The BJA Editorial Fellowship 2024: a barometer for the state of academic anaesthesiology, perioperative, pain, and critical care medicine.

Throughout its 100-yr history, a key ambition of the British Journal of Anaesthesia has been to foster our academic community by addressing the needs of individuals in the early stages of their independent clinical and research careers. Longitudinal mentoring and peer networking are critical for establishing a community of like-minded peers and mentor-advisors required to navigate the challenges of academic medicine. In 2019, the Journal launched an Editorial Fellowship scheme, aimed at comprehensively demystifying the process of peer review, editing, and publishing through guided mentorship and experiential learning.

Surgical Video Projection onto a Mannequin: An Educational Tool for Simulation Practice of Perioperative Anesthetic Management.

Simulation practice is known to be effective in anesthesiology education. In our simulation practice of general anesthesia for open cholecystectomy at the Tohoku University simulation center, we projected a surgical video onto a mannequin's abdomen. In this observational study, we investigated whether video-linked simulation practice improved students' performance. We retrospectively compared the general anesthesia simulation practice scores of fifth-year medical students in a video-linked or conventional group. In the simulation practice, we evaluated the performance of each group in three sections: perioperative analgesia, intraoperative bleeding, and arrhythmia caused by abdominal irrigation. The primary endpoint was the total score of the simulation practice. The secondary endpoints were their scores on each section. We also investigated the amount of bleeding that caused an initial action and the amount of bleeding when they began to transfuse. The video group had significantly higher total scores than the conventional group (7.5 [5-10] vs. 5.5 [4-8], p = 0.00956). For the perioperative analgesia and arrhythmia sections, students in the video group responded appropriately to surgical pain. In the intraoperative bleeding section, students in both groups scored similarly. The amount of bleeding that caused initial action was significantly lower in the video group (200 mL [200-300]) than in the conventional group (400 mL [200-500]) (p = 0.00056).Simulation practice with surgical video projection improved student performance. By projecting surgical videos, students could practice in a more realistic environment similar to an actual case.

BJS commission on surgery and perioperative care post-COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues' experiences and published evidence. METHODS: In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. RESULTS: BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. CONCLUSION: The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.

Team training and surgical crisis management.

Team training and crisis management derive their roots from fundamental learning theory and the culture of safety that burgeoned forth from the industrial revolution through the rise of nuclear energy and aviation. The integral nature of telemedicine to many simulation-based activities, whether to bridge distances out of convenience or necessity, continues to be a common theme moving into the next era of surgical safety as newer, more robust technologies become available.

Integrating Sleep Knowledge Into the Anesthesiology Curriculum.

There is common ground between the specialties of anesthesiology and sleep medicine. Traditional sleep medicine curriculum for anesthesiology trainees has revolved around the discussion of obstructive sleep apnea (OSA) and its perioperative management. However, it is time to include a broader scope of sleep medicine-related topics that overlap these specialties into the core anesthesia residency curriculum. Five main core competency domains are proposed, including SLeep physiology; Evaluation of sleep health; Evaluation for sleep disorders and clinical implications; Professional and academic roles; and WELLness (SLEEP WELL). The range of topics include not only the basics of the physiology of sleep and sleep-disordered breathing (eg, OSA and central sleep apnea) but also insomnia, sleep-related movement disorders (eg, restless legs syndrome), and disorders of daytime hypersomnolence (eg, narcolepsy) in the perioperative and chronic pain settings. Awareness of these topics is relevant to the scope of knowledge of anesthesiologists as perioperative physicians as well as to optimal sleep health and physician wellness and increase consideration among current anesthesiology trainees for the value of dual credentialing in both these specialties.

Efficacy of an Online Curriculum for Perioperative Goals of Care and Code Status Discussions: A Randomized Controlled Trial.

