Using simulation to iteratively test and re-design a cognitive aid for use in the management of severe local anaesthetic toxicity.

Introduction: Cognitive aids, such as a guideline for the management of severe local anaesthetic (LA) toxicity, are tools designed to help users complete a task. Human factors experts recommend the use of simulation to iteratively test and re-design these tools. The purpose of this study was to apply human factors engineering principles to the testing and iterative re-design of three existing cognitive aids used for the management of severe LA toxicity and to use these data to develop a 'new' cognitive aid. Methods: Twenty anaesthetist-anaesthetic assistant pairs were randomised into four groups. Each of the first three groups received one of three different existing cognitive aids during a standardised simulated LA toxicity crisis. Postsimulation semistructured interviews were conducted to identify features beneficial and detrimental to the format and usability of the aid. Synthesis of the interview data with established checklist design recommendations resulted in a prototype aid, which was subjected to further testing and re-design by the fourth group (five more pairs) under the same conditions thus creating the final iteration of the new aid. Results: Features of the new aid included a single-stream flowchart structure, single-sided, large-font design with colour contrast, simplified instructions and no need for calculations. This simplified tool contains only the information users reported as essential for the immediate crisis management. Conclusions: Utilisation of formative usability testing and simulation-based user-centred design resulted in a visually very different cognitive aid and reinforces the importance of designing aids in the context in which they are to be used. Simplified tools may be more appropriate for use in emergencies but more detailed guidelines may be necessary for training, education and development of local standard operating procedures. Iterative simulation-based testing and re-design is likely to be of assistance when developing aids for other crises, and to eliminate design failure as a confounder when investigating the relationship between use of cognitive aids and performance.

Classroom and simulation team training: a randomized controlled trial.

OBJECTIVE: To test the hypotheses that classroom and simulation-based crew resource management (CRM) training interventions improve teamwork attitudes and behaviours of participants and that classroom training combined with simulation-based training provide synergistic improvements. DESIGN: A randomized controlled trial. SETTING: Area Health Service in New South Wales, Australia. PARTICIPANTS: A total of 157 doctors, nurses and midwives randomized into one of four groups, consisting of three intervention groups and a control group. INTERVENTION: One-day CRM-based classroom course; one-day CRM style simulation-based training or classroom training followed by simulation-based training. MAIN OUTCOME MEASURES: Pre- and post-test quantitative participant teamwork attitudes, and post-test quantitative trainee reactions, knowledge and behaviour. RESULTS: Ninety-four doctors, nurses and midwives completed pre-intervention attitude questionnaires and 60 clinicians completed post-intervention assessments. No positive changes in teamwork attitudes were found associated with classroom or simulation training. Positive changes were found in knowledge (mean difference 1.50, 95% confidence interval (CI) 0.58-2.43, P = 0.002), self-assessed teamwork behaviour (mean difference 2.69, 95% CI 0.90-6.13, P = 0.009) and independently observed teamwork behaviour (mean difference 2.30, 95% CI 0.30-4.30, P = 0.027) when classroom-only trained group was compared with control; however, these changes were not found in the group that received classroom followed by simulation training. CONCLUSIONS: Classroom-based training alone resulted in improvements in participant knowledge and observed teamwork behaviour. The study found no additional impact of simulation training.

Managing quality in an anesthesia department.

PURPOSE OF REVIEW: To provide a practical approach to measure and then improve the quality of an academic anesthesia department. RECENT FINDINGS: The quality of any entity is defined by the user. Anesthesia departments should adopt practices that meet their specific operational needs. The relative importance of each of the user groups will be determined by the purpose of an individual department. Four categories of users will be considered: patients, surgeons (and other proceduralists), the hospital organization and the department itself (i.e. faculty and trainees). Patients value avoiding nausea and vomiting and pain after surgery, surgeons want cases to start on time with low turnover times, and the hospital desires high throughput of surgical cases, all facilitated by department faculty who value professional development. Quality improvement efforts in anesthesia should be aligned with broad healthcare quality improvement initiatives and avoid distortions in perceptions of quality by over-emphasizing what is easily measurable at the expense of what is important. SUMMARY: Departments of anesthesia should develop performance criteria in multiple domains and recognize the importance of human relationships (between staff and between staff and patients) in quality and safety. To improve the value of anesthesia services, departments should identify their user groups, survey them to determine what attributes are important to the user, then deliver, measure, monitor and improve them on an ongoing basis.

How much work is enough work? Results of a survey of US and Australian anesthesiologists' perceptions of part-time practice and part-time training.

