Designing and Implementing a Competency-Based Training Program for Anesthesiology Residents at the University of Ottawa.

Competency-based medical education is gaining traction as a solution to address the challenges associated with the current time-based models of physician training. Competency-based medical education is an outcomes-based approach that involves identifying the abilities required of physicians and then designing the curriculum to support the achievement and assessment of these competencies. This paradigm defies the assumption that competence is achieved based on time spent on rotations and instead requires residents to demonstrate competence. The Royal College of Physicians and Surgeons of Canada (RCPSC) has launched Competence by Design (CBD), a competency-based approach for residency training and specialty practice. The first residents to be trained within this model will be those in medical oncology and otolaryngology-head and neck surgery in July, 2016. However, with approval from the RCPSC, the Department of Anesthesiology, University of Ottawa, launched an innovative competency-based residency training program July 1, 2015. The purpose of this paper is to provide an overview of the program and offer a blueprint for other programs planning similar curricular reform. The program is structured according to the RCPSC CBD stages and addresses all CanMEDS roles. While our program retains some aspects of the traditional design, we have made many transformational changes.

Impact of anesthetic handover on mortality and morbidity in cardiac surgery: a cohort study.

OBJECTIVE: Clinical handover is a critical moment in patient care. The authors tested the hypothesis that handover of anesthesia care is associated with increased mortality and morbidity in patients undergoing cardiac surgery. DESIGN: This was a single-center, retrospective cohort study of prospectively collected data. SETTING: The study was conducted in a quaternary care cardiac surgery center and university research hospital. PARTICIPANTS: All patients undergoing cardiac surgical procedures between April 1, 1999 and October 31, 2009 were included in the study. INTERVENTIONS: Propensity-score matching was used to adjust for differences between patients who received intraoperative handover of anesthesia care and those who did not, and in-hospital mortality and morbidity were compared using multivariate logistic modeling. MEASUREMENTS AND MAIN RESULTS: 14,421 patients met the inclusion criteria for this study; handover occurred in 966 cases (6.7%). After propensity-score matching, 7,137 patients were included for analysis. In-hospital mortality was 5.4% in the handover group and 4.0% in the non-handover group (match-adjusted odds ratio, 1.425; 95% confidence interval, 1.013-2.006; p = 0.0422); the incidence of major morbidity was 18.5% in the handover group and 15.6% in the non-handover group (match-adjusted odds ratio, 1.274; 95% confidence interval, 1.037-1.564; p = 0.0212). CONCLUSIONS: Handover of anesthetic care during cardiac surgery is associated with a 43% greater risk of in-hospital mortality and 27% greater risk of major morbidity. Further studies are required to explore this relationship and to systematically evaluate and improve the process of handover.

Impact of subglottic suctioning on the incidence of pneumonia after cardiac surgery: a retrospective observational study.

OBJECTIVE: Continuous aspiration of subglottic secretions (CASS) has been found to decrease the incidence of pneumonia in the general intensive care unit (ICU) population, but its benefit in cardiac surgery patients is unclear. The present study aimed to determine whether the routine use of CASS in cardiac surgical patients was associated with decreased pneumonia. DESIGN: A retrospective, single-center observational study. SETTING: The study was conducted in a quaternary care cardiac surgery center and university research hospital. PARTICIPANTS: 4,880 patients undergoing cardiac surgery were studied. INTERVENTIONS: The control group (no CASS) received a standard endotracheal tube and underwent surgery between April 1, 2007 and March 31, 2009. The intervention group (CASS) received a subglottic suctioning endotracheal tube and underwent surgery between June 1, 2009 and May 31, 2011. The primary outcome was the development of pneumonia, and the secondary outcomes were 30-day in-hospital mortality, ventilation time, need for tracheostomy, ICU length of stay (LOS), and hospital LOS. MEASUREMENTS AND MAIN RESULTS: The unadjusted incidence of pneumonia was 1.9% in the CASS group and 5.6% in the control group (p<0.0001). The CASS group also had lower 30-day in-hospital mortality (2.1% v 3.3%; p = 0.007), median ventilation time (8.42 v 7.3 hours; p<0.0001), and shorter median ICU LOS (1.77 v 1.17 days; p<0.0004) compared with the control group. Tracheostomy rates and median hospital LOS did not differ between groups. After adjusting using multivariable modeling, CASS remained an independent risk predictor for pneumonia (odds ratio [OR] 0.342, 95% confidence interval [CI] 0.239-0.490) and ICU LOS (OR 0.817, 95% CI 0.718-0.931). CONCLUSIONS: The universal implementation of CASS in a quaternary care cardiac surgical population was associated with a decreased incidence of pneumonia.

