The gap between attitudes and processes related to 'family-friendly' practices in anaesthesia training in New Zealand: A survey of anaesthesia supervisors of training and departmental directors.

Gender inequity persists within the anaesthetic workforce, despite approaching numerical parity in Australia and New Zealand. There is evidence, from anaesthesia and the wider health workforce, that domestic gender norms regarding parental responsibilities contribute to this. The creation of 'family-friendly' workplaces may be useful in driving change, a concept reflected in the gender equity action plan developed by the Australian and New Zealand College of Anaesthetists. This study aimed to explore the extent to which a family-friendly culture exists within anaesthesia training in New Zealand, from the perspective of leaders in anaesthesia departments. An electronic survey composed of quantitative and qualitative questions was emailed to all supervisors of training, rotational supervisors and departmental directors at Australian and New Zealand College of Anaesthetists accredited training hospitals in New Zealand. Twenty-eight of the 71 eligible participants responded (response rate 39%). The majority (61%) agreed with the statement 'our department has a "family friendly" approach to anaesthesia trainees'; however, there was a discrepancy between views about how departments should be and how they actually are. Several barriers contributing to this discrepancy were identified, including workforce logistics, governance, departmental structures and attitudes. Uncertainty in responses regarding aspects of working hours, parental leave and the use of domestic sick leave reflect gaps in understanding, with scope for further enquiry and education. To redress gender bias seriously through the development of family-friendly policies and practices requires supportive governance and logistics, along with some cultural change.

The flip side of speaking up: a new model to facilitate positive responses to speaking up in the operating theatre.

BACKGROUND: Speaking up is important for patient safety, but only if the concern raised is acknowledged and responded to appropriately. While the power to change the course of events rests with those in charge, research has focussed on supporting those in subordinate positions to speak up. We propose responsibility also rests with senior clinical staff to respond appropriately. We explored the perceptions of senior staff on being spoken up to in the operating theatre (OT), and factors moderating their response. METHODS: We undertook interviews and focus groups of fully qualified surgeons, anaesthetists, nurses, and anaesthetic technicians working in OTs across New Zealand. We used grounded theory to analyse and interpret the data. RESULTS: With data from 79 participants, we conceptualise three phases in the speaking up interaction: 1) the content of the speaker's message and the tone of delivery; 2) the message interpreted through the receiver's filters, including beliefs on personal fallibility and leadership, respect for the speaker, understanding the challenges of speaking up, and personal cultural and professional norms around communication; and 3) the receiver's subsequent response and its effects on the speaker, the observing OT staff, and patient care. CONCLUSIONS: The speaking up interaction can be high stakes for the whole OT team. The receiver response can strengthen team cohesion and function, or cause distress and tension. Our grounded theory uncovers multiple influences on this interaction, with potential for re-framing and optimising the speaker/receiver interaction to improve team function and patient safety.

Evaluation of the effect of multidisciplinary simulation-based team training on patients, staff and organisations: protocol for a stepped-wedge cluster-mixed methods study of a national, insurer-funded initiative for surgical teams in New Zealand public hospitals.

INTRODUCTION: NetworkZ is a national, insurer-funded multidisciplinary simulation-based team-training programme for all New Zealand surgical teams. NetworkZ is delivered in situ, using full-body commercial simulators integrated with bespoke surgical models. Rolled out nationally over 4 years, the programme builds local capacity through instructor training and provision of simulation resources. We aim to improve surgical patient outcomes by improving teamwork through regular simulation-based multidisciplinary training in all New Zealand hospitals. METHODS AND ANALYSIS: Our primary hypothesis is that surgical patient outcomes will improve following NetworkZ. Our secondary hypotheses are that teamwork processes will improve, and treatment injury claims will decline. In addition, we will explore factors that influence implementation and sustainability of NetworkZ and identify organisational changes following its introduction. The study uses a stepped-wedge cluster design. The intervention will roll out at yearly intervals to four cohorts of five District Health Boards. Allocation to cohort was purposive for year 1, and subsequently randomised. The primary outcome measure is Days Alive and Out of Hospital at 90 days using patient data from an existing national administrative database. Secondary outcomes measures will include analysis of postoperative complications and treatment injury claims, surveys of teamwork and safety culture, in-theatre observations and stakeholder interviews. ETHICS AND DISSEMINATION: We believe this is the first surgical team training intervention to be implemented on a national scale, and a unique opportunity to evaluate a nation-wide team-training intervention for healthcare teams. By using a pre-existing large administrative data set, we have the potential to demonstrate a difference to surgical patient outcomes. This will be of interest to those working in the field of healthcare teamwork, quality improvement and patient safety. New Zealand Health and Disability Ethic Committee approval (#16/NTB/143). TRIAL REGISTRATION NUMBER: Australian and New Zealand Clinical Trials Registry ID ACTRN12617000017325 and the Universal Trial Number is U1111-1189-3992.

