Anaesthetists' non-technical skills.

This review presents the background to the development of the anaesthetists' non-technical skills (ANTS) taxonomy and behaviour rating tool, which is the first non-technical skills framework specifically designed for anaesthetists. We share the experience of the anaesthetists who designed ANTS in relation to applying it in a department of anaesthesia, using it in a simulation centre, and the process of introducing it to the profession on a national basis. We also consider how ANTS is being applied in relation to training and research in other countries and finally, we discuss emerging issues in relation to the introduction of a non-technical skills approach in anaesthesia.

Beyond monitoring: distributed situation awareness in anaesthesia.

Situation awareness (SA) is one of the essential non-technical skills for effective and safe practice in high-risk industries, such as healthcare; yet, there is limited research of its significance in anaesthetic practice. In this paper, we review this scant research that focuses on SA as patient monitoring alone and advocate for a more comprehensive view of SA in anaesthetic practice and training that extends beyond monitoring, namely, a distributed cognition approach. We identify further factors influencing anaesthetists' SA and provide a case that resulted in an anaesthetic fatality to illustrate the application of an alternative view of SA in anaesthesia. Distributed SA in anaesthetic practice provides the foundation for further research that may in turn influence the teaching and assessment of this important non-technical skill.

"There is a chain of Chinese whispers ...": empirical data support the call to formally teach handover to prequalification doctors.

BACKGROUND: Changing patterns of work in the hospital setting mean different teams look after the same group of patients over the course of any given day. Shift handovers, or hand/sign-off, can give rise to miscommunication of critical information, a patient safety issue. How can we best prepare new doctors for handover? METHODS: This was a qualitative, focus-group study, exploring the views of doctors (Foundation Year, Senior House Officers, Registrars and Consultants) and night nurse practitioners, in Aberdeen, UK. RESULTS: Five focus groups were carried out with 21 participants. Using framework analysis, five main themes relevant to the task of effectively handing over, and how to best teach handover, emerged. These were: definition of handover; experience of handover as a junior doctor; perceptions of junior doctors' handover skills and attitudes; systems factors, and their interaction with individual factors; and the "what" and the "how" of teaching handover. CONCLUSIONS: New doctors feel unprepared for handover and are seen as poor at handing over. Certain skills are required for effective handover, but professional attitudes are also critical. The skills identified reflect those suggested in policy documents based on expert panel views. Poor systems are a barrier to effective learning and practice. Our empirical approach adds to existing knowledge by highlighting that handover is not solely a skills-based task; there are complex interactions between individual and systems factors; and junior doctors should be prepared for handover prequalification. These data can be used to plan optimal handover teaching for medical students.

Peak expiratory flow in Afro-Caribbean children with and without sickle cell anaemia.

AIMS: To create a reference range of peak expiratory flow (PEF) results of Afro-Caribbean children and determine whether interpretation of PEF results in children with sickle cell anaemia (SCA) differed according to whether comparison was made of results obtained from children of similar age or height. METHODS: A prospective observational study was carried out in two specialist sickle cell disease clinics. Seventy-eight nonasthmatic African and Caribbean (AC) controls (age range 2.6-17.8 years), and 99 nonasthmatic SCA children (age range 3.4-17.3 years) were recruited. PEF was measured using a dry rolling sealed spirometer before and after bronchodilator therapy. RESULTS: PEF results in the AC controls correlated with height (r = 0.88, p< 0.0001). Comparison of similarly aged children demonstrated that pre- (p = 0.02) and post- (p = 0.04) bronchodilator PEF results were lower in the SCA children, but comparison of children of similar height revealed no statistically significant differences in PEF results between children with SCA and controls. The SCA children tended to be shorter than the controls. CONCLUSION: The results suggest PEF measurements are not a useful method of monitoring the respiratory status of children with sickle cell disease.

Pulmonary function abnormalities in children with sickle cell disease.

BACKGROUND: Adults with sickle cell disease (SCD) have restrictive lung function abnormalities which are thought to result from repeated lung damage caused by episodes of pulmonary vaso-occlusion; such episodes start in childhood. A study was therefore undertaken to determine whether children with SCD have restrictive lung function abnormalities and whether the severity of such abnormalities increases with age. METHODS: Sixty four children with SCD aged 5-16 years and 64 ethnic matched controls were recruited. Weight and sitting and standing height were measured, and lung function was assessed by measurement of lung volumes and forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF) before and after bronchodilator. RESULTS: Compared with the control subjects, the children with SCD had lower mean (SD) sitting height (69 (6.3) cm v 73 (7.7) cm; p=0.004), sitting:standing height ratio (0.50 (0.02) v 0.51 (0.01); p<0.0001), weight (33 (10.9) kg v 41 (14.9) kg; p=0.001), functional residual capacity measured by a helium gas dilution technique (1.2 (0.3) l v 1.3 (0.4) l; p=0.04), FEV1 (1.5 (0.5) l v 1.9 (0.7) l; p=0.0008), FVC (1.7 (0.6) l v 2.1 (0.8) l; p=0.001), and PEF (3.9 (1.3) l/s v 4.8 (1.5) l/s; p=0.0004). The effect of age on lung function differed significantly between the children with SCD and the controls for total lung capacity and vital capacity measured by plethysmography and functional residual capacity measured by helium gas dilution. CONCLUSION: Lung function differs significantly in children with SCD compared with ethnic matched controls of a similar age. Our results suggest that restrictive abnormalities may become more prominent with increasing age.

