Anesthesia Training Research Articles

A Ketamine Package for Use in Emergency Cesarean Delivery When No Anesthetist is Available: An Analysis of 401 Consecutive OperationsAnesthesia and AnalgesiaAnesthesia and Analgesia

(Int J Gynecol Obstet. 2022;158:377–384) Average maternal mortality in low-income countries has been reported as 40 times higher than that of high-income countries. One contributing factor to this discrepancy is the shortage of surgical care either due to inaccessible resources or inaccessible clinicians such as anesthesiologists. There is a particularly noticeable gap in anesthesiology care, as most low-income countries do not have anesthesiology training programs, or the programs do not produce enough clinicians to fully staff what is needed. This study aimed to understand the implications of using ketamine as an anesthetic to support emergency surgical delivery if no anesthetist is available. Effectiveness and safety was evaluated through maternal and newborn outcomes. The primary outcome was maternal and infant survival, and the ability of ketamine to safely support cesarean deliveries (CD).

SP1.7 DILEMMAs in emergency laparotomy care: preliminary results of an international quality enhancement initiative focused on decision making

Abstract Aim The aim of our study is to assess how professionals take decisions when evaluating suitability of patients for emergency laparotomy or palliation. Methods We created and validated a dataset of 90 case vignettes based on real patients admitted with surgical pathology correctable only via an emergency laparotomy. We removed information concerning real life outcomes. We submitted the vignettes to consultants and trainees in surgery, anaesthesia and intensive care, asking them if they would offer an emergency laparotomy. Concordance between assessors and real life decisions, accuracy scores (the lower the value the higher the likelihood of operating on patients that survived) and inconsistency scores were calculated. Judgement Analysis methodology (binomial logistic regression) was used to identify variables relevant to the decision making process for each participant. Results This report includes results for the first 100 participants. Twelve centres provided data (4 from Italy, 7 from the UK, 1 from Greece). 47 consultants, 9 SAS doctors, 28 higher trainees, 13 core trainees or equivalent took part in the study. 59 were surgeons, 25 anaesthetists and 9 intensivists. Average concordance between decision makers and real life was 78.9%. Median accuracy was 16.5 (IQR 11-30.5). Median inconsistency was 13% (IQR 7%-20%). Accuracy and consistency were better for consultants and worse for trainees. Judgment Analysis demonstrated differences between grades, specialities and institutions. Conclusions Different clinicians, when faced with the same information, make different decisions. Our data supports the adoption of multidisciplinary decision making protocols as well as senior involvement.

Anesthesiologists’ conceptions of learning anesthesia in the context of their specialty training program: a phenomenographic study

BackgroundTraining anesthesiologists poses challenges and complexities, particularly in defining and teaching excellence in anesthesia. Existing anesthesia curricula primarily emphasize the acquisition of knowledge, practical skills, and professional competencies, often neglecting the development of intangible skills like tacit knowledge. Despite efforts to establish learning goals through carefully describing competencies, there is a risk of oversimplifying the intricate aspects of professional anesthesia practice. Therefore, the objective of this study is to gain a deeper understanding of the genuine curriculum of a specialty training program in anesthesia. This will be achieved by exploring the perceptions of learners with different levels of experience within the program.MethodsThis study employs a phenomenographic research approach to explore the conceptions of anesthesiology trainees and specialists, specifically from a student’s perspective, regarding what constitutes an excellent anesthesiologist i.e., what to learn, and the learning process associated with it.ResultsThis study identified three different conceptions of learning anesthesia within the context of a specialty training program: “Learning Competencies of Anesthesia,“ “Learning Work as an Anesthesiologist” and “Learning Being an Anesthesiology Professional.“ These conceptions ranged from a relatively instrumental view of education and self-responsibility for learning to a perspective of continuous personal reflection and development integrated with professional interaction. The three conceptions can be described in six dimensions describing the variation in approach to learning and the conceptualization of an anesthesiologist. Relationships between the conceptions and the dimensions were represented in a descriptive framework, showing the hierarchy of increasing understanding.ConclusionThis study has uncovered diverse learner perspectives among anesthesiologists at various experience levels concerning their understanding of the role of an anesthesiologist and the associated learning process. These distinct understandings can be categorized into different groups and presented in a descriptive framework that encapsulates the fundamental elements and important educational aspects of an anesthesiologist’s progression through a specialty training program in anesthesia. By recognizing and integrating these diverse perspectives, anesthesia education can be enhanced, ultimately resulting in improved preparation of future anesthesia curriculum, teaching and assessments.