BACKGROUND: Preoperative goals of care (GOC) and code status (CS) discussions are important in achieving an in-depth understanding of the patient's care goals in the setting of a serious illness, enabling the clinician to ensure patient autonomy and shared decision making. Past studies have shown that anesthesiologists are not formally trained in leading these discussions and may lack the necessary skill set. We created an innovative online video curriculum designed to teach these skills. This curriculum was compared to a traditional method of learning from reading the medical literature. METHODS: In this bi-institutional randomized controlled trial at 2 major academic medical centers, 60 anesthesiology trainees were randomized to receive the educational content in 1 of 2 formats: (1) the novel video curriculum (video group) or (2) journal articles (reading group). Thirty residents were assigned to the experimental video curriculum group, and 30 were assigned to the reading group. The content incorporated into the 2 formats focused on general preoperative evaluation of patients and communication strategies pertaining to GOC and CS discussions. Residents in both groups underwent a pre- and postintervention objective structured clinical examination (OSCE) with standardized patients. Both OSCEs were scored using the same 24-point rubric. Score changes between the 2 OSCEs were examined using linear regression, and interrater reliability was assessed using weighted Cohen's kappa. RESULTS: Residents receiving the video curriculum performed significantly better overall on the OSCE encounter, with a mean score of 4.19 compared to 3.79 in the reading group. The video curriculum group also demonstrated statistically significant increased scores on 8 of 24 rubric categories when compared to the reading group. CONCLUSIONS: Our novel video curriculum led to significant increases in resident performance during simulated GOC discussions and modest increases during CS discussions. Further development and refinement of this curriculum are warranted.

Educating surgical oncology providers on perioperative opioid use: A departmental survey 1 year after the intervention.

BACKGROUND AND OBJECTIVES: A department-wide opioid reduction education program resulted in a 1-month change in perceptions of opioid needs and prescribing recommendations for surgical oncology patients. This study's aim was to re-evaluate if early trends were retained 1 year later. METHODS: Surgical Oncology attendings, fellows, and advanced practice providers at a Comprehensive Cancer Center were surveyed 1-year after an August 2018 opioid reduction education program, to compare departmental and individual opioid prescribing habits. RESULTS: The September 2019 response rate was 54/93 (58%), with 41 completing both the post-education and 1-year follow-up surveys. The departmental and matched cohort continued to recommend a lower quantity of discharge opioids for all five index operations (by >50%) and expected less postoperative days to zero opioid needs, when compared to pre-education perceptions. Providers continued to agree that discharge opioid prescriptions should be based on a patient's last 24 hours of inpatient opioid use. There was universal agreement that each respondent's opioid administration had decreased in the past year. CONCLUSIONS: The initial 1-month improvements in perioperative opioid prescribing perceptions were retained 1 year later by Surgical Oncology providers who recommended fewer discharge opioids, faster weaning to zero opioids, and standardized patient-specific discharge opioid volume calculations.

Road to Perioperative Medicine: A Perspective From China.

With the development of anesthesiology, patient safety has been remarkably improved, but the postoperative mortality rate at 30 days is still as high as 0.56%-4%, and the morbidity is even higher. Three years ago, the Chinese Society of Anesthesiology proposed that the direction of the anesthesiology development should be changed to perioperative medicine in China. Anesthesiologists should pay more attention to the long-term outcome. In this article, we introduced what we have done, what the challenges are, and what we should do in the future with regard to the practice of perioperative medicine in China.

A basic anesthesia training program for nurses in Chad: first steps for a south-south academic cooperation program.

PURPOSE: Safe perioperative care remains a large public healthcare problem in low- and middle-income countries. Anesthesia care provided by trained professionals is one of the essential determinants to address this situation. This article reports the design and implementation of a focused anesthesia educational program for nurses in Chad. METHOD: This program consisted of four full-time courses of one month each, taught in a local hospital. The program included supervised practice in the operating room and post-anesthesia recovery room, skills lab simulation training, high fidelity crisis simulation, theoretical classes, integration sessions, evaluations, and structured feedback sessions. RESULTS: Seven male nurses, aged 28-40 yr, were accepted and successfully completed the program. The median [interquartile range] students' global satisfaction with the program was high (86 [85-93]%). Cognitive and skills assessment improved significantly after the program. Students subsequently worked in city and district hospitals performing essential and emergency surgical interventions. CONCLUSIONS: This is a novel south-south academic cooperation program for nurses in Chad. The program evaluation indicated a high level of satisfaction, effective cognitive and skills learning, and changes in clinical behaviour. Addressing the lack of adequate provision of anesthesia care is a task still to be faced, and this program depicts a bridge alternative until formal educational programs are implemented in the country.

