Systems safety in nonoperating room anesthesia locations.

PURPOSE OF REVIEW: Nonoperating room anesthesia (NORA) care is an area of rapid growth over the last decade. However, literature describing safety systems in NORA is limited. This review evaluates historical safety models described by Donabedian and Reason, assesses the NORA environment and safety concerns that may contribute to adverse events, and provides potential solutions via a human-centered systems safety design. RECENT FINDINGS: Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 provides a framework for quality and patient safety improvement. Although the previous SEIPS 2.0 model has been used to evaluate NORA environments with focus on the case volume, high productivity pressure, and significant physical constraints common to NORA sites, literature describing SEIPS 3.0 in relation to NORA care is sparse. Given the rate of malpractice claims for death in NORA settings, solutions that address the multifactorial nature of adverse events are needed. SUMMARY: The SEIPS 3.0 model may be applied to NORA care. Changes should focus on staffing ratios, staff/patient education, checklist utilization, burnout prevention, scheduling efficiency, anesthesia workstation standardization, communication improvements, room layout, medication and supply availability and storage, and the global managerial approach. Team members must demonstrate flexibility and a willingness to adapt to successfully implement change.

Morbidity, mortality, and systems safety in non-operating room anaesthesia: a narrative review.

Non-operating room anaesthesia (NORA) describes anaesthesia delivered outside a traditional operating room (OR) setting. Non-operating room anaesthesia cases have increased significantly in the last 20 yr and are projected to account for half of all anaesthetics delivered in the next decade. In contrast to most other medication administration contexts, NORA is performed in high-volume fast-paced environments not optimised for anaesthesia care. These predisposing factors combined with increasing case volume, less provider experience, and higher-acuity patients increase the potential for preventable adverse events. Our narrative review examines morbidity and mortality in NORA settings compared with the OR and the systems factors impacting safety in NORA. A review of the literature from January 1, 1994 to March 5, 2021 was conducted using PubMed, CINAHL, Scopus, and ProQuest. After completing abstract screening and full-text review, 30 articles were selected for inclusion. These articles suggested higher rates of morbidity and mortality in NORA cases compared with OR cases. This included a higher proportion of death claims and complications attributable to inadequate oxygenation, and a higher likelihood that adverse events are preventable. Despite relatively few attempts to quantify safety concerns, it was possible to find a range of systems safety concerns repeated across multiple studies, including insufficient lighting, noise, cramped workspace, and restricted access to patients. Old and unfamiliar equipment, lack of team familiarity, and limited preoperative evaluation are also commonly noted challenges. Applying a systems view of safety, it is possible to suggest a range of methods to improve NORA safety and performance.

Train-the-trainer: Pilot trial for ebola virus disease simulation training.

Background: Highly infectious but rare diseases require rapid dissemination of safety critical skills to health-care workers (HCWs). Simulation is an effective method of education; however, it requires competent instructors. We evaluated the efficacy of an internet-delivered train-the-trainer course to prepare HCWs to care for patients with Ebola virus disease (EVD). Methods: Twenty-four individuals without prior EVD training were recruited and divided into two groups. Group A included nine trainees taught by three experienced trainers with previous EVD training. Group B included 15 trainees taught by five novice trainers without previous EVD training who completed the train-the-trainer course. We compared the efficacy of the train-the-trainer course by examining subject performance, measured by time to complete 13 tasks and the proportion of steps per task flagged for critical errors and risky and positive actions. Trainees' confidence in their ability to safely care for EVD patients was compared with a self-reported survey after training. Results: Overall trainees' confidence in ability to safely care for EVD patients did not differ by group. Participants trained by the novice trainers were statistically significantly faster at waste bagging (P = 0.002), lab specimen bagging (P = 0.004), spill clean-up (P = 0.01), and the body bagging (P = 0.008) scenarios compared to those trained by experienced trainers. There were no significant differences in the completion time in the remaining nine training tasks. Participants trained by novice and experienced trainers did not differ significantly with regard to the proportion of steps in a task flagged for critical errors, risky actions, or positive actions with the exception of the task "Man Down in Gown" (12.5% of steps graded by experienced trainers compared to 0 graded by novice trainers, P = 0.007). Discussion: The online train-the-trainer EVD course is effective at teaching novices to train HCWs in protective measures and can be accomplished swiftly.

Development of a Sterile Personal Protective Equipment Donning and Doffing Procedure to Protect Surgical Teams from SARS-CoV-2 Exposure during the COVID-19 Pandemic.

Background: The coronavirus disease 2019 (COVID-19) pandemic has become an increasingly challenging problem throughout the world. Because of the numerous potential modes of transmission, surgeons and all procedural staff represent a unique population that requires standardized procedures to protect themselves and their patients. Although several protocols have been implemented during other infectious disease outbreaks, such as Ebola virus, no standardized protocol has been published in regard to the COVID-19 pandemic. Methods: A multidisciplinary team of two surgeons, an anesthesiologist, and an infection preventionist was assembled to create a process with sterile attire adapted from the National Emerging Special Pathogen Training and Education Center (NETEC) donning and doffing process. After editing, a donning procedure and doffing procedure was created and made into checklists. The procedures were simulated in an empty operating room (OR) with simulation of all personnel roles. A "dofficer" role was established to ensure real-time adherence to the procedures. Results: The donning and doffing procedures were printed as one-page documents for easy posting in ORs and procedural areas. Pictures from the simulation were also obtained and made into flow chart-style diagrams that were also posted in the ORs. Conclusions: Coronavirus disease 2019 (COVID-19) is a quickly evolving pandemic that has spread all over the globe. With the rapid increase of infections and the increasing number of severely ill individuals, healthcare providers need easy-to-follow guidelines to keep themselves and patients as safe as possible. The processes for donning and doffing personal protective equipment (PPE) presented here provide an added measure of safety to surgeons and support staff to provide quality surgical care to positive and suspected COVID-19-positive patients.