Can team training make surgery safer? Lessons for national implementation of a simulation-based programme.

AIM: Unintended patient harm is a major contributor to poor outcomes for surgical patients and often reflects failures in teamwork. To address this we developed a Multidisciplinary Operating Room Simulation (MORSim) intervention to improve teamwork in the operating room (OR) and piloted it with 20 OR teams in two of the 20 District Health Boards in New Zealand prior to national implementation. In this study, we describe the experience of those exposed to the intervention, challenges to implementing changes in clinical practice and suggestions for successful implementation of the programme at a regional or national level. METHODS: We undertook semi-structured interviews of a stratified random sample of MORSim participants 3-6 months after they attended the course. We explored their experiences of changes in clinical practice following MORSim. Interviews were recorded, transcribed and analysed using a general inductive approach to develop themes into which interview data were coded. Interviews continued to the point of thematic saturation. RESULTS: Interviewees described adopting into practice many of the elements of the MORSim intervention and reported positive experiences of change in communication, culture and collaboration. They described sharing MORSim concepts with colleagues and using them in teaching and orientation of new staff. Reported barriers to uptake included uninterested colleagues, limited team orientation, communication hierarchies, insufficient numbers of staff exposed to MORSim and failure to prioritise time for team information sharing such as pre-case briefings. CONCLUSION: MORSim appears to have had lasting effects on reported attitudes and behaviours in clinical practice consistent with more effective teamwork and communication. This study adds to the accumulating body of evidence on the value of simulation-based team training and offers suggestions for implementing widespread, regular team training for OR teams.

Improved scores for observed teamwork in the clinical environment following a multidisciplinary operating room simulation intervention.

AIMS: We ran a Multidisciplinary Operating Room Simulation (MORSim) course for 20 complete general surgical teams from two large metropolitan hospitals. Our goal was to improve teamwork and communication in the operating room (OR). We hypothesised that scores for teamwork and communication in the OR would improve back in the workplace following MORSim. We used an extended Behavioural Marker Risk Index (BMRI) to measure teamwork and communication, because a relationship has previously been documented between BMRI scores and surgical patient outcomes. METHODS: Trained observers scored general surgical teams in the OR at the two study hospitals before and after MORSim, using the BMRI. RESULTS: Analysis of BMRI scores for the 224 general surgical cases before and 213 cases after MORSim showed BMRI scores improved by more than 20% (0.41 v 0.32, p<0.001). Previous research suggests that this improved teamwork score would translate into a clinically important reduction in complications and mortality in surgical patients. CONCLUSIONS: We demonstrated an improvement in scores for teamwork and communication in general surgical ORs following our intervention. These results support the use of simulation-based multidisciplinary team training for OR staff to promote better teamwork and communication, and potentially improve outcomes for general surgical patients.

Multidisciplinary operating room simulation-based team training to reduce treatment errors: a feasibility study in New Zealand hospitals.

AIMS: Communication failures in healthcare are frequent and linked to adverse events and treatment errors. Simulation-based team training has been proposed to address this. We aimed to explore the feasibility of a simulation-based course for all members of the operating room (OR) team, and to evaluate its effectiveness. METHODS: Members of experienced OR teams were invited to participate in three simulated clinical events using an integrated surgical and anesthesia model. We collected information on costs, Behavioural Marker of Risk Index (BMRI) (a measure of team information sharing) and participants' educational gains. RESULTS: We successfully recruited 20 full OR teams. Set up costs were NZ$50,000. Running costs per course were NZ$4,000, excluding staff. Most participants rated the course highly. BMRI improved significantly (P = 0.04) and thematic analysis identified educational gains for participants. CONCLUSION: We demonstrated feasibility of multidisciplinary simulation-based training for surgeons, anesthetists, nurses and anaesthetic technicians. The course showed evidence of participant learning and we obtained useful information on cost. There is considerable potential to extend this type of team-based simulation to improve the performance of OR teams and increase safety for surgical patients.