RéSUMé: OBJECTIF: Des soins périopératoires sécuritaires demeurent un important problème de santé publique dans les pays à faible et à moyen revenu. Les soins anesthésiques offerts par des professionnels formés constituent l'un des éléments déterminants essentiels pour régler le problème. Cet article rapporte la conception et la mise en œuvre d'un programme spécialisé de formation en anesthésie s'adressant au personnel infirmier au Tchad. MéTHODE: Ce programme était composé de quatre cours intensifs d'une durée d'un mois chacun, donnés dans un hôpital local. Le programme comportait une pratique supervisée en salle d'opération et en salle de réveil, des séances pratiques en laboratoire de simulation, une simulation de crise haute fidélité, des classes théoriques, des séances d'intégration, des évaluations et des séances de rétroaction structurées. RéSULTATS: Sept infirmiers âgés de 28 à 40 ans ont été acceptés dans le programme et l'ont terminé avec succès. La satisfaction globale moyenne [écart interquartile] des étudiants était élevée (86 [85­93] %). L'évaluation cognitive et des connaissances s'est considérablement améliorée après avoir suivi le programme. Les étudiants ont par la suite travaillé dans des hôpitaux de ville et de district réalisant des interventions chirurgicales essentielles et urgentes. CONCLUSION: Il s'agit d'un programme de coopération universitaire sud-sud innovant au Tchad. L'évaluation du programme a indiqué un niveau élevé de satisfaction, un apprentissage efficace au niveau cognitif et des compétences, ainsi que des changements au niveau du comportement clinique. Il reste encore beaucoup de travail pour régler le problème suscité par l'absence d'une offre adéquate de soins anesthésiques, et ce programme décrit une alternative temporaire intéressante jusqu'à ce que des programmes de formation formels soient mis en œuvre dans ce pays.

Summative Objective Structured Clinical Examination Assessment at the End of Anesthesia Residency for Perioperative Ultrasound.

While standardized examinations and data from simulators and phantom models can assess knowledge and manual skills for ultrasound, an Objective Structured Clinical Examination (OSCE) could assess workflow understanding. We recruited 8 experts to develop an OSCE to assess workflow understanding in perioperative ultrasound. The experts used a binary grading system to score 19 graduating anesthesia residents at 6 stations. Overall average performance was 86.2%, and 3 stations had an acceptable internal reliability (Kuder-Richardson formula 20 coefficient >0.5). After refinement, this OSCE can be combined with standardized examinations and data from simulators and phantom models to assess proficiency in ultrasound.

A Foundation Programme educational placement in peri-operative medicine for older people: mixed methods evaluation.

We established an innovative Foundation placement in peri-operative medicine for older patients in response to the need for training in 'whole patient' medicine and the challenge of fewer Foundation doctors in acute surgical roles. The placement and underpinning curriculum were co-designed with junior doctors and other clinical stakeholders. This resulted in a modular design offering acute and community experience and dedicated quality improvement project time. To evaluate the placement we used a mixed methods study based on Kirkpatrick's model of workplace learning. Level 1 (trainee reaction) was evaluated using Job Evaluation Study Tool questionnaires and nominal group technique. Levels 2 and 3 (trainee learning/behaviour) were assessed using a Likert-style survey mapped to curriculum objectives, e-portfolio completion, nominal group technique and documentation of completed quality improvement projects and oral/poster presentations. Sixty-eight foundation trainees underwent the new placement. A similar-sized 'control' sample (n = 57) of surgical Foundation trainees within the same Trust was recruited. The trainees in the peri-operative placement attained both generic Foundation and specific peri-operative curriculum competencies, and gave higher job satisfaction scores than trainees in standard surgical placements. The top three ranked advantages from the nominal group sessions were senior support, clinical variety and project opportunities. Universal project completion resulted in high rates of poster and platform presentations, and in sustained service changes at hospital level.

