Anesthesia Crisis Resource Management Research Articles

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

This Month in Anesthesiology

This Month in Anesthesiology

A Method for Measuring the Effectiveness of Simulation-Based Team Training for Improving Communication Skills

Team behavior and coordination, particularly communication or team information-sharing, are critical for optimizing team performance; research in medicine generally provides no accepted method for measurement of team information-sharing. In a controlled simulator setting, we developed a technique for placing clinical information (probes) with members of a team of trainees participating in a 1-day Anesthesia Crisis Resource Management course and later tested the teams for knowledge of the probes as an indicator of overall team information-sharing. Despite the low level of team information-sharing, we demonstrated construct validity of the probe methodology by the correlation of measured change in team information-sharing from beginning to end of training with self-rated change. There was no statistical difference in "group sharing" from beginning to end of training, despite trainees' survey responses that the course would be useful for their education and practice.

Crises Management in Anesthesiology

Every now and then, one comes across a book that tackles a particular subject in a rather special way. This is what I found with this 300-page softcover book. It is unique because it covers the basic principles of how anyone involved in the practice of anesthesia should approach one of the most challenging and important tasks: managing critical events. This book is written for everyone who administers anesthesia, from the experienced practitioner to those who are beginning their training. The first section, “Basic Principles of Crisis Management in Anesthesiology,” is particularly distinct because it focuses on the mind of the anesthesia provider and analyzes his or her expertise in terms of its component parts. The 2 chapters in this section are very psychology-oriented and discuss the theories of dynamic decision-making and the principles of anesthesia crisis resource management. The material is similar to the programs that are part of airline pilot training. The second section, “The Catalog of Critical Events in Anesthesiology,” outlines 83 events based primarily but not exclusively on various body systems and specific types of surgery. These include everything from hypoxemia, hypotension, myocardial infarction, the difficult airway, and local anesthetic toxicity to various equipment-related events. Each “event” is described under the headings of “Definition,” “Etiology,” “Typical Situations,” “Prevention,” “Manifestations,” “Similar Events,” “Management,” “Complications,” and “Suggested Readings.” The authors assume that the reader has a sound knowledge base and adequate technical skills. The book is not meant to be either a reference text on anesthesia or a “cookbook.” Instead, “The Catalog of Critical Events” is a guide only. The “Management” section is purposely not in the form of a decision tree or algorithm, rather, the management guides are written more as a hierarchical list of what to check or to do in roughly the same order that an experienced practitioner would do them. Although comprehensive, this book makes no claim to be exhaustive. It focuses on the anesthesia provider's mind, trying to help him or her optimize his or her own performance. The catalog presents events in a uniform, concise fashion and strives to improve the recognition of and response to a crisis. It is very easy to read and is truly a source of education that no one but the most thrill-seeking anesthetist wants to experience but that every anesthesia provider will experience. This innovative book effectively captures the essence of what should become instinctive. What it describes should be required reading for anyone who administers anesthesia.

Crisis resource management training for an anaesthesia faculty: a new approach to continuing education.

Human error and system failures continue to play a substantial role in adverse outcomes in health care. Anaesthesia crisis resource management addresses many patient safety issues by teaching behavioural skills for critical events but it has not been systematically utilized to teach experienced faculty. An anaesthesia crisis resource management course was created for the faculty of our medical school's anaesthesia teaching programmes. The course objectives were to understand and improve participants' proficiency in crisis resource management (CRM) skills and to learn skills for debriefing residents after critical events. Through surveys, measurement objectives assessed acceptance, utility and need for recurrent training immediately post-course. These were measured again approximately 1 year later along with self-perceived changes in the management of difficult or critical events. The highly rated course was well received in terms of overall course quality, realism, debriefings and didactic presentation. Course usefulness, CRM principles, debriefing skills and communication were highly rated immediately post-course and 1 year later. Approximately half of the faculty staff reported a difficult or critical event following the course; of nine self-reported CRM performance criteria surveyed all claimed improvement in their CRM non-technical skills. A unique and highly rated anaesthesia faculty course was created; participation made the faculty staff eligible for malpractice premium reductions. Self-reported CRM behaviours in participants' most significant difficult or critical events indicated an improvement in performance. These data provide indirect evidence supporting the contention that this type of training should be more widely promoted, although more definitive measures of improved outcomes are needed.

Do anaesthesiologists feel alone in the operating room?

