of any patient with unexplained organ dysfunction, whether or not an obvious infection is initially detected. Perioperative providers frequently care for patients with sepsis. This simulation case challenges participants to recognize and manage a presentation of postoperative sepsis, providing an opportunity to discuss the rationale behind sepsis management during debriefing. METHODS: Assuming the role of an anesthesia provider, the participant takes over the care of a 62-year-old female who has just undergone cystoscopy and is extubated in the operating room (OR). The participant receives a brief handoff from the outgoing anesthesiologist while the patient awaits a postanesthesia care unit slot. The case has been uneventful, aside from intermittent hypotension responsive to IV fluids and boluses of phenylephrine. Within minutes of the handoff, the patient becomes somnolent and hypotensive. Efforts to treat hypotension eventually precipitate hypoxemia. Trainees must recognize and manage this cardiopulmonary decompensation. The scenario benefits from an OR simulation environment containing an anesthetic ventilator, anesthesia drugs and equipment, and a mannequin on an OR table. RESULTS: Twelve residents completed the simulation scenario. Formal feedback was collected via email questionnaire from faculty instructors within 30 days of teaching each session. DISCUSSION: Sepsis presents a diagnostic dilemma in part because no single diagnostic test rules the syndrome in or out. Multiple operational definitions of sepsis in the academic literature add to the confusion for clinicians. Our case simulation challenges perioperative providers to make a timely diagnosis and initiate appropriate treatment of sepsis.

Twitter-Augmented Journal Club: Educational Engagement and Experience So Far.

Social media is a nascent medical educational technology. The benefits of Twitter include (1) easy adoption; (2) access to experts, peers, and patients across the globe; (3) 24/7 connectivity; (4) creation of virtual, education-based communities using hashtags; and (5) crowdsourcing information using retweets. We report on a novel Twitter-augmented journal club for anesthesia residents: its design, implementation, and impact. Our inaugural anesthesia Twitter-augmented journal club succeeded in engaging the anesthesia community and increasing residents' professional use of Twitter. Notably, our experience suggests that anesthesia residents are willing to use social media for their education.

Evaluation of a Standardized Program for Training Practicing Anesthesiologists in Ultrasound-Guided Regional Anesthesia Skills.

OBJECTIVES: Practicing anesthesiologists have generally not received formal training in ultrasound-guided perineural catheter insertion. We designed this study to determine the efficacy of a standardized teaching program in this population. METHODS: Anesthesiologists in practice for 10 years or more were recruited and enrolled to participate in a 1-day program: lectures and live-model ultrasound scanning (morning) and faculty-led iterative practice and mannequin-based simulation (afternoon). Participants were assessed and recorded while performing ultrasound-guided perineural catheter insertion at baseline, at midday (interval), and after the program (final). Videos were scored by 2 blinded reviewers using a composite tool and global rating scale. Participants were surveyed every 3 months for 1 year to report the number of procedures, efficacy of teaching methods, and implementation obstacles. RESULTS: Thirty-two participants were enrolled and completed the program; 31 of 32 (97%) completed the 1-year follow-up. Final scores [median (10th-90th percentiles)] were 21.5 (14.5-28.0) of 30 points compared to 14.0 (9.0-20.0) at interval (P < .001 versus final) and 12.0 (8.5-17.5) at baseline (P < .001 versus final), with no difference between interval and baseline. The global rating scale showed an identical pattern. Twelve of 26 participants without previous experience performed at least 1 perineural catheter insertion after training (P < .001). However, there were no differences in the monthly average number of procedures or complications after the course when compared to baseline. CONCLUSIONS: Practicing anesthesiologists without previous training in ultrasound-guided regional anesthesia can acquire perineural catheter insertion skills after a 1-day standardized course, but changing clinical practice remains a challenge.

Simulation in teaching regional anesthesia: current perspectives.

The emerging subspecialty of regional anesthesiology and acute pain medicine represents an opportunity to evaluate critically the current methods of teaching regional anesthesia techniques and the practice of acute pain medicine. To date, there have been a wide variety of simulation applications in this field, and efficacy has largely been assumed. However, a thorough review of the literature reveals that effective teaching strategies, including simulation, in regional anesthesiology and acute pain medicine are not established completely yet. Future research should be directed toward comparative-effectiveness of simulation versus other accepted teaching methods, exploring the combination of procedural training with realistic clinical scenarios, and the application of simulation-based teaching curricula to a wider range of learner, from the student to the practicing physician.

Simulation-based mastery learning with deliberate practice improves clinical performance in spinal anesthesia.

Introduction. Properly performing a subarachnoid block (SAB) is a competency expected of anesthesiology residents. We aimed to determine if adding simulation-based deliberate practice to a base curriculum improved performance of a SAB. Methods. 21 anesthesia residents were enrolled. After baseline assessment of SAB on a task-trainer, all residents participated in a base curriculum. Residents were then randomized so that half received additional deliberate practice including repetition and expert-guided, real-time feedback. All residents were then retested for technique. SABs on all residents' next three patients were evaluated in the operating room (OR). Results. Before completing the base curriculum, the control group completed 81% of a 16-item performance checklist on the task-trainer and this increased to 91% after finishing the base curriculum (P < 0.02). The intervention group also increased the percentage of checklist tasks properly completed from 73% to 98%, which was a greater increase than observed in the control group (P < 0.03). The OR time required to perform SAB was not different between groups. Conclusions. The base curriculum significantly improved resident SAB performance. Deliberate practice training added a significant, independent, incremental benefit. The clinical impact of the deliberate practice intervention in the OR on patient care is unclear.