Review of the enhanced recovery pathway for children: perioperative anesthetic considerations.

PURPOSE: Enhanced recovery after surgery (ERAS) pathways have been used for two decades to improve perioperative recovery in adults. Nevertheless, little is known about their effectiveness in children. The purpose of this review was to consider pediatric ERAS pathways, review the literature concerned with their potential benefit, and compare them with adult ERAS pathways. SOURCE: A PubMed literature search was performed for articles that included the terms enhanced recovery and/or fast track in the pediatric perioperative period. Pediatric patients included those from the neonatal period through teenagers and/or youths. PRINCIPAL FINDINGS: The literature search revealed a paucity of articles about pediatric ERAS. This lack of academic investigation is likely due in part to the delayed acceptance of ERAS in the pediatric surgical arena. Several pediatric studies examined individual components of adult-based ERAS pathways, but the overall study of a comprehensive multidisciplinary ERAS protocol in pediatric patients is lacking. CONCLUSION: Although adult ERAS pathways have been successful at reducing patient morbidity, the translation, creation, and utility of instituting pediatric ERAS pathways have yet to be realized.

Surgical safety checklist training: a national study of undergraduate medical and nursing student teaching, understanding and influencing factors.

INTRODUCTION: Use of the WHO surgical safety checklist is consistently recognised to reduce harm caused by human error during the perioperative period. Inconsistent engagement is considered to contribute to persistence of surgical Never Events in the National Health Service. Most medical and nursing graduates will join teams responsible for the perioperative care of patients, therefore appropriate undergraduate surgical safety training is needed. AIMS: To investigate UK medical and nursing undergraduate experience of the surgical safety checklist training. METHODS: An eight-item electronic questionnaire was distributed electronically to 32 medical schools and 72 nursing schools. Analysis was conducted for the two cohorts, and responses from final year students were included. RESULTS: 87/224 (38.8%) of medical students received teaching on the surgical safety checklist, compared with 380/711 (52.0%) of nursing students. 172/224 (76.8%) of medical students and 489/711 (66.9%) of nursing students understood its purpose and 8/224 (3.6%) medical students and 54/711 (7.4%) nursing students reported never being included in the Time Out. After adjusting for confounding factors, provision of formal teaching in checklist use increased understanding significantly (OR 50.39 (14.07 to 325.79, P<0.001)), as did routine student involvement in time outs (OR 5.72 (2.36 to 14.58, P<0.001)). DISCUSSION: Knowledge of perioperative patient safety systems and the ability to participate in safety protocols are important skills that should be formally taught at the undergraduate level. Results of this study show that UK undergraduate surgical safety checklist training does not meet the minimum standards set by the WHO.

Standard Setting for Clinical Performance of Basic Perioperative Transesophageal Echocardiography: Moving beyond the Written Test.