432 Returning to Surgical training. Are we meeting the need?

Abstract Aims The association of time out of training (TOOT) with skills fade is well documented. Despite the establishment of Supported Return to Training (SRTT) in 2017, engagement from Surgical trainees is suboptimal. We sought to evaluate this. Methods An online survey of Yorkshire Surgical trainees was conducted in January 2022. Results were analysed as were Yorkshire SRTT data for the past 2 years. Results Of 22 respondents, 18 had had time out, 3 were planning it and 3 considering it in future. SRTT was used by 52.6%, 21% felt it did not meet their needs whilst 15.8% were unaware of SRTT. This is reflected in the regional HEE data. In the previous 2 years 85 surgical trainees had taken TOOT but only 22 (26%) had engaged with the SRTT process, compared with 60% of Obstetrics and Gynaecology (O&G) trainees and 87% of Anaesthetic trainees. Analysis of the reasons for TOOT showed that surgical trainees most commonly took time out for research (OOPR) (28%) or parental leave (28%) whilst 67% of Anaesthetics and 49% of O&G trainees had time out for parental leave. Conclusions Despite having higher numbers of returning trainees, engagement with the SRTT process from the school of surgery is poor. This is likely multifactorial, reflecting the demographics of what is perceived as a less family friendly specialty, failure to recognise or acknowledge skills fade among OOPR trainees and an existing offering that is not fit for purpose. A collaborative exploration of these issues is required to address this.

Evaluation of the effectiveness of artificial intelligence for ultrasound guided peripheral nerve and plane blocks in recognizing anatomical structures

BackgroundWe aimed to assess the accuracy of artificial intelligence (AI) based real-time anatomy identification for ultrasound-guided peripheral nerve and plane block in eight regions in this prospective observational study. MethodsAfter obtaining ethics committee approval and written informed consent from 40 healthy volunteers (20 men and 20 women, between 18 and 72 years old), an ultrasound device installed with AI software (Nerveblox, SmartAlfa, Turkey) were used to scan regions of the cervical plexus, brachial plexus, pectoralis (PECS), rectus sheet, femoralis, canalis adductorius, popliteal, and ESP by three anesthesiology trainees. During scanning by a trainee, once software indicates 100 % scan success of associated anatomic landmarks, both raw and labeled ultrasound images were saved, assessed, and validated using a 6-point scale between 0 and 5 by two expert validators. Evaluation scores of the validators for each block were compared according to demographics (gender, age, and BMI) and block type exists. ResultsThe scores were not different except ESP, femoralis, and cervical plexus regions between the experts. The mean scores of the experts for the PECS, popliteal and rectus sheath were significant between males and females (p < 0.05). In terms of BMI, significant differences in the scores were observed only in the canalis adductorius, brachial plexus, and ESP regions (p < 0.05). ConclusionsUltrasound guided AI-based anatomy identification was performed in commonly used eight block regions by the trainees where AI technology can successfully interpret the anatomical structures in real-time sonography which would be valuable in assisting anesthesiologists.

Development of obstetric anesthesia core competencies for USA residency programs through a Delphi process.

