Improving neuromuscular monitoring and reducing residual neuromuscular blockade via e-learning: A multicentre interrupted time-series study (INVERT study).

BACKGROUND: Neuromuscular monitoring should be applied routinely to avoid residual neuromuscular block. However, anaesthetists often refrain from applying it, even when the equipment is available. We aimed to increase neuromuscular monitoring in six Danish anaesthesia departments via e-learning. METHODS: Interrupted time series study, with baseline data from a previous study and prospective data collection after implementation of the module, which was available for 2 weeks from 21 November 2016. We included all patients receiving general anaesthesia with muscle relaxants until 30 April 2017. Main outcome was application of acceleromyography, grouped as succinylcholine only and non-depolarising relaxants. Secondary outcomes were last recorded train-of-four ratio (non-depolarising) relaxants and score on a ten-question pre- and post-course multiple-choice test. RESULTS: The post-intervention data consisted of 6525 cases (3099 (48%) succinylcholine only, 3426 (52%) non-depolarising relaxants). Analysing all departments, we found a positive pre-intervention trend in application of acceleromyography for both groups, of estimated 7.5% and 4.8% per year, respectively (p < .001). The monitoring rate increased significantly for succinylcholine in two departments post-intervention (p = .045 and .010), and for non-depolarising relaxants in one department (p = .041), but followed by a negative trend of -37.0% per year (p = .041). The rate was already close to 90% at the time of the intervention and the mean last recorded train-of-four ratio was 0.97 (SD 0.21), also without a significant change. The median score on the post-course test increased from 7 (IQR 5-8) to 9 (IQR 8-10) (p < .001, Wilcoxon Signed-Ranks Test). CONCLUSION: We found no overall effect of the e-learning module on application of neuromuscular monitoring, although the post-course test indicated an effect on anaesthetists' knowledge in this field. TRIAL REGISTRATION: Trial registration: Clinicaltrials.gov identifier: NCT02925143. https://clinicaltrials.gov/ct2/show/NCT02925143.

What Makes for Good Anesthesia Teaching by Faculty in the Operating Room? The Perspective of Anesthesiology Residents.

Background Teaching during patient care is an important competency for faculty. Little is known about anesthesiology resident preferences for teaching by anesthesiology faculty in the operating room (OR). If the behaviors and characteristics of anesthesia teaching in the OR that are most valued by residents were identified, faculty could incorporate that best practice to teach residents during OR cases. The objective of this phenomenological study was to interview anesthesiology residents to determine what they perceive the best faculty teachers are doing in the OR to educate residents. Methods Thirty randomly selected anesthesiology residents (10 in each post-graduate year class) were interviewed using a semi-structured approach with a predetermined question: "Based on your experiences as a resident, when you think about the best-attending teachers in the OR, what are the best-attending teachers doing in the OR to teach that other faculty maybe are not doing?" Interviews were recorded, transcribed, converted into codes, and grouped into themes derived from the cognitive apprenticeship framework, which includes content, teaching methods, sequencing, and social characteristics. Results Resident responses were separated into a total of 134 answers, with similar answers grouped into one of 27 different codes. The most commonly mentioned codes were: autonomy - step back and let resident work through (mentioned by 13 residents), reasoning - explain why attending does things (12), context - teach something relevant to the case (8), commitment - take time to teach (8), literature - bring relevant papers (8), prior knowledge - assess the baseline level (7), flexibility - be open to trying different approaches (7), focus on just a few learning points (6), reflection - ask resident questions (6), provide real-time feedback (6), teach back - ask residents to explain what they were taught in their own words (5), belonging - facilitate communication with the OR team (5), psychological safety - be open and approachable (5), equanimity - stay calm and collected (5), select proper timing for instruction when the resident is not occupied with patient care (5), visualization - use graphs or diagrams (5), and specify learning goals ahead of time (5). Conclusion The best practice for OR teaching, as perceived by anesthesia residents, includes social characteristics, such as context, commitment, psychological safety, equanimity, and proper timing, as well as teaching methods, such as autonomy, reasoning, literature, prior knowledge, flexibility, reflection, real-time feedback, and teach back. Further studies can determine if training anesthesiology faculty to incorporate these elements increases the caliber of daily teaching in the OR.

