This Month In: Anesthesiology

As part of the Next Accreditation System of the Accreditation Council of Graduate Medical Education, anesthesia residents will need to be assessed across 25 proposed milestones, each of which has five possible levels of performance, every 6 months. Logic was created to score on a series of quality metrics each completed anesthesia case stored in the perioperative management system for which a resident provided care. The cases and associated scores were brought into the perioperative data warehouse and data visualizations were created to show the residency program director and the clinical competency committee performance of all residents on each metric over time and the individual resident their performance compared to aggregate data for their residency class and the complete residency cohort over time. These objective, near–real-time data leveraged from the electronic medical record provide the residency program director, the clinical competency committee, and residents with feedback on 12 of the 25 proposed milestones with minimal ongoing effort.

Anatomical validation studies of cervical ultrasound images are uncommon. This study presents a meticulous and detailed study of the sonographic anatomy and landmarks of the cervical spine. The authors constructed an anatomical model of the cervical spine and a laser-precise, three-dimensional measurement device that allowed them to correlate ultrasound images and specific gross anatomical features of the spine. With this model, they developed a clear and reproducible technique for accurately identifying each of the cervical vertebral levels using ultrasound. This article stands out for its precision, rigor, and reproducibility. The anatomic work sets the stage for meaningful application of ultrasound for image-guided needle placement during cervical interventions. Anatomical bony landmarks described include the mastoid process, the transverse process of C1, the tubercles of C6 and C7, and the cervical laminae. The cervical dorsal laminae serve as reliable bony landmarks to detect cervical segmental levels in vivo. This careful study of human anatomy is a precise guide to the optimal use of ultrasound to visualize the cervical spine in clinical practice. See the accompanying Editorial View onpage 10.

Patient-controlled analgesia with intravenous opioids or epidural analgesia offers excellent analgesia for many postoperative patients. These modalities also expose patients to risk of serious harm. Root cause analysis can help to identify underlying problems with the system that can be corrected to reduce risk. This study was designed to compare the incidence of adverse events on an acute pain service in three hospitals before and after the introduction of a formal root cause analysis process. A total of 35,384 patients were tracked over the 7 yr of this study. The “after” cohort showed significant reductions in the overall event rate (1.47 % vs. 2.35% or 1 in 68 vs. 1 in 42), the rate of respiratory depression (0.41% vs. 0.71%), the rate of severe hypotension (0.78% vs. 1.34%), and the rate of patient-controlled analgesia pump programming errors (0.00% vs. 0.08%). Associated with the improvement in safety, the incidence of severe pain increased from 6.5 to 10.5%, which may have been related to the project’s overall move to reduce the dose of PCA opioids. Implementation of root cause analysis was associated with an improvement in the safety of patients on an organized pain service.

Decades of experience with the Objective Structured Clinical Examination (OSCE) has amassed substantial evidence of the usefulness of this approach in testing higher levels of competency. The American Board of Anesthesiology recently announced its intent to add the OSCE to the Part 2 (oral) board examination for primary certification in anesthesiology. This paper reviews the history of the OSCE and its current application in medical education. The article includes a discussion of test design and implementation with emphasis on reliability and validity measures. See the accompanying Editorial View on page 4.

Five key behavioral domains identified as lacking in underperforming residents were used to design seven simulation scenarios appropriate for first-year anesthesia residents. Performance characteristics of 22 first-year residents and 8 pediatric fellows in these scenarios evaluated using a seven-point behaviorally anchored rating scale supported the validity of simulation-based assessment to identify gaps in performance early in resident training. See the accompanying Editorial View on page 18.

To determine themes of good and bad teaching, as perceived by residents, nearly 800 faculty evaluations by residents that were significantly above or below the mean were examined. Of these, 13 themes correlated with above-average ratings and 12 with below-average ratings. From these 13 recommendations were generated in the domains of teaching, supervision, feedback, and interpersonal interactions. See the accompanying Editorial View onpage 22.

This review article addresses the nonrational cognitive processes in human decision making, identifies vulnerable anesthesia decisions, and suggests strategies for mitigating effects of these processes. How the most common nonrational cognitive processes (heuristics, preferences for certainty, overconfidence, affective [emotional] influences, memory distortions, bias, and social forces such as fairness or blame) can be mitigated are discussed.

The American Accreditation Council for Graduate Medical Education is transitioning to a competency-based system with milestones to measure progress and define success of residents. Instead of being time based, residents will progress as they acquire skills assessed by core anesthesiology faculty who will function as “trained observers.” This will create logistic challenges, and require new educational approaches to provide flexibility to meet the differing times for residents to achieve expert status and achieve milestones.