Anesthesia Crisis Resource Management Research Articles

A prospective randomized comparative study of effectiveness of simulation-based training in improving the performance of non-technical skill among postgraduate students during anaesthesia crisis resource management

Background Non-technical skills are pivotal in ensuring patient safety during anaesthesia crisis resource management. Simulation-based training has emerged as a promising educational approach for enhancing these skills. This study protocol outlines a prospective randomised comparative study aimed at assessing the impact of simulation-based training on the performance of anaesthesia residents during anaesthesia crisis resource management, with a focus on task management, teamwork, situational awareness, and decision-making skills, using the Assessment of Non-Technical Skills (ANTS) scoring system. Methods Anesthesia residents in postgraduate years 1 and 2 from the Department of Anesthesia at Acharya Vinoba Bhave Rural Hospital will be included as study participants. Informed consent will be obtained, and no exclusion criteria will be applied. Participants will undergo an orientation session covering essential crisis management and simulation knowledge. The study will employ advanced simulation equipment, including a Human Patient Simulator (HPS) mannequin, an anaesthesia machine, and a simulated operating room. Faculty members have selected six distinct perioperative emergency scenarios for simulation sessions. Participants will be grouped in pairs and exposed to three scenarios during each session. Debriefing and feedback will follow each scenario, reinforcing non-technical skills. Experienced staff anesthesiologists, trained in the Assessment of Non-Technical Skills (ANTS) scoring system, will serve as assessors to evaluate participant performance. Expected outcomes Data collected will include ANTS scores, debriefing feedback, and post-test results. Statistical analysis will be employed to assess the effectiveness of simulation-based training in enhancing non-technical skills among anaesthesia residents during anaesthesia crisis resource management.

Clinical triggers and vital signs influencing crisis acknowledgment and calls for help by anesthesiologists: A simulation-based observational study

Study objectiveIn a perioperative emergency, anesthesiologists must acknowledge the unfolding crisis promptly, call for timely assistance, and avert patient harm. We aimed to identify vital signs and qualitative factors prompting crisis acknowledgment and to compare responses between observers and participants in simulation. DesignProspective, simulation-based, observational study. SettingAn anesthesia crisis resource management course at a freestanding simulation center. SubjectsSixty attending anesthesiologists from a variety of practice settings. InterventionsIn each case, a primary anesthesiologist in charge (PAIC) managed a simulated patient undergoing a uniformly scripted sequence of perioperative anaphylaxis and called for help from another anesthesiologist when a crisis began. Anesthesiologist observers (AOs) viewed the case separately and recorded times of crisis onset. MeasurementsSimulation footage was reviewed by investigators for patient vital signs and participant behaviors at times of crisis acknowledgment, with the call for help as an explicit proxy for PAIC crisis acknowledgment. These factors were categorized, and group-level data were compared. ResultsNineteen PAICs and 41 AOs were included. Clinicians acknowledged crises around a mean arterial pressure (MAP) of 65 mmHg and oxygen saturation of 94% as anaphylactic shock progressed. PAICs acknowledged crises at a higher respiratory rate than AOs (20 vs. 18 breaths/min, p = 0.038). Other vitals and timing of crisis acknowledgment did not differ between PAICs and AOs. Nearly half of all participants (45%) identified crises at MAP <65 mmHg. Timing of crisis acknowledgment varied widely (range: 421 s). ConclusionsDespite overall heterogeneity in clinical performance, anesthesiologists acknowledged crises per standard definitions of hypotension. Thresholds for crisis acknowledgment did not significantly differ between PAICs and AOs, suggesting minimal effect from active care responsibility. Many indicated crises at MAP <65 mmHg or after significant deterioration, risking failure-to-rescue events. We suggest that crisis management instruction should address triggers for requesting help.

