July 13, 2017

Study seeks to improve emergency event management

Anesthesiology has a long history of scrutinizing its practice and developing strategies for improvement.

Anesthesiology has a long history of scrutinizing its practice and developing strategies for improvement.

In a recent prospective, observational study, 263 board-certified anesthesiologists from across the United States volunteered to participate as part of already scheduled continuing education simulation courses that focused on the management of life-threatening events. Participants were video recorded, allowing independent experts to rate the technical and behavioral performance of the clinicians.

The study — published this week in the Online First edition of Anesthesiology, the peer-reviewed medical journal of the American Society of Anesthesiologists (ASA) — identified opportunities to improve the emergency event management performance of all clinicians, according to the principal investigator and lead author, Matthew Weinger, M.D., professor of Anesthesiology, Biomedical Informatics and Medical Education at Vanderbilt University Medical Center (VUMC).

Matthew Weinger, M.D.

“Anesthesia care in the U.S. is safer than it has ever been,” said Weinger, director of the Center for Research and Innovation in Systems Safety at Vanderbilt. “We wanted to identify ways to make perioperative care even safer. Our study shows that medicine can still learn more from other industries about how they prepare systems and professionals to respond to unexpected life-threatening events.

“The American Board of Anesthesiology has recognized that the skills of practicing anesthesiologists need to be constantly developed. We wanted to prove that we could study performance in an accurate and reproducible way using simulated care at multiple sites. This study shows that there are opportunities for improvement and that further research to understand the performance of experienced practitioners is necessary.”

The study, “Simulation-based Assessment of the Management of Critical Events by Board-certified Anesthesiologists,” conducted by an interdisciplinary team from 12 academic institutions, sought to determine whether standardized, mannequin-based simulation can reliably characterize how experienced physicians manage simulated medical emergencies. The study’s focus was, first, to establish psychometric properties of the assessment methods and, second, to identify those aspects of event management that could be addressed in future graduate medical education, continuing medical education and practice improvement activities.

Participants attended a Maintenance of Certification training course at one of eight simulation centers endorsed by the American Society of Anesthesiologists. Each of the consenting volunteers participated in two 20-minute, standardized, high-fidelity simulated medical crisis scenarios. A second physician arrived to help about halfway through the scenario.

In this study, approximately 80 percent of critical actions were carried out, with three-quarters of performances scored as average or better on the rating scales. In low scoring simulated care encounters, critical actions were more often omitted.

“One of our most important findings was that a very effective, and also relatively simple, action was calling for help. The arrival of a second caregiver nearly always improved overall performance.”

While the study methods were not able to determine competence, ability or skill of individual clinicians, the study was able to describe the spectrum of performance seen in complex simulations of well-known crisis events.

This study of a large sample of experienced physicians observed several specific areas for performance improvement during the simulations: failure to escalate therapy when the initial response was ineffective; failure to engage another team member, especially when action by that person was required; failure to use available resources like calling for help; and failure to follow evidence-based guidelines.

“The results suggest that processes and tools that enhance the ability of clinicians and teams to respond to acute events could be strengthened,” said David Gaba, M.D., a study co-investigator and professor of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine. “As board-certified anesthesiologists, we are at the forefront of improving clinical care as a specialty by being self-critical and asking hard questions of ourselves.”

Simulation is an effective method to train and assess the crisis management skills for all clinicians, said Weinger.

“Continuous professional learning of things most critical to your practice is essential. This is a wake-up call for any clinician who is expected to manage life-threatening events that have time-critical expectations.”