SANTANDER-02-12 Anaesthetists work in dynamic and complex environments. Teamwork is required and team error can be defined as action or inaction leading to deviation from team or organizational intentions [1]. Effective teamwork is an error-management technique, and communication also has several positive side effects, such as fewer and shorter delays, and increases efficiency [2]. Leadership is an essential ingredient of success in the search for safety, as it is throughout the enterprise of quality [3]. The aim of this study is to assess anaesthesiologists' self-perception regarding their teamwork and team organization. We show preliminary data of a projected broader study. Methods and Results: 14 staff anaesthesiologists who attended an Anaesthesia Crisis Resource Management course at Santander Simulation Centre were surveyed before and after the course (Tables 1 and 2) to study their self-perception regarding teamwork and team organization.Table 1: Pre-course survey results.Table 2: Post-course survey results.Conclusions: The anaesthesiologists surveyed have a poor self-perception about team organization and teamwork during their job. Anaesthesiologists have developed a deficient skill in communication. Simulator training may improve the patient safety by emphasizing the significance of team organization and enhancing communication among the team. From their written and verbal comments, most believed they learned a great deal about teamwork. Because these results are subjective thoughts, it would be necessary to develop an objective measurement instrument, which avoids some of the limitations of traditional approaches to measuring teamwork attributes. It is desirable that simulator training involves complete operating room teams to achieve improved performance [4].

Emergency medicine crisis resource management (EMCRM): pilot study of a simulation-based crisis management course for emergency medicine.

To determine participant perceptions of Emergency Medicine Crisis Resource Management (EMCRM), a simulation-based crisis management course for emergency medicine. EMCRM was created using Anesthesia Crisis Resource Management (ACRM) as a template. Thirteen residents participated in one of three pilot courses of EMCRM; following a didactic session on principles of human error and crisis management, the residents participated in simulated emergency department crisis scenarios and instructor-facilitated debriefing. The crisis simulations involved a computer-enhanced mannequin simulator and standardized patients. After finishing the course, study subjects completed a horizontal numerical scale survey (1 = worst rating to 5 = best rating) of their perceptions of EMCRM. Descriptive statistics were calculated to evaluate the data. The study subjects found EMCRM to be enjoyable (4.9 +/- 0.3) (mean +/- SD) and reported that the knowledge gained from the course would be helpful in their practices (4.5 +/- 0.6). The subjects believed that the simulation environment prompted realistic responses (4.6 +/- 0.8) and that the scenarios were highly believable (4.8 +/- 0.4). The participants reported that EMCRM was best suited for residents (4.9 +/- 0.3) but could also benefit students and attending physicians. The subjects believed that the course should be repeated every 8.2 +/- 3.3 months. The EMCRM participants rated the course very favorably and believed that the knowledge gained would be beneficial in their practices. The extremely positive response to EMCRM found in this pilot study suggests that this training modality may be valuable in training emergency medicine residents.

Management of anaphylactic shock evaluated using a full-scale anaesthesia simulator.

The diagnosis of an anaphylactic reaction during anaesthesia is not the first consideration for the anaesthetist and might be missed. The aim of this study was to describe anaesthetists' management of an anaphylactic reaction concerning diagnosing, treatment and application of anaesthesia crisis resource management (ACRM) in a full-scale anaesthesia simulator. Forty-two anaesthetists in teams of two attended training sessions with a critical incident of anaphylactic shock in a full-scale simulator. Trained observers from the study group evaluated the medical treatment according to a treatment sequence developed from the literature and graded the ACRM performance on a five-point scale where 1 is bad and 5 is best. None of the teams made the correct diagnosis within 10 min and treatment according to the treatment sequence was not initiated. Only 6/21 teams considered the right diagnosis but first after hints from the instructor 15 min after the start of the incident. Evaluation of the use of the total ACRM concept (that is the use of all of the ACRM expressions seen in a total connection: called general impression) gave a median value of 2.0 with a range of (1-3). Anaphylactic shock was difficult to diagnose and no structured plans were used for the treatment in the simulated incident in this study.