The standard for anesthesia residency training in the USA mainly relies on the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project, a framework that lacks specific directives for subspecialties including obstetric anesthesia. We aimed to identify core competencies in obstetric anesthesiology that can be adapted to different residency training programs to help improve the quality of training and accountability of the institutions within the USA. We identified a preliminary list of competencies from review of existing competency-based obstetric anesthesia training curricula and practice guidelines. We used a modified Delphi methodology to achieve expert consensus among members of the Society for Obstetric Anesthesia and Perinatology education committee. The panellists were asked to evaluate the importance of each competency using a five-point Likert scale, with consensus after two rounds defined at 80% agreement. The responders were also asked at which level of training each competency should be attained. The Delphi rounds had 75% response rate and derived 94 competencies that were categorized under the six ACGME domains: patient care (38), medical knowledge (45), system-based practice (two), practice-based learning and improvement (five), interpersonal communication skills (two), and professionalism (two). We generated a residency training competency list for obstetric anesthesiology through expert consensus. This list can be used by residency training programs to develop a structured competency-based curriculum with tangible milestones, thereby reducing heterogeneity in the standard of training.

Defining and assessing competence in regional anesthesiology training

Defining and assessing competence in regional anesthesiology training

Pediatric Cardiac Anesthesia Training and Staffing in the National Health Service.

Considerable importance is attached to the process of training, appointing and retaining highly specialized pediatric anesthetists, such as those with a congenital heart disease practice. For the 10-year period from April 2012 to March 2022, we wished to establish changes in the absolute number of consultant pediatric cardiac anesthetic posts in NHS Level 1 Centres, turnover in such posts, and what training appointees had received. An email survey was sent to the Centre Representative from the Congenital Cardiac Anesthesia Network in each of the eleven NHS Level 1 Pediatric Congenital Heart Disease Centre. Further follow up was completed in order to confirm accuracy of responses. We defined a pediatric cardiac anesthetist as a consultant with a clinical practice including provision of anesthetic management for children undergoing cardiac surgery incorporating the use of cardiopulmonary bypass. The response rate to our survey was 100%. Over the study period the number of consultants increased from 69 to 81, though three posts were unfilled as at March 2022. There were 55 departures and 65 appointees. Five consultants moved between NHS Units. 52 consultants received formal fellowship training and 13 switched into pediatric cardiac anesthesia from an existing general pediatric anesthetic post, with a period of supplementary training within their institution. Appointees reported extensive additional training variably including fellowships in general pediatric anesthesia, adult cardiac anesthesia and pediatric intensive care, both within and outside the United Kingdom. There has been both an expansion in the number of posts, as well as considerable turnover in consultant posts in the last 10 years. Training standards which support and guide individuals as they develop a practice in this highly specialized field should reflect different routes into the speciality and could be established with the support and advice of the Congenital Cardiac Anesthesia Network.

Enhanced Learning in Obstetric Anesthesia: A Review of Simulation-Based Training Techniques

Simulation-based training is a valuable approach for enhancing learning in obstetric anesthesia. Simulations offer a controlled and realistic environment for healthcare providers to practice and refine their skills, improving their proficiency and confidence in managing complex obstetric anesthesia scenarios. Simulation-based training in obstetric anesthesia offers several benefits, such as recreating rare and critical events, enhancing teamwork and communication, and improving decision-making skills. It also provides a safe space for learners to make mistakes, receive feedback, and reflect on their performance, ultimately leading to improved patient outcomes. Effective simulation-based training programs incorporate key elements such as curriculum design, debriefing techniques, and assessment methods. The review emphasizes the importance of interprofessional training and teamwork exercises, as effective communication and collaboration are vital in managing obstetric emergencies. Although simulation-based training has shown promising results in improving knowledge, technical skills, and confidence among obstetric anesthesia providers, challenges exist. These include cost considerations, resource availability, and the need for ongoing research to validate the transferability of simulation-acquired skills to real-world clinical settings. This review provides an update on simulation-based training techniques and advancements in the field of obstetric anesthesia.