BACKGROUND: Credible methods for assessing competency in basic perioperative transesophageal echocardiography examinations have not been reported. The authors' objective was to demonstrate the collection of real-world basic perioperative transesophageal examination performance data and establish passing scores for each component of the basic perioperative transesophageal examination, as well as a global passing score for clinical performance of the basic perioperative transesophageal examination using the Angoff method. METHODS: National Board of Echocardiography (Raleigh, North Carolina) advanced perioperative transesophageal echocardiography-certified anesthesiologists (n = 7) served as subject matter experts for two Angoff standard-setting sessions. The first session was held before data analysis, and the second session for calibration of passing scores was held 9 months later. The performance of 12 anesthesiology residents was assessed via the new passing score grading system. RESULTS: The first standard-setting procedure resulted in a global passing score of 63 ± 13% on a basic perioperative transesophageal examination. The global passing score from the second standard-setting session was 73 ± 9%. Three hundred seventy-one basic perioperative transesophageal examinations from 12 anesthesiology residents were included in the analysis and used to guide the second standard-setting session. All residents scored higher than the global passing score from both standard-setting sessions. CONCLUSIONS: To the authors' knowledge, this is the first demonstration that the collection of real-world anesthesia resident basic perioperative transesophageal examination clinical performance data is possible and that automated grading for competency assessment is feasible. The authors' findings demonstrate at least minimal basic perioperative transesophageal examination clinical competency of the 12 residents.

[Significance of Multi-center Respiratory Surgery Perioperative Team Training Including Various Medical Staffs].

We report the development of a multi-center/multi- specialist perioperative team development training program about respiratory surgery. Participants were members of the team, including anesthesiologists, respiratory surgeons, and operation nurses. A ques- tionnaire survey was conducted prior to course partici- pation to clarify any questions team members had. The courses included a lecture and simulation training with scenario-based discussions or the use of a simulator. Scenarios included massive bleeding during pulmonary artery damage, intractable hypoxia during one lung ventilation, and severe hypotension accompanied with hypoxia after tracheal extubation. We also discussed the best method for preoperative smoking cessation for better surgery outcome. After each course, participants discussed problems associated with perioperative medi- cal safety of respiratory surgery in the context of each theme. Simulation-based perioperative team training with anesthesiologists, respiratory surgeons, and opera- tion nurses may serve as a vehicle to promote periop- erative obstetrics safety.

The Perioperative Educational Program for Improving Upper Arm Dysfunction in Patients with Breast Cancer at 1-Year Follow-Up: A Prospective, Controlled Trial.

The many women with breast cancer who underwent axillary lymph node dissection (ALND) suffer from the upper arm dysfunction. In this study, we investigated the effectiveness of a perioperative educational program for improving upper arm dysfunction in breast cancer patients following ALND. This study was a sub-analysis of a previous controlled trial with an educational program. The subjects of this analysis included 64 patients following ALND who completed measurements at 12 months. The perioperative educational program consisted of monitoring of arm dysfunction, exercises, massage, and lifestyle adjustments. The intervention group (37 patients) received this perioperative educational program over 12 months, while 27 patients in the control group received written information about shoulder exercise from on-site staff only before surgery. Primary outcomes were shoulder range of motion (ROM), arm girth, and grip strength. Secondary outcomes were evaluated with the Subjective Perception of Post-Operative Functional Impairment of the Arm (SPOFIA) scores, the Disabilities of the Arm, Shoulder and Hand (DASH) scores, and the Medical Outcome Study 36-Item Short-Form Health Survey v2 (SF-36v2). The SF-36v2 measures health-related quality of life (QOL). Primary and secondary outcomes were compared between groups at 1 week (after drainage tube removal) and 12 months after surgery, using the Mann-Whitney U test. The horizontal extension was significantly improved only in the intervention group. Moreover, the SPOFIA score was significantly improved in the intervention group, and other scores of the secondary outcomes were similar between the two groups. The perioperative educational program may improve postoperative upper arm dysfunction and symptoms.

The future of anesthesiology: implications of the changing healthcare environment.