Factors influencing anesthesiologistsperceived usefulness of ACRM (Anaesthesia Crisis Resources Management) key points after a combined ACLS (AHA)-ACRM similation training

Background: The factors that may contribute to learners’ perception about the usefulness of Anaesthesia Crisis Resource Management (ACRM) key points are little known. Objectives: We investigated the link between demographic factors and the effect of an ACRM simulation training on anaesthesiologists’ perceived value of ACRM key points. Design: A prospective pre- and post-test survey from December 2017 to December 2019 of 111 anaesthesiologists involved into a combined ACRM-ACLS course in a simulation centre. Methods: Before and after the course participants were asked to indicate which were, in their opinion, the 5 ACRM key points most relevant for managing an anaesthetic emergency. No taxonomy tool of the 15 ACRM key points was used for teaching purposes. Main outcome measures: Pre-/post-course differences in participants’ subjective choices were connected by logistic regression analysis with demographic factors which included age, gender, years of work as anaesthesiologist, the amount of updating exposure, and familiarity with ACRM. Results: In median participants (47 M/64 F) had an age of 42 years (IQR 34-55 years), and 10 years working experience as anaesthesiologists (IQR 4-20 years). Around 20% of them had never heard of ACRM prior to this course. Communication was selected by up to 75% of participants without pre-/post-course differences. Although the other 4 ACRM points remained heterogeneously selected even after the course, we observed post-course vs pre-course increase in the selection rate of the ACRM points that address leadership, correct distribution of workload and utilization of all available resources. Among participants’ characteristics, the lack of familiarity with ACRM was the only significant predictor of the number of pre- to post-course changes in ACRM key points selection (OR=3.03, CI 95% 1.04 -9.09; p=0.0418). Conclusions: The familiarity with ACRM should be considered when planning ACRM training, especially in cases where the ACRM training is not yet part of a formal education in anaesthesia.

HISTORICAL SELECTION: Rosenberg MB. Simulation technology in anesthesiology. Anesth Prog. 2000;47(1):8-11.

HISTORICAL SELECTION: Rosenberg MB. Simulation technology in anesthesiology. Anesth Prog. 2000;47(1):8-11.

Simulation Technology in Anesthesiology.

Simulation Technology in Anesthesiology.

Board 245 - Program Innovations Abstract Anesthesia Crisis Resource Management (ACRM)- Integration of Clinical Simulation Training Program for Specialists in Anesthesiology. Universidad Mayor, Santiago, Chile (Submission #373)

Board 245 - Program Innovations Abstract Anesthesia Crisis Resource Management (ACRM)- Integration of Clinical Simulation Training Program for Specialists in Anesthesiology. Universidad Mayor, Santiago, Chile (Submission #373)

Board 356 - Research Abstract The Magic of the Inquiry

Introduction/Background A core element of simulation-based trainings is the debriefing after the simulation scenario.1 Yet, evidence as to how such debriefings should be guided by the instructor so that trainees benefit most effectively is just beginning to emerge.2 In particular, indepth analyses of the functions of different interventions of the debriefers are rare.3 Understanding what debriefers actually do during debriefings and how these actions might impact the learner’sreflections could help debriefers facilitate effectively and simulation faculty development programs target debriefing techniques more accurately. Methods We videotaped and qualitatively analyzed seven 45-60 minute debriefings conducted during Anesthesia Crisis Resource Management Courses. Debriefers and learners communications were coded independently. Debriefers statements and inquiries were coded based on current debriefing concepts (e.g., regarding type of advocacy, type of inquiry).1,4 Learners reactions were coded based on Gibbs reflective cycle.3,5 Results Forty two anesthesia residents and nurses and three debriefers participated. We found that debriefers asked various types of questions (e.g., regarding emotions, cognitions, ideas, circular), stated a variety of advocacies (e.g., observations, ’pseudo-observations’ [e.g., “Here you were thinking that …”], opinions, appreciations) and used further intervention techniques such as previewing, paraphrasing, medical and psychological input. Overall, the amount of inquiries was twice as low than the amount of other communication types. We also found that learners communications consisted mostly of descriptions, explanations and Conclusions whereas indepth reflections such as mental models were rare. Performing a lag sequential analysis - a method for analyzing temporal patterns in sequentially coded interactions to detect whether behavior sequences emerge above chance, we analyzed what types of debriefer communications were followed by learners revealing mental models.6 We found that learners revealed mental models after the debriefers asked for ideas (Z=3.59; p < 0.001), made implicit suggestions (e.g., “So, here you were not sure what to do, right?”) (Z= 2.13; p < 0.05), asked a systemic questions (e.g., “What would you have needed from here to speak up?”) (Z=3.59; p < 0.001), and paraphrased learners statements (Z=3.17; p < 0.001). Other types of debriefer interventions did not elicit learners’ mental models. Conclusion We found that debriefers used a broad spectrum of micro-level debriefing techniques but that only some of them elicited the revealing of mental models by learners. This is an important finding as it provides ideas on how to detect and address learners mental models more efficiently during the debriefing. We also found that debriefers used more ’telling’ than ’inquiring’. Further research should investigate the optimal balance of these two very different kinds of communication.7

