Identification, Characterization, and Ranking of Candidate Metrics for Selection to Anesthesiology Residency: An Iterative Survey of Program Directors.

Background: The primary aim of this study was to identify and stratify candidate metrics used by anesthesiology residency program directors (PDs) to develop their residency rank lists through the National Resident Matching Program. Methods: Sixteen PDs comprised the participants, selected for diversity in geography and program size. We used a 3-round iterative survey to identify and stratify candidate metrics. In the first round, participants listed metrics they planned to use to evaluate candidates. In the second round, metrics from the first round were ranked by importance, and criteria were solicited to define an exceptional, strong, average, marginal, and uncompetitive candidate for each metric. In the third round, aggregated results were presented and participants refined their rankings. Results: Of the 16 PDs selected, 15 participated in the first and second survey rounds, and 10 in the third. Eighteen candidate metrics were indicated by 8 or more PDs for residency selection. All 10 PDs from the final round identified passing Step 1 of the United States Medical Licensing Exam (USMLE) and the absence of "red flags" like a failed rotation as key selection metrics, both averaging an importance score of 4.9 out of 5. Other metrics identified by all PDs included clerkship evaluation comments, USMLE Step 2 scores, class rank, letters of recommendation, personal statement, and program and geographical signals. Conclusions: The study reveals key metrics anesthesiology residency PDs use for candidate ranking, which may offer candidates insights into their competitiveness for anesthesiology residency.

Assessment of cardiopulmonary point-of-care ultrasound objective structured clinical examinations in graduating anesthesiology residents across multiple residency programs.

STUDY OBJECTIVE: To implement and assess a cardiopulmonary point-of-care ultrasound (POCUS) objective structured clinical examination (OSCE) in a large cohort of graduating anesthesia residents. DESIGN: Observational cohort study. SETTING: University-affiliated hospitals. SUBJECTS: 150 graduating anesthesia residents in their last nine months of training. INTERVENTIONS: A standardized cardiopulmonary OSCE was administered to each resident. MEASUREMENTS: The cardiac views evaluated were parasternal long axis (PLAX), apical 4 chamber (A4C), and parasternal short axis (PSAX). The pulmonary views evaluated were pleural effusion (PLE) and pneumothorax (PTX). In addition, a pre- and post-exam survey scored on a 5-point Likert scale was administered to each resident. MAIN RESULTS: A4C view (mean 0.7 ± 0.3) scored a lower mean, compared to PSAX (mean 0.8 ± 0.3) and PLAX (mean 0.8 ± 0.4). Residents performed well on the PTX exam (mean 0.9 ± 0.3) but more poorly on the PLE exam (mean 0.6 ± 0.4). Structural identification across cardiac and pulmonary views were mostly high (means >0.7), but advanced interpretive skills and maneuvers had lower mean scores. Pre- and post- OSCE survey results were positive with almost all questions scoring >4 on the Likert scale. CONCLUSION: Our study demonstrates that a cardiopulmonary POCUS OSCE can be successfully implemented across multiple anesthesia training programs. While most residents were able to perform basic ultrasound views and identify structures, advanced interpretive skills and maneuvers performed lower.

Defining entrustable professional activities for first year anesthesiology residents: A Delphi study.

INTRODUCTION: The use of entrustable professional activities (EPAs) as a basis for assessment may bridge the gap between the theory of competency-based education and clinical practice. The purpose of this study was to develop and validate EPAs for United States (US) first-year clinical anesthesia (CA-1) residents for anesthesiology residency programs to use as the basis for curriculum development and workplace assessment. METHODS: From a list of EPAs abstracted from the literature, an expert panel through a modified Delphi consensus process established EPAs for the CA1 curriculum. RESULTS: The final list of EPAs after group consensus had 28 EPAs, with 14 (50%) considered to be applicable to the CA-1 year. An 80% consensus rate was used to accept or reject the final list. CONCLUSION: This study applied a construct validity lens to EPA development providing assurance that the EPAs adopted are appropriate for use in workplace-based assessment and entrustment decision-making.

Milestone Learning Trajectories of Residents at Five Anesthesiology Residency Programs.

Construct: Every six months, residency programs report their trainees' Milestones Level achievement to the Accreditation Council for Graduate Medical Education (ACGME). Milestones should enable the learner and training program to know an individual's competency development trajectory. Background: Milestone Level ratings for residents grouped by specialty (e.g., Internal Medicine and Emergency Medicine) show that, in aggregate, senior residents receive higher ratings than junior residents. Anesthesiology Milestones, as assessed by both residents and faculty, also have a positive linear relationship with postgraduate year. However, these studies have been cross-sectional rather than longitudinal cohort studies, and studies of how individual residents progress during the course of training are needed. Longitudinal data analysis of performance assessment trajectories addresses a relevant validity question for the Next Accreditation System. We explored the application of learning analytics to longitudinal Milestones data to: 1) measure the frequency of "straight-lining"; 2) assess the proportion of residents that reach "Level 4" (ready for unsupervised practice) by graduation for each subcompetency; 3) identify variability among programs and individual residents in their baseline Milestone Level and rates of improvement; and 4) determine how hypothetically constructed growth curve models fit to the Milestones data reported to ACGME. Approach: De-identified Milestone Level ratings in each of the 25 subcompetencies submitted semiannually to the ACGME from July 1, 2014 to June 30, 2017 were retrospectively analyzed for graduating residents (n = 67) from a convenience sample of five anesthesia residency programs. The data reflected longitudinal resident Milestone progression from the beginning of the first year to the end of the third and final year of clinical anesthesiology training. The frequency of straight-lining, defined as the resident receiving the same exact Milestone Level rating for all 25 subcompetencies on a given 6-month report, was calculated for each program. Every resident was evaluated six times during training with the possibility of six straight-lined ratings. Findings: The number of residents in each program ranged from 5-21 (Median 13, range 16). Mean Milestone Level ratings for subcompetencies were significantly different at each six-month assessment (p < 0.001). Frequency of straight-lining varied significantly by program from 9% - 57% (Median 22%). Depending on the program, 53%-100% (median 86%) of residents reached the graduation target Level 4 or higher in all 25 anesthesiology subcompetencies. Nine to 18% of residents did not achieve a Level 4 rating for at least one subcompetency at any time during their residency. Across programs, significant variability was found in first-year clinical anesthesia training Milestone Levels, as well in the rate of improvement for five of the six core competencies. Conclusions: Anesthesia residents' Milestone Level growth trajectories as reported to the ACGME vary significantly across individual residents as well as by program. The present study offers a case example that raises concerns regarding the validity of the Next Accreditation System as it is currently used by some residency programs.