A pilot study investigating the effects of remote ischemic preconditioning in high-risk cardiac surgery using a randomised controlled double-blind protocol.

The efficacy of remote ischemic preconditioning (RIPC) in high-risk cardiac surgery is uncertain. In this study, 96 adults undergoing high-risk cardiac surgery were randomised to RIPC (3 cycles of 5 min of upper-limb ischemia induced by inflating a blood pressure cuff to 200 mmHg with 5 min of reperfusion) or control. Main endpoints were plasma high-sensitivity troponin T (hsTNT) levels at 6 and 12 h, worst post-operative acute kidney injury (AKI) based on RIFLE criteria, and noradrenaline duration. hsTNT levels were log-normally distributed and higher with RIPC than control at 6-h post cross-clamp removal [810 ng/ml (IQR 527-1,724) vs. 634 ng/ml (429-1,012); ratio of means 1.41 (99.17% CI 0.92-2.17); P=0.04] and 12 h [742 ng/ml (IQR 427-1,700) vs. 514 ng/ml (IQR 356-833); ratio of means 1.56 (99.17% CI 0.97-2.53); P=0.01]. After adjustment for baseline confounders, the ratio of means of hsTNT at 6 h was 1.23 (99.17% CI 0.88-1.72; P=0.10) and at 12 h was 1.30 (99.17% CI 0.92-1.84; P=0.05). In the RIPC group, 35/48 (72.9%) had no AKI, 5/48 (10.4%) had AKI risk, and 8/48 (16.7%) had either renal injury or failure compared to the control group where 34/48 (70.8%) had no AKI, 7/48 (14.6%) had AKI risk, and 7/48 (14.6%) had renal injury or failure (Chi-squared 0.41; two degrees of freedom; P = 0.82). RIPC increased post-operative duration of noradrenaline support [21 h (IQR 7-45) vs. 9 h (IQR 3-19); ratio of means 1.70 (99.17% CI 0.86-3.34); P=0.04]. RIPC does not reduce hsTNT, AKI, or ICU-support requirements in high-risk cardiac surgery.

Registrar sleep patterns and supervision during two different rosters in a tertiary Australasian intensive care unit.

OBJECTIVE: To compare registrar sleep and supervision hours before and after a change in roster to accommodate more senior registrar (SR) positions, and to identify risky patterns of sleep on night shifts. DESIGN, SETTING AND PARTICIPANTS: Prospective study of 21 registrars on two different roster templates from September 2010 to May 2011 in the intensive care unit of Wellington Regional Hospital, Wellington, New Zealand. INTERVENTION: Roster change from 13 registrars and one SR to 10 registrars and four SRs. MAIN OUTCOME MEASURES: Mean sleep and supervision hours by shift; episodes of sleep ≤ 5 hours, wakefulness ≥17 hours, sleep during shift, waking before 16:00 before night shifts. RESULTS: 990 sleep surveys were analysed. There was no significant difference between groups in mean sleep or supervision hours for any shift. Two hundred and thirty-six night shifts were analysed. Registrars slept ≤5 hours before 19/236 (8.1%) night shifts; had ≥17 hours wakefulness before 79/236 night shifts (33.5%); woke by 16:00 107/ 236 (45.3%) times; and slept during 86/236 (36.4%) night shifts. Registrars arrived at work having either woken before 16:00 or had ≤5 hours of sleep on 114/236 (48.3%) night shifts. CONCLUSIONS: Changing the registrar roster to meet the training demands of our senior trainees did not adversely affect registrar sleep or supervision. Registrars may be taking on unnecessary risk due to poor sleep hygiene around night shifts. We suggest sleep education and scheduled sleep time during night shifts.

A gender-based analysis of work patterns, fatigue, and work/life balance among physicians in postgraduate training.