Pediatric Anesthesiology 2013 Meeting Review

Pediatric Anesthesiology 2013 Meeting Review

Measuring the Effects of Team Resource Management Training for the Fire Service

Applications of Crew Resource Management training outside of the aviation industry, such as in anesthesia (crisis resource management) or the fire service (team resource management, TRM) are becoming increasingly popular. However, the effectiveness of such training and its suitability for the different target groups is seldom evaluated. In this study, TRM training for a German fire service was developed based on a needs assessment and instructional design theory. Fifty-nine firefighters participated in this study and received a half-day training intervention. The TRM training itself was evaluated and its impact on knowledge acquisition and attitude changes was measured at three different measurement times, before the training (T0), directly after the training (T1) and seven months later (T2). The TRM training was judged as enjoyable and useful and the participants stated a positive knowledge acquisition. Results regarding the declarative knowledge showed a significant knowledge acquisition from T0 to T1 and a significant decrease in knowledge seven months later; nevertheless, the participants still had significantly more knowledge at T2 than before the training. For three of the seven measured teamwork-relevant attitudes, significant positive changes from T0 to T1 could be demonstrated and the attitude changes remained stable over seven months. Further research is needed to investigate the application of TRM in different professions and also the effectiveness of recurrent training in these fields.

High-Fidelity Simulation—Emergency Medicine

igh-fidelity simulation (HFS) has become an essential tool for training any health care providers in virtually every field of medicine. The rimary benefit of using HFS as an educational and evaluative tool is that earners can practice medical decision-making and procedural skills on imulated patients in an environment where the risk of error will not harm n actual patient. These technologies and the educational constructs esigned around their use were developed to practice skills without ncurring risk. Medicine followed precedents set by model high reliability rganizations such the military with its war games exercises, the aeropace industry with flight training of pilots and astronauts, and the nuclear ower industry to train personnel to deal effectively and resiliently in rises situations. Bridging the gap between other industries and mediine, Gaba and DeAnda pioneered the use of simulation in anesthesia to rain anesthesiologists. Their report described the creation of a compreensive anesthesia simulation environment that re-created an operating oom. Appropriate monitoring equipment was included as was a realistic ntubation/thorax mannequin, which allowed for the formulation of ealistic problems within the operating room. Built on Gaba’s work in the 1980s, the subspecialty of anesthesia was he first to adopt it as an educational tool within the field of medicine. he first study regarding training in emergency medicine occurred in 999 and emphasized airway training. This advanced airway course used imulation to teach rapid sequence intubation skills as well as how to anage problems during rapid sequence intubation. The idea of using HFS to limit human error and improve safety was nitially introduced by the airlines and National Aeronautics and Space dministration as a Crew Resource Management (CRM) Curriculum. It as then used to create an Anesthesia Crisis Resource Management

Crisis Resource Management of the Airway in a Patient with Klippel-Feil Syndrome, Congenital Deafness, and Aortic Dissection

Klippel-Feil syndrome is a visually arresting deformity wherein severe restriction of cervical motion predicts a difficult airway. Even minor distraction of the neck risks cervical spine or neurologic injury, so regional techniques, awake fiberoptic intubation, or awake tracheostomy are recommended anesthetic approaches. We present a case of aortic dissection in a Klippel-Feil syndrome patient for whom congenital bilateral deafness, coupled with the urgency of the surgery, mitigated against the recommended first-choice techniques. Using anesthesia crisis resource management methods, a multi-member team rehearsed predefined roles and then managed the airway via inhaled induction of anesthesia, followed by flexible fiberoptic intubation.

Simulation-based education in Canada: will anesthesia lead in the future?