Utilization of Intraoperative Real-time Three-Dimensional Transoesophageal Echocardiography to Objectively Assess Improvement in Synchronization and Regional Wall Motion after Coronary Reperfusion.

It is well known that myocardial ischemia leads to Regional Wall Motion Abnormalities (RWMAs) and reversible depression of Left Ventricular (LV) systolic function. Transoesophageal Echocardiography (TEE) is an established tool for early diagnosis of new RWMAs. However, evaluation of RWMAs by echocardiography is largely qualitative and relies on visual assessment of wall segments. Evaluation of LV systolic function and Ejection Fraction (EF) is more reproducible and accurate with Real-Time 3D Echocardiography (RT3DE) as compared with two-dimensional and M-mode techniques. Primary advantages for RT3DE are fast and largely automated volumetric analysis of LV function and LV volumes, without geometric assumptions and risk of underestimating volumes in foreshortened views. This case illustrates the use of intraoperative RT3DE during coronary artery bypass surgery to objectively assess: LV systolic function with LV volumes and RWMAs and improvement in cardiac synchronization following coronary reperfusion.

Acute ascending aortic intramural hematoma as a complication of the endovascular repair of a Type B aortic dissection.

Endovascular aortic graft repair (EVAR) for patients with Type B aortic dissection is a less invasive surgical procedure (compared to traditional open surgical repair) that is associated with less morbidity and shortened recovery times. However, there are notable complications for the patients undergoing EVAR. We report a patient who was brought to our hospital with a Type B dissection and underwent a thoracic EVAR but suffered iatrogenic aortic injury resulting in cardiac tamponade. This case study highlights the importance of intraoperative transesophageal echocardiography to facilitate early detection of possible EVAR complications.

Pre-operative regional block anesthesia enhances operative strategy for arteriovenous fistula creation.

PURPOSE: We aim to assess the effect of regional block anesthesia on vein diameter, type of AVF placement, and fistula size and flow volume. METHODS: 30 patients presenting for AV access procedures were followed prospectively. Vein diameters via venous ultrasound and planned location for AV access were documented. Supraclavicular brachial plexus block was followed by repeat ultrasound and alterations in operative plan were noted. Patients returned to clinic for duplex ultrasound assessment. RESULTS: Average increase from baseline vein diameter with regional block was most pronounced in the lower cephalic (34%), upper cephalic (24.2%), and basilic veins (31.3%) and less in the brachial vein (8.7%). Type of AVF was modified following regional block in 14%. The rate of native AVF placement improved from 89% to 93% with regional block. Twenty-three AVF patients were available for follow-up (mean 24 weeks). Average fistula size was 7.9 mm (CI 6.9-8.9) and all patent fistulas developed flow volume >600 mL/min. Primary patency was attained in 83%. One thrombosis occurred after a basilic artery was lacerated during dialysis access. The average fistula increased 0.33 cm from post-block diameter (SD 0.22, P<.05). CONCLUSIONS: Vein diameter increases significantly in the basilic and cephalic veins following regional block anesthesia and may improve the rate of native fistula placement. Propensity to dilate after regional block anesthesia does not predict size of the fistula.

Efficacy of an ultrasound-guided subsartorial approach to saphenous nerve block: a case series.

PURPOSE: The saphenous nerve, a branch of the femoral nerve, is a pure sensory nerve that supplies the anteromedial aspect of the lower leg from the knee to the foot. There is limited evidence of the effectiveness of ultrasound-guided techniques to block the saphenous nerve. We therefore undertook a retrospective case series to investigate the efficacy of an ultrasound-guided subsartorial approach to saphenous nerve block. METHODS: During a four-month period, all patients receiving a subsartorial saphenous nerve block for lower extremity surgery at our institution had their medical records reviewed. Patient demographics and data were recorded, including block characteristics, intraoperative anesthetic management, pre-block, post-block, and postoperative pain scores, as well as postoperative analgesic dosing. Preoperative block success was defined by minimal intraoperative analgesic administration and a pain score of 0 in the postanesthesia care unit not requiring analgesic supplementation. Postoperative block success was defined by reduction of pain score to 0 without need for additional analgesic dosing. RESULTS: Thirty-nine consecutive patients were identified as receiving an ultrasound-guided subsartorial saphenous nerve block. Overall, this ultrasound-guided technique was found to have a 77% success rate. CONCLUSION: This case series shows that an ultrasound-guided subsartorial approach to saphenous nerve blockade is a moderately effective means to anesthetize the anteromedial lower extremity. The success rate is based on stringent criteria with an endpoint of postoperative analgesia. A randomized prospective study would provide a more definitive answer regarding the efficacy of this technique for surgical anesthesia.