PURPOSE OF REVIEW: Anesthesiology is at a crossroad, particularly in the USA. We explore the changing and future roles for anesthesiologists, including the implication of new models of care such as the perioperative surgical home, changes in payment methodology, and the impact other refinements in healthcare delivery will have on practice opportunities and training requirements for anesthesiologists. RECENT FINDINGS: The advances in the practice of anesthesiology are having a significant impact on patient care, allowing a more diverse and complex patient population to benefit from the knowledge, skills and expertise of anesthesiologists. Expanded clinical opportunities, increased utilization of technology and expansion in telemedicine will provide the foundation to care for more patients in diverse settings and to better monitor patients remotely while ensuring immediate intervention as needed. Although the roles of anesthesiologists have been diverse, the scope of practice varies from one country to another. The changing healthcare needs in the USA in particular are creating new opportunities for American anesthesiologists to define expanded roles in healthcare delivery. To fulfill these evolving needs of patients and health systems, resident training, ongoing education and methods to ensure continued competency must incorporate new approaches of education and continued certification to ensure that each anesthesiologist has the full breadth and depth of clinical skills needed to support patient and health system needs. SUMMARY: The scope of anesthesia practice has expanded globally, providing anesthesiologists, particularly those in the USA, with unique new opportunities to assume a broader role in perioperative care of surgical patients.

Impact assessment of perioperative point-of-care ultrasound training on anesthesiology residents.

BACKGROUND: The perioperative surgical home model highlights the need for trainees to include modalities that are focused on the entire perioperative experience. The focus of this study was to design, introduce, and evaluate the integration of a whole-body point-of-care (POC) ultrasound curriculum (Focused periOperative Risk Evaluation Sonography Involving Gastroabdominal Hemodynamic and Transthoracic ultrasound) into residency training. METHODS: For 2 yr, anesthesiology residents (n = 42) received lectures using a model/simulation design and half were also randomly assigned to receive pathology assessment training. Posttraining performance was assessed through Kirkpatrick levels 1 to 4 outcomes based on the resident satisfaction surveys, multiple-choice tests, pathologic image evaluation, human model testing, and assessment of clinical impact via review of clinical examination data. RESULTS: Evaluation of the curriculum demonstrated high satisfaction scores (n = 30), improved content test scores (n = 37) for all tested categories (48 ± 16 to 69 ± 17%, P < 0.002), and improvement on human model examinations. Residents randomized to receive pathology training (n = 18) also showed higher scores compared with those who did not (n = 19) (9.1 ± 2.5 vs. 17.4 ± 3.1, P < 0.05). Clinical examinations performed in the organization after the study (n = 224) showed that POC ultrasound affected clinical management at a rate of 76% and detected new pathology at a rate of 31%. CONCLUSIONS: Results suggest that a whole-body POC ultrasound curriculum can be effectively taught to anesthesiology residents and that this training may provide clinical benefit. These results should be evaluated within the context of the perioperative surgical home.

Enhanced recovery simulation in colorectal surgery: design of virtual online patients.

BACKGROUND: The aim of the present study was to design virtual patients (VP) involving enhanced recovery programs (ERP) in colorectal surgery, in order to train surgical residents in peri-operative care. Indeed, ERP have changed perioperative care and improved patients outcomes in colorectal surgery. Training, using online VP with different pre- and post-operative cases, may increase implementation of ERP. METHODS: Pre- and post-operative cases were built in the virtual world of Second Life™ according to a linear string design method. All pre- and post-operative cases were storyboarded by a colorectal surgeon in accordance with guidelines in both ERP and colorectal surgery, and reviewed by an expert in colorectal surgery. RESULTS: Four pre-operative and five post-operative cases of VP undergoing colorectal surgery were designed, including both simple and complex cases. Comments were provided through case progression to allow autonomic practice (such as "prescribed", "this is not useful" or "the consultant does not agree with your decision"). Pre-operative cases involved knowledge in colorectal diseases and ERP such as pre-operative counseling, medical review, absence of bowel preparation in colonic surgery, absence of fasting, minimal length incision, and discharge plan. Post-operative cases involved uneventful and complicated outcomes in order to train in both simple implementation of ERP (absence of nasogastric tube, epidural analgesia, early use of oral analgesia, perioperative nutrition, early mobilization) and decision making for more complex cases. CONCLUSION: Virtual colorectal patients have been developed to train in ERP through pre- and post-operative cases. Such patients could be included in a whole pathway care training involving technical and non-technical skills.