It is remarkable that 40 years have elapsed since Denson and Abrahamson first introduced high fidelity simulation (Sim One) to facilitate the teaching of endotracheal intubation and the induction of anesthesia. The concept of utilizing a simulator for clinical training was far ahead of its time and not immediately embraced by anesthesiologists or other educators. Simulation technology for medical education underwent a revival in the mid-1980s when computer-generated screen based simulation programs made their appearance, focusing primarily on pharmacology and physiology applications relevant to anesthesia. The anesthesiologist could choose one of many scenarios that might be encountered by a clinical anesthesiologist. These programs allowed the learner to interpret information and make pharmacological and therapeutic decisions. Such simulators were novel and afforded a meaningful learning experience, especially for novice learners; however, they did not duplicate the application of practical skills and knowledge in a clinical environment in real time. In 1986, Gaba et al. at Stanford University developed a full-scale, high fidelity simulator (‘‘The Comprehensive Anesthesia Simulation Environment [CASE]’’) which allowed the anesthesiologist to manage critical situations. With Jeff Cooper in Boston, they developed an organized program called ‘‘Anesthesia Crisis Resource Management’’ (ACRM), applying principles from the airline industry where pilots and airline crew use ‘‘Crew Resource Management’’ programs to elicit human responses in a realistic environment. The objective of ACRM is to teach participants the importance of non-technical skills such as team working, task management, decision-making and situation awareness, focusing on communication and leadership skills. In the late 90s, several simulation centres appeared in Canada, led by anesthesiologists, to allow learners to practice difficult and rare scenarios without placing patients at risk. Today, simulation centres have been developed in over 50 centres across Canada, including many community colleges, in addition to hospitals and universities. In spite of the exponential growth of simulation, many professions and disciplines have been slow to recognize that simulationbased education is more than a teaching tool—it is a novel form of ‘‘experiential education’’, with which non-technical skills required in professional practice can be learned. Educators know that these are difficult (if not impossible) to teach in the clinical environment. Most Canadian academic departments of anesthesia have been progressive in integrating simulation into the undergraduate and/or postgraduate curricula. Undergraduate medical students who are given time in an anesthesia simulator, enthusiastically compete with each other to manage the airway, and pharmacologically treat simple hemodynamic problems. It is often their first opportunity to independently treat a ‘‘patient problem’’ and the majority find it very enjoyable and a great learning experience. At the postgraduate level, simulators are used to teach firstyear residents how to ‘‘troubleshoot’’ the anesthesia gas machine through clinically relevant scenarios, and manage common intraoperative anesthetic problems. Postgraduate years 2–5 often spend at least two, three-hour sessions each year in the simulation center. They usually share this experience in a small group and are usually not in the same R. J. Byrick, MD (&) V. N. Naik, MD Department of Anesthesia, St. Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada e-mail: robert.byrick@utoronto.ca

Excellence in Anesthesiology

Excellence in Anesthesiology

Use of High Fidelity Operating Room Simulation to Assess and Teach Communication, Teamwork and Laparoscopic Skills: Initial Experience

Structured opportunities for learning communication, teamwork and laparoscopic principles are limited for urology residents. We evaluated and taught teamwork, communication and laparoscopic skills to urology residents in a simulated operating room. Scenarios related to laparoscopy (insufflator failure, carbon dioxide embolism) were developed using mannequins, urology residents and nurses. These scenarios were developed based on Accreditation Council for Graduate Medical Education core competencies and performed in a simulation center. Between the pretest scenario (insufflation failure) and the posttest scenario (carbon dioxide embolism) instruction was given on teamwork, communication and laparoscopic skills. A total of 19 urology residents participated in the training that involved participation in at least 2 scenarios. Performance was evaluated using validated teamwork instruments, questionnaires and videotape analysis. Significant improvement was noted on validated teamwork instruments between scenarios based on resident (pretest 24, posttest 27, p = 0.01) and expert (pretest 16, posttest 25, p = 0.008) evaluation. Increased teamwork and team performance were also noted between scenarios on videotape analysis with significant improvement for adherence to best practice (p = 0.01) and maintenance of positive rapport among team members (p = 0.02). Significant improvement in the setup of the laparoscopic procedure was observed (p = 0.01). Favorable face and content validity was noted for both scenarios. Teamwork, intraoperative communication and laparoscopic skills of urology residents improved during the high fidelity simulation course. Face and content validity of the individual sessions was favorable. In this study high fidelity simulation was effective for assessing and teaching Accreditation Council for Graduate Medical Education core competencies related to intraoperative communication, teamwork and laparoscopic skills.