Severe tracheobronchial compression in a patient with Turner's syndrome undergoing repair of a complex aorto-subclavian aneurysm: anesthesia perspectives.

We present a case of severe tracheobronchial compression from a complex aorto-subclavian aneurysm in a patient with Turner's syndrome undergoing open surgical repair. Significant airway compression is a challenging situation and requires careful preoperative preparation, maintenance of spontaneous breathing when possible, and consideration of having an alternative source of oxygenation and circulation established prior to induction of general anesthesia. Cardiopulmonary monitoring is essential for safe general anesthesia and diagnosis of unexpected intraoperative events.

Glycosylated hemoglobin levels and outcome in non-diabetic cardiac surgery patients.

PURPOSE: In diabetics, elevated preoperative hemoglobin A1c (HbA1c) levels are associated with increased complication rates after cardiac surgery. While many non-diabetics also have elevated HbA1c, the relationship with outcome in these patients is not well understood. Therefore, in a cohort of non-diabetic patients, we tested the hypothesis that preoperative HbA1c is associated with early mortality risk after cardiac surgery. METHODS: In this retrospective observational study, we accessed data from a prospectively collected quality assurance database for a cohort of 1,474 non-diabetic elective cardiac surgery patients with documented preoperative HbA1c levels. The relationship of HbA1c with death within 30 days of surgery was examined using logistic regression modeling. Acute kidney injury and infection were similarly assessed using multivariable linear and logistic regression. RESULTS: Thirty-one percent of patients (n = 456) had elevated HbA1c values (>6.0%). Patients with elevated HbA1c had higher fasting and peak intraoperative blood glucose values. Also, an elevated HbA1c level was independently associated with increased 30-day mortality (odds ratio 1.53 per percent increase [1.24-1.91]; P = 0.0005). This relationship persisted even after "borderline" diabetics were excluded. Furthermore, acute kidney injury was associated with elevated baseline HbA1c (P = 0.01). No association was found between HbA1c and postoperative infection risk (P = 0.48). CONCLUSION: In non-diabetics, an elevated preoperative HbA1c level (>6.0%) is independently associated with significantly greater early mortality risk after elective cardiac surgery. Our findings suggest that HbA1c may have value as a screening tool to identify high-risk non-diabetic cardiac surgery patients.

Impact of early renal recovery on survival after cardiac surgery-associated acute kidney injury.

BACKGROUND: Cardiac surgery-associated acute kidney injury (CSA-AKI) is a major postoperative complication. Although some early recovery is common, its effect on long-term outcomes is unclear. We tested the hypothesis that early renal recovery after CSA-AKI is independently associated with improved long-term survival. METHODS: Data were examined for 10,275 consecutive patients undergoing isolated coronary artery bypass grafting from 1996 to 2005. Patients with CSA-AKI were identified, defined as a peak postoperative creatinine level exceeding 50% above baseline. Renal recovery was characterized using postoperative creatinine values. The recovery variable with the strongest association with 1-year survival was selected and validated internally. The independent association of early renal recovery with long-term survival during a 10-year follow-up was assessed with Cox proportional hazards modeling. RESULTS: CSA-AKI occurred in 1113 patients (10.8%). The renal recovery variable with the strongest association with 1-year survival was the percentage decrease in creatinine 24 hours after its peak value (PD24; C index, 0.72; p=0.002). Cox proportional hazards analysis showed a significant negative association between PD24 and long-term mortality (0.82 hazard ratio for each 10% change). CONCLUSIONS: Early recovery of renal function is associated with improved long-term survival after CSA-AKI. This variable is clinically useful because it occurs immediately after the peak creatinine level and simultaneously helps define the severity of AKI and the magnitude of recovery. Given the high risk of death associated with postoperative AKI, early renal recovery seems to offer a distinct survival benefit and may represent an important therapeutic focus.