This article reports the results of a written survey administered to anesthesiologists in Australia and the United States regarding their opinions toward part-time practice and training. Although type of work and case volume were acknowledged to be important, most respondents reported a need for guidelines regarding levels of minimum acceptable clinical activity. A major recurring theme was that interindividual variation in competence is so great that no one set of rules can encompass each individual's circumstances with regard to minimum hours to stay competent and need to re-train after more than 6 months away from routine clinical practice. Guidelines regarding volume and variety of clinical work to acquire and maintain competence while practicing part-time may deserve further study to maintain quality and safety.

Part-time clinical anesthesia practice: a review of the economic, quality, and safety issues.

Part-time clinical practice in anesthesia is increasing due to the feminization and the aging of the medical workforce, as well as the arrival of generations X and Y to the health care workforce. Recruiting the best and brightest physicians requires accommodating their needs and interests, as well as retaining older workers who wish to reduce their hours as they approach retirement. This article discusses steps to help departments or groups optimally manage the part-time anesthesia workforce.

The impact of service-specific staffing, case scheduling, turnovers, and first-case starts on anesthesia group and operating room productivity: a tutorial using data from an Australian hospital.

BACKGROUND: In this tutorial, we consider the impact of operating room (OR) management on anesthesia group and OR labor productivity and costs. Most of the tutorial focuses on the steps required for each facility to refine its OR allocations using its own data collected during patient care. METHODS: Data from a hospital in Australia are used throughout to illustrate the methods. OR allocation is a two-stage process. During the initial tactical stage of allocating OR time, OR capacity ("block time") is adjusted. For operational decision-making on a shorter-term basis, the existing workload can be considered fixed. Staffing is matched to that workload based on maximizing the efficiency of use of OR time. RESULTS: Scheduling cases and making decisions on the day of surgery to increase OR efficiency are worthwhile interventions to increase anesthesia group productivity. However, by far, the most important step is the appropriate refinement of OR allocations (i.e., planning service-specific staffing) 2-3 mo before the day of surgery. CONCLUSIONS: Reducing surgical and/or turnover times and delays in first-case-of-the-day starts generally provides small reductions in OR labor costs. Results vary widely because they are highly sensitive both to the OR allocations (i.e., staffing) and to the appropriateness of those OR allocations.

Mean operating room times differ by 50% among hospitals in different countries for laparoscopic cholecystectomy and lung lobectomy.

We explored whether there were large differences in operating room (OR) times for two common procedures performed by multiple surgeons at each of several hospitals thousands of miles apart. Mean OR time, "wheels in" to "wheels out," for ten consecutive cases of each of laparoscopic cholecystectomy and lung lobectomy were obtained for each of ten hospitals in eight countries from their OR logs. After log transformation, the OR times were analyzed by analysis of variance. Mean OR times differed significantly among hospitals (P = 0.006, laparoscopic cholecystectomy; P < 0.001, lung lobectomy). The second longest average OR time was 50% longer than the second shortest average OR time for both laparoscopic cholecystectomy and lung lobectomy. Differences in OR times among the hospitals we studied were large enough to affect the productivity of OR nurses and anesthesia providers. Thus, international benchmarking studies to understand differences in OR times worldwide may be beneficial.

Inhibition of chymotrypsin through surface binding using nanoparticle-based receptors.

Efficient binding of biomacromolecular surfaces by synthetic systems requires the effective presentation of complementary elements over large surface areas. We demonstrate here the use of mixed monolayer protected gold clusters (MMPCs) as scaffolds for the binding and inhibition of chymotrypsin. In these studies anionically functionalized amphiphilic MMPCs were shown to inhibit chymotrypsin through a two-stage mechanism featuring fast reversible inhibition followed by a slower irreversible process. This interaction is very efficient, with a K(i)(app) = 10.4 +/- 1.3 nM. The MMPC-protein complex was characterized by CD, demonstrating an almost complete denaturation of the enzyme over time. Dynamic light scattering studies confirm that inhibition proceeds without substantial MMPC aggregation. The electrostatic nature of the engineered interactions provides a level of selectivity: little or no inhibition of function was observed with elastase, beta-galactosidase, or cellular retinoic acid binding protein.

Gold nanoparticle-mediated transfection of mammalian cells.

Mixed monolayer protected gold clusters (MMPCs) functionalized with quaternary ammonium chains efficiently transfect mammalian cell cultures, as determined through beta-galactosidase transfer and activity. The success of these transfection assemblies depended on several variables, including the ratio of DNA to nanoparticle during the incubation period, the number of charged substituents in the monolayer core, and the hydrophobic packing surrounding these amines. Complexes of MMPCs and plasmid DNA formed at w/w ratios of 30 were most effective in promoting transfection of 293T cells in the presence of 10% serum and 100 microM chloroquine. The most efficient nanoparticle studied (MMPC 7) was approximately 8-fold more effective than 60 kDa polyethylenimine, a widely used transfection agent.