Anesthesiologist Management of Perioperative Do-Not-Resuscitate Orders: A Simulation-Based Experiment

This study was performed to assess perioperative reevaluation of Do-Not-Resuscitate (DNR) orders by practicing anesthesiologists. As part of an Anesthesia Crisis Resource Management course, an anesthesiologist interviewed a patient-actor with prostate cancer and bone metastases scheduled for a central venous catheter placement. The chart included a properly documented DNR order and the patient-actor's scripted responses emphasized that he would accept resuscitative efforts only "if the adverse clinical events were believed to be both temporary and reversible." Later, the subject assumed responsibility for the anesthesia in which the patient subsequently developed an iatrogenically induced pneumothorax, became apneic, and had a cardiovascular arrest requiring a prolonged resuscitation. Responses to these events and a following survey were evaluated. Fifty-seven percent of the subjects (17/30) addressed resuscitation during the preoperative interview; 27% (8/30) decided to suspend the DNR order and 30% (9/30) instituted a goal-directed or procedure-directed DNR order. Ninety percent (27/30) of the groups chose to continue resuscitative efforts until the simulation ended. Of the surveyed participants, over 90% would place a chest tube, intubate the trachea, do chest compressions, and perform cardiac defibrillation. Common reasons for intervening were reversibility, iatrogenicity, and that intervention would be consistent with the patient's goals. Inadequacies in perioperative reevaluation of DNR orders existed at all stages. Simulation of perioperative DNR orders is a useful way to elicit anesthesiologist's actions in the heat of the moment, which may bring us closer to understanding the actions of anesthesiologists during clinical practice.

Differences in Safety Climate Among Hospital Anesthesia Departments and the Effect of a Realistic Simulation-Based Training Program

Safety climate is often measured via surveys to identify appropriate patient safety interventions. The introduction of an insurance premium incentive for simulation-based anesthesia crisis resource management (CRM) training motivated our naturalistic experiment to compare the safety climates of several departments and to assess the impact of the training. We administered a 59-item survey to anesthesia providers in six academic anesthesia programs (Phase 1). Faculty in four of the programs subsequently participated in a CRM program using simulation. The survey was readministered 3 yr later (Phase 2). Factor analysis was used to create scales regarding common safety themes. Positive safety climate (% of respondents with positive safety attitudes) was computed for the scales to indicate the safety climate levels. The usable response rate was 44% (309/708) and 38% (293/772) in Phases 1 and 2 respectively. There was wide variation in response rates among hospitals and providers. Eight scales were identified. There were significantly different climate scores among hospitals but no difference between the trained and untrained cohorts. The positive safety climate scores varied from 6% to 94% on specific survey questions. Faculty and residents had significantly different perceptions of the degree to which residents are debriefed about their difficult clinical situations. Safety climate indicators can vary substantially among anesthesia practice groups. Scale scores and responses to specific questions can suggest practices for improvement. Overall safety climate is probably not a good criterion for assessing the impact of simulation-based CRM training. Training alone was insufficient to alter engrained behaviors in the absence of further reinforcing actions.

The Use of Simulation Education in Competency Assessment: More Questions than Answers

Stanford University School of Medicine, Stanford, California. edlera@stanford.eduWith great interest many anesthesia educators have read three manuscripts in previous issues of Anesthesiology. Morgan, a well-known and respected researcher in simulation education, and her coauthors presented a thoughtful description of the use of simulation in the evaluation of teamwork in obstetrical practice.1However, in light of their conclusions that the “study does not support the use of Human Factors Rating Scale for assessment of obstetrical teams” and recommended limited use of the Global Rating Scale, taken along with Murray and Enarson’s reflective editorial2on the difficulties of teamwork and communication skills assessment, I fear that some anesthesia educators might be tempted to throw the newly born discipline of “simulation based assessment” out with the proverbial bathwater.Morgan et al. ’s investigation1raises several issues that need to be addressed in light of our urgent need to develop authentic teaching and assessment of clinical competency in anesthesiology.3The most pressing is our need for reliable and valid performance assessment tools used in anesthesia education, training, and practice.Morgan et al. found the Human Factors Rating Scale and Global Rating Scale assessment tools of limited reliability in the obstetrical setting; however, they do not further examine the sources of variance in the reliability other than from the raters themselves. Although the number of raters, the number of items, and the occasions of testing seem to be sufficient, we have no definitive analysis of this. Classic Test Theory and the use of interrater reliability and inter- and intraclass correlations for diagnosis of measurement error does not provide a view of the relative importance or interactions of these and other variances sources. Modern Test Theory, specifically Generalizability Theory, provides an analysis of multiple sources of variance and determination of optimal sampling not only for raters but also for subjects, items, and occasions of testing.4–6In this investigation,1the nonconcordance of the correlations of both Human Factors Rating Scale and Global Rating Scale suggest that something else is going on here. It could be the result of nonparallel scenarios, lack of rater training, or (more significantly), faulty construct validity of the Human Factors Rating Scale and Global Rating Scale for the anesthesia Crisis Resource Management trait. However, we do not know from this report.On reviewing of the original development of the Human Factors Rating Scale7and its 2000 revision, we still do not have formal psychometric analysis of its construct validity and factor status “due to limited sample size.”8Although its authors claim that the items cluster around “team roles, authority/command structure, stress recognition and organizational climate,”8these highly complex behaviors warrant more formal factor analysis before general use. We as anesthesiologists would not use a new clinical test without knowing the measure of its specificity and sensitivity; we should be equally rigorous with the degree of validity and reliability in high-stakes testing and use of resource-intense instruction. Modern Test Theory offers many advantages necessary for the authentic assessment of complex cognitive, technical, and behaviors skills in simulation-based education and performance assessment.9Stanford University School of Medicine, Stanford, California. edlera@stanford.edu