PURPOSE: To document fatigue in New Zealand junior doctors in hospital-based clinical training positions and identify work patterns associated with work/life balance difficulties. This workforce has had a duty limitation of 72 hours/week since 1985. The authors chose a gender-based analytical approach because of the increasing proportion of female medical graduates. METHOD: The authors mailed a confidential questionnaire to all 2,154 eligible junior doctors in 2003. The 1,412 respondents were working > or = 40 hours/week (complete questionnaires from 1,366: response rate: 63%; 49% women). For each participant, the authors calculated a multidimensional fatigue risk score based on sleep and work patterns. RESULTS: Women were more likely to report never/rarely getting enough sleep (P < .05), never/rarely waking refreshed (P < .001), and excessive sleepiness (P < .05) and were less likely to live with children up to 12 years old (P < .001). Fatigue risk scores differed by specialty but not by gender.Fatigue risk scores in the highest tertile were an independent risk factor for reporting problems in social life (odds ratio: 3.83; 95% CI: 2.79-5.28), home life (3.37; 2.43-4.67), personal relationships (2.12; 1.57-2.86), and other commitments (3.06; 2.23-4.19).Qualitative analyses indicated a common desire among men and women for better work/life balance and for part-time work, particularly in relation to parenthood. CONCLUSIONS: Limitation of duty hours alone is insufficient to manage fatigue risk and difficulties in maintaining work/life balance. These findings have implications for schedule design, professional training, and workforce planning.

Simulation-based training delivered directly to the pediatric cardiac intensive care unit engenders preparedness, comfort, and decreased anxiety among multidisciplinary resuscitation teams.

OBJECTIVES: Resuscitation of pediatric cardiac patients involves unique and complex physiology, requiring multidisciplinary collaboration and teamwork. To optimize team performance, we created a multidisciplinary Crisis Resource Management training course that addressed both teamwork and technical skill needs for the pediatric cardiac intensive care unit. We sought to determine whether participation improved caregiver comfort and confidence levels regarding future resuscitation events. METHODS: We developed a simulation-based, in situ Crisis Resource Management curriculum using pediatric cardiac intensive care unit scenarios and unit-specific resuscitation equipment, including an extracorporeal membrane oxygenation circuit. Participants replicated the composition of a clinical team. Extensive video-based debriefing followed each scenario, focusing on teamwork principles and technical resuscitation skills. Pre- and postparticipation questionnaires were used to determine the effects on participants' comfort and confidence regarding participation in future resuscitations. RESULTS: A total of 182 providers (127 nurses, 50 physicians, 2 respiratory therapists, 3 nurse practitioners) participated in the course. All participants scored the usefulness of the program and scenarios as 4 of 5 or higher (5 = most useful). There was significant improvement in participants' perceived ability to function as a code team member and confidence in a code (P < .001). Participants reported they were significantly more likely to raise concerns about inappropriate management to the code leader (P < .001). CONCLUSIONS: We developed a Crisis Resource Management training program in a pediatric cardiac intensive care unit to teach technical resuscitation skills and improve team function. Participants found the experience useful and reported improved ability to function in a code. Further work is needed to determine whether participation in the Crisis Resource Management program objectively improves team function during real resuscitations.

Simulation at the point of care: reduced-cost, in situ training via a mobile cart.

OBJECTIVE: The rapid growth of simulation in health care has challenged traditional paradigms of hospital-based education and training. Simulation addresses patient safety through deliberative practice of high-risk low-frequency events within a safe, structured environment. Despite its inherent appeal, widespread adoption of simulation is prohibited by high cost, limited space, interruptions to clinical duties, and the inability to replicate important nuances of clinical environments. We therefore sought to develop a reduced-cost low-space mobile cart to provide realistic simulation experiences to a range of providers within the clinical environment and to serve as a model for transportable, cost-effective, widespread simulation-based training of bona-fide workplace teams. DESIGN: Descriptive study. SETTING: A tertiary care pediatric teaching hospital. MEASUREMENTS AND MAIN RESULTS: A self-contained mobile simulation cart was constructed at a cost of $8054 (mannequin not included). The cart is compatible with any mannequin and contains all equipment needed to produce a high quality simulation experience equivalent to that of our on-site center--including didactics and debriefing with videotaped recordings complete with vital sign overlay. Over a 3-year period the cart delivered 57 courses to 425 participants from five pediatric departments. All individuals were trained among their native teams and within their own clinical environment. CONCLUSIONS: By bringing all pedagogical elements to the actual clinical environment, a mobile cart can provide simulation to hospital teams that might not otherwise benefit from the educational tool. By reducing the setup cost and the need for dedicated space, the mobile approach provides a mechanism to increase the number of institutions capable of harnessing the power of simulation-based education internationally.

Electroencephalography artifacts in workplace alertness monitoring.