4 Anaesthesia simulators

The practice of anaesthesia involves routine activities which have the potential to develop into critical incidents. Moreover, many life-threatening complications in anaesthesia are so rare that practitioners seldom, if ever, come across them in routine practice. In this respect, anaesthesia is comparable to industries such as aviation and the nuclear power industry. Simulators and training devices are regularly used in these industries to maintain the efficiency and proficiency of operators. Within the past few years, there has been an increasing interest in the use of simulators in anaesthesia. Many computer screen-based and full-scale anaesthesia simulators have been developed and evaluated. The computer screen-based simulators are less expensive and more widely available. However, they lack the ability to simulate reality and certain other aspects of anaesthesia such as the human-machine and interpersonal interactions. Full-scale simulators recreate the whole anaesthesia work environment, but the disadvantage of these simulators is their high acquisition and running cost. The major purpose of anaesthesia simulators is to rehearse the management of both frequently occurring and rare events during anaesthesia. Full-scale anaesthesia simulators are ideal for training anaesthetists about the concepts of human-machine interactions and the complications of working in a complex environment. Many simulator-based training courses, which involve these concepts, have been developed and are being conducted in many training centres (e.g. the Anaesthesia Crisis Resource Management course and, the Rational Anaesthesia course). Simulators are also useful for continuing education of practising anaesthetists. Routine in-training examinations, assessment of trainees with questionable competence and periodic re-examination of practitioners could be conducted on simulators. As research tools, simulators can be used to study the responses of anaesthesia personnel to critical incidents, the utility of different displays and alarm modalities, the effects of artifacts or false alarms on problem-solving performance, and the effect of fatigue and other stresses on anaesthetists' performance. In addition, anaesthesia simulators can be used to evaluate the ergonomics and performance of equipment, especially during the development phase. Interest in anaesthesia simulators is increasing rapidly and the devices are constantly being improved. However, the full potential of these devices in the practice of anaesthesia needs to be explored further.

Anaesthesia crisis resource management training: an intimidating concept, a rewarding experience

This two-part study was performed to identify and address anaesthetists' concerns regarding anaesthesia simulation and to evaluate the response of practitioners to simulation-based Anaesthesia Crisis Resource Management Training (ACRM). First, 150 survey questionnaires were distributed to participants of the Anaesthesia Practice '94 meeting in Toronto and to staff and resident anaesthetists at the Sunnybrook Health Science Centre. In the second part of the study, 35 anaesthetists from the Toronto area who participated in Anaesthesia Crisis Resource Management (ACRM) workshops at the Canadian Simulation Centre completed an anonymous exit evaluation questionnaire. Among staff anaesthetists (n = 42), 19% of the surveyed respondents had never heard about anaesthesia simulation, whereas all residents (n = 17) had heard of, or seen an anaesthesia simulator. Horizontal numerical scale ratings (from 1-10, with 10 being extremely supportive) indicated support for the purchase of a simulator (8.3 +/- 2.0 for staff, 9.2 +/- 1.1 for residents). Staff and residents anticipated substantial anxiety while training with a simulator (6.8 +/- 2.4 and 7.6 +/- 1.4 respectively, with 10 indicating extreme anxiety). Participants in the ACRM workshops at the Canadian Simulation Centre enjoyed the course (1.2 +/- 0.6, on a scale form 1 through 5, with 1 indicating total support and 5 representing no support), felt that it would be beneficial to most anaesthetists (1.2 +/- 0.5) and should be taken, on average, every 18 mo. Even though the majority of respondents have not been exposed to anaesthesia simulators, they appear to support their use in education strongly. Whereas substantial anxiety could delay the introduction of simulation based education, participants of ACRM workshops enjoy the courses and perceive them as very educational.

Anesthesia crisis resource management: real-life simulation training in operating room crises.

Little formal training is provided in anesthesiology residency programs to help acquire, develop, and practice skills in resource management and decision making during crises in practice. Using anesthesia crisis resource management (ACRM) principles developed at another institution, 68 anesthesiologists and 4 nurse-anesthetists participated in an ACRM training course held over a 2 and a half-month period. The anesthesia environment was recreated in a real operating room, with standard equipment and simulations requiring actual performance of clinical interventions. Scenarios included overdose of inhalation anesthetic, oxygen source failure, cardiac arrest, malignant hyperthermia, tension pneumothorax, and complete power failure. A detailed questionnaire was administered following the debriefing and completed by all participants, documenting their immediate impressions. Participants rated themselves as having performed well in the simulator. Senior attendings and residents rated themselves more highly than did their junior counterparts. The potential benefit of this course for anesthesiologists to practice anesthesia more safely in a controlled exercise environment, was rated highly by both groups. Over one half of respondents in all categories felt that the course should be taken once every 12 months; another third of each group felt that the course should be taken once every 24 months. While no senior attendings believed that the course should be taken once every 6 months, approximately 10% of respondents in other categories that it should. Of respondents in the senior and junior attending category, 5% felt the course should never be taken. Although attendings were less favorable than residents in their rating of the value of the course, both groups were still enthusiastic.

Anesthesia Crisis Management and Human Error in Anesthesiology

Anesthesia is a dynamic, complex world in which decisions must be made rapidly, often with partial information and uncertainty. Previous studies of anesthesiologists' responses to adverse events have demonstrated that even experienced anesthesiologists are not optimally prepared to manage crises. A new training course which is aimed at improving the crisis management skills of anesthesiologists is described. The course borrows concepts from “Cockpit Resource Management” training in aviation and uses lectures, videotapes, and realistic simulation with expert debriefing to teach “Anesthesia Crisis Resource Management.”