Anaesthetists' Non-Technical Skills (ANTS): evaluation of a behavioural marker system.

BACKGROUND: Non-technical skills are critical for good anaesthetic practice but are not addressed explicitly in normal training. Realization of the need to train and assess these skills is growing, but these activities must be based on properly developed skills frameworks and validated measurement tools. A prototype behavioural marker system was developed using human factors research techniques. The aim of this study was to conduct an experimental evaluation to establish its basic psychometric properties and usability. METHOD: The Anaesthetists' Non-Technical Skills (ANTS) system prototype comprises four skill categories (task management, team working, situation awareness, and decision making) divided into 15 elements, each with example behaviours. To investigate its experimental validity, reliably and usability, 50 consultant anaesthetists were trained to use the ANTS system. They were asked to rate the behaviour of a target anaesthetist using the prototype system in eight videos of simulated anaesthetic scenarios. Data were collected from the ratings forms and an evaluation questionnaire. RESULTS: The results showed that the system is complete, and that the skills are observable and can be rated with acceptable levels of agreement and accuracy. The internal consistency of the system appeared sound, and responses regarding usability were very positive. CONCLUSIONS: The findings of the evaluation indicated that the ANTS system has a satisfactory level of validity, reliability and usability in an experimental setting, provided users receive adequate training. It is now ready to be tested in real training environments, so that full guidelines can be developed for its integration into the anaesthetic curriculum.

Anaesthetists' attitudes to teamwork and safety.

A questionnaire survey was conducted with 222 anaesthetists from 11 Scottish hospitals to measure their attitudes towards human and organisational factors that can have an impact on effective team performance and consequently on patient safety. A customised version of the Operating Room Management Attitude Questionnaire (ORMAQ) was used. This measures attitudes to leadership, communication, teamwork, stress and fatigue, work values, human error and organisational climate. The respondents generally demonstrated positive attitudes towards the interpersonal aspects of their work, such as team behaviours and they recognised the importance of communication skills, such as assertiveness. However, the results suggest that some anaesthetists do not fully appreciate the debilitating effects of stress and fatigue on performance. Their responses were comparable with (and slightly more favourable than) those reported in previous ORMAQ surveys of anaesthetists and surgeons in other countries.

The importance of using ethnically appropriate reference ranges for growth assessment in sickle cell disease.

Height and weight were measured and body mass index (BMI) calculated in 56 sickle cell disease (SCD), 57 Caucasian (CC), and 63 African/Caribbean (AC) 3-9 year old children. The SCD children were taller, but had similar weight and BMI to the CC controls. The SCD group had lower weight and BMI than the AC controls. The AC controls were of greater height, weight, and BMI than CC controls. These data highlight the importance of using ethnically appropriate reference ranges.

Perioperative management of the elderly trauma patient.

This article reviews the physiology and pathology associated with ageing and the impact these may have on the perioperative and anaesthetic care of the elderly trauma patient. The current literature on this subject is summarized and, based on this, recommendations are made for perioperative management.

Anaesthesia for hip fracture: a survey of Scottish practice.

A postal survey of all senior anaesthetists with routine commitment to an acute trauma list in 13 Scottish hospitals was conducted to delineate contemporary anaesthetic practice for hip fracture surgery. Almost equal use of general and regional anaesthesia was reported, however the techniques used for general anaesthesia were different from those described in previous literature in this group. The recently released Scottish Intercollegiate Guidelines Network (SIGN) guidelines for the management of elderly people with fractured hip state that seniority of anaesthetist is important for improved outcome but there is no difference between either general or regional anaesthesia. However these conclusions relate to techniques and drugs which are now rarely used during general anaesthesia for hip fracture surgery. Further work to assess the impact of new techniques and agents on outcome for this group of patients may be required.

Anaesthetic breathing systems in the accident and emergency department.

We report two cases where patients with an acute head injury developed hypercapnia as a result of the inappropriate use of the Magill breathing circuit. The Magill circuit is inefficient when used for controlled ventilation because the patient is ventilated with his own expired gas and develops hypercapnia. The suitability of alternative breathing systems are discussed.