OBJECTIVE: This study assessed the effect of removing artifacts from workplace electroencephalography (EEG) recordings on power spectra and the consequent interpretation of changes in alertness. METHODS: EEG was recorded for 27 air traffic controllers on the night shifts of four roster cycles. On two of the four night shifts, each controller was given a 40-minute opportunity to nap, while on the other two they remained awake (105 shifts in total). Recordings for the last hour of each night shift were screened for artifacts by an experienced viewer (who viewed the EEG in isolation from other electrophysiological recordings). The effects of the nap opportunity on the EEG power spectra were then analyzed in a mixed model analysis of variance in the presence and absence of artifact-contaminated data. RESULTS: Overall, 89.3% of the EEG recordings contained artifacts. Removal of these data markedly altered the interpretation of how the nap opportunities affected the EEG power spectra. The spectral parameters of the artifact appeared to be different when the participants were given the opportunity to nap. CONCLUSIONS: Removal of artifacts can dramatically affect the interpretation of workplace EEG recordings. This potential source of error is often unreported.

Work patterns and fatigue-related risk among junior doctors.

BACKGROUND: To reduce fatigue-related risk among junior doctors, recent initiatives in Europe and the USA have introduced limits on work hours. However, research in other industries has highlighted that other aspects of work patterns are important in generating fatigue, in addition to total work hours. The Australian Medical Association (AMA) has proposed a more comprehensive fatigue risk management approach. OBJECTIVES: To evaluate the work patterns of New Zealand junior doctors based on the AMA approach, examining relationships between different aspects of work and fatigue-related outcomes. METHODS: An anonymous questionnaire mailed to all house officers and registrars dealt with demographics, work patterns, sleepiness, fatigue-related clinical errors, and support for coping with work demands. Each participant was assigned a total fatigue risk score combining 10 aspects of work patterns and sleep in the preceding week. RESULTS: The response rate was 63% (1366 questionnaires from doctors working > or =40 hours a week). On fatigue measures, 30% of participants scored as excessively sleepy (Epworth Sleepiness Score >10), 24% reported falling asleep driving home since becoming a doctor, 66% had felt close to falling asleep at the wheel in the past 12 months, and 42% recalled a fatigue-related clinical error in the past 6 months. Night work and schedule instability were independently associated with more fatigue measures than was total hours worked, after controlling for demographic factors, The total risk score was a significant independent risk factor for all fatigue measures, in a dose-dependent manner (all p<0.01). Regular access to adequate supervision at work reduced the risk of fatigue on all measures. CONCLUSIONS: To reduce fatigue-related risk among junior doctors, account must be taken of factors in addition to total hours of work and duration of rest breaks. The AMA fatigue risk assessment model offers a useful example of a more comprehensive approach.

Effective management of anaesthetic crises: development and evaluation of a college-accredited simulation-based course for anaesthesia education in Australia and New Zealand.

The Effective Management of Anesthetic Crises (EMAC) course is a joint initiative between the Australian and New Zealand College of Anesthetists (ANZCA) and simulation centers. This standardized 2.5-day course has become an integral component of training for Fellowship of ANZCA and as such is an innovative development on the global anesthesia scene.Since its inception in 2002, over 600 anesthetists, with equal numbers of specialists and trainees, have attended EMAC throughout Australia, New Zealand, and Hong Kong. Course evaluations from 499 anesthetists and a follow-up survey showed strong support for the course and its relevance to clinical practice. The course is perceived by participants as changing their practice and improving their management of anesthetic crises.Exposure to the concepts of effective crisis management is now widespread in the anesthetic community in the region and should contribute to improved patient safety.

Education to address medical error--a role for high fidelity patient simulation.

AIMS: To describe and evaluate a simulation based course that emphasizes the role of teamwork in the management of both crises and errors. METHODS: The course allowed participants to experience and manage simulated crises. Emphasis was placed on important error management strategies such as communication, leadership and delegation of workload. A computerized mannequin that is physiologically and pharmacologically responsive was used to run life-like crisis scenarios. The scenarios were videotaped and reviewed during a debriefing discussion after each crisis. Scenarios were alternated with tutorials that addressed error management, communication and medico-legal issues. Participants evaluated the courses using 5-point Likert scales and free comments. RESULTS: In 1999 and 2000, 172 participants (34% of New Zealand anaesthetists) attended one of these courses. Evaluation forms were received from 151 participants (88%). The global evaluations had median scores of 4 or 5 and all respondents would recommend the course to others. The responses from 50 participants indicated that the course should be repeated at least every two years. CONCLUSION: New Zealand anaesthetists found this an acceptable and useful form of training. Teamwork is an effective strategy in crisis management and error reduction and is worthy of consideration within the broader context of medical education.