Durability of Non-Technical Skills Following Crisis Resource Management Training.

BACKGROUND: Non-technical skills, such as task management, team working, situation awareness and decision making, are vital to anesthesia crisis resource management.(1) These skills are often taught using a high fidelity patient simulator. Previous studies have demonstrated improvement in non-technical skills following a debriefing of a simulated crisis, and sustained skills two months after the training session. This same study showed these skills are not learned through clinical duties exclusively.(2) We conducted this study to examine the durability of teaching non-technical skills over time. METHODS: After institutional ethics approval, 8 junior anesthesia residents were recruited as subjects. Each had one individual debriefing of their management of a crisis prior to a pre-test. The pre-test was the management of a simulated intraoperative cardiopulmonary arrest, followed by a videotape-assisted debriefing focused on their non-technical skills. No subjects participated in a simulator session for eight months. Eight months after their pre-test, each subject returned to manage a post-test, consisting of the management of a similar intraoperative cardiopulmonary arrest. Videotaped performances were reviewed by two expert blinded independent assessors who rated each subject’s non-technical skills, using a previously validated and reliable marking system.(1) RESULTS: A significant improvement in non-technical skills was observed eight months after a simulated crisis resource management training session (p<0.001)(see Figure).FigureCONCLUSIONS: Not only are measurements of residents’ non-technical skills sustained with respect to simulated crisis management eight months following a training session - they are improved. Residents’ reflection on their simulated crisis experience and debriefing may have lead to improvement. Improvement may also be secondary to non-technical skills that were practiced clinically, after simulator sessions. Educators should be reassured that the non-technical skills learned during simulated crisis management training sessions are durable.

A national collaborative simulation project: paediatric anaesthetic emergencies

In collaboration with nine simulation centres in the United Kingdom, we are developing a national core skills paediatric simulation course for specialist registrars (SpRs) during their paediatric anaesthetic training module. The Royal College of Anaesthetists (RCA) states: ‘(trainees should have) strategies and practice for the management of anaesthetic emergencies in children: loss of airway, laryngospasm, failed venous access, suxamethonium apnoea and anaphylaxis including latex allergy’ (1). This is unlikely due to the limited time SpRs spend in paediatric anaesthesia, the time constraints of the European working time directive and the centralisation of paediatric services. Paediatric simulators may provide this exposure in a short time frame. High fidelity patient simulators are computer driven mannequins that mimic the anatomy, physiology and pharmacology of a vast number of different patients and pathological states. Any intervention by the learner, leads to real‐time interactive changes in the patient/simulator condition. This includes airway manipulation, airway instrumentation, ventilation strategies, delivery of anaesthetic gases and delivery of intravenous fluids and drugs. In the aviation industry simulator training has enhancedsafety (2); whether simulator training in medicine improves clinical performance or patient safety has yet to be proven. What is known is that simulator training improves confidence and performance when dealing with a simulated scenario for the second time and healthcare workers find simulator training both useful and enjoyable (3–6). After ethical approval the first stage of this project involved development of five evidence based peer reviewed scenarios. An extensive literature review for each scenario was completed. Evidence based management guidelines for each of the emergencies were drawn up. After some iteration the scenarios and guidelines were endorsed by the participating centres. The next stage involves programming the simulators and planning the content and structure of the course. A pilot course will be run at one simulation centre to assess validity of the emergency scenarios.Conclusions: This is the first time a national collaborative simulator project has been undertaken in the UK. It may be extremely useful in training for emergencies in paediatric anaesthesia. It is a model that could be adapted for simulator training in other specialities in medicine.References 1 Royal College of Anaesthetists. The CCST in Anaesthesia III. 2nded. London: RCA, 2003: 27.2 Robert L Helmreich. On error management: lessons from aviation. BMJ 2000; 320: 781–785 (Education and debate).3 Riley RH, Wilks DH, Freeman JA. Anaesthetists’ attitudes towards an anaesthesia simulator. A comparative study: U.S.A. and Australia. Anaesth Intensive Care 1997; 25: 514–519.4 Kurrek MM, Fish KJ. Anaesthesia crisis resource management training: an intimidating concept, a rewarding experience. Can J Anaesth 1996; 43: 430–434.5 Cleave‐Hogg D, Morgan PJ. Experimental learning in anaesthesia simulation centre: analysis of students’ comments. Med Teach 2002; 24: 23–26.6 Chopra V et al. Does training on an anaesthesia simulator lead to an improvement in performance? Br J Anaesth 1994; 73: 293–297.

