Current state of reflective learning in anaesthesiology residents: a call for 'reflection-on-action' training in Singapore.

INTRODUCTION: Reflective learning is the cognitive process whereby information from new experiences is integrated into existing knowledge structures and mental models. In our complex healthcare system, reflective learning (specifically 'reflection on action') is important for postgraduate learners. We observed that our anaesthesiology residents were not building on their competence through deliberate experiential and reflective practice. This qualitative study explored the current state and challenges of reflective learning in anaesthesia training in Singapore. METHODS: This study was conducted at KK Women's and Children's Hospital, Singapore, from 1 January 2018 to 31 October 2018. A semi-structured interview format was used in focus groups. Information collection continued until data saturation was reached. The interviews were coded and analysed, and themes were identified. Seven focus group interviews involving 19 participants were conducted. RESULTS: Reflective learning was found to be poor. It was of concern that the stimuli for reflection and reflective learning emerged from medical errors, critical incidents and poor patient outcomes. Challenges identified were: (a) lack of an experiential learning framework; (b) need for reflective training; (c) quality of experiential triggers; (d) clinical pressures; and (e) poor learner articulation and feedback. We described some strategies to frame, teach and stimulate reflective learning. CONCLUSION: This study described the state and challenges of reflective learning in anaesthesia training. We advocate the implementation of reflective training strategies in postgraduate training programmes in Singapore. Research is warranted to integrate patient feedback and outcomes into reflective practice.

Fibreoptic intubation in airway management: a review article.

Since the first use of the flexible fibreoptic bronchoscope, a plethora of new airway equipment has become available. It is essential for clinicians to understand the role and limitations of the available equipment to make appropriate choices. The recent 4th National Audit Project conducted in the United Kingdom found that poor judgement with inappropriate choice of equipment was a contributory factor in airway morbidity and mortality. Given the many modern airway adjuncts that are available, we aimed to define the role of flexible fibreoptic intubation in decision-making and management of anticipated and unanticipated difficult airways. We also reviewed the recent literature regarding the role of flexible fibreoptic intubation in specific patient groups who may present with difficult intubation, and concluded that the flexible fibrescope maintains its important role in difficult airway management.

Development and validation of a predictive risk factor model for epidural re-siting in women undergoing labour epidural analgesia: a retrospective cohort study.

BACKGROUND: Epidural catheter re-siting in parturients receiving labour epidural analgesia is distressing to the parturient and places them at increased complications from a repeat procedure. The aim of this study was to develop and validate a clinical risk factor model to predict the incidence of epidural catheter re-siting in labour analgesia. METHODS: The data from parturients that received labour epidural analgesia in our centre during 2014-2015 was used to develop a predictive model for epidural catheter re-siting during labour analgesia. Multivariate logistic regression analysis was used to identify factors that were predictive of epidural catheter re-siting. The forward, backward and stepwise variable selection methods were applied to build a predictive model, which was internally validated. The final multivariate model was externally validated with the data collected from 10,170 parturients during 2012-2013 in our centre. RESULTS: Ninety-three (0.88%) parturients in 2014-2015 required re-siting of their epidural catheter. The training data set included 7439 paturients in 2014-2015. A higher incidence of breakthrough pain (OR = 4.42), increasing age (OR = 1.07), an increased pain score post-epidural catheter insertion (OR = 1.35) and problems such as inability to obtain cerebrospinal fluid in combined spinal epidural technique (OR = 2.06) and venous puncture (OR = 1.70) were found to be significantly predictive of epidural catheter re-siting, while spontaneous onset of labour (OR = 0.31) was found to be protective. The predictive model was validated internally on a further 3189 paturients from the data of 2014-2015 and externally on 10,170 paturients from the data of 2012-2013. Predictive accuracy of the model based on C-statistic were 0.89 (0.86, 0.93) and 0.92 (0.88, 0.97) for training and internal validation data respectively. Similarly, predictive accuracy in terms of C-statistic was 0.89 (0.86, 0.92) based on 2012-2013 data. CONCLUSION: Our predictive model of epidural re-siting in parturients receiving labour epidural analgesia could provide timely identification of high-risk paturients required epidural re-siting.