A Pilot Study of Simulation Training in Difficult Bag Mask Ventilation Using a Computerized Patient Simulator.

OBJECTIVE: Bag mask ventilation (BMV) is fundamental to airway management. Simulation is effective in airway management training, but its effectiveness for difficult BMV training is less clear. We evaluated the difference between type of training (simulation vs on patients) and the pass rate on a post-test on patients. DESIGN: A single center pilot study was performed with 32 medical students randomized to participate in difficult BMV training on simulators or patients. Pre- and post-training tests on the simulator and on patients were recorded. Surveys of trainee confidence level were collected. The primary goal was to estimate the difference between type of training (simulation vs on patients) and the pass rate on the post-test on patients with an improvement of 10% or more in passing rate considered as a meaningful improvement. Secondary outcomes included whether or not participants passed the simulator post-test, post-test on patient confidence, and pre- and post-test confidence. MEASUREMENTS AND MAIN RESULTS: Participants trained on the simulator had 13% higher passing rate on the post-test on patients compared to participants trained on patients (88% vs 75%). In addition, subjects that passed the simulator post-test had 11 times the odds of passing a post-test on patients relative to subjects that did not pass the simulator post-test (P = 0.023, odds ratio = 11.0, 95% confidence interval [CI] = 1.48-81.6). Post-training confidence levels were higher among those who passed the simulator pre-test and post-test and received simulator training. CONCLUSIONS: Simulation training for difficult BMV led to a higher passing rate on a post-test on patients compared to those trained on patients. This finding will need to be confirmed in larger randomized controlled trials. Successfully completing difficult BMV training on a simulator with a passing grade correlated with passing a test on difficult BMV on patients.

Advantages of the New Tao Mask for Bag Mask Ventilation: a randomized crossover trial.

BACKGROUND AND AIMS: Manual bag mask ventilation is a life saving skill. An investigation was made to compare two different facemasks used in bag mask ventilation, the standard and the novel Tao face mask, and evaluate the ability of novices to achieve adequate tidal volume. METHODS: The study design was a crossover trial, which randomized forty medical students with no previous airway experience to learn bag mask ventilation with the standard mask and the Tao face mask. Primary outcome measures were mean and median tidal volume per mask, and secondary measures were hand area, age, gender, and order of mask usage. RESULTS: Medical students who used the Tao mask first achieved significantly more tidal volume than those who used the standard mask first (p = 0.002). However, when comparing face masks that were used second, the tidal volume did not differ significantly between the two masks (p = 1.000). Greater tidal volume was achieved on the second attempt relative to the first attempt with each mask. There was significantly more tidal volume achieved with greater hand size with the standard mask, whether it was used first or second (p < 0.001 and p = 0.012 respectively). Greater hand size was associated with greater tidal volume in the Tao mask also, but only when used first (p < 0.001). When first attempting bag mask ventilation, inexperienced students achieved greater tidal volume with the Tao Mask. The results also suggest that hand size matters less when using the Tao Mask. CONCLUSION: When first attempting bag mask ventilation inexperienced students achieved greater tidal volume with the Tao Mask. The results also suggest that hand size matters less when using the Tao mask.

Labor Epidural Analgesia and Postpartum Depression.

INTRODUCTION: Epidural labor analgesia may decrease the risk of postpartum depression (PPD). METHODS: In a secondary analysis of a prospective study, the association between epidural utilization and PPD was evaluated using a Fisher's exact test. PPD was defined as an Edinburgh Postnatal Depression score of ≥ 10 at 6-8 weeks postpartum. RESULTS: 20% (13/65) of women meet criteria for PDD. 24% (n=12/50) of women who received epidural labor analgesia developed PPD, compared to 6.7% (n=1/15) of women who did not receive epidural labor analgesia (P = 0.27). CONCLUSIONS: Labor epidural analgesia did not reduce the risk of postpartum depression.

An approach to moderate sedation simulation training.

INTRODUCTION: Each year millions of patients undergo procedures that require moderate sedation. These patients are at risk of complications from oversedation that can progress to respiratory depression or even death. This article describes the creation of a simulation-based medical education course for nonanesthesiologists who use sedation in their specialty practice and preliminary data from our precourse and postcourse assessments. METHODS: Our course combined online and lecture-based didactics with simulation education to teach moderate sedation and basic emergency airway management to nonanesthesiologists. After online precourse materials were reviewed, participants attended an 8-hour simulation-based training course focused on the recognition of different levels of sedation, medication titration, sedation reversal, and airway support and rescue. To evaluate the course, precourse, and postcourse educational impacts, cognitive and simulation tests were administered. Participants completed a postcourse survey. RESULTS: To date, 45 physicians have participated in the course. We have cognitive performance data on 19 participants and survey data for 45 participants. Postcourse simulation tests results were improved compared with precourse tests. Our course was rated "better" or "much better" in comparison to courses using lecture-only format by 100% of the participants. CONCLUSIONS: A course using a combination of didactic and simulation education to teach moderate sedation is described. Our initial data demonstrated a significant increase in knowledge, skills, and clinical judgment. Future research efforts should focus on examining the validity and reliability of scenario scoring and the impact of training on clinical practice.