The Value of Simulation Training during Anesthesia Residency

Stanford University School of Medicine, Stanford, California. geoffl@stanford.eduIt is hard to measure the intangibles of skilled anesthesia management such as leadership, planning, and dynamic problem solving, let alone to link them unequivocally to specific patient outcomes. Although simulation training has been advanced as a method to help develop crisis management and other “nontechnical” skills, proof of this link is currently incomplete.1–3However, a recent example may highlight the value of simulation training during anesthesia residency with respect to these issues. On a recent international medical trip, the operating room's sole oxygen supply, an H-cylinder, was accidentally knocked over, severely damaging its regulator and causing a high-pressure leak necessitating its immediate removal. Because oxygen was the only gas supplied to the anesthesia machine, all fresh gas flow to the anesthetized and paralyzed patient ceased, and the oxygen supply alarm sounded.Options at this point included (1) hand ventilation through the circuit (taking advantage of a functional carbon dioxide–absorbing system), but diluting the alveolar anesthetic level and risking wastage of oxygen through small leaks in the circuit, or (2) apneic oxygenation from a quiescent circuit. The latter was chosen, because it would be the means most likely to maintain alveolar anesthetic and oxygen levels while freeing hands to prepare for an intravenous anesthetic. Accordingly, further ventilation was temporarily suspended, and the sidestream carbon dioxide sampling line was disconnected and capped (so as not to waste oxygen from the circuit). Fortunately, a pulse oximeter was available.The personnel management of this situation focused on dispatching others to obtain a self-inflating ventilation bag from the recovery room (the one and only such device in the entire hospital) and making preparations for an intravenous anesthetic, while seeking a replacement for the damaged oxygen pressure regulator. In this particular event, the patient experienced 6–7 min of apnea and remained anesthetized while maintaining oxyhemoglobin saturations of 100%.When faced with an oxygen supply loss, the near explosion of an unsecured cylinder, and a loud alarm, one's first instinct may be to vigorously ventilate the patient. However, by closing the pressure relief valve and discontinuing sidestream carbon dioxide analysis, one can ensure a 4- to 15-min oxygen supply (depending on fraction of inspired oxygen, functional residual capacity, and patient metabolism). It is not clear how long it would have taken to sort through these options from first principles under these difficult conditions without previous exposure to a similar problem during a crisis simulation course in residency (Anesthesia Crisis Resource Management, Stanford University School of Medicine, Stanford, California).4–6In this course, trainees manage both common and novel operating room complications, allowing them to develop templates for technical and behavioral responses to such situations. The use of high-fidelity human patient simulators and recreated operating room environments in courses such as this capture both the stress and the immediacy of real patient emergencies and, ideally, provide the first exposure to plausible catastrophes in a setting where no patients' lives are at risk. When a potentially catastrophic oxygen supply failure arose in real life, its management seemed relatively routine because, virtually speaking, I'd been there before.Stanford University School of Medicine, Stanford, California. geoffl@stanford.edu