Development of an Objective Structured Clinical Examination Using the American Board of Anesthesiology Content Outline for the Objective Structured Clinical Examination Component of the APPLIED Certification Examination.

The goal of this study was to use the American Board of Anesthesiology Objective Structured Clinical Examination (OSCE) content outline as a blueprint to develop and administer a 9-station mock OSCE with station-specific checklists to senior residents (n = 14). The G- and Ф-coefficient reliability estimates were 0.76 and 0.61, respectively. Residents judged the scenarios as either extremely or somewhat realistic (88%). It is feasible to develop and administer a mock OSCE with rigorous psychometric characteristics.

Improving Neuromuscular Monitoring and Reducing Residual Neuromuscular Blockade With E-Learning: Protocol for the Multicenter Interrupted Time Series INVERT Study.

BACKGROUND: Muscle relaxants facilitate endotracheal intubation under general anesthesia and improve surgical conditions. Residual neuromuscular blockade occurs when the patient is still partially paralyzed when awakened after surgery. The condition is associated with subjective discomfort and an increased risk of respiratory complications. Use of an objective neuromuscular monitoring device may prevent residual block. Despite this, many anesthetists refrain from using the device. Efforts to increase the use of objective monitoring are time consuming and require the presence of expert personnel. A neuromuscular monitoring e-learning module might support consistent use of neuromuscular monitoring devices. OBJECTIVE: The aim of the study is to assess the effect of a neuromuscular monitoring e-learning module on anesthesia staff's use of objective neuromuscular monitoring and the incidence of residual neuromuscular blockade in surgical patients at 6 Danish teaching hospitals. METHODS: In this interrupted time series study, we are collecting data repeatedly, in consecutive 3-week periods, before and after the intervention, and we will analyze the effect using segmented regression analysis. Anesthesia departments in the Zealand Region of Denmark are included, and data from all patients receiving a muscle relaxant are collected from the anesthesia information management system MetaVision. We will assess the effect of the module on all levels of potential effect: staff's knowledge and skills, patient care practice, and patient outcomes. The primary outcome is use of neuromuscular monitoring in patients according to the type of muscle relaxant received. Secondary outcomes include last recorded train-of-four value, administration of reversal agents, and time to discharge from the postanesthesia care unit as well as a multiple-choice test to assess knowledge. The e-learning module was developed based on a needs assessment process, including focus group interviews, surveys, and expert opinions. RESULTS: The e-learning module was implemented in 6 anesthesia departments on 21 November 2016. Currently, we are collecting postintervention data. The final dataset will include data from more than 10,000 anesthesia procedures. We expect to publish the results in late 2017 or early 2018. CONCLUSIONS: With a dataset consisting of thousands of general anesthesia procedures, the INVERT study will assess whether an e-learning module can increase anesthetists' use of neuromuscular monitoring. TRIAL REGISTRATION: Clinicaltrials.gov NCT02925143; https://clinicaltrials.gov/ct2/show/NCT02925143 (Archived by WebCite® at http://www.webcitation.org/6s50iTV2x).

[The effect on mold formation when leaving the first slice in situ in white sliced bread].

INTRODUCTION: To study the effect on mold formation when leaving the first slice in situ in white sliced bread (WSB). MATERIAL AND METHODS: We randomized 20 bags of WSB from a single production batch to either have the first slice removed or left in situ and compared mold formation and dryness on day ten. We removed two slices of bread from each bag daily and used blinded outcome assessors. RESULTS: We found mold in seven vs. six bags in the groups (p = 1.00). Results on dryness were inconsistent. The study may have been underpowered. CONCLUSION: Leaving the end slice in situ may not affect mold formation in WSB.