Effect of expertise on diagnosis accuracy, non-technical skills and thought processes during simulated high-fidelity anaesthetist scenarios.

Background: The expert performance approach can be used to examine expertise during representative field-based tasks, while collecting process-tracing measures such as think-aloud verbal reports. Collecting think-aloud verbal reports provides an insight into the cognitive mechanisms that support performance during tasks. Method: We examined the thought processes and performance of anaesthetists during simulated environments. Verbal reports of thinking and the anaesthetists' non-technical skills (ANTS) were recorded to examine cognitive processes, non-technical behaviours and diagnosis accuracy during fully immersive, high-fidelity medical scenarios. Skilled (n=6) and less skilled (n=9) anaesthetists were instructed to respond to medical scenarios experienced in theatre. Results: Skilled participants demonstrated higher diagnosis accuracy and ANTS scores compared to less skilled participants. Furthermore, skilled participants engaged in deeper thinking and verbalised more evaluation, prediction and deep planning statements. Conclusions: The ability to employ an effective cognitive processing strategy, more efficient non-technical behaviours and superior diagnosis is associated with superior performance in skilled participants.

Obstructive sleep apnea can be safely managed in a level 2 critical care setting after laparoscopic bariatric surgery.

BACKGROUND: In the United Kingdom, demand for intensive care beds (level 3 critical care) often outstrips supply, leading to frequent and frustrating cancellation of complex elective surgery. It has been suggested that patients with obstructive sleep apnea who undergo bariatric surgery should be admitted to a level 3 facility for routine postoperative management. We have questioned the validity of this dogma in the era of laparoscopic bariatric surgery by using a simple easily applicable algorithm. OBJECTIVES: The aim of this study was to investigate the clinical outcome of patients with obstructive sleep apnea (OSA) without admission to the intensive care unit after laparoscopic bariatric surgery. METHODS: For the first 24 hours after surgery, all patients were admitted to a level 2 (high-dependency) area on a general surgical ward with experience of bariatric surgery. They received supplemental oxygen, continuous pulse oximetry, and judicious analgesic administration using a combination of small boluses of i.v. morphine together with i.v. paracetamol. Perioperative continuous positive airway pressure support was not routinely given, unless patients with OSA had oxygen saturation below their recorded preoperative level on 2 consecutive readings. RESULTS: A total of 1623 patients underwent laparoscopic bariatric surgery over a 12-year period. Of those, 192 had OSA with a median operative body mass index of 52 kg/m(2) (range 34-78 kg/m(2)). The incidence of respiratory complications and the median length of stay (3 nights) were identical in patients with OSA and those without OSA. Four patients self-administered perioperative continuous positive airway pressure, but none required transfer to intensive care or mechanical ventilation. There were no in-hospital deaths. CONCLUSION: Laparoscopic bariatric surgery in patients with OSA is well tolerated and does not require the routine use of level 3 critical care facilities.