Modifiable risk factors for post-operative delirium in older adults undergoing major non-cardiac elective surgery: a multi-centre, trainee delivered observational cohort feasibility study and trainee survey

BackgroundPost-operative delirium (POD) is an acute brain failure which may occur following major surgery, with serious implications for participants and caregivers. Evidence regarding optimal anaesthetic management for older participants at higher risk of POD is conflicting. We conducted a feasibility study of our protocol in 5 centres to guide sample size estimation and inform future recruitment strategies for a larger cohort study.MethodsParticipants aged over 65 and scheduled for major surgery were recruited. They were assessed pre-operatively for delirium, cognitive impairment, depression, comorbidity, activity levels and alcohol use. Details of management during surgery, all medications and complications were recorded by a trainee-led research team. Participants were assessed for delirium in the immediate recovery period and then on post-operative days 1–4 using the 4 question attention test (4AT) with complications assessed at day 4 using the post-operative morbidity survey (POMS). Primary outcomes were the incident rates of POD. Secondary outcomes were number of eligible patients, recruitment rates and retention rates throughout the study, time required for data collection, preoperative risk factors assessment and daily postoperative delirium assessments. Also to assess the added value of employing the regional trainee research network (INCARNNET) to deliver the study. Specifically, what proportion of patient consent, data collection and post-operative testing is performed by anaesthesia trainees from this group, especially the success of weekend delirium assessment by trainees? A survey was completed at the end of the study by the trainees involved regarding their involvement in the study.ResultsNinety-five participants were recruited, of whom 93 completed the study. Overall, POD occurred in 9 patients. Of these, three were detected in recovery and six on post-op days 1–4. Median length of stay was 6 days. Recruitment rates were high in all but one site. 59 (62%) participants were consented by trainees and 189 (63%) of post op delirium assessments were performed by trainees. A total of six patients declined the study (in a follow up survey of trainees). Pre-existing cognitive impairment, depression and problem drinking were detected in 4(4.3%), 3(3.2%) and 5(5.37%) participants, respectively. Co-morbidity was common with 55(59%) in class three or four of the geriatric index of morbidity. Overall, from a total of 641 data points, levels of missing data were as follows, site A = 9.3%, B = 13.5%, C = 15.4%, D = 10.9%, E = 11.1% (data could not be completed retrospectively).ConclusionsA multi-centre observational cohort study of delirium carried out by UK trainee anaesthetists is feasible. Patients are content to undergo day of surgery consent and multiple short questionnaires pre-operatively. Proposed data, especially pharmacological, should be carefully considered for their relevance to modifiable mechanisms that can lead to POD. Future research to enable prognostic modelling of POD should involve large scale cohort studies of enriched populations to capture a higher POD incidence. POD remains a common complication in older persons undergoing major surgery in the UK and studies of interventions are urgently needed.Trial registrationAll methods were carried out in accordance with relevant guidelines and regulations. The study was retrospectively registered with ISRCTN94663125 on 07/02/2018.

National consensus on entrustable professional activities for competency-based training in anaesthesiology.

Entrustable Professional Activities (EPA) are specialty specific tasks or responsibilities, combining the clinical workplace and the long-demanded competency-based medical education. The first step to transform time-based into EPA-based training is to reach consensus on core EPAs that describe sufficiently the workplace. We aimed to present a nationally validated EPA-based curriculum for postgraduate training in anaesthesiology. Using a predefined and validated list of EPAs, we applied a Delphi consensus approach, involving all German chair directors of anaesthesiology. We then conducted a subsequent qualitative analysis. Thirty-four chair directors participated in the Delphi survey (77% response) and twenty-five completed all the questions (56% overall response). Reflected by the intra-class-correlation, the consensus on the importance (ICC: 0.781, 95% CI [0.671, 0.868]) and the year of entrustment (ICC: 0.973, 95% CI [0.959, 0.984]) of each EPA reached high levels of agreement among the chair directors. The comparison of data assessed in the preceding validation and present study showed excellent and good levels of agreement (ICC entrustment: 0.955, 95% CI [0.902, 0.978]; ICC importance: 0.671, 95% CI [-0.204, 0.888]). The adaptation process, based on the qualitative analysis, resulted in a final set of 34 EPAs. We present an elaborate, fully described and nationally validated EPA-based curriculum, reflecting a broad consensus among different stakeholders of anaesthesiology. We hereby provide a further step towards competency-based postgraduate anaesthesiology training.

Evaluation of practice change following SAFE obstetric courses in Tanzania: a prospective cohort study.

Anaesthesia has been shown to contribute disproportionately to maternal mortality in low-resource settings. This figure exceeds 500 per 100,000 live births in Tanzania, where anaesthesia is mainly provided by non-physician anaesthetists, many of whom are working as independent practitioners in rural areas without any support or opportunity for continuous medical education. The three-day Safer Anaesthesia from Education (SAFE) course was developed to address this gap by providing in-service training in obstetric anaesthesia to improve patient safety. Two obstetric SAFE courses with refresher training were delivered to 75 non-physician anaesthetists in the Mbeya region of Tanzania between August 2019 and July 2020. To evaluate translation of knowledge into practice, we conducted direct observation of the SAFE obstetric participants at their workplace in five facilities using a binary checklist of expected behaviours, to assess the peri-operative management of patients undergoing caesarean deliveries. The observations were conducted over a 2-week period at pre, immediately post, 6-month and 12-month post-SAFE obstetric training. A total of 320 cases completed by 35 participants were observed. Significant improvements in behaviours, sustained at 12 months after training included: pre-operative assessment of patients (32% (pre-training) to 88% (12 months after training), p < 0.001); checking for functioning suction (73% to 85%, p = 0.003); using aseptic spinal technique (67% to 100%, p < 0.001); timely administration of prophylactic antibiotics (66% to 95%, p < 0.001); and checking spinal block adequacy (32% to 71%, p < 0.001). Our study has demonstrated positive sustained changes in the clinical practice amongst non-physician anaesthetists as a result of SAFE obstetric training. The findings can be used to guide development of a checklist specific for anaesthesia for caesarean section to improve the quality of care for patients in low-resource settings.

Predictors of anesthesia ready time: Analysis and benchmark data

ObjectivePatients undergoing congenital cardiac surgery require induction of anesthesia. Our objective was to identify the median anesthesia ready time and the predictors of this time. MethodsBy using the Society of Thoracic Surgeons Congenital Heart Surgery Database, we identified patients who underwent cardiopulmonary bypass procedures from 2017 to 2021. Univariate and multivariable regression modeling to predict the anesthesia ready time was performed using mixed-effects linear regression. ResultsAfter exclusion of outliers, 44,418 cases were analyzed. The median anesthesia ready time was 51 minutes (interquartile range, 38-66). On multivariable analysis, independent predictors of a longer anesthesia ready time included decreasing weight (0.3 min/10 kg, 95% CI, 0.1-0.6; P = .011), prematurity (1.5 minutes, 95% CI, 0.8-2.2; P < .001), and presence of chromosomal abnormality (3.4 minutes, 95% CI, 1.5-5.2; P < .001). An increase in the duration in anesthesia ready time was seen with increasing Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery mortality category with an additional 7.8 minutes (95% CI, 5.2-10.4; P < .001) for a Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery 5 procedure compared with Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery 1. Emergency versus elective case designation was associated with an anesthesia ready time reduction of 3.6 minutes (95% CI, 1.1-6.1; P = .005), and an afternoon case start was associated with an anesthesia ready time reduction of 4.2 minutes (95% CI, 2.8-5.6; P < .001). The presence of an anesthesia trainee increased the anesthesia ready time by 3.8 minutes (95% CI, 2.6-5.0; P < .001). The presence of an airway in situ decreased the anesthesia ready time by 3.6 minutes (95% CI, 1.6-5.5; P < .001), whereas an in situ arterial line decreased the anesthesia ready time by 7.4 minutes (95% CI, 4.6-10.2; P < .001). Placement of a central venous line increased the anesthesia ready time by 8.5 minutes (95% CI, 5.9-11.1; P < .001). ConclusionsThe median anesthesia ready time was 51 minutes. For patients with characteristics associated with prolonged anesthesia ready time, consideration should be given to allocation of additional anesthesia staffing to improve efficiency.

Improving Postgraduate Anaesthesiology Training in a Low-Middle Income Country by Embracing the New Trends in Medical Education.

Postgraduate medical training has increasingly adapted to competency-based medical education (CBME). In an endeavour to stay abreast with the new trends in medical education and adapt to CBME frameworks, an in-depth review and revision of the Anaesthesiology training curriculum were conducted. The authors worked on the task from December 2020 to December 2021. Learning outcomes were defined and corresponding competencies were identified and relevant teaching, learning and assessment strategies were aligned with each learning outcome. Additionally, lists were devised for topics to be covered through didactic lectures and simulation-based workshops. The revised curriculum is currently being implemented in a phased manner. Formative workplace-based assessment tools are being introduced to complement CBME. Moreover, daily clinical assessments, entrustable professional activity (EPA), simulation-based workshops and assessments have been introduced. Key Words: Anaesthesiology, Postgraduate training, Curriculum revision, Competency-based medical education, Low-middle income country, Simulation-based training.

The Ethiopian Anesthetist Licensing Examination and Associated Improvement in in-School Student Performance: A Retrospective Study.

Ethiopia introduced a national licensing examination (NLE) in response to growing concerns about the competence of graduates and the quality of education. This study aimed to assess the associated in-school student performance changes in anesthetist training programs following NLE implementation. Academic records of 1493 graduate anesthetists were retrospectively obtained from eight universities before (n=932) and after (n=561) NLE implementation. Four universities were first-generation (oldest), three were second-generation, and one was third-generation (newest). We compared the yearly (Y1 to Y4) and cumulative grade point averages (GPA) to assess if there were in-school student performance differences between the two periods. The Kruskal-Wallis and Mann-Whitney U-tests were used to compare groups. Results are presented as a median, interquartile range, a 95% confidence interval (CI) for median differences, and Cohen's r effect size. Overall, there was a small to moderate improvement in student academic performance following NLE implementation. However, the statistically significant differences were limited to first-generation university students and those entering directly from high school. We found considerable positive differences in all five performance measures in first-generation university students, with Year-1 GPA and cumulative GPA measurements exhibiting large effect sizes (Cohen's r = 0.96 and 0.79, respectively, p <0.005). Those entering from high school demonstrated significant differences in four of five performance measures, with the largest positive gains on the year-1 GPA (median before [n=765] and after [n=480]: 3.11-3.30, 95% CI (0.09, 0.22), r=0.46, p <0.005)). Second- and third-generation university students showed no significant differences, while nurse entrants exhibited a significant difference in their Y2GPA scores only with an actual drop in performance. The Ethiopian anesthetist NLE is associated with an overall modest in-school academic performance improvement, supporting its use. The stagnant or declining performance among nurse entrants and the newest (second and third) generation university students deserve further scrutiny.

COMPARISON OF PRE PROCEDURAL AND REAL TIME ULTRASOUND GUIDED SPINAL ANESTHESIA FOR TRAUMATIC LOWER LIMB INJURY

Objectives:The study aimed to compare real time ultrasound-guided approach with pre procedural ultrasound-guided approach for spinal anaesthesia in trauma patients. Methods: 200 patients in two groups: group pre-procedure (PP) and group real time (RT) of 100 patients in each group using inclusion and exclusion criteria. Standard monitoring done and Spinal anesthesia was administered by a trained anesthetist. The outcome measures included the number of attempts took to access the subarachnoid space, number of skin punctures, time from first needle insertion to completion of the intrathecal injection, total procedure time, success rate of cerebrospinal fluid acquisition, failure and complications were recorded and statistical analysis was performed. A two-tailed p-value &lt;0.05 was considered as statistically significant. Results: Mean number of needle passes, median number of skin puncture, total time for successful lumbar puncture, the block failure rate and procedural complications were significantly less in the RT group as compared to PP group. There are widely varying reports of the failure rate of spinal anesthesia in the literature. The individual studies have reported higher success rates (97% and 100%) using real-time US guidance than with pre-procedure ultrasound (80%). Conclusion: Real-time ultrasound-guided technique is a clinically feasible, higher success rate, less time consuming and less complication rate as compared to preprocedural ultrasound guidance technique.

Quality of chest compressions performed by anaesthetic trainees with and without audiovisual feedback

Introduction: The use of audiovisual feedback devices on chest compression (CC) metrics such as the rate and depth has been proven to improve resuscitation quality. This study compared the quality of CC performed by anaesthetic trainees on manikins with audiovisual feedback and subsequent skill retention without the feedback. Methods: CC metrics measured were the compression rate and depth recorded and reviewed by RescueNet® Code Review software, which recorded compressions in target. Fifty participants performed 2 minutes of CC without audiovisual feedback (CC1), followed by another 2 minutes of CC with audiovisual feedback (CC2), separated by 5 minutes of rest. Those who achieved at least 70% of compressions in target during CC2 performed another 2 minutes of CC without audiovisual feedback at 30 minutes (CC3) and 5–7 days (CC4) later. Results: The baseline compressions in target during CC1 was 14.43 ± 20.18%, improving significantly to 81.80 ± 7.61% (p &lt; 0.001) with audiovisual feedback (CC2). Forty-five (90%) participants achieved compressions in target of at least 70% during CC2. However, without the feedback, compressions in target decreased significantly to 56.33 ± 27.02% (p &lt; 0.001) and 49.32 ± 33.86% (p &lt; 0.001) at 30 minutes (CC3) and 5–7 days (CC4) later, respectively. The overall effect size for the compressions in target was 0.625. Conclusion: Audiovisual feedback device usage significantly improves CC performance, but improved skills were not fully retained when CC was performed without the device afterwards. Therefore, real-time audiovisual feedback may ensure better CC, a component of cardiopulmonary resuscitation.

Simulation Training in a Lower Middle-Income Country: Supporting a New Center and Developing Low-Cost Models for Critical Skill Acquisition.

There is a demand for surgical simulation training to be made accessible in low-resource countries. We conducted a pilot workshop at a new state-of-the-art simulation center and evaluated two novel low-cost surgical simulation models in a lower middle-income country (LMIC). A hands-on workshop to train local educators about simulation training was held at a new simulation center. Participant surveys were analyzed following the "training-the-trainer" workshop. Low-cost, hybrid-fidelity pericardiocentesis and thoracic cavity simulation training models were created using locally available materials. These models recreated the pertinent anatomy at a cost under 20 US dollars each. The models were used to train 109 postgraduate anesthesiology trainees during two hands-on medical education workshops. Participant surveys were collected and analyzed. Of the local educators who participated in the "training-the-trainer" workshop, 65% "agreed" and 35% "strongly agreed" with the claim that the simulations better prepared the trainees to teach the clinical scenarios. Additionally, 65% of local educators "agreed" and 35% "strongly agreed" that the simulations prepared them to navigate interprofessional care in those scenarios. The low-cost pericardiocentesis simulation was ranked as "good" or "outstanding" by 100% of survey respondents. The low-cost thoracostomy simulation was ranked as "good" or "outstanding" by 64% of survey respondents. Both the pericardiocentesis and thoracostomysimulators were valued for their low-cost design, the recreation of essential anatomy, and immersive design elements. Our team successfully implemented novel simulators for skilltraining in an LMIC by working in close collaboration with local experts, with the advancement of local simulation instruction practices.Collaboration is key to increasing access to surgical simulations, particularly in low- to middle-income countries.

A consensus statement on the meaning, value and utility of training programme outcomes, with specific reference to anaesthesiology: A consensus statement on training programme outcomes.

It is timely and necessary to consider what Postgraduate Medical Training Programme outcomes are, how they are defined and revised over time, and how they can be used to align health professional performance with the healthcare needs of society. This article which addresses those issues, with specific reference to training in anaesthesiology, was prepared using a modified nominal group (or expert panel) approach.

A Brief History of Anesthesia in Somaliland.

A Brief History of